Facts Views and Vision in ObGyn最新文献

Background: Apical prolapse, characterised by the descent of the vaginal apex, uterus, or cervix, is commonly treated by laparoscopic sacrocolpopexy, the current gold standard. Laparoscopic pectopexy (LP) has emerged as an effective alternative, particularly advantageous for obese patients due to its technical approach.

Objectives: To demonstrate a standardised 10-step surgical technique for performing laparoscopic pectopexy combined with supracervical hysterectomy, aiming to provide a safe and reproducible method for the treatment of apical prolapse.

Participant: A 68-year-old female patient presenting with symptomatic, advanced apical pelvic organ prolapse (POP-Q stage IV) consented to the procedure.

Intervention: The patient underwent LP following a 10-step surgical protocol: (1) division of the round ligaments and dissection towards the pelvic sidewall, (2) identification of the iliopectineal ligament, (3) division of the uterovesical peritoneum and development of the vesicovaginal space, (4) supracervical hysterectomy, (5) opening of the rectovaginal space, (6) closure of the cervical canal, (7) mesh insertion and fixation to cervix, anterior and posterior vagina, (8) bilateral anchoring of the mesh lateral arms to the iliopectineal ligaments, (9) closure of the overlying peritoneum, and (10) morcellation of the uterine corpus. The surgery was completed with minimal blood loss and no intraoperative complications.

Conclusions: LP combined with supracervical hysterectomy is a safe, effective, and reproducible surgical option for apical prolapse repair, demonstrating favourable perioperative outcomes and early discharge.

What is new?: This video-based demonstration introduces a standardised 10-step approach to LP combined with supracervical hysterectomy, facilitating adoption of this technique by surgeons with advanced minimally invasive skills, and highlighting its potential benefits, especially in obese patients.

Background: There is a growing unmet need to digitalise the management of clinical data in medicine. Web-based scoring applications for endometriosis align with this trend.

Objectives: This study aimed to evaluate a web-based application that automatically calculates endometriosis staging scores [revised American Society for Reproductive Medicine classification (r-ASRM), the revised Enzian classification (#Enzian), Endometriosis Fertility Index (EFI)] and compare it to manual scoring in a proof-of-concept study.

Methods: 20 endometriosis cases operated on in 2022 were retrospectively selected. Six experienced gynaecologists were randomly allocated to either the conventional paper-based method or the digital application for staging of disease.

Main outcome measures: Completion time, score consistency among examiners and methods, and user satisfaction were recorded using a Likert scale and a subjective mental effort questionnaire (SMEQ).

Results: In comparison to the paper-based method, the web-based tool reduced scoring time by 25.1 seconds (128.0 vs. 153.1, P<0.05), was perceived as easier to use (higher Likert scale scores), and was associated with low-to-moderate mental effort on the SMEQ. The agreement between electronic and paper forms was rated as very good to excellent for r-ASRM [intraclass correlation coefficient (ICC): 0.93] and #Enzian (ICC: 0.84), while it was moderate for EFI (ICC: 0.67). Interrater agreement utilising the electronic form demonstrated high levels, yielding very good to excellent results for r-ASRM (ICC: 0.93) and EFI (ICC: 0.82) while showing moderate agreement for #Enzian (ICC: 0.63).

Conclusions: The application facilitates sequential data entry for users and automatically calculates r-ASRM, #Enzian, and EFI scores. It decreases scoring duration, strongly aligns with the paper-based method, and enhances user satisfaction.

What is new?: This tool can potentially improve clinical efficiency, accuracy, and consistency in the staging of endometriosis.

Background: Uterine fibroids are the most common benign solid neoplasms of the uterus. Hysteroscopy represents the gold standard treatment for submucosal fibroids.

Objectives: The aim of this study was to retrospectively analyse all consecutive symptomatic patients diagnosed with the International Federation of Gynecology and Obstetrics G0-G3 fibroids who underwent hysteroscopic myomectomy, to identify factors that may influence the feasibility of single step myomectomy.

Methods: The study included all consecutive symptomatic patients, diagnosed with G0-G3 fibroid. Surgical procedure was performed by a single experienced surgeon. All patients underwent postoperative hysteroscopic control 30-40 days after the procedure.

Main outcomes measures: Evaluation of feasibility of hysteroscopic myomectomy in a single surgical step.

Results: One hundred and twenty-five patients were included. In 97 women (77.6%) the fibroid was removed in one single step; 28 patients (22.4%) had a residual fibroid. Of these patients, in 10 cases (35.7%) the residual fibroid was removed during the office hysteroscopic control, 16 (57.2%) and 2 (7.1%) patients required II- and III-time myomectomy, respectively. 85.6% of patients did not need a second time surgery under general anaesthesia. At univariate and multivariate analysis, diameter was found to be the parameter most related to single-step fibroid removal with P=0.001 and P<0.001 respectively. For G0-3 fibroids <3 cm in 72% (66/92) of cases the 15 Fr mini-resectoscope was used with one step myomectomy in 89.4% of cases.

Conclusions: In expert hands, single step hysteroscopic myomectomy is feasible for G0-3 fibroids. The possibility to use miniaturized instruments for myomectomy may improve the surgical outcomes and prevent intra- and post-operative complications, in particular uterine perforation by avoiding cervical dilation. Further studies are needed to evaluate the true efficacy of 15 Fr mini-resectoscope in the removal of G0-G3 fibroids <3 cm.

What is new?: Hysteroscopic myomectomy in a single surgical step is feasible for G0-G3 fibroids, with diameter being the only independent factor influencing the success of the procedure. In expert hands, the success rate of single step myomectomy by using miniaturized instruments in fibroids ≤3 cm, is 89.4%.

Background: Accessory cavitated uterine malformations (ACUMs) are a rare obstructive uterine anomaly that remains poorly understood, posing challenges for clinical management. The aetiopathogenesis is hypothesised to involve the duplication and persistence of ductal Müllerian tissue usually near the round ligament attachment, potentially related to gubernaculum dysfunction. ACUM is specifically classified by Acién's system, though rare variants necessitate continued international research to refine classification frameworks.

Objectives: This consensus aims to develop good clinical practice recommendations for the pathophysiology, terminology, clinical presentation, diagnosis, and treatment of ACUM.

Methods: A working group consisted of Chinese and European experts, after approval from the European Society for Gynaecological Endoscopy, developed recommendations based on the best available evidence and experts' opinion.

Results: Patients with ACUM present with typical symptoms such as dysmenorrhea and dyspareunia, and atypical symptoms, including gastrointestinal and generalised pelvic pain. Diagnostic criteria include isolated cavitated lesions in the anterolateral myometrium near the round ligament, lined by endometrial tissue and filled with haemorrhagic fluid, surrounded by a myometrial mantle with concentric orientation of myometrial fibres, and typically associated with a normal uterine cavity. Diagnosis is most accurately made through ultrasound and magnetic resonance imaging. Surgical excision of the ACUM is considered the definitive treatment offering near-complete symptom resolution, and minimally invasive approach should be preferred when possible. The timing of surgery and the interval before attempting pregnancy remain unclear. The mode of delivery post-surgery is individualised based on the degree of myometrial involvement.

Conclusions: The current consensus summarises the existing evidence on ACUM providing good clinical practice recommendations for their management. Existing gaps in the understanding and management of ACUMs, highlight the need for further research to guide clinical decision-making.

What is new?: Good clinical practice recommendations for ACUM aiming to understand and optimise their management.

Background: Cervical cerclage is used to prevent preterm delivery caused by cervical insufficiency, thereby reducing neonatal morbidity and mortality rates. Transabdominal cerclage is usually performed in women who previously underwent transvaginal cerclage that failed to prevent pregnancy loss, or in those with a short cervix where transvaginal cerclage was not feasible.

Objectives: To estimate the efficacy of pre-conceptional laparoscopic cerclage in facilitating term delivery and live birth.

Methods: A systematic review was conducted according to the PRISMA 2020 guidelines. This study was registered in PROSPERO (CRD42024545316). A search was conducted up to the 15th of April 2024, in the PubMed and Cochrane databases, using a combination of terms "laparoscopy", "transabdominal" and "cerclage". Original studies investigating the role of pre-conceptional laparoscopic cerclage on pregnancy outcomes after follow-up were eligible for inclusion in this review.

Main outcomes measures: Prevalence of deliveries after 37 weeks of gestation and live birth rates.

Results: Ten studies involving 1060 patients were included. The pooled prevalence of deliveries after 37 weeks of pregnancy was 70% [95% confidence interval (CI) 60%-79%, 7 studies, 515 pregnancies, I2: 85%] and the pooled prevalence of live birth was 92% (95% CI 86%-95%, 10 studies, 713 pregnancies, I2: 69%). Significantly higher rates of delivery after 37 weeks of pregnancy were associated with the use of mersilene tape compared to conventional sutures [odds ratio (OR): 2.98, 95% 1.95-4.56] and the use of an anterior knot compared to a posterior knot (OR: 2.26, 95% CI: 1.50-3.40).

Conclusions: Pre-conceptional laparoscopic cerclage achieved high rates of live birth after 37 weeks in women considered at high risk of preterm delivery. Comparative research is needed to better understand the efficacy of pre-conceptional laparoscopic cerclage as well as refine the indications for this procedure, optimise surgical techniques, and determine the best timing for cerclage placement.

What is new?: Pre-conceptional laparoscopic cerclage may prevent future preterm births and second-trimester pregnancy losses.

Background: Uterine malformations are congenital anomalies arising from abnormal Müllerian duct development during embryogenesis. These can be linked to vaginal cysts, resulting in complex malformations. One rare form is the unicornuate uterus, where only one duct develops, leading to complications like severe pain due to a rudimentary, non-communicating horn.

Objectives: To describe a combined approach using ultrasound, hysteroscopy, and robotic-assisted laparoscopy for complex uterine anomalies.

Participant: A 30-year-old nulliparous woman with unilateral kidney agenesis and acute pelvic pain referred to our centre.

Intervention: 2D ultrasound suggested a complex malformation. 3D ultrasound and magnetic resonance imaging confirmed a U4a uterus. Hysteroscopy revealed a hemicavity with one tubal ostium. Robotic-assisted laparoscopy enabled right salpingectomy and removal of the rudimentary horn while preserving the ovary. Intraoperative ultrasonography guided the drainage of vaginal cysts. As a result, vaginal cysts were drained, and the rudimentary horn was removed with ovarian preservation. The patient was discharged without complications and spontaneously conceived a healthy pregnancy 8 months later.

Conclusions: Unicornuate uterus with non-communicating horn and renal agenesis is a rare condition. A combined approach using ultrasound, hysteroscopy, and robotic-assisted laparoscopy allows comprehensive evaluation and treatment.

What is new?: This is the first reported case of simultaneous and synergistic use of hysteroscopy and robotic-assisted laparoscopy for complex genital malformations under ultrasonographic guidance.

This prospective cohort study evaluated virtual reality (VR) use during outpatient hysteroscopy in a UK tertiary hospital (Nov 2022-Apr 2023). Of 105 eligible women, 38 (36.2%) used VR; most who declined preferred to remain undistracted. Mean pain score was 5.5, slightly lower than the expected 5.7. Mild side effects included dizziness and claustrophobia. Nearly all users (94.7%) would recommend VR, and all rated it "acceptable" or "very acceptable." While VR may improve patient experience, limited uptake highlights the importance of tailoring pain management to individual preferences.

Background: In the context of outpatient hysteroscopy (OPH), performing a single procedure integrating the operative and diagnostic part is known as "See & Treat hysteroscopy". The virtual reality (VR) technology provides an immersive virtual environment that can provide a non-invasive analgesic. To date, there is limited evidence regarding its use in the OPH setting.

Objectives: To evaluate the feasibility and effectiveness of VR technology for pain and anxiety management in OPH.

Methods: Unblinded, prospective, randomised controlled trial, conducted at the Hysteroscopy Unit of the University of Naples "Federico II" between May and July 2024. Women aged 18-70 years, indicated for OPH, were randomised into a control group (standard OPH care) and an intervention group (OPH care with the addition of a VR headset).

Main outcome measures: Pain and anxiety were assessed through subjective measures: numerical rating scale (NRS) scores before and after the procedure, and objective measures: heart and respiratory rate pre- and during the procedure. Satisfaction, time, and success rates were also evaluated.

Results: Overall, 116 women were enrolled. The VR group compared to the control group reported significantly lower mean standard deviation NRS scores for pain [3.9 (2.7) vs. 5.4 (3.0); mean difference 1.5, 95% confidence interval (CI) 0.4 to 2.5] and anxiety [3.2 (2.1) vs. 4.8 (2.8); mean difference 1.6, 95% CI 0.7 to 2.5] respectively. Regarding satisfaction, 96.5% of the VR group would use the headset again, whereas 3.5% requested its removal. All women in the control group desired a distraction. No serious adverse events were reported.

Conclusions: VR technology proved feasible and effective for pain and anxiety management in OPH, particularly during operative procedures.

What is new?: Its use can support the implementation of the See & Treat philosophy.

Background: Ovarian remnant syndrome (ORS) is a rare condition defined by the presence of residual tissue of ovarian origin, histologically confirmed in a woman with a previous salpingo-oophorectomy, usually as a result of difficult surgery in the presence of adhesions.

Objectives: To evaluate the existing literature on ORS.

Methods: A narrative review was performed. A search for relevant articles was carried out in PubMed for the period from January 2014 to July 2024. Three original cases of ORS are also reported.

Main outcome measures: All available literature on the subject was analysed and articles relevant to the topic of the review were included. Additional articles were reviewed to provide an overview of the issue.

Results: A total of 10 different cases of ORS found in the literature were analysed, together with 3 original cases.

Conclusions: The presence of distorted anatomy and extensive adhesions may lead to an increased risk of residual ovarian tissue. Residual ovarian tissue may sometimes evolve into a malignant lesion. When difficult oophorectomy is suspected, the surgeon must proceed with caution to complete oophorectomy. Strict follow-up is essential to detect ORS.

What is new?: This is the first narrative review including cases described in the literature and three new original cases. Our work provides a comprehensive and global view of this condition and may help in clinical practice to reduce the risk of ORS through appropriate surgical planning and possibly early diagnosis of the syndrome.

Indocyanine green (ICG) with near-infrared imaging is a valuable adjunct in minimally invasive gynaecological surgery, enhancing anatomical visualisation and surgical precision. This narrative review synthesises current evidence on ICG's clinical applications, safety, and practical implementation in benign gynaecology. ICG supports bladder and ureteric identification, cavity integrity checks, and assessment of bowel and ovarian perfusion. It also aids detection of endometriosis lesions, though diagnostic accuracy remains variable. ICG is safe and feasible, with growing evidence supporting its role across a range of procedures. Further research is needed to standardise protocols, assess cost-effectiveness, and support broader adoption in clinical practice.