Does viewing of surgical specimen improve patient satisfaction? A cohort study

The purpose of this study was to assess a cohort of patients who underwent elective gynecologic surgery to determine whether viewing of intraoperative photographic images by patients played a role in patient satisfaction. Three hundred and eighteen patients participated in this study, out of which 159 patients were assigned to view the operative photographic pictures and 159 were not. According to the results obtained in this study, a greater number of women who viewed their operative photographic pictures, expressed satisfaction in comparison to those who did not. In addition, this difference was significantly greater in those who encountered intra- and/or postoperative complications.

A diagnostically challenging case of ureterovaginal fistula after laparoscopic hysterectomy

A complicated case of iatrogenic ureterovaginal fistula in a 56-year-old woman after laparoscopic-assisted vaginal hysterectomy, which persisted after several attempts of repair including ureterocystoneostomy, is presented. Accurate radiologic work-up enabled us to identify a refluxing ureteral stump, which was not ligated at the time of ureterocystoneostomy, as the origin of urinary leakage. Surgical principles that should be adhered to when managing such complex cases to obtain successful long-lasting outcome are described.

Identifying risk factors for uterine rupture

Uterine rupture, whether in the setting of a prior uterine incision or in an unscarred uterus, is an obstetric emergency with potentially catastrophic consequences for both mother and child. Numerous studies have been published regarding various risk factors associated with uterine rupture. Despite the mounting data regarding both antepartum and intrapartum factors, it currently is impossible to predict in whom a uterine rupture will occur. This article reviews the data regarding these antepartum and intrapartum predictors for uterine rupture. The author hopes that the information presented in this article will help clinicians assess an individual's risk for uterine rupture.

Inflammatory status influences aromatase and steroid receptor expression in endometriosis

Aberrant up-regulation of aromatase in eutopic endometrium and implants from women with endometriosis has been reported. Aromatase induction may be mediated by increased cyclooxygenase-2 (COX-2). Recently, we demonstrated that progesterone receptor (PR)-A and PR-B serve an antiinflammatory role in the uterus by antagonizing nuclear factor kappaB activation and COX-2 expression. PR-C, which antagonizes PR-B, is up-regulated by inflammation. Although estrogen receptor alpha (ERalpha) is implicated in endometriosis, an antiinflammatory role of ERbeta has been suggested. We examined stage-specific expression of aromatase, COX-2, ER, and PR isoform expression in eutopic endometrium, implants, peritoneum, and endometrioma samples from endometriosis patients. Endometrial and peritoneal biopsies were obtained from unaffected women and those with fibroids. Aromatase expression in eutopic endometrium from endometriosis patients was significantly increased compared with controls. Aromatase expression in endometriosis implants was markedly increased compared with eutopic endometrium. Aromatase mRNA levels were increased significantly in red implants relative to black implants and endometrioma cyst capsule. Moreover, COX-2 expression was increased in implants and in eutopic endometrium of women with endometriosis as compared with control endometrium. As observed for aromatase mRNA, the highest levels of COX-2 mRNA were found in red implants. The ratio of ERbeta/ERalpha mRNA was significantly elevated in endometriomas compared with endometriosis implants and eutopic endometrium. Expression of PR-C mRNA relative to PR-A and PR-B mRNA was significantly increased in endometriomas compared with eutopic and control endometrium. PR-A protein was barely detectable in endometriomas. Thus, whereas PR-C may enhance disease progression, up-regulation of ERbeta may play an antiinflammatory and opposing role.

The effect of oral contraceptives on aromatase expression in the eutopic endometrium of patients with endometriosis

OBJECTIVE

To determine the effect of oral contraceptives containing gestodene on aromatase expression in the endometrium of patients diagnosed with endometriosis.

PATIENTS AND METHODS

Endometrial biopsies were taken at the time of laparoscopy in 40 patients with endometriosis, 16 of whom were using an oral contraceptive containing gestodene at the time of laparoscopy. The remaining 24 patients were receiving no form of treatment for endometriosis. Endometrial biopsies taken from 23 patients with normal echographic signs and no symptoms were used as controls. Aromatase expression was evaluated in endometrial samples using immunohistochemistry.

RESULTS

In the untreated, symptomatic endometriosis patients, aromatase expression was detected during the proliferative phase in 92% of cases, while in the symptom-free control patients aromatase was expressed in only 9% of cases. In patients with endometriosis who were using oral contraceptives, there were significantly fewer cases of positive endometria compared with the untreated patients with endometriosis (6%).

CONCLUSION

Oral contraceptives containing gestodene are effective in decreasing aromatase expression in the eutopic endometrium of patients with endometriosis.

[Paraumbilical block for strangulated umbilical hernia in emergency]

The authors describe a strangulated umbilical hernia surgery performed in emergency with a paraumbilical block associated with a local infiltration. For this patient, 3-4 ASA status, in occlusion, with iterative vomiting and coagulation disorders, general or spinal anaesthesia were high-risk technics. Paraumbilical block, sometimes used for anaesthesia or/and analgesia for programmed umbilical hernia surgery, allowed surgery with good conditions and procured prolonged postoperative analgesia. This block, easy to perform, is an interesting alternative in emergency for general or spinal anaesthesia in high-risk patients.

Prospective, case–control study of surgical efficiency of ultrasonic shear (‘harmonic scalpel’) thyroidectomy compared with conventional thyroidectomy

Objectives and hypothesis:

To evaluate the efficacy of ultrasonic shear (‘harmonic scalpel’) thyroidectomy, compared with conventional thyroidectomy.

Study design:

Prospective, case–control comparison.

Methods:

Twenty-three consecutive patients were recruited over an eight-month period. Patients were divided into two groups according to their thyroidectomy technique, i.e. ultrasonic shear technique (harmonic scalpel) vs conventional technique (scalpel and bipolar diathermy). Surgical time, thyroidectomy type and thyroid specimen weight were recorded by theatre nursing staff. The ratio of surgical time to specimen weight, in minutes per gram, was used to measure surgical efficiency. The unpaired Student's t-test was used for statistical analysis.

Results:

The mean surgical time per specimen unit weight was 2.56 min/g for harmonic scalpel thyroidectomy and 5.99 min/g for conventional thyroidectomy. This difference was statistically significant (p = 0.037). The difference was most evident for procedures involving smaller thyroid glands.

Conclusions:

Our study suggests that thyroidectomy using a harmonic scalpel is more time-efficient than conventional thyroidectomy, especially when operating on smaller thyroid glands.

Use of the SF-36 questionnaire to predict quality-of-life improvement after laparoscopic colorectal resection for endometriosis

BACKGROUND

Laparoscopic colorectal resection for endometriosis can improve quality of life (QOL), but the results vary widely from one woman to another. The aim of this study was to determine whether the preoperative results on the Physical Component Summary (PCS) and Mental Component Summary (MCS) subscales of the SF-36 questionnaire could predict the improvement in QOL after surgery.

METHODS

The predictive value of the subscales was first evaluated on a training set of 57 patients. A mathematical model, quantified with respect to discrimination and calibration was then applied to the validation set of 36 patients.

RESULTS

Women with preoperative PCS and MCS scores below 37.5 and 44.5, respectively, had 80.7% and 84.2% probabilities of seeing their scores improve after surgery, whereas women with preoperative scores above 46.5 and 47.5, respectively, had probabilities of 0% and 10.7% to improve their scores.

CONCLUSIONS

With our mathematical model, the postoperative improvement in QOL can be reliably predicted. This model should help to identify those women who are most likely to benefit from this major surgery.

Laparoscopic management of uterine prolapse with cystocele and rectocele using "Gynemesh PS"

OBJECTIVE

Our department performed laparoscopic correction of uterine or vault prolapse with cystocele and rectocele using the "Gynemesh PS." The aim of this study was to evaluate the surgical outcomes and perioperative morbidity after a laparoscopic operation.

MATERIALS AND METHODS

From August 2004 to September 2005, we performed laparoscopic pelvic floor repairs in 6 cases of vault prolapse and 15 cases of uterine prolapse at the Department of Obstetrics and Gynecology at the Kyungpook National University Hospital (Daegu, Korea). Uterine and vault prolapse were repaired by laparoscopic rectocele and cystocele repair using the Gynemesh PS, uterosacral ligament suspension, paravaginal repair, and Burch colposuspension. In uterine prolapse, we also carried out a subtotal hysterectomy. The stage of prolapse was classified by means of the pelvic organ prolapse quantification (POPQ) system.

RESULTS

The mean age, Q-index, and parity were 64 years (range, 47-79), 24.6 (range, 18.7 approximately 27.8), and 5 (range, 3 approximately 10), respectively. Mean operation time was 141 minutes (range, 90 approximately 211). Mean estimated blood loss was 53 mL (range, 20 approximately 80). Mean hospital stay was 5 days (range, 3 approximately 9 days). There were no major complications, but postoperative voiding difficulty developed in 1 case. Mean preoperative POPQ stage was 3 and immediate, 6-week, 3-month, 6-month, and 1-year postoperative POPQ score was 0. Mean follow-up period was 7.5 months (range, 3 approximately 13). The objective success rate was 100%.

CONCLUSIONS

Laparoscopic pelvic floor repair is an effective procedure and enables us to combine the advantages of laparotomy with the low morbidity of the vaginal route. In Europe, the sacrocolpopexy was more popular, but uterosacral ligament suspension is the most natural anatomic repair of defects and, hence, the least likely to be predisposed to future defects in the anterior or posterior vaginal wall or to compromise vaginal function. However, further studies are required on the long-term efficiency and reliability in order to evaluate the value of this technique.

Acquisition of laparoscopic surgical skills in a district general hospital

Minimal access surgery (MAS) has become an essential skill in contemporary gynaecological surgical practice. This survey was carried out to assess the current state of basic laparoscopic surgical training in a District Hospital setting. Potential areas of improvement were identified for increasing trainees' experience. It is hoped that this survey, albeit in a single unit, may reflect experiences in other units and thus encourage further discussion and analysis in this important component of training.

Sonography of endometriosis in infrequent sites

We reviewed the sonographic features of endometriosis in infrequent sites, including the abdominal wall, appendix, perineum, and bladder. Familiarity with the clinical setting and the sonographic appearance of endometriosis in both frequent and infrequent sites can help facilitate prompt, accurate diagnosis and treatment.

Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies

OBJECTIVE

1) To investigate the relationship between operator experience and the success of outpatient hysteroscopy; and 2) to determine if the introduction of normal saline and the use of narrow-caliber hysteroscopes and vaginoscopic approach are associated with a lower failure rate.

DESIGN

Retrospective study.

SETTING

Teaching-hospital based outpatient hysteroscopy clinic.

PATIENT(S)

Five thousand consecutive women undergoing outpatient hysteroscopy between October 1988 and June 2003.

INTERVENTION(S)

The hysteroscopies were carried out both by experienced operators and by trainees. Procedures were performed using 4-mm and 2.9-mm telescopes with 5-mm and 3.5-mm diagnostic sheaths, respectively. Between October 1988 and 1996, the uterine cavity was distended with CO(2) (CO(2) period), whereas normal saline was preferred after 1997 (1997-2003: saline period). Traditional technique of hysteroscope insertion and vaginoscopic approach were used depending on operator preference and experience and patient characteristics.

MAIN OUTCOME MEASURE(S)

Success, failure, and complication rates.

RESULT(S)

The hysteroscopies were successfully performed in nearly 95% of cases by 362 operators (mean 13.8 hysteroscopies per operator) with different levels of expertise. Failure and complication rates were 5.2% and 5.4%, respectively, without any significant difference between CO(2) and saline periods. Vasovagal attacks and shoulder pain were significantly higher during the CO(2) period. The success of outpatient hysteroscopy was negatively affected by postmenopausal status, nulliparity, need for cervical dilatation or local anaesthesia, traditional technique of hysteroscope insertion, and use of a 5-mm hysteroscope.

CONCLUSION(S)

A high level of expertise is not a prerequisite to performing hysteroscopy on an outpatient basis. Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the wider gynecology community.

A aplicação de adesivo de cianoacrilato por histeroscopia e os testes de perviedade na esterilização tubária de ovelhas

OBJETIVO: avaliar, por meio de testes de prenhez e de perviedade, a eficácia da obstrução tubária de ovelhas com adesivo de cianoacrilato aplicado por via histeroscópica. MÉTODO: 12 ovelhas adultas, com uma gestação anterior, foram distribuídas em três grupos: G-PO (n=3) submetidas à laqueadura tubária tipo Pomeroy; G-SH (n=3) aplicação de solução salina no istmo tubário por histeroscopia, e G-AD (n=6) aplicação de 0,5mL de n-butil-2-cianoacrilato no interior do istmo tubário, por histeroscopia. Depois de acasaladas por 90 dias com machos de comprovada fertilidade, as ovelhas não prenhas foram submetidas à laparotomia, retiradas as tubas uterinas, medidos os seus diâmetros e preparadas para testes de perviedade pela aplicação de azul de metileno e de pressão hidráulica (80mmHg). RESULTADOS: As ovelhas de G-PO e G-AD não ficaram prenhas (0%), em contraste com as SH (100%). O G-PO apresentou maior concentração de aderências (66,6%) e de granulomas (100%) em relação ao grupo AD (0%); o adesivo manteve-se íntegro no lúmen tubário. O diâmetro da tuba uterina em G-AD (0,650 ± 0,16 cm) foi significantemente maior do que o das tubas em G-PO (0,195 ± 0,04* cm) (p=0,01). Os testes de perviedade de pressão e corante foram negativos para todo o grupo PO e somente um animal em AD mostrou-se positivo para o teste de pressão. CONCLUSÃO: a aplicação histeroscópica de cianoacrilato no lúmen tubário de ovelhas impediu eficientemente a fecundação, constituindo procedimento eficaz e de boas perspectivas para aplicação futura em humanos.

Laparoscopically assisted versus open surgery for endometrial cancer--a meta-analysis of randomized controlled trials

There is no clear consensus on the advantages of laparoscopically assisted surgery (LAS) versus open surgery (OS) for endometrial cancer. The present study compared LAS versus OS for patients with endometrial cancer with regard to operative parameters and outcomes. A search of the PubMed, EMBASE, the China Biological Medicine Datadase (CBMdisc), Ovid, and the Cochrane Library identified four studies that met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random effects models. The effect was calculated as an odds ratio (OR) or weighted mean difference (WMD) with 95% confidence intervals (CIs). Level of significance was set at P < 0.05. Outcomes of 331 patients were studied. When randomized controlled trials were analyzed, OR for LAS was 0.34 (95% CI: 0.13, 0.89; P = 0.03) for postoperative complications and 0.14 (95% CI: 0.05, 0.39; P = 0.0002) for incidence of transfusion; and WMD for LAS was 263.58 mL (95% CI: 467.71, 59.45 mL; P = 0.01) for blood loss, 38.09 min (95% CI: 10.50, 65.68 min; P = 0.007) for operation time, and 3.35 days (95% CI: 3.84, 2.86 days; P < 0.00001) for hospital stay. There was no difference in patients in terms of recurrence and survival. The present study has shown that LAS was associated with fewer postoperative complications, lower incidence of transfusion, less blood loss, longer operation time, and shorter hospital stay. What's more, no significant difference was found in terms of recurrence and survival. When performed by suitably specialized surgeons in selected patients, it appears to be a better choice than OS.

Effect of laparoscopic hysterectomy on the vascularization of the lower urinary tract

INTRODUCTION

The aim of this prospective study was to evaluate the changes in the vascularization of the lower urinary tract following laparoscopic hysterectomy (LH).

METHODS

Seventy women undergoing LH not under the indication of a uterine myoma were included. All subjects underwent urinalysis, pelvic examination, and introital color Doppler ultrasonography and completed a urinary questionnaire before and 6 months after LH. One-hour pad tests and urodynamic studies were performed in clinically incontinent women pre- and postoperatively.

RESULTS

Evaluation of the Doppler velocimetric parameters of bladder neck and periurethral vessels before and after LH, including number of vessels, pulsatility index, systolic peak, and minimum diastole, revealed no statistically significant differences (p > 0.05). In addition, the prevalence of stress urinary incontinence (SUI) decreased significantly from 37.1% (n = 26) preoperatively to 17.1% (n = 12) postoperatively (p < 0.01). A total of 19 patients reported no further SUI following LH. Their urinary leakages on the pad tests had all <10 g before surgery. When we analyzed the data of the women reporting no further SUI (n = 19) and de novo SUI (n = 5) following LH, the changes in the pulsatility index also showed no significant difference from the pre-LH values (p > 0.05).

CONCLUSIONS

The results of our study suggest that LH has little impact on the blood flow of bladder neck and urethra. Although some women experienced relief of the symptoms of mild or de novo SUI after LH, this being unrelated to changes in the vascularization of the lower urinary tract.

Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design

OBJECTIVE

To compare the impact of 1000 micrograms of self-administered vaginal misoprostol versus self-administered vaginal placebo at home on preoperative cervical ripening in both premenopausal and postmenopausal women before operative hysteroscopy.

DESIGN

Two separate but identical parallel, randomised, double-blind, placebo-controlled sequential trials, one in premenopausal women and one in postmenopausal women. The boundaries for the sequential trials were calculated on the primary outcomes of a difference of cervical dilatation > or = 1 mm, with the assumption of a type 1 error of 0.05 and a power of 0.95.

SETTING

Norwegian university teaching hospital.

SAMPLE

Eighty-six women referred to outpatient operative hysteroscopy.

METHODS

The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before outpatient operative hysteroscopy.

MAIN OUTCOME MEASURES

Preoperative cervical dilatation (primary outcome), number of women who achieve a preoperative cervical dilatation > or = 5 mm, acceptability, complications and adverse effects (secondary outcomes).

RESULTS

In premenopausal women, the mean cervical dilatation was 6.4 mm (SD 2.4) in the misoprostol group and 4.8 mm (SD 2.0) in the placebo group, the mean difference in cervical dilatation being 1.6 mm (95% CI 0.5-2.7). Among the premenopausal women receiving misoprostol, 88% achieved a cervical dilatation of > or = 5 mm compared with 65% in the placebo group. Twelve percent of the women who received misoprostol were difficult to dilate compared with 32% who received placebo. Dilatation was also quicker in the misoprostol group. Misoprostol had no effect on cervical ripening in postmenopausal women compared with placebo, and 43% of the women were difficult to dilate. The trials were terminated after analysis of 21 postmenopausal women and 65 premenopausal women after reaching a conclusion on the primary outcome with only 28% of the number of women needed in a fixed sample size trial. Three of 45 women who received misoprostol experienced severe lower abdominal pain, and there was an increased occurrence of light preoperative bleeding in the misoprostol group. Most women did not experience misoprostol-related adverse effects. The majority (83% of premenopausal and 76% of postmenopausal women) found self-administered vaginal misoprostol at home to be acceptable. There were two serious complications in the premenopausal misoprostol group: uterine perforation with subsequent peritonitis and heavy postoperative bleeding requiring blood transfusion, but these were not judged to be misoprostol related. Complications were otherwise comparatively minor and distributed equally between the two dosage groups.

CONCLUSIONS

One thousand micrograms of self-administered vaginal misoprostol 12 hours prior to operative hysteroscopy has a significant cervical ripening effect compared with placebo in premenopausal but not in postmenopausal women. Self-administered vaginal misoprostol of 1000 micrograms at home the evening before operative hysteroscopy is safe and highly acceptable, although a small proportion of women experienced severe lower abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this regimen, which is very cheap and easy to use.

Disseminated peritoneal leiomyomatosis: an unusual complication of laparoscopic myomectomy

INTRODUCTION

We report a case of disseminated peritoneal leiomyomatosis arising after laparoscopic myomectomy.

CASE REPORT

The patient presented with a large abdominopelvic mass 9 months post laparoscopic myomectomy. Clinical examination and imaging revealed a mass lying separately from the uterus and the ovaries. The large myoma and several small peritoneal myomas were removed by a laparotomy.

CONCLUSION

Disseminated leiomyomas have rarely been reported after laparoscopic myomectomy and hysterectomy. They could be bits left after morcellation or could be parasitic myomas. Hence, this rare condition must be kept in mind whenever a patient presents with abdominal masses following myomectomy or hysterectomy.

Abdominal sacral colpopexy: surgical pearls and outcomes

Vaginal vault prolapse is a challenging form of pelvic organ prolapse that occurs in combination with cystocele, rectocele, or enterocele in nearly 75% of affected patients. Clinical presentation will vary depending on the associated defects. Any successful therapy for vaginal vault prolapse will depend on a thorough evaluation of the vaginal compartments and concomitant lower urinary tract function. Surgical correction of vaginal vault prolapse can be achieved through a variety of vaginal or abdominal approaches. This review focuses on the abdominal approach for vaginal vault prolapse surgery. We review outcomes of abdominal sacral colpopexy (ASC) and available comparisons to vaginal vault suspension. We address the role of laparoscopy and robotics in ASC and examine the outcomes of such procedures. We also discuss available literature on the management of the lower urinary tract in combination with ASC.

Necrotic mass after transurethral resection of a bladder tumor: novel management with robotic partial cystectomy

A 76-year-old female with a history of high-grade transitional cell carcinoma (TCC) of the bladder presented with persistent nocturia and urge incontinence and was diagnosed with a necrotic bladder lesion. Cystoscopy revealed a 4 cm area of necrosis, ulceration, calcification, and fat. Transurethral biopsy confirmed the lesion to be benign, and two attempts to re-epithelialize the area of necrosis with cold scraping of exudate failed. Decision was then made to proceed with removal of necrotic lesion with bladder preservation. With the aid of concomitant cystoscopic visualization of the necrotic lesion, a robotic partial cystectomy with bladder reconstruction was performed. The patient tolerated the procedure, had an uneventful post-operative course, and remains asymptomatic and disease-free at last follow-up of 6 months. To our knowledge, this case represents the first report of a necrotic lesion as a complication of transurethral resection of a bladder tumor (TURBT) and the first description of a robotic partial cystectomy for the management of either benign or malignant bladder disease.

Normal endometrial cells in cervical cytology: systematic review of prevalence and relation to significant endometrial pathology

OBJECTIVES

To estimate the prevalence of normal endometrial cells (NECs) and the proportion of NECs associated with significant endometrial pathology in conventional and liquid-based cytology (LBC) cervical smears; and to assess the association between NECs and clinical symptoms in women with endometrial hyperplasia or carcinoma.

METHODS

Systematic review of the literature and meta-analysis of prevalence and proportion data. The review was confined to studies reporting on NECs in smears from postmenopausal women or women aged 40+.

RESULTS

A total of 22 relevant primary studies were identified from 1970 to 2007. The overall summary estimate for the prevalence of NECs in smears from postmenopausal women or women aged 40+ in all screening smears was 0.4% (95% CI 0.2-0.7%); this was 0.3% (95% CI 0.1-0.5%) and 0.9% (95% CI 0.5-1.4%) for conventional and LBC smears, respectively; P = 0.003 for difference. The overall estimate for the proportion of NECs associated with significant endometrial pathology was 7% (95% CI 4-10%); this was 11% (95% CI 8-14%) and 2% (95% CI 1-2%) for conventional and LBC smears, respectively; P < 0.001 for difference. In women with significant endometrial pathology, the presence of NECs in followed-up women was associated with abnormal uterine bleeding in 79% (95% CI 68-87%) of cases.

CONCLUSION

Compared with conventional cytology, LBC may be associated with a higher prevalence of NECs but these are less likely to be associated with endometrial pathology. This finding might be explained by more consistent use of sampling instruments for LBC with better access to the endocervical canal or alternatively by changes over time, broadly coincident with the introduction of LBC, in the population in which NECs are reported. In followed-up women with NECs, most endometrial pathology is accompanied by symptoms, implying that a relatively smaller number of additional cases are identified through follow-up of asymptomatic women.