Facts Views and Vision in ObGyn最新文献

Background: Deep infiltrating endometriosis (DIE) is a severe condition which requires innovative surgical approaches to address complex anatomical distortions, reduce operative risks, and enhance outcomes.

Objectives: To demonstrate the effectiveness of integrating three advanced surgical techniques-reverse laparoscopic technique, natural orifice specimen extraction surgery (NOSES), and advanced intraoperative bleeding control strategies-in managing a complex case of DIE.

Participant: A 29-year-old nulligravida patient presented with hypermenorrhea, dysmenorrhea, urinary symptoms, and bowel dysfunction. Magnetic resonance imaging revealed a 3.3 cm #ENZIAN C3 intestinal nodule, bilateral ovarian endometriomas and multiple uterine fibroids.

Intervention: Advanced techniques reverse laparoscopic technique, associated with intraoperative bleeding control strategies such as vasopressin injection, temporary ligation of uterine arteries, and infundibulopelvic ligaments; combined with NOSES for specimen extraction. Patient included in this video gave consent for the publication of this video article and its online posting, including social media, journal's website, scientific literature websites, and other applicable sites. Operative time, estimated blood loss, preservation of anatomical structures, postoperative recovery time, symptom resolution, and complications were assessed. Surgery was completed in 180 minutes, with minimal blood loss (40 cc). The patient tolerated a general anti-inflammatory diet by postoperative day two and was discharged without complications. One month postoperatively, the patient showed significant symptom improvement.

Conclusions: The combination of different techniques in the same surgery can clearly lead to favourable results and outcomes, ensuring optimal recovery with superior cosmetic and functional outcomes, particularly in fertility-preserving surgeries.

What is new?: The combination of NOSES, the reverse laparoscopic technique, and advanced bleeding control strategies ensures optimal management for complex procedures in DIE surgeries with fertility preservation.

Background: Opportunistic salpingectomy during hysterectomy with ovarian preservation may reduce the risk of ovarian cancer, but concerns remain that adding salpingectomy to hysterectomy could affect ovarian vascularisation and subsequent function.

Objectives: To assess the feasibility of a full-scale trial to evaluate changes in menopausal symptoms based on the menopause rating scale (MRS) six months following hysterectomy, with and without opportunistic salpingectomy.

Methods: A prospective observational pilot study of premenopausal women age 40 to 55 years scheduled for hysterectomy with ovarian preservation was conducted, where participants were counselled and given the option of concomitant salpingectomy or not.

Main outcome measures: Forty-six out of 50 women chose opportunistic salpingectomy. It took 17 months to recruit 50 patients. Complete follow-up data was achieved in 43 of the 50 participants.

Results: The median MRS score remained unchanged in the opportunistic salpingectomy group at 9 [interquartile range (IQR): 3-14], both before surgery and six months afterwards (n=39). In contrast, the group of women who did not undergo opportunistic salpingectomy had a median MRS score of 11 (IQR: 3-16) preoperatively, which increased to 25 (IQR: 6-32) six months postoperatively (n=4).

Conclusions: The majority of patients in our cohort opted for opportunistic salpingectomy. However, no deterioration in menopausal symptoms was observed in this group after six months. A randomised controlled trial comparing hysterectomy with and without opportunistic salpingectomy in this patient population may not be feasible, given the strong patient preference for salpingectomy and slow recruitment.

What is new?: The development of subjective menopausal symptoms is evaluated after hysterectomy with opportunistic salpingectomy.

Background: Recurrent implantation failure (RIF) and repeated pregnancy loss remain major challenges in assisted reproductive technology, often without identifiable causes despite high-quality embryo transfers. Emerging evidence suggests that abnormalities in the junctional zone (JZ) of the uterus may impair implantation.

Objectives: To evaluate the efficacy of hysteroscopic (HSC) sub-endometrial exploration combined with intrauterine application of budesonide-enriched crosslinked hyaluronic acid (HA) gel on pregnancy outcomes in women with RIF and complete JZ loss on magnetic resonance imaging (MRI).

Methods: This single-centre observational pilot study included 20 women with RIF and MRI-confirmed loss of JZ differentiation. All patients had excellent cryopreserved blastocysts, either from an egg donation program or derived from their own autologous oocytes (<37 years). Under conscious sedation, patients underwent HSC sub-endometrial exploration with micro-incisions at the lateral walls and fundus, followed by intrauterine instillation of budesonide-enriched HyaRegen^® gel. [BioRegen Biomedical (Changzhou) Co., Ltd.].

Main outcome measures: Clinical pregnancy rate, live birth rate, and maternal/neonatal outcomes.

Results: Eighteen of 20 women (90%) conceived. In the donor group, all 9 pregnancies led to live births. In the autologous group, 8 of 9 pregnancies were successful; one was medically terminated at 20 weeks due to foetal malformation. All 17 neonates were healthy at birth and six-month follow-up.

Conclusions: Preliminary observations of this novel approach suggest that it may contribute to improving implantation and live birth rates in women with unexplained RIF and JZ abnormalities.

What is new?: This study introduces a targeted intrauterine intervention for RIF patients with loss of JZ differentiation, combining HSC exploration and budesonide-HA gel therapy.

Background: Deep infiltrating endometriosis, particularly involving the rectovaginal space, represents one of the most challenging surgical benign gynaecologic conditions. While hysterectomy is a definitive option in women without fertility desire, these procedures are technically complex and associated with higher risks of complications. The anterior colpotomy first technique has been developed as an alternative approach to simplify dissection and improve surgical safety in such advanced cases.

Objectives: Stepwise video demonstration of laparoscopic hysterectomy for deep infiltrating endometriosis involving rectovaginal space by the anterior colpotomy first technique.

Participant: A 47-year-old woman presented with dysmenorrhea, dyspareunia and dyschezia unresponsive to medical treatment. Transvaginal ultrasound and magnetic resonance imaging (MRI) revealed bilateral 5 cm endometriomas, 2 cm endometriotic nodules on both utero-sacral ligaments, and a 4 cm nodule in the Douglas pouch. A further 3 cm superficial endometriotic nodule on the rectosigmoid colon was also revealed on MRI. According to the Enzian classification, the score was A3, B2/2, C3. Laparoscopic hysterectomy, bilateral salpingo-oophorectomy and endometriotic excision of lesions were planned. Operation time was 210 minutes, and blood loss was 50 mL. On the postoperative fourth day patient was discharged. The patient remained pain-free at 25 months follow-up.

Intervention: Surgical steps for anterior colpotomy first technique could be divided into following steps: 1) entry into retroperitoneum, 2) ligation of uterine artery at the branching point from hypogastric artery, 3) development of vesicouterine space, 4) dissection of ureter and transection of lateral parametrium, 5) combining lateral and anterior compartments, 6) anterior colpotomy, 7) developing rectovaginal space from lateral to midline, 8) completion of posterior colpotomy, 9) excision of endometriotic nodule and leaving nodule on rectosigmoid colon, 10) completion of hysterectomy, 11) rectal shaving and resection of endometriotic lesions, 12) Bubble test, assessment of ureteral integrity and ladder filling with saline. In this technique, it is more feasible to do anterior colpotomy first and to develop rectovaginal space from lateral sides towards midline instead of dealing with the posterior compartment at the beginning of surgery. Ultimately endometriotic nodule between the rectosigmoid colon and the uterus is cut, leaving the endometriotic nodule on the rectosigmoid colon.

Conclusions: Laparoscopic hysterectomy with anterior colpotomy first technique makes complicated hysterectomies easier in patients with deep infiltrating endometriosis.

What is new?: This video article presents a stepwise demonstration of the anterior colpotomy first technique for laparoscopic hysterectomy in deep

Background: Minimally invasive sacrocolpopexy (SCP) has emerged as the gold standard procedure for pelvic organ prolapse. However, it entails a deep surgical dissection, essential for proper mesh positioning, and is not devoid of intraoperative and postoperative complications, including sporadic cases of potentially life-threatening intraoperative bleeding or postoperative haematomashaematomas. The appropriate management of bleeding complications in this area varies depending on the individual case and presence of hemodynamic instability, from emergency open surgery to a conservative wait-and-see approach.

Objectives: To illustrate an effective method for the management of bleeding complications of SCP and raise awareness about this unusual complication.

Participant: A 69-year-old woman underwent laparoscopic revision surgery due to evidence of a voluminous presacral haematoma on the second postoperative day after SCP.

Intervention: The effectiveness of minimally invasive revision surgery for the management of voluminous presacral haematoma following laparoscopic SCP was assessed. Laparoscopic revision surgery allowed for the complete drainage of the haematoma without complications, resulting in discharge on postoperativeday seven.

Conclusions: The video reviews the steps of the laparoscopic approach for performing a successful and safe revision surgery to manage presacral haematomas after SCP, and illustrates the procedure's adaptability, also providing specific tips and tricks to successfully perform this procedure without the need for mesh removal, thereby preserving the best outcome for the patient.

What is new?: This is the first description of the surgical management of a retroperitoneal hematoma following colposacropexy. The study's conclusions provide a valuable resource for gynecologists facing patients presenting with a retroperitoneal presacral hematoma after prosthetic surgery for prolapse.

Background: Relugolix-combination therapy (CT) (oestradiol 1 mg and norethindrone acetate 0.5 mg) is a new gonadotropin-releasing hormone antagonist licensed to treat heavy menstrual bleeding (HMB) associated with uterine fibroids; but little real-world data exists to guide practice.

Objectives: To evaluate the efficacy and safety of relugolix-CT in women with fibroid-associated HMB in two large Italian hospitals.

Methods: A retrospective multicentre study was conducted on 102 women with symptomatic fibroids and HMB, defined as a Pictorial Blood Assessment Chart (PBAC) score >100, who were treated with relugolix-CT for up to 24 months. Women were divided into three groups: group 1 (n=81) receiving only relugolix-CT treatment; group 2 (n=11) receiving at least two months of relugolix-CT prior to hysteroscopic, laparoscopic or open myomectomy; group 3 (n=10) receiving at least two months of pre- and post-myomectomy relugolix-CT.

Main outcomes measures: The primary outcome was resolution of HMB, defined as a PBAC score <100. Secondary outcomes included the side effects of treatment.

Results: The population mean age was 43.8 years (±6.06), and the mean baseline PBAC score was 329.9 (± 217 standard deviation). In women treated with relugolix-CT alone, 71 (94.7%) responded after two months. By nine months, only 36 (44.4%) women continued with relugolix-CT. Resolution of HMB was sustained in most women who continued treatment at each follow-up time point. By two months prior to myomectomy, HMB resolved in all women receiving relugolix-CT pre-surgery and nine (90%) women continuing relugolix-CT after myomectomy. No major side effects were reported.

Conclusions: This real-world study supports previous controlled trial data showing relugolix-CT to be a safe, efficacious medical treatment for HMB with fibroids.

What is new?: Real-life clinical data support the use of relugolix-CT to treat symptomatic fibroids in isolation or combined with myomectomy.

Dual operating is increasingly recognised as a valuable strategy in complex gynaecological surgery. Models include supervising (trainer-trainee), buddy (comparable proficiency within a specialty), and inter-specialty (collaboration across specialities). Each approach offers unique benefits for patient safety, surgical training, and surgeon wellbeing. Buddy operating in particular promotes peer-to-peer learning, shared responsibility, and enhances decision-making. As minimally invasive gynaecology evolves, embedding these models into practice may strengthen training, and improve outcomes and workforce resilience. Further evidence is needed to evaluate long-term benefits and cost-effectiveness in different clinical contexts.

Advanced pelvic surgeries, such as radical hysterectomy, deep endometriosis surgery and sacrocolpopexy, pose risks to autonomic pelvic nerves leading to voiding dysfunction and reduced quality of life. This review article evaluates neuropelveological strategies for preventing and managing bladder dysfunction by exploring pelvic neural anatomy, nerve-sparing techniques, and postoperative rehabilitation approaches. Nerve-sparing approaches can reduce postoperative urinary retention and improve recovery of bladder function. Neuromodulation techniques provide additional support in managing persistent voiding dysfunction in selected cases. A multidisciplinary approach integrating detailed knowledge of pelvic neural anatomy, precise surgical techniques and structured postoperative management can minimise bladder dysfunction and optimise patient outcomes.