Facts Views and Vision in ObGyn最新文献

Background: Various surgical techniques for the treatment of colorectal endometriosis have been described, and the benefit of a preventive stoma remains unclear.

Objectives: The aim of our study is to evaluate the risk of complications in patients who underwent surgery for colorectal endometriosis without a policy of preventive stoma.

Methods: Retrospective cohort study of 97 consecutive patients treated for colorectal endometriosis in an expert centre from January 2022 to January 2024.

Main outcome measures: Complications after colorectal endometriosis surgery in patients without preventive stoma.

Results: Forty-three patients were managed by segmental resection, 20 patients by single-disc excision, 5 patients by double-disc excision and 29 patients by rectal shaving. 48 patients required vaginal suturing. We found complications in 14% of patients. Severe complications (Clavien-Dindo ≥3) were encountered in 8.24% of patients. 3.09% developed a rectovaginal fistula. Patients with a colorectal endometriosis nodule larger than 3 cm had more complications than patients with smaller nodules (57.1% vs. 42.9% of total complications), with a P-value close to the statistical significance.

Conclusions: Surgery for colorectal endometriosis performed in high-volume centres by expert surgeons leads to a reduction in the risk of postoperative complications. In our study, we did not perform routine preventive stoma formation, and we did not find an increase in postoperative complications compared to the literature.

What is new?: This study provides data on the risk of postoperative complications in patients undergoing surgery for colorectal endometriosis without a preventive stoma policy.

Background: The uterus, a complex organ, performs crucial functions including fertilisation, embryonic implantation, and supporting fetal development. Infantile uterus, resembling a prepubescent girl's uterus, and uterine hypoplasia, characterised by a smaller than normal size but with a normal body/cervix ratio, present significant reproductive challenges.

Objectives: This study aims to critically review the existing literature on the infantile uterus and uterine hypoplasia, focusing on the aetiology, clinical features, diagnosis and treatment options.

Methods: A comprehensive narrative review was conducted based on a thorough database search in PubMed, Google Scholar, Scopus, and Web of Science, complemented by cross-referencing relevant articles. Inclusion criteria included studies on the aetiology, clinical features, diagnosis, and treatment of infantile uterus and uterine hypoplasia.

Main outcome measures: Diagnostic criteria based on measurements and therapeutic options.

Results: The review revealed distinct characteristics of infantile uterus and uterine hypoplasia. The infantile uterus has a body/cervix ratio of 1:1 or 1:2, resembling that of a prepubescent girl, while uterine hypoplasia maintains a normal body/cervix ratio of 2:1 but is smaller in size. Diagnostic criteria include a total uterine length of less than 6 cm and specific ultrasound features such as reduced intercornual distance. Therapeutic options include hormonal therapy, particularly oestrogen administration, and surgical interventions aimed at expanding the uterine cavity. Hormonal treatments showed variable effectiveness, primarily beneficial in cases of oestrogen deficiency, while surgical approaches demonstrated some success in enhancing fertility outcomes in women with a hypoplastic uterus.

Conclusions: Infantile uterus and uterine hypoplasia remain poorly understood, with no consensus on their aetiology. Accurate diagnosis relies on specific measurements and body/cervix ratios. Treatment options, including hormonal and surgical interventions, show limited success, indicating a need for further research to optimise management strategies.

What is new?: This review highlights the diagnostic challenges and the limited efficacy of current treatments for infantile uterus and uterine hypoplasia, emphasising the need for standardised diagnostic criteria and further research aiming to elucidate more effective therapeutic approaches.

Background: Dilation and curettage and vacuum aspiration are frequently performed gynaecological procedures used to treat uterine pathology. This procedure carries a risk of uterine perforation, which can lead to injury of abdominal organs and, rarely, to fallopian tubes.

Objectives: To evaluate symptoms and diagnostic signs and to propose the most appropriate management for the intussusception and incarceration of fallopian tubes following uterine aspiration and curettage.

Methods: We screened three major databases (Medline, Scopus, Google Scholar) from 2000 to May 2024. Our review examined tubal incarceration, causes, management, symptoms, parity, diagnosis timelines, visceral injury, and surgical complications. The methodological quality of the included studies was assessed using the JBI Critical Appraisal Checklist for case reports.

Main outcome measures: Diagnostic methods, complications and management of tubal incarceration following uterine perforation.

Results: We identified 24 papers, all of which were case reports or case series. In our analysis, tubal incarceration was observed in 25 of 26 cases (96.2%) and in 2 of which (7.7%) it was associated with the entrapment of the infundibulopelvic ligament. In 1 of 26 cases (3.8%) intussusception of the fallopian tube was observed. The most frequently manifested symptoms were abdominopelvic pain, vaginal bleeding, vaginal discharge and amenorrhoea. The mean time to diagnosis was 15.4 months, with transvaginal ultrasound being the primary diagnostic tool, followed by hysteroscopy and diagnostic laparoscopy.

Conclusions: Diagnosing this condition should involve a detailed medical history, a comprehensive clinical examination, and imaging evaluations. If instrumental investigations are negative but suspicion remains, hysteroscopy and/or laparoscopy may be necessary.

What is new?: Tubal incarceration complicating uterine perforation can be managed using hysteroscopy and laparoscopy.

Background: The complexity of surgical management in women with deep infiltrating endometriosis (DIE) demands the optimisation of perioperative care protocols to ensure optimal postoperative outcomes.

Objectives: This meta-analysis evaluates the effectiveness of Enhanced Recovery After Surgery (ERAS) protocols compared to conventional perioperative care in patients undergoing surgery for DIE.

Methods: A systematic literature search was conducted in Medline, Scopus, Google Scholar, Cochrane CENTRAL, and ClinicalTrials.gov databases from inception till August 2024. Meta-analysis was performed with RevMan 5.4 software (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2020), with mean differences (MDs), pooled risk ratios (RR) and random-effects model. Quality assessment was performed using the Risk of Bias in Non-randomised Studies of Interventions and Risk of Bias tools.

Main outcome measures: Primary outcomes assessed were postoperative length of hospital stay and readmission rates. Secondary outcomes included Clavien-Dindo grade I-II and grade III or higher complication rates.

Results: Four comparative studies were included, encompassing a total of 1,662 patients. ERAS protocols significantly reduced the mean length of hospital stay [MD: -2.88 days; 95% confidence interval (CI): -5.34 to -0.41; P=0.02] without increasing readmission rates (RR: 1.13; 95% CI: 0.75-1.73; P=0.55). No significant differences were observed in Clavien-Dindo grade I-II complications (RR: 0.75; 95% CI: 0.49-1.16; P=0.20) or grade III or higher complications rates (RR: 0.60; 95% CI: 0.27-1.33; P=0.21).

Conclusions: ERAS protocols appear to reduce the length of hospital stay without increasing complications or readmissions in DIE surgery. However, further large-scale randomised studies still needed to be conducted to confirm these findings.

What is new?: The application of ERAS protocols is associated with better postoperative outcomes in patients undergoing major surgeries for DIE.

Background: Pelvic organ prolapse (POP) is a common gynaecological condition that can have an adverse impact on women's quality of life. Apical prolapse refers to the descending of the vaginal apex, uterus or cervix. Nowadays, laparoscopic sacropexy (LS) is the gold standard surgical method for the treatment of apical prolapse. However, defecation and urinary problems are often detected in patients who underwent LS. Laparoscopic pectopexy (LP) is a newer procedure for apical prolapse correction that uses the iliopectineal ligaments as fixation point for the surgical mesh.

Objectives: To review the current evidence of the effectiveness and safety of LP and compare outcomes with other commonly used techniques for apical prolapse treatment.

Methods: A literature search was carried out in MEDLINE, PubMed and ClinicalTrials.gov databases. The search was restricted to humans, female patients and currently used surgical procedures.

Main outcome measures: The current recommendations from leading global scientific associations and prevailing trends in accepted clinical protocols.

Results: LP was found to have shorter learning curve and operating times, better improvement in quality of life scores including sexual function and low complication rates.

Conclusions: LP appears to be a viable alternative to LS. However, further prospective, comparative studies are necessary to evaluate its long-term effectiveness and morbidity.

What is new?: This review summarises the evidence and current role of LP in the treatment of POP.

Background: Hysterectomy is a common surgical procedure in gynaecology, performed through abdominal, vaginal, and laparoscopic techniques. The vaginal route is typically preferred for benign conditions like fibroids, adenomyosis, and uterine prolapse due to shorter operative time, faster recovery, reduced pain, and fewer complications. In cases where the uterus is large or vaginal access is restricted, a laparoscopic approach may be necessary. A minimally invasive alternative, Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES), allows hysterectomy via vaginal access using a combination of endoscopic and laparoscopic techniques.

Objectives: To evaluate if sexual quality of life (sQoL) is impaired by using vNOTES for hysterectomy compared to conventional laparoscopy in benign gynaecology.

Methods: A retrospective monocentric study. One hundred and twenty seven patients were included in the study. Of these, 91 underwent TLH and 36 vNOTES hysterectomies between September 2020 and October 2022 at Brugmann University Hospital.

Main outcome measures: This study compares sQoL after hysterectomy performed via conventional laparoscopy versus vNOTES for benign gynecological conditions.

Results: Regarding surgical characteristics, there were no differences between the two groups in terms of operative time, drop in blood haemoglobin levels and days of hospitalisation. Arousal and Orgasm scores are improved post-operatively in patients suffering from adenomyosis (4.47 vs. 3.91 P 0.04 for arousal and 5.07 vs. 4.26, P 0.016 for orgasm).

Conclusions: The vNOTES method shows shorter hospital stay and faster re-introduction to sexual life over conventional laparoscopy for total hysterectomy in patients with benign gynaecology.

What is new: Our study shows that in patients suffering from adenomyosis, sQoL improved after hysterectomy using the vNOTES approach.

Background: The presence of complete uterine septum, cervical septum and longitudinal vaginal septum (class U2bC1V1 according European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy classification) is a rare congenital anomaly of the female genital tract. The diagnosis of this anomaly is very challenging, significantly influencing the type of treatment to be performed.

Objectives: We propose a one-stop diagnosis through the combined use of 2D-3D ultrasound (US) and hysteroscopy and the minimally invasive endoscopic treatment of this anomaly, emphasising the diagnostic and therapeutic differences compared to U2bC2V1 anomaly.

Participant: Stepwise demonstration with video footage of an integrated approach in the management of a patient with a class U2bC1V1 anomaly. The patient was 23 years old and presented with dyspareunia and a previous miscarriage. We performed a one-stop diagnosis through the combined use of diagnostic hysteroscopy and 2D-3D pelvic US and a minimally invasive endoscopic treatment with a 15Fr bipolar miniresectoscope.

Intervention: Hysteroscopic control performed 40 days after the procedure showed a regular vagina, a normal single cervix and a normal uterine cavity. No intra- or postoperative complications occurred. The patient was discharged 3 hours after the procedure. The total operation time was 24 minutes.

Conclusions: Making an accurate diagnosis of a single cervix with cervical septum and a double cervix is crucial in the management of patients with complex genital anomalies. An accurate diagnosis is possible when combining hysteroscopy and US. Minimally invasive endoscopic treatment of U2bC1V1 anomaly with a 15 Fr bipolar miniresectoscope is an effective and safe procedure, easier when compared to the treatment of U2bC2V1 anomaly.

What is new?: This video article describes the hysteroscopic criteria for the differential diagnosis between single cervix with cervical septum and double cervix.

Submucosal uterine fibroids are the rarest type of fibroids. They can lead to abnormal uterine bleeding and may play a role in infertility and miscarriage. Hysteroscopic myomectomy is the preferred treatment to relieve bleeding caused by these fibroids and to restore the normal structure of the uterine cavity. The European Society for Gynaecological Endoscopy Uterine Fibroids Working Group developed recommendations based on the best available evidence and expert opinion for the surgical treatment of uterine fibroids. In this second part of the recommendations, hysteroscopic approaches are described. This review explores the techniques related to hysteroscopic myomectomy, focusing on narrower scopes, fluid management and advances in tissue removal systems and electrosurgery.

This is the case of a 30-year-old nulliparous patient with a complete uterine septum, double cervix and non- obstructive longitudinal vaginal septum (Class U2bC2V1 according to the ESHRE/ESGE classification). The patient presented with severe dyspareunia and dysmenorrhea. Imaging revealed a complex Müllerian anomaly and hysteroscopic treatment was agreed. We present an approach of hysteroscopic metroplasty after insertion of a Foley catheter balloon in one uterine hemi-cavity, which serves as a guide for septum resection using a resectoscope in the contralateral hemi-cavity. No complications were encountered. The patient was discharged after a short period of observation. A post-operative evaluation revealed complete resection of the vaginal septum and the formation of a single, normal uterine cavity.