Facts Views and Vision in ObGyn最新文献

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.

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.