Facts Views and Vision in ObGyn最新文献

Background: Rectovaginal/colorectal endometriosis is severe form of endometriosis requiring complex surgery, where pre-operative gonadotrophin releasing hormone agonists (GnRHa) are used to improve the surgical outcomes but the evidence supporting this is limited.

Objectives: To evaluate the association between pre-operative use of GnRHa and perioperative and postoperative complications in patients undergoing surgery for rectovaginal or colorectal endometriosis.

Methods: We analysed prospectively collected data from British Society for Gynaecological Endoscopy-accredited endometriosis centres between 2009 and 2021. Multivariable logistic regression analysis was performed to model the odds of each complication by pre-operative GnRHa use, controlling for patient age, body mass index, smoking status, whether a hysterectomy was performed, history of previous endometriosis surgery and surgical complexity.

Main outcome measures: The association of GnRHa use with perioperative and postoperative complications.

Results: We included 9,433 patients aged 18-55 years from 101 specialist endometriosis centres from six countries including UK, USA, Sri Lanka, Saudi Arabia, Turkey and Iran. Patients receiving pre-operative GnRHa were associated with higher rate of perioperative complications [odds ratio (OR): 1.31, 95% confidence interval (CI): 1.08-1.59, P=0.007], late complications (OR: 1.477, 95% CI: 1.15-1.9, P=0.002) and pelvic haematoma (OR: 2.251, 95% CI: 1.41-3.64, P<0.001). After controlling for confounding factors, GnRHa use remained significantly associated with colostomy (aOR: 4.05: 95% CI: 1.51-12.7, P=<0.001] pelvic haematoma (aOR: 3.08, 95% CI: 1.72-5.75, P<0.001) and abscess (aOR: 2.25, 95% CI: 1.10-4.79, P=0.029). Health related quality of life (HR-QOL) improved in the Pre-GnRHa group at 12 months and 24 months (mean difference 2.09/100, 95% CI, 0.27-3.92, P=0.025) and (mean difference 2.85/100, 95% CI 0.55-5.16, P=0.015).

Conclusions: Pre-operative use of GnRHa has been associated with a higher incidence of perioperative and late complications, including significantly increased odds of colostomy, pelvic hematoma and abcess formation. There is need of careful patient counselling and further prospective research to clarify the pre-operative use of GnRHa in rectovaginal/colorectal endometriosis.

What is new?: There is need of caution use of pre-operative GnRHa in deep rectovaginal/colorectal endometriosis surgery due to increased association of the risks of complications such as colostomy, pelvic haematoma and abcess. Despite long-term improvement in HR-QOL, there is need for careful patient selection and counselling.

Background: Endometrioid adenocarcinoma is a common endometrial cancer, linked to excess oestrogen exposure. Obesity, a major risk factor, can lead to unopposed oestrogen and endometrial cancer. Surgery is the standard treatment for early-stage disease. However, obese patients with a high body mass index (BMI) may be unsuitable due to surgical risks.

Objectives: We present a novel completely endoscopic technique for placing a levonorgestrel-releasing intrauterine system (LNG-IUS) in an obese patient with early-stage endometrioid adenocarcinoma (FIGO 2009 stage IA, grade 1) who was not a surgical candidate due to multiple comorbidities.

Participant: An 82-year-old obese woman (BMI: 48.9 kg/m²) with abnormal uterine bleeding was referred to our gynaecological department. Endometrial thickening, without spread beyond the uterus, was observed by transvaginal ultrasound and magnetic resonance imaging, and final diagnosis of early stage endometrioid adenocarcinoma was confirmed by hysteroscopic endometrial biopsy. Due to her high-risk status and anatomical challenges, initial management involved oral medication and regular biopsies. After a year of presence of a stable disease, a new technique for LNG-IUS placement was attempted.

Intervention: The LNG-IUS was successfully placed within the uterine cavity using a 5 mm XL Bettocchi hysteroscope and a 5 Fr grasping forceps, without needing vaginal speculum or cervical grasping. The patient tolerated the procedure well. Follow-up at six months was negative, without signs of recurrence.

Conclusions: This case demonstrates the feasibility and safety of a total endoscopic LNG-IUS placement as an alternative for obese patients with early-stage endometrioid adenocarcinoma who are not surgical candidates.

What is new?: This is the first description of a total endoscopic technique for LNG-IUS placement performed without speculum or anesthesia.

Background: Caesarean scar pregnancy (CSP) is a pathologic entity with rising incidence over recent years. So far, there are many treatment methods and protocols suggesting surgical or medical interventions and their combinations. More and more laparoscopic surgery is applied to treat scar pregnancy with excellent results. A proper surgical strategy is a key point for optimal surgical outcome.

Objectives: To present a standardised technique for the laparoscopic management of CSP.

Participant: Patients with CSP having the indication of laparoscopic treatment.

Intervention: The video presents a systematic approach of the laparoscopic treatment of CSP clearly divided into 10 steps: 1. Prepare the surgery; 2. Inspection of the pelvis; 3. Bladder dissection; 4. Preventive haemostasis; 5. Hysterotomy; 6. Evacuation of conception products; 7. Excision of niche scar tissue; 8. Evacuation of the uterine cavity; 9. Suturing of the uterine defect; 10. Removal of the uterine artery clips. The main outcome measures are the efficacy of the laparoscopic management of CSP and the postoperative uterine reconstruction in terms of ultrasonic measurement of the isthmic myometrial layer thickness. Patients are released from the hospital the day after the surgery, and a follow-up ultrasound is scheduled three months post-operatively. In the case presented in the video, the myometrial wall is increased from 3 mm preoperatively to 13 mm three months postoperatively.

Conclusions: The main advantage of this technique is the ability to treat CSP, remove the uterine isthmocele, and reconstruct the lower uterine segment simultaneously. The 10 steps proposed in a logical sequence may shorten the surgery's learning curve and reduce possible complications.

What is new?: We present a systematic approach that provides a safe and easily reproducible technique for managing CSP.

Background: Uterine-preserving procedures for pelvic organ prolapse (POP) are favoured and are becoming increasingly popular. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) presacral-uterosacral hysteropexy is a novel native tissue repair for POP.

Objectives: This study aimed to evaluate the safety of this uterine-preserving procedure and its midterm efficacy in treating POP.

Methods: Between December 2020 and December 2022, patients with symptomatic POP who underwent vNOTES presacral-uterosacral hysteropexy at a tertiary teaching hospital were retrospectively analysed. The patient characteristics, follow-up outcomes, and complications were recorded and analysed.

Main outcomes measures: We investigated anatomical success, subjective improvement, perioperative parameters, and operative complications.

Results: Fifty-eight patients (median age 41 years) completed a mean 24.4-month (± 6.8) follow-up. There were two women (3.4%) who experienced recurrence. There was a significant improvement in POP-Q scores in all compartments at the last follow-up compared to the baseline (P<0.001). 94.8% of patients were satisfied with their operations. The urinary and prolapse symptoms improved significantly (P<0.001), and sexual function was significantly improved (P<0.001). There were no intraoperative complications, and one patient experienced fever and delayed haemorrhage after surgery.

Conclusions: vNOTES presacral-uterosacral hysteropexy may be a safe and feasible technique for women with POP who desire to preserve their uterus. This procedure demonstrates promising medium-term anatomical and subjective outcomes in treating POP.

What is new?: This is a new mesh-free surgical procedure that combines the benefits of laparoscopic sacrohysteropexy and vNOTES uterosacral ligament hysteropexy to treat women with POP who desire uterine preservation, aiming to gain long-term anatomical success and minor complications.

Background: Modern minimally invasive gynaecological surgery greatly contributes to women's health; however, it can be physically demanding for surgeons. A plethora of available data shows that the optimisation of ergonomics in the operating room (OR) is crucial for the health and efficiency of surgeons.

Objectives: To provide an overview of the importance of ergonomics and clinically useful, concise recommendations.

Methods: A literature review with critical analysis of available data.

Main outcome measures: Impact of ergonomics on the prevalence of musculoskeletal disorders (MSDs), fatigue levels, efficiency and subjective comfort among surgeons.

Results: Evidence suggests that MSDs are highly prevalent among minimally invasive gynaecological surgeons and that several ergonomic interventions can greatly reduce muscle strain and improve clinical practice, with the most important being the planning of brief intraoperative breaks, the selection of proper laparoscopic instruments and the positioning of the operating table and monitor at the correct height. The adoption of robotic surgery can also improve surgical ergonomics. Clinical practice recommendations for ergonomic improvement in gynaecological laparoscopy based on the existing evidence are provided.

Conclusions: Surgeons must be aware of the optimal ergonomic settings in the OR and impose measures to reduce risks and achieve a comfortable environment.

What is new?: A comprehensive, praxis-oriented review with exact ergonomic advice for minimally invasive gynaecological surgeons.

Background: Several new robotic platforms are being commercialised, with different features in terms of types of consoles, numbers of arms, and targeting transabdominal or natural orifice approaches. The benefits of robotic surgery over laparoscopy have yet to be conclusively demonstrated in gynaecology, as several studies comparing perioperative and postoperative patient outcomes have reported no significant differences, leading to a lack of precise recommendations in surgical guidelines for both gynaecologic oncology and benign gynaecology. In addition, these outcomes must be balanced against the high costs of robotic surgery, in particular when considering building an infrastructure for safe telesurgery to democratise access to telementoring and remote interventions.

Objectives: Drawing from the expertise gained at the IRCAD Research and Training Center in Strasbourg, France, this article aims to provide an overview of the unveiled benefits of robotic-assisted surgery in gynaecology, investigating the role of digital surgery integration.

Methods: The objective of this narrative review is to provide an overview of the latest advancement in digital robotic-assisted surgery in gynaecology and illustrate the benefits of this approach related to the easiest integration with new technologies. To illustrate such evidence, PubMed, Google Scholar, and Scopus databases were searched.

Main outcome measures: In the era of surgical innovation and digital surgery, the potential of robotic surgery becomes apparent through the capacity to integrate new technologies. Image-guided surgery techniques, including the analysis of preoperative and intraoperative images, 3D reconstructions and their use for virtual and augmented reality, and the availability of drop-in robotic ultrasound probes, can help to enhance the quality, efficacy and safety of surgical procedures.

Results: The integration of artificial intelligence, particularly computer vision analysis of surgical workflows, is put forward to further reduce complications, enhance safety, and improve operating room efficiency. Additionally, new large language models can assist during procedures by providing patient history and aiding in decision-making. The education and training of young surgeons will undergo radical transformations with robotic surgery, with telementoring and shared procedures in the side-by-side double-console setup.

Conclusions: Robotic systems play a fundamental role in the transition towards digital surgery, aiming to improve patient care through integration of such new technologies.

What is new?: While the advantages of robotic surgery in terms of perioperative outcomes have yet to be demonstrated, the benefits of its easiest integration with new technologies are evident.

Background: Total laparoscopic hysterectomy (TLH) is associated with reduced post-operative pain and enhanced recovery, allowing same-day discharge (SDD). However, adoption of SDD TLH is not established, and practice varies.

Objectives: To conduct a national survey of UK gynaecologists with an interest in laparoscopic surgery to obtain their views, opinions and experience of SDD TLH.

Methods: Members of the British Society for Gynaecological Endoscopy were invited to complete an online questionnaire between January 2023 and January 2024.

Main outcome measures: The questionnaire consisted of 16 questions about SDD TLH covering three domains: (i) service provision, (ii) prognostic variables and (iii) information giving and education.

Results: One hundred and forty-eight clinicians from 148/215 NHS hospitals (69%) responded. One hundred and thirty one (89%) respondents thought that SDD following TLH was beneficial, and 48 (32%) hospitals had an established service. Adequate pain control was considered the most important factor to achieve SDD TLH, followed by control of nausea and vomiting. Seventy-eight (53%) respondents removed the urinary catheter at the end of the procedure. All respondents believed that managing patients' expectations was important to achieve compliance with SDD and 123 (83%) thought that developing an online preadmission patient information resource was needed.

Conclusions: One third of UK NHS hospitals have a SDD TLH service but there is variation in availability and protocols (pre-, peri- and post-operative management). These data can help develop health service strategy to promote SDD after TLH and standardise protocols.

What is new?: The survey quantifies and demonstrates hospital-level variation in uptake and practice of SDD provision after TLH.

Leiomyosarcomas (LMS) arise from smooth muscle and represents only 6% of all sarcomas. LMS originating from major blood vessels, called vascular LMS, are detected mostly in the inferior vena cava. Arterial LMS are a rarity. We present a 43-year-old patient with a LMS arising from the left external iliac artery. The patient was referred to us with symptoms of left lower abdominal pain extending to the left limb and underwent a contrast computed tomography which suggested a suspicious mass near the left iliac vessels. She underwent laparoscopic excision of the tumour, whose histological examination revealed an LMS G2 arising from the external iliac artery. Immunohistochemically CD34, p53, Desmin, as well as smooth muscle actin, tested positive.

Background: Caesarean scar pregnancy (CSP) is an uncommon complication in women with prior caesarean deliveries. Treatment options include both medical and surgical approaches, but there is no consensus on definitive management.

Objectives: We propose a step-by-step video demonstration of a conservative approach for CSP, using hysteroscopic treatment with tissue removal device (TRD) after uterine artery embolisation (UAE).

Participant: A 34-year-old woman with two previous caesarean deliveries was diagnosed with a CSP involving an 8-week embryo implanted in the isthmocele. Initial management consisted of UAE performed at another hospital. The patient was then referred to the Digital Hysteroscopic Clinic, CLASS Hysteroscopy of Policlinico Gemelli in Rome, for hysteroscopic removal of residual trophoblastic tissue.

Intervention: Safety and effectiveness of a novel conservative CSP management, involving TRD following UAE. Preoperative assessment, combining transvaginal ultrasound and diagnostic hysteroscopy, revealed trophoblastic remnants inside the uterine niche with an extremely thin myometrial margin. The procedure was performed under general anaesthesia, according to an ambulatory model of care. A TRD with a soft tissue blade was used for the complete removal of the lesion.

Conclusions: This video article suggests that TRD hysteroscopic treatment after UAE is a safe and effective approach for CSP. This conservative management minimises the risk of complications such as bleeding and uterine perforation. Additionally, the TRD avoids the use of electrosurgery, potentially reducing the incidence of subsequent intrauterine adhesions. Further studies are needed to confirm these results in the long term.

What is new?: This is the first reported case of conservative CSP management combining UAE with hysteroscopic resection using a TRD.