Facts Views and Vision in ObGyn最新文献

Background: Robotic-assisted hysterectomy is increasingly performed using modular platforms such as the Hugo™ roboticassisted surgery (RAS) system, but optimal or personalised docking strategies remain undefined.

Objectives: To establish expert consensus on port placement and docking configurations for hysterectomy with the Hugo™ RAS system and to identify patient anthropometric factors requiring modification of standard setups.

Methods: A modified Delphi consensus was conducted involving two iterative rounds of anonymous, structured questionnaires distributed to an international panel of gynaecological robotic surgeons experienced with the Hugo™ RAS system. Survey items addressed preferred docking configurations, the influence of patient anthropometry on docking strategy, and specific technical adjustments in non-standard scenarios. Consensus was predefined as ≥66.7% agreement.

Main outcome measures: Expert agreement on docking setups, port placement modifications, and anthropometric variables influencing technical adjustments.

Results: Seventeen experts completed round one and 16 completed round two. No single docking configuration reached consensus as universally optimal for standard hysterectomy. Ranking exercises identified the "standard" hysterectomy setup as the most preferred configuration, followed by the "alternate" and the "three-arm" setups. All experts agreed that patient anthropometry requires modification of port placement. Elevated body mass index (BMI), large uterine size and small pelvis were identified as key variables: increasing inter-port distance was recommended for BMI >30, cranial port displacement for large uteri, while no consensus emerged for patients with a small pelvis. A modified bridge configuration was proposed, and achieved strong expert agreement.

Conclusions: No single docking configuration is deemed to be universally optimal for Hugo™ RAS hysterectomy. Expert practice combines a limited number of preferred setups with patient-tailored adjustments.

What is new?: This study provides the first Delphi-based expert consensus on Hugo™ RAS docking strategies, emphasizing patient-specific adjustments and flexible preoperative planning.

Background: Laparoscopic lateral suspension is an alternative to sacrocolpopexy when access to the sacral promontory is restricted or unsafe. However, prolapse recurrence may occur due to mesh arm detachment or progressive fascial attenuation. Pectineal fixation is an alternative approach that may provide a stronger, more stable anchoring vector and improved force distribution.

Objectives: To describe a minimally invasive salvage surgical strategy for managing recurrent anterior compartment prolapse in a patient with a history of laparoscopic lateral suspension and inaccessible sacral promontory.

Participant: A 73-year-old woman presented with symptomatic vaginal bulging fifteen years after undergoing laparoscopic lateral suspension with subtotal hysterectomy and bilateral adnexectomy following an aborted promontofixation. Examination revealed a grade 2-3 cystocele and a grade 2 hysterocele without mesh exposure. Laparoscopy confirmed bilateral detachment of the anterior mesh arms from the lateral abdominal wall.

Intervention: Laparoscopic anterior colporrhaphy was undertaken to reinforce the pubocervical fascia, with exposure supported by a device. The detached mesh arm was carefully trimmed and then secured using non-absorbable Ethibond® 1 sutures, with one fixation point anchored to the Cooper's ligament and the other to the mesh itself, in accordance with the principles of tension-free pectopexy bilaterally. Peritonisation was completed to fully cover the mesh.

Conclusions: Recurrent anterior prolapse after lateral suspension where the sacral promontory is inaccessible promontory can be managed by reusing the detached mesh arms and refixing to Cooper's ligament as a salvage strategy.

What is new?: Reinforcing the native fascia and refixing the mesh to the pectineal ligament provides an anatomically sound solution while avoiding the risks of sacral promontory dissection.

Background: The location and size of abdominal incisions to enable tissue extraction might increase the risk of incisional hernia (IH).

Objectives: To determine the reported incidence of IH after specimen extraction in gynaecological minimally invasive surgery.

Methods: On January 9^th 2025 we performed a systematic literature review of PubMed, Embase, and Clarivate Analytics/Web of Science Core Collection from inception to 25 May 2023. Minimally invasive surgery, IH, specimen extraction, morcellation and gynaecology were used as search terms. All cohort studies and randomised controlled trials reporting IHs after minimally invasive gynaecological surgery with either morcellation or abdominal specimen extraction through an enlarged trocar site or mini-laparotomy were included.

Main outcomes measures: The primary outcome was the incidence of IH. Secondary outcomes included incision length and location, time to diagnosis and risk factors for developing IH.

Results: Thirty one studies were identified, of which three retrospective cohort studies met the inclusion criteria. The reported incidence of IH was between 0.02% and 8.3%, with a time to diagnosis spanning two days to two and a half years. Data were lacking or insufficient on the size and location of the incision and on the technique used for specimen extraction.

Conclusions: There is a lack of evidence on the risk of developing IH in minimally invasive gynaecological surgery. Given the increasing use of minimally invasive surgical techniques, there is a pressing need for high-quality research on the prevalence and risk factors of IH, as well as on interventions aimed at mitigating this risk.

What is new?: This review reveals a lack of high-quality evidence and consistent reporting on factors influencing IH after specimen extraction in minimally invasive gynaecological surgery.

Fertility preservation (FP) has become an essential dimension of modern medicine, reflecting the paradigm shift from survival alone to survivorship. Once confined to oncology, FP now spans a broad spectrum of medical, social, and technological contexts. Surgical innovations, including fertility-sparing surgery and ovarian transposition, allow reproductive potential to be safeguarded without compromising oncological safety. Cryobiology has been transformed by the transition from slow-freezing to vitrification, establishing oocyte and embryo cryopreservation as gold-standard approaches with outcomes comparable to fresh cycles. Alongside onco-fertility, "social freezing" has emerged as a tool of reproductive autonomy, though it raises counselling and ethical challenges related to age, expectations, and equity of access. Resilience in FP also requires psychosocial support: while emotional distress is common, evidence shows that interventions such as mindfulness and structured counselling improve mental health even if conception outcomes remain unchanged. In parallel, ovarian tissue cryopreservation for patients unable to undergo stimulation and immature testicular tissue banking extend possibilities, with early clinical successes highlighting future translational pathways. Uterus transplantation has emerged as the first-line treatment of congenital absence of a uterus and can restore fertility after a hysterectomy performed for cervical cancer. Looking ahead, regenerative approaches, including stem-cell-based strategies, 3D bio-printing of genital tissues, tissue engineering, and artificial uterus systems, signal the next frontier, while underscoring the need for further research as well as robust ethical, legal, and safety frameworks. FP thus represents a multidisciplinary and rapidly evolving field that integrates oncology, reproductive medicine, gynaecology, transplantation surgery, psychology, and laboratory disciplines. Its trajectory is defined by both technological innovation and the imperative to align medical progress with patient autonomy, equity, and long-term quality of life.

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.