Facts Views and Vision in ObGyn最新文献

Breast cancer screening by mammography is widely used. The diagnostic accuracy is limited, with a positive predictive value of 16%. Therefore, a stepwise investigation, with repeat mammography and confirmation by pathology, is usually proposed. Although this stepwise investigation intends to avoid overtreatment, the many false positives result in unnecessary fear and diagnostic surgery in many women. The false negatives are not known since these women have not been investigated. Given the estimated low risk of missing breast cancer and the slow growth, repeating a screening mammography every two years is sufficient. The false positive screening results, increase with breast density, and breast density increases when hormone replacement therapy (HRT) is given. It, therefore, is suggested to use clinical judgment and stop HRT for 3 to 6 months before repeating the mammography instead of starting immediately a stepwise investigation in all women.

Background: Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility.

Objectives: Our main objective was to determine a predictive score of uterine extraction feasibility to optimise surgical planning of total hysterectomy. As secondary objectives, we examined the correlation between uterine volume predicted by preoperative ultrasound and the final weight of the surgical specimen and analysed the impact of the uterine extraction modality on operative and hospitalisation times.

Materials and methods: We defined a Uterine Extraction Score (UES) based on the ratio between uterine sizes and vaginal access. This score was retrospectively applied to a cohort of 178 patients who were hysterectomised for benign conditions between January 2019 and December 2022.

Main outcome measures: The UES allows identification of three groups of decreasing feasibility of vaginal extraction, symbolised by traffic light colours: green - vaginal extraction without morcellation, orange -vaginal extraction with morcellation, red - abdominal morcellation by mini-laparotomy or primary laparotomy.

Results: The results show that the UES--predicted, and the observed routes of extraction concord in 92% of cases. There is a strong correlation between estimated volume and final uterine weight. Uterine morcellation lengthens the operative time and the hospital stay.

Conclusions: The UES seems to be a reliable tool to predict the route of uterine extraction in total hysterectomy.

What is new?: The development of a new scoring system empowers surgeons with decisive information to enhance perioperative outcomes.

Background: Our study aimed to create a novel technique using n-butyl cyanoacrylate (n-BCA) for minimal access simulation training on cadavers in deep endometriosis excision.

Objectives: A step-by-step video demonstration of using n-BCA in cadavers to simulate deep endometriosis. This technique is integrated into training sessions using cadavers aimed at enhancing surgical proficiency for deep endometriosis procedures.

Material and methods: Video article describing using n-BCA in cadavers as a simulation model.

Result: This technique has been used in a hands-on cadaveric training course, and positive feedback supports the recommendation to incorporate this technique.

Conclusion: Utilizing a human cadaver model proves beneficial for enhancing understanding of deep pelvic innervation. Implementing n-BCA in these cadaver dissections demonstrates both reproducibility and safety. This approach significantly contributes to refining surgical expertise in the excision of deep infiltrating endometriosis.

Background: The LAparoscopic Versus Abdominal hysterectomy (LAVA) randomised controlled trial comparing laparoscopic hysterectomy (LH) and abdominal hysterectomy (AH) closed prematurely on the grounds of futility. Here we identify the challenges faced and lessons learnt.

Objectives: To explore the views and experiences of clinical/research staff in order to understand how these might act as barriers to trial participation and recruitment.

Materials and methods: Review of the trial progress and collation of the views and experiences of clinical/ research staff on all aspects of the trial. Data were collected from transcribed conversations, email, phone, or video conferencing interactions and analysed descriptively.

Main outcome measures: Site set-up milestones, recruitment rates and reasons provided by clinical/research staff for site's declining to participate. Opinions, preferences and experiences of clinicians/researchers and challenges to participation and recruitment.

Results: The mean time from initial site contact to opening was 253 days and 68 days to randomise their first participant. 265 patients were screened from 13 sites over 13 months, 154 were eligible, and 75 (59%) were randomised. Of the 53 not randomised, 23 (43%) women preferred LH whilst 6 (11%) preferred AH. The main reasons given for failure to recruit or activate set-up in the 21 sites open or in set-up, were lack of research/ clinical capacity imposed by the COVID-19 pandemic and lack of clinician equipoise.

Conclusions: The main reasons for the LAVA trial failure were lack of equipoise amongst surgeons and the adverse impact of the COVID-19 pandemic on clinical/research services.

What is new?: Surgeons' preference for laparoscopic hysterectomy is not shared by most patients. Many patients prefer an open hysterectomy to a laparoscopic one.

Adhesions are a frequent, clinically relevant, and often costly complication of surgery that can develop in any body location regardless of the type of surgical procedure. Adhesions result from surgical trauma inducing inflammatory and coagulation processes and to date cannot be entirely prevented. However, the extent of adhesion formation can be reduced by using good surgical technique and the use of anti-inflammatory drugs, haemostats, and barrier agents. Strategies are needed in the short-, medium- and longer-term to improve the prevention of adhesions. In the short-term, efforts are needed to increase the awareness amongst surgeons and patients about the potential risks and burden of surgically induced adhesions. To aid this in the medium- term, a risk score to identify patients at high risk of adhesion formation is being developed and validated. Furthermore, available potentially preventive measures need to be highlighted. Both clinical and health economic evaluations need to be undertaken to support the broad adoption of such measures. In the longer- term, a greater understanding of the pathogenic processes leading to the formation of adhesions is needed to help identify effective, future treatments to reliably prevent adhesions from forming and lyse existing ones.

Background: Endometriosis is a chronic inflammatory oestrogen-dependent disease. It is characterised by elevated inflammatory markers in the peritoneal milieu with subsequent adhesiogenesis. Nowadays, excisional, and ablative surgeries are considered the main treatment of endometriosis, and adhesiolysis is being performed almost routinely during these procedures. Postoperative adhesion formation is a significant concern for many surgeons, especially as endometriosis patients are assumed to be predisposed to adhesiogenesis. In order to minimise adhesiogenesis after endometriosis surgery, the usage of different barrier methods have been discussed in the literature. Recent studies aim to investigate the effect of potato starch preparations on adhesion formation in endometriosis patients.

Objectives: We aim to describe the findings of a second-look laparoscopy on patients who received a starch-based anti-adhesive agent.

Materials and methods: We present a retrospective case series that included the medical, surgical, and histopathologic data of three patients.

Main outcome measures: Intraperitoneal adhesion formation and peritoneal inflammation.

Results: All three patients had de-novo adhesions during the second-look laparoscopy. Pathological examination revealed noncaseating granulomatosis of the peritoneum in all patients.

Conclusion: The use of potato starch-based agents as a peritoneal adhesion prophylaxis in laparoscopic endometriosis surgery could lead to granulomatous peritoneal inflammation. Correct application by avoiding powder remnants through complete rinsing and transformation to gel seems to be an important factor to avoid this adverse effect.

What is new?: We aim to highlight that potato starch-based anti-adhesive agents similar to the one used in this study could be a cause of adhesiogenesis and peritoneal inflammation.

Background: Knot security of half-knot (H) sequences varies with rotation, but half-knots risk destabilisation.

Objectives: To investigate the rotation of half-hitch (S) sequences on knot security.

Materials and methods: The loop and knot security of symmetrical and asymmetrical sliding and blocking half-hitch sequences was measured using a tensiometer.

Results: Loop security of symmetrical sliding half-hitch sequences is much higher than asymmetrical sequences, increasing from 6+2 to 21+2 and from 27+6 to 48+5 Newton (N) for 2 and 4 half-hitches respectively (both P<0.0001). Symmetrical sliding sequences are more compact and remain in the same plane, squeezing the passive thread, while asymmetrical sequences rotate loosely around the passive end. Blocking sequences are superior when asymmetrical since changing the passive end acts like changing rotation, transforming the asymmetrical sliding into a symmetrical blocking half-hitch on the new passive thread. The knot security of 2 sliding and 1 blocking half-hitch doubles from 52+3 to 98+2 N for the worst (asymmetric sliding and symmetric blocking, SSaSsb) or best rotation sequences (SSsSab). Adding a second asymmetric blocking half-hitch (Sab) increases security further to 105+3 N. The overall knot security of four-throw, correctly rotated, half-hitch (SSsSabSab) or half-knot (H2H1sH1s, H2H2a and H2H2s) sequences is similar for four suture diameters.

Conclusion: Rotation affects the security of half-hitch sequences, which should be symmetrical when sliding, and asymmetrical when blocking.

What is new?: Half-hitch sequences are clinically superior to half-knot sequences. They do not risk destabilisation, and loop security improves approximation of tissues under traction, permitting tight knots.

Background: In 2023, our Centre validated a surgical approach for patients with anterior/apical prolapse associated with severe posterior colpocele, using a laparoscopic posterior vaginal plication (LPP) combined with standard sacral colpopexy (LSC), demonstrating significant benefits in terms of anatomical repair.

Objectives: A step-by-step video demonstration of Laparoscopic Posterior Vaginal Plication (LPP) combined with "two-mesh" Sacral Colpopexy (LSC).

Material and methods: Surgical technique of a LSC with 2 separate meshes is described.

Results: This video-article describes, with a step-by-step approach, a combined prosthetic and fascial laparoscopic technique to treat severe posterior colpocele.

Conclusions: LPP can be considered a feasible procedure during a standard LSC in patients with concomitant severe posterior prolapse.

Xanthogranulomatous endometritis (XGE) is an uncommon inflammatory benign condition that can mimic endometrial cancer. The majority of the reported cases of XGE have been observed in postmenopausal women, often presenting clinically as haematometra or benign senile pyometra. We report a case of XGE in a 73-year-old woman who presented with pyometra. Diagnostic hysteroscopy is an important tool when accompanied by endometrial samples for histology in suspected cases. Knowledge of this uncommon disease is crucial for accurate diagnosis. XGE is a benign condition, however, there have been reported cases of chronic active XGE and bacterial infection in which hysterectomy was required due to complications.

Background: Cavernous haemangiomas are benign vascular tumours that are known to occasionally involve the female genital tract, including the uterus. They are often underdiagnosed during pregnancy, although they can also lead to severe postpartum or antepartum haemorrhage.

Objectives: Describe our case of an uncommon second-trimester pregnancy loss in a woman with a diffuse cavernous haemangioma of the uterus and cervix and review the wider literature.

Methods: The review was conducted using MEDLINE, Scopus and PubMed electronic databases from beginning of the database to May 2023, using the following keywords: arteriovenous malformation; cavernous haemangioma/hemangioma; uterine neoplasms; pregnancy complications; abnormal vaginal bleeding.

Main outcome measures: Description of the characteristics of cavernous haemangioma during pregnancy as well as diagnostic criteria and treatment options.

Results: Twenty publications were included in the review, which included English-language case reports over a period from 1959 to 2022. No pathognomonic symptoms for cavernous haemangioma of the uterus in a pregnant woman were noted. Complications including massive secondary postpartum haemorrhage, haemoperitoneum, and severe thrombocytopenia with anaemia after delivery were reported.

Conclusions: Diagnosis and management during pregnancy can be challenging and requires considerable attention, with a multidisciplinary approach including gynaecologists, radiologists, and pathologists to avoid major complications.

What is new?: An additional case of diffuse cavernous haemangioma of the uterus and cervix is described, that adds to the little existing literature.