Facts Views and Vision in ObGyn最新文献

Background: Hysteroscopy is recognised as the gold standard for diagnosing and treating intrauterine pathologies. Despite its broad acceptance, management practices appear to be diverse.

Objectives: To explore gynaecologists' approaches to managing intrauterine pathologies, assessing their diagnostic habits, therapeutic strategies, and the surgical techniques adopted in clinical practice.

Methods: The project was undertaken by the European Society for Gynaecological Endoscopy (ESGE) Special Interest Group on hysteroscopy. All ESGE members were invited to participate in the study through an online questionnaire hosted on the SurveyMonkey platform.

Main outcome measures: Procedural setting, equipment availability, preferred instruments, pain management, and satisfaction with hysteroscopic practices.

Results: Four hundred and fifty-one of 4000 (11.25%) gynaecologists from 57 countries responded. Two hundred eighty one (74%) of the participants performed hysteroscopy using a vaginoscopic approach. Pain management practices varied, with 46% of respondents reporting minimal or no use of analgesics. Procedural settings were distributed across office-based environments 107 (23.7%), outpatient facilities 183 (40.6%), and operating rooms 161 (35.6%). Two hundred and ninety-nine (87.9%) of respondents reported that diagnostic facilities were well-equipped, and 282 (74.4%) expressed satisfaction with the available operative equipment. Polypectomy was the most frequently performed operative procedure.

Conclusions: The observed variability in the practice of hysteroscopy among ESGE members highlights the need for standardised guidelines to improve consistency and patient outcomes.

What is new?: This survey provides an overview of the hysteroscopic management of intrauterine pathologies among ESGE members.

Background: Although the benefit of nerve-sparing surgery for deep endometriosis (DE) with postoperative voiding dysfunction has been demonstrated, it requires a high level of surgical skill to accurately remove endometriosis lesions while preserving autonomic nerves in situations of severe adhesions and fibrosis and has been performed only by expert surgeons. However, endometriosis is a common disease, and methods for intraoperative identification of endometriosis lesions, ureters, vessels, and nerves using near-infrared imaging with indocyanine green (ICG) have been explored to enable more surgeons to safely offer such procedures to their patients.

Objectives: To demonstrate the step-by-step technique of single-port robotic nerve-sparing DE surgery with ICG navigation.

Participant: The patient was a 48-year-old woman with chronic pelvic pain. Magnetic resonance imaging revealed uterine adenomyosis and a right ovarian endometrioma with DE involving the uterosacral ligament and surface of the rectum.

Intervention: An intravenous injection of 0.25 mg/kg body weight of ICG for intraoperative near-infrared fluorescence (NIR) imaging with the da Vinci Single-Port.

Conclusions: The use of ICG with NIR during nerve-sparing DE surgery may improve the surgeon's decision-making process. ICG may be useful in highlighting pelvic autonomic nerves, identifying DE lesions, checking for pelvic organ injury, and assessing tissue perfusion and haemostasis. However, further research is needed to confirm the possible role of ICG in this setting.

What is new?: This video illustrates the potential of ICG fluorescence to enhance intraoperative visualisation of autonomic nerves and DE lesions, offering educational insights into safer and more widely accessible advanced surgical techniques.

Endometriosis in a surgical scar is a rare but important clinical phenomenon that can lead to significant morbidity, especially in women with a history of caesarean sections. We present a case of a 35-year-old woman with chronic right iliac fossa pain and prolonged, heavy menstrual bleeding (HMB) with minimal improvement after hormonal treatment with the combined oral contraceptive pill. She had undergone two prior caesarean deliveries, and imaging raised the suspicion of utero-abdominal wall scar endometriosis at the site of the previous uterine incision. Intraoperative findings confirmed a mass extending from the abdominal wall into the uterine scar. The lesion was completely excised, and histopathology confirmed endometriosis. Post-surgical recovery was uneventful, with resolution of pain and HMB. This case highlights the importance of considering scar endometriosis in the differential diagnosis of abdominal wall masses and pain in patients following caesarean section, and underscores that surgical excision can be curative.

Background: Sexual functioning is a complex phenomenon driven by multiple physical, psychological and social factors, necessitating comprehensive evaluation.

Objectives: To assess the impact of laparoscopic deep endometriosis (DE) surgery on sexual functioning and distress in comparison to healthy controls.

Methods: Retrospective cohort study including 125 sexually active women who underwent DE surgery and who completed patient-reported outcome measurements (PROMs) pre- and postoperatively. Postoperative data were compared to prospectively collected data from 134 healthy controls.

Main outcome measures: Postoperative female sexual function index (FSFI-9), including the FSFI-9 total score (percentage of best possible FSFI-9 score), and the Female Sexual Distress Scale-Revised score. Secondary outcomes included pain scores, depressive symptoms, quality of life (QoL), relational satisfaction and positive affect.

Results: Sexual functioning significantly improved across all domains (desire, arousal, lubrication, orgasm, satisfaction, pain, distress) after DE surgery. The FSFI-9 total score increased from 65% pre-operatively [mean 29.3 (27.2, 31.23)] to 75% at 3 months [mean 33.6 (32.3, 34.9), P<0.001)] and 74% at 6 months [mean 33.1 (31.0-35.0), P<0.001] after DE surgery, compared to 85% in healthy controls [mean 38.08 (37.21-38.87)]. In addition, an improvement in QoL, pain scores, depressive symptoms and positive affect was observed. Bowel surgery or reoperations did not affect postoperative sexual functioning. Compared to healthy controls, DE patients reported similar sexual functioning 3 months post-surgery, except for significantly lower sexual arousal, lubrication and pain. At 6 months, these differences persisted, with DE patients also reporting significantly lower sexual satisfaction, higher pain scores and poorer QoL across multiple domains compared to controls.

Conclusions: DE surgery (including bowel surgery) does significantly improve sexual functioning and distress. However, sexual functioning and distress remain inferior compared to healthy peers.

What is new?: This study provides comprehensive pre- and postoperative PROMs to assess the impact of DE surgery on sexual functioning and to evaluate other key influencing factors.

Hysteroscopic metroplasty improves reproductive outcomes in women with a dysmorphic uterus, but the impact of adenomyosis in these patients is uncertain. We retrospectively analysed 69 women who underwent metroplasty for a dysmorphic uterus, with histological assessment of the excised tissue. Adenomyosis was more frequently identified at histology in patients with recurrent pregnancy loss compared to those with infertility/single miscarriage (54% vs. 27%, P=0.03). Following surgery, the clinical pregnancy rate in the overall cohort reached 65%, and the live birth rate (LBR) per pregnancy increased from 0% to 62% (P<0.01). Among patients with histological evidence of adenomyosis, the LBR was 43%, compared to 71% in those without adenomyosis (P=0.07). Hysteroscopic metroplasty appears to improve reproductive outcomes overall. Larger, prospective studies are needed to better define the role of adenomyosis in this patient population.

The management of infertility in women with bowel endometriosis remains a significant clinical challenge. The two primary therapeutic approaches include first-line medically assisted reproduction (MAR) and primary bowel surgery, with or without subsequent fertility treatments. While surgery can significantly improve fertility outcomes, the success of these interventions is influenced by several factors, and MAR may still be necessary for certain patients, especially those over 35 years or with complex disease patterns. In this narrative review, we assessed the outcomes of the main therapeutic strategies commonly offered to patients with bowel endometriosis-associated infertility and discussed the challenges inherent in evaluating reproductive outcomes in women with colorectal endometriosis.

Background: The rate of kidney transplantation has been steadily increasing worldwide, accompanied by significant improvements in post-transplant survival rates. However, transplant recipients have a higher incidence of malignancies compared with the general population, and their oncological management often poses unique challenges. In recent years, major advances in the treatment of ovarian cancer (OC) have expanded the therapeutic options available for recurrent disease. Two randomised trials have underscored the role of surgery in platinum-sensitive recurrent OC while minimally invasive approaches have demonstrated reduced morbidity without compromising oncologic outcomes in carefully selected patients. For frail and immunosuppressed individuals, the minimally invasive approach may offer substantial advantages- including fewer wound complications, shorter hospitalisation, and earlier resumption of oral intake and immunosuppressive therapy. Despite these potential benefits, evidence regarding the feasibility and safety of minimally invasive secondary cytoreduction in kidney-transplanted patients remains limited.

Objectives: To demonstrate the feasibility and outcomes of robotic surgery in a platinum-sensitive OC recurrence in a frail, kidney-transplant patient.

Participant: A woman in her 50s with a history of kidney transplantation presented with isolated pelvic high-grade serous OC recurrence. Positron emission tomography scan revealed a 15 mm solid lesion with increased uptake infiltrating the rectum.

Intervention: A robot-assisted rectal resection was performed using the Da Vinci Xi Surgical System. The approach included four 8 mm robotic trocars: trans umbilical optical port, right and left iliac fossa, suprapubic region, and one 10 mm laparoscopic port at the left Palmer's point. Colorectal anastomosis was completed using the Ethicon Endo-Surgery 60 mm stapler by a specialised peritoneal and retroperitoneal team.

Conclusions: R0 resection was achieved with no complications or delays in immunosuppressive therapy resumption; final histology confirmed rectal involvement, and adjuvant chemotherapy was promptly initiated. At the two-year follow-up, the patient was disease-free.

What is new?: This case supports minimally invasive surgery as a valid approach in selected, frail, immunosuppressed patients with isolated OC recurrence.