Plastic suction curette as uterine manipulator at combined laparoscopic sterilization: a prospective study of 531 cases

OBJECTIVE

To determine the efficacy and safety of a plastic suction curette (PSC) as uterine manipulator during combined surgical abortion and laparoscopic sterilization.

METHODS

This prospective observational study was conducted between January 1996 and December 2003 in a university teaching hospital and a district hospital. All cases of combined first trimester surgical abortion and laparoscopic sterilization were performed under general anaesthesia in the day surgery unit. A straight or curved PSC with a diameter of 7-12 mm was used for surgical abortion and, afterwards, to manipulate the uterus at laparoscopic sterilization. The negative pressure of 600 mmHg or -80 kPa was maintained during manipulation. Any intra-operative trauma or difficulties in identifying the tubes and blood loss during sterilization were noted.

RESULTS

A total of 531 cases of combined abortion and laparoscopic sterilization were performed. There was no failure to identify the tubes nor any uterine perforation; blood loss was minimal. No patient required hospital admission because of direct surgical complications.

CONCLUSION

The plastic suction curette is a safe and efficient uterine manipulator at combined laparoscopic sterilization procedure.

Second-generation endometrial ablation treatment: Novasure

The Novasure endometrial ablation system consists of a single-use device and a radiofrequency controller. It is a three-dimensional, triangular-shaped bipolar ablation device. The generator functions at 500 kHz and has a power cut-off limit set at a tissue impedance of 50 Ohms. The self-terminating procedure is based on tissue impedance or time. A cavity assessment system works to detect perforations in the uterine cavity. No pretreatment is necessary. Randomized controlled trials have shown that the Novasure system has an amenorrhoea rate of 44-56% at 1-year follow-up, and the 5-year results of a randomized trial will be published shortly. Prospective observational studies show even higher amenorrhoea rates of up to 58-75% up to 5-year follow-up. Hysterectomy rates in the prospective trial were very low (4%). In summary, the Novasure endometrial ablation system is an effective second-generation ablation technique, resulting in a high percentage of amenorrhoea.

Major complications of operative gynecologic laparoscopy in Southern Taiwan: A follow-up study

STUDY OBJECTIVES

This follow-up study examined the major complications among 4307 operative gynecologic laparoscopies. The overall complication rate and each individual category were compared with those of our previous study period. The clinical outcome and salvage procedures were correlated with the time of recognition and the severity of initial procedures in the individual injury type.

DESIGN

Retrospective, comparative study based on medical record reviewing (Canadian Task Force classification II-3).

SETTING

Tertiary teaching hospital, Chi Mei Foundation Hospital in southern Taiwan.

PATIENTS

Records of women (n = 4307) aged 40.5 +/- 11.7 years (mean +/- SD [95% CI 40.1-40.5]) who underwent operative gynecologic laparoscopies from January 2000 through February 2006 were reviewed in this study. The complications were compared with those of our previous study based on 1507 laparoscopies performed between December 1992 and November 1999 for follow-up comparison.

INTERVENTIONS

Gynecologic laparoscopic surgeries.

MEASUREMENTS AND MAIN RESULTS

Thirty-four complications occurred in 31 patients requiring repair procedures, 3 of whom had multiple complications, with an overall complication rate of 0.72% (31/4307). There were 13 bladder injuries (0.30%), 7 bowel injuries (0.16%), 3 cases of internal bleeding (0.07%), 4 vaginal stump hematomas or abscesses (0.09%), 3 ureteral injuries (0.07%), 3 major vessel injuries (0.07%), and 1 trocar site hematoma (0.02%). In addition, there were 125 (2.88%) postoperative blood transfusions without additional operative intervention. The major complication rate decreased compared with that of the previous study (0.72% [95% CI 0.51%-1.02%] vs 1.59% [95% CI 1.07%-2.36%]; p = .005). The overall complication rates were not significantly different between laparoscopic hysterectomy (LH) group and non-LH group. However, bladder injury happened more frequently in the LH group, whereas bowel injury was more common in the non-LH group. In addition, the severity of the original injury, timing of recognition, and accompanying salvage procedures correlated with the clinical outcomes.

CONCLUSION

The significantly decreased major complication rate, as compared with that of our previous study period, confirms the importance of experience accumulation and use of preventive maneuvers in reducing the complication rate. There were no significant differences among the individual injury category during these 2 study periods. The manifestations of bowel injury were highly variable and individualized. The accumulation of surgical experience with the aid of preventive maneuvers is helpful to reduce the complication rate significantly.

Sonographic Evaluation of Ectopic Pregnancy

Ectopic pregnancy is a high-risk condition that occurs in 1.9% of reported pregnancies. Although the clinical triad of pain, bleeding, and amenorrhea is considered very specific for an ectopic pregnancy, ultrasound plays important role in detecting the exact location of the ectopic pregnancy and also in providing guidance for minimally invasive treatment. This article discusses the main sonographic features of ectopic pregnancy at various common and unusual locations. In addition, it provides insight into the role of hormonal markers in the diagnosis and management of ectopic pregnancy.

Treatment approaches for painful bladder syndrome/interstitial cystitis

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a disease of unknown aetiology, characterised by severe pressure and pain in the bladder area or lower pelvis that is frequently or typically relieved by voiding, along with urgency or frequency of urination in the absence of urinary tract infections. PBS/IC occurs primarily in women, is increasingly recognised in young adults, and may affect as many as 0.1-1% of adult women. PBS/IC is often comorbid with allergies, endometriosis, fibromyalgia, irritable bowel syndrome and panic syndrome, all of which are worsened by stress. As a result, patients may visit as many as five physicians, including family practitioners, internists, gynaecologists, urologists and pain specialists, leading to confusion and frustration. There is no curative treatment; intravesical dimethyl sulfoxide, as well as oral amitriptyline, pentosan polysulfate and hydroxyzine have variable results, with success more likely when these drugs are given together. Pilot clinical trials suggest that the flavonoid quercetin may be helpful. Lack of early diagnosis and treatment can affect outcomes and leads to the development of hyperalgesia/allodynia.

A summary of reported pregnancies after hysteroscopic sterilization

The purpose of this article is to describe 64 unintended pregnancies reported by patients who had undergone hysteroscopic sterilization and to provide recommendations for avoiding post-procedure pregnancies. Sixty-four pregnancies out of an estimated 50,000 procedures were reported to the device manufacturer from 1997 through December 2005. Most occurred in patients without appropriate follow-up. Other causes included misread hysterosalpingograms, undetected preprocedure pregnancies, and failure to follow product-labeling guidelines. The risk of pregnancy with hysteroscopic sterilization may be reduced by educating patients about the necessity of follow-up, ensuring that patients use effective contraception before and after placement, following the instructions for use, and adhering to the hysterosalpingography protocol.

Laparoscopic supracervical versus total hysterectomy

Hysterectomy is one of the most effective surgical procedures developed in modern medical times. It treats multiple diagnoses with low morbidity in a reliable manor with very reproducible results. Therefore, in order to improve this procedure, any new procedure must be able to produce these same results with decreased morbidity. This article examines these criteria and evaluates the ability of laparoscopic supracervical hysterectomy to accomplish this task.

Instillation of Skin, Nephrostomy Tract, and Renal Puncture Site with Ropivacaine Decreases Pain and Improves Ventilatory Function after Percutaneous Nephrolithotomy

BACKGROUND AND PURPOSE

Pain after percutaneous nephrolithotomy (PCNL) is well investigated, but no optimal management strategy has yet been defined. Ventilatory changes after uncomplicated PCNL remain obscure. We investigated whether pain can be managed with a combination of a parenteral non-narcotic drug and instillation of a local anesthetic into the operative field. We also measured ventilatory changes early after PCNL to determine whether this analgesic modality improves ventilatory status.

PATIENTS AND METHODS

In a randomized blinded study, 34 well-matched patients underwent PCNL with single subcostal access. At the end of the operation, 30 mL of either 0.02% ropivacaine or saline was instilled into the renal puncture site, nephrostomy tract, and skin. Postoperatively, patients received parenteral metamizol (dipyrone) (500 mg/dose) on demand. Pain visual analog score (VAS), peak expiratory flow rate (PEF), and blood-gas analysis were performed at 2, 6, and 24 hours postoperatively. The number of analgesic doses required was recorded.

RESULTS

The VAS at 6 hours, time to first analgesic demand, and total analgesic need were significantly lower (P=0.001, 0.008, and 0.001, respectively) in the ropivacaine group, whereas the PEF at 2 and 6 hours was significantly higher (P=0.001 for each). Analgesic use in the first 12 and 24 hours was lower in this group. Blood-gas analysis was within the normal range in both groups. Time of surgery and hemoglobin decrease were not significantly different.

CONCLUSIONS

A decrease in PEF indicating restricted ventilation appears early after PCNL. Because these patients were chosen carefully to have normal function preoperatively, this decrease was attributed to nociception. A combination of ropivacaine instillation with metamizol decreases pain and analgesic use and improves PEF more than use of metamizol alone. Such a multimodal pain-management strategy is effective in minimizing postoperative opioid use with proper pain management, resulting in better ventilation.

Laparoscopic management of juvenile cystic adenomyoma of the uterus: Report of two cases and review of the literature

Two cases of juvenile cystic adenomyoma of the uterus treated by laparoscopic surgery are reported. Preoperative diagnostic imaging procedures located a cystic structure within the uterine nodule of each of these young women with severe dysmenorrhea. Under a diagnosis of cystic adenomyoma, laparoscopic excision was performed. Histopathologic examination of the resected tissues showed the presence of an endometrial structure composed of epithelium and stroma within myometrial nodule. In both of these patients, dysmenorrhea disappeared postoperatively.

A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding

OBJECTIVES

Abnormal uterine bleeding (AUB) impacts women's health-related quality of life (HRQoL) and puts a heavy economic burden on society. To date, this burden has not been systematically studied. We conducted a systematic review of the medical literature to evaluate the impact of AUB on HRQoL and to quantify the economic burden of AUB from a societal perspective.

METHODS

We searched the PubMed and Cochrane databases, and article bibliographies for the period up to July 2005. Teams of two reviewers independently abstracted data from studies that reported outcomes of interest: prevalence, HRQoL, work impairment, and health-care utilization and costs associated with AUB.

RESULTS

The search yielded 1009 English-language articles. Ninety-eight studies (including randomized controlled trials, observational studies, and reviews) that met the inclusion and exclusion criteria underwent a full-text review. The prevalence of AUB among women of reproductive age ranged from 10% to 30%. The HRQoL scores from the 36-item Short-Form Health Survey Questionnaire (SF-36) suggested that women with AUB have HRQoL below the 25th percentile of that for the general female population within a similar age range. The conservatively estimated annual direct and indirect economic costs of AUB were approximately $1 billion and $12 billion, respectively. These figures do not account for intangible costs and productivity loss due to presenteeism.

CONCLUSIONS

The burden of AUB needs further and more thorough investigation. Additional research should prospectively evaluate the impact of AUB and the value of treatment provided to help guide future health resource allocation and clinical decision-making.

Diagnostic value of ductoscopy in the diagnosis of nipple discharge and intraductal proliferations in comparison to standard methods

BACKGROUND

Ductoscopy is gaining increased importance in the diagnosis of nipple discharge of unclear origin and intraductal proliferation. For this reason we compared its diagnostic value and feasibility to standard diagnostic methods.

MATERIAL AND METHODS

Ductoscopy was compared to mammography, galactography, sonography, magnetic resonance imaging (MRI), nipple smear, fine needle aspiration cytology (FNAC), and high-speed core biopsy; feasibility, sensitivity, and specificity were investigated for each method.

RESULTS

71 ductoscopies were evaluated, which were followed up by open biopsies. Here, 3 invasive and 8 ductal carcinomas in situ were found, as well as 3 atypical ductal hyperplasias, 44 papillomas/papillomatoses, and 13 benign findings. Feasibility of ductoscopy was in this series 100%. Duct sonography showed the highest sensitivity (67.3%), followed by MRI (65.2%), galactography (56.3%), ductoscopy (55.2%), and FNAC (51.9%). The highest specificity was shown by FNAC, core biopsy, and galactography (each 100.0%), followed by mammography (92.3%), nipple smear (77.8%), ductoscopy, and duct sonography (each 61.5%); the lowest specificity was displayed by MRI (25.0%).

CONCLUSION

The results confirm that ductoscopy can be performed within the same range of sensitivity and specificity as other techniques. In order to make conclusive statements about ductoscopy, especially in order to precisely define the indications for this method, a prospective multicenter study was initiated.

[Laparoscopic repair of an incomplete post obstetrical uterine rupture. About one case]

The rate of incomplete uterine ruptures is unknown. These ruptures are usually asymptomatic but may cause chronic pelvic pain and/or intermenstrual bleeding. The conservative surgical repair techniques described in the literature are often practised by vaginal, combined (vaginal and laparoscopic) or hysteroscopic way. We propose an exclusive laparoscopic repair technique with satisfactory anatomical and functional short-term results.

Caesarean scar pregnancy

Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. Little is known about its incidence and natural history. With increasing incidence of caesarean section worldwide, more and more cases are diagnosed and reported. Transvaginal ultrasound and colour flow Doppler provides a high diagnostic accuracy with very few false positives. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage, thus preserving the uterus and future fertility. Management plan should be individually tailored. Available data suggest that termination of pregnancy is the treatment of choice in the first trimester soon after the diagnosis. Expectant treatment has a poor prognosis because of risk of rupture. There are no reliable scientific data on the risk of recurrence of the condition in future pregnancy, role of the interval between the previous caesarean delivery and occurrence of caesarean scar pregnancy, and effect of caesarean wound closure technique on caesarean scar pregnancy. In this article, we aim to find the demography, pathophysiology, clinical presentation, most appropriate methods of diagnosis and management, with their implications in clinical practice for this condition.

Medical liability insurance claims on entry-related complications in laparoscopy

BACKGROUND

Installation of the pneumoperitoneum is an essential part of laparoscopic surgery. Creation can be performed by either the open or a closed technique. The aim of this study was to assess the number of and contributing factors to entry-related complications in medical liability insurance claims in The Netherlands.

METHODS

A retrospective chart review was performed, including all malpractice claims filed at MediRisk, which is presently the largest medical liability mutual insurance company for institutions, mainly hospitals, in healthcare in The Netherlands.

RESULTS

From January 1993 to December 2005, 41 claims were identified as entry-related complications which comprised 18% of all laparoscopy-related complications leading to claims. Most were young (median age = 35 years) female patients who had routine, nonadvanced, laparoscopic procedures planned as short-stay or day-care procedures. The claims were equally divided between general surgery (n = 20) and gynecology (n = 21). A total of 51 structures were injured. There were 18 vascular structure injuries, 30 bowel injuries, and three other injuries. An open entry technique was used in only two (5%) patients. Vascular injury was exclusively associated with closed entry. In only 19 (46%) patients the entry-related complication was diagnosed peroperatively, consisting of 70% of the vascular and 25% of the bowel injuries. Twenty-six patients (64%) were admitted to the intensive care unit for a median of five days. There was no mortality. Besides conversion, the majority of the patients filed a claim to compensate for a longer hospital stay and related costs. A payment was made in 17 (57%) of the 30 settled claims.

CONCLUSIONS

Medical liability claims concerning laparoscopic entry-related complications comprised a fifth of all laparoscopy-related claims. Claims concerning entry-related complications occurred in young patients who had routine, nonadvanced procedures. In the investigated cases most claims involved the closed-entry technique.

Interstitial Cystitis and Female Sexual Dysfunction

OBJECTIVES

To use the Female Sexual Function Index (FSFI) to compare female sexual dysfunction in patients with interstitial cystitis/painful bladder syndrome (IC) with that in controls.

METHODS

Consecutive patients with IC and asymptomatic controls were tested for voiding diary voided volumes, Pelvic Pain and Urgency/Frequency Questionnaire scores, and FSFI scores.

RESULTS

Of the 97 subjects, 75 had IC and 22 were controls. The mean age was 38 and 43 years (P = 0.09), the voided volume was 165 mL and 294 mL (P <0.0001), and the Pelvic Pain and Urgency/Frequency Questionnaire score was 18 versus 3 (P <0.0001) for the IC and control groups, respectively. The total adjusted FSFI scores differed between patients with IC and the controls (20.2 +/- 9.6 versus 29.0 +/- 6.8, respectively, P <0.001). Using 26.55 as the cutpoint, 51 patients with IC (68%) had an abnormal FSFI score versus 3 controls (14%; P <0.001). Patients with IC scored worse on all domains of female sexual dysfunction than did the controls (P <0.01).

CONCLUSIONS

The results of our study have shown that female patients with IC have sexual dysfunction, including pain, more commonly than do controls.

Prise en charge de l'endométriose: évaluation clinique et biologique

No symptom is pathognomonic for endometriosis. Main symptoms are pain (chronic pelvic pain, dysmenorrhea, deep dyspareunia, pain on defecation, cyclic pain) and infertility (grade C). There is no relation between rAFS endometriosis classification and symptoms intensity and frequency (grade B). Endometriosic lesions location and symptoms type are related to each other as well as symptoms intensity and lesions deepness or adhesion numbers (grade B). Clinical evidence is the same for infertile endometriosic women (grade C). Screening for depression is required among patients suffering from chronic endometriosic pelvic pain (grade C). Clinical examination includes: 1) retrocervix area inspection as well as upper part of posterior vaginal wall in search for typical bluish lesions (grade B); 2) vaginal examination in search for: a) uterosacral ligaments nodules (grade B); b) pain in uterosacral ligaments extension (grade B); 3) re-examination during menstruation increases its performance (grade B). No biological check-up in endometriosis diagnosis is necessary (grade A). CA 125 increase is related to: endometriomas and deep lesions volume (grade B), surgically treated infertile women prognosis (grade B). Presurgical endometriosis diagnosis is bettered by using diagnosis pattern in selected population (grade B). Rating scales are recommended in diagnosis and therapeutic follow up (grade B). Quality of life scales are useful to evaluate therapeutic efficiency (grade B).

Angiographic uterine artery embolization followed by immediate curettage: An efficient treatment for controlling heavy bleeding and avoiding recurrent bleeding in cervical pregnancy

Two cases of cervical pregnancy with heavy bleeding successfully treated by uterine artery embolization (UAE) followed by immediate curettage are described in this report. Case 1 demonstrated intermittent bleeding after serious bleeding was successfully controlled by UAE. Serum beta human chorionic gonadotropin (beta-hCG) level rose remarkably after a short time decline. Transvaginal sonography consistently revealed a heterogeneous mass in the cervix. Repeated UAE followed by immediate curettage was performed and complete resolution was achieved. Case 2 was also successfully managed by UAE followed by immediate curettage after failure of medical treatment. This report suggests that UAE followed by immediate curettage is a safe and efficient procedure for controlling heavy bleeding and avoiding recurrent bleeding when fertility capacity is desired in cases of cervical pregnancy with fetal cardiac activity and high beta-hCG concentration.

The Role of the Urinary Epithelium in the Pathogenesis of Interstitial Cystitis/Prostatitis/Urethritis

The urothelium plays a pivotal role as a barrier between urine and its solutes and the underlying bladder. Bladder surface mucus is a critical component of this function. The biologic activity of mucus that imparts this barrier function is generated by the highly anionic polysaccharide components (eg, glycosaminoglycans), which are extremely hydrophilic and trap water at the outer layer of the umbrella cell. This trapped water forms a barrier at the critical interface between urine and the bladder. The result is a highly impermeable urothelium that serves as a key protective barrier for the bladder interstitium. In interstitial cystitis (IC), disruption of the urothelial barrier may initiate a cascade of events in the bladder, leading to symptoms and disease. Specifically, epithelial dysfunction leads to the migration of urinary solutes, in particular, potassium, that depolarize nerves and muscles and cause tissue injury. Exogenous heparinoids can restore the barrier function of the urothelium and thus successfully treat patients with IC. Groups of patients who have been given a diagnosis of IC, chronic prostatitis, and urethritis have been shown to have IC by virtue of their shared potassium sensitivity. It would seem, therefore, that mucous deficiency may be present throughout the lower urinary tract. If one is to rename these diseases, perhaps it is best to do so in reference to a shared loss of epithelial barrier function. A name such as lower urinary dysfunctional epithelium would incorporate all of these diseases under a single pathophysiologic process. As a result of these discoveries, a new paradigm for diagnosis and treatment is emerging.

Optimizing Outcomes in Laparoscopic Urologic Training: Toward A Standardized Global Consensus

BACKGROUND AND PURPOSE

Laparoscopic urologic surgery (LUS) is one of the fastest growing subspecialties in the surgical world. The procedures require technical expertise and finesse; unlike their open counterparts, there is significant limitation in the margin for error. Various ethical, medicolegal, and health economy demands have made training in laparoscopic urologic surgery challenging. Whereas several groups have sought solutions through models, there remains a lack of consensus on the optimal training program. We review the current LUS programs with a conscious effort to decipher the basic tenets of an optimal training program and propose training models based on published evidence, in conjunction with current trends in LUS.

METHODS

A literature search of MEDLINE, Pubmed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Google Scholar was performed, seeking publications from January 1970 to July 2006 on laparoscopic surgical training pertaining to urology. Additionally, we looked at pertinent abstracts of the annual meetings of the American Urological Association, the European Association of Urology, and the World Congress of Endourology for the period January 1996 to and inclusive of August 2006.

RESULTS AND CONCLUSIONS

To date, no study has documented a global consensus on optimal LUS training programs. Our search identified several models, some of which were applied successfully in the form of minifellowships. There remain no clear guidelines on the optimum LUS training program. The optimal program may need to be tailored to individual units, based on resources (this includes country-specific health economics, mentor availability, and caseload). Further studies are needed to help elucidate how individual programs can be initiated with a global minimum standard applicable to all training programs.

Management of ruptured corpus luteum cyst of pregnancy occurring in a 15-year-old girl by laparoscopic surgery with intraoperative autologous blood transfusion

BACKGROUND

Laparoscopic surgery is a minimally invasive procedure with many advantages. However, laparoscopic treatment of ruptured corpus luteum cyst of pregnancy with massive hemoperitoneum occurring in a young girl has not previously been reported.

CASE

A 15-yr-old girl presenting with acute abdomen and hemoperitoneum was referred to our department. A urinary pregnancy test was positive and an ultrasound revealed a gestational sac in the uterine cavity, the preoperative differential diagnosis was narrowed to either intrauterine pregnancy with ruptured corpus luteum cyst or heterotopic pregnancy. Emergency laparoscopic surgery was performed to investigate the cause of hemoperitoneum and a diagnosis of ruptured corpus luteum cyst of pregnancy was established. After retrieving pooled blood in the abdominal cavity for intraoperative autologous blood transfusion, the rupture site with active bleeding was laparoscopically sutured and hemostasis was achieved. At the same time, intrauterine pregnancy was electively terminated at the request of the patient and her family. The postoperative course was uneventful.

CONCLUSION

Ruptured corpus luteum cyst of pregnancy manifesting massive hemoperitoneum is a rare but life-threatening disorder that can occur even in a young girl. Ovarian conservative treatment can laparoscopically be performed with intraoperative autologous blood transfusion.

Small bowel obstruction after vaginal vault suspension: a series of three cases

Surgical correction of pelvic organ prolapse is increasingly common. The vaginal approach is often favored secondary to its limited peritoneal cavity access and low complication rates. A thorough review of the literature revealed no previous reports of primary vaginal reconstructive surgery leading to small bowel obstruction (SBO). Three patients who underwent transvaginal hysterectomy, uterosacral ligament vaginal vault suspension, and other reconstructive procedures subsequently suffered from SBO. All patients failed conservative management and required surgery. All were treated with laparoscopy initially, but two patients required laparotomy to correct iatrogenic enterotomies. The complication of SBO should be considered in the post vaginal surgery patient with abdominal pain. Though laparoscopic surgery can be considered, our experience has been discouraging. Candidate selection is critical and care should be taken to avoid enterotomy.

Essure®sterilization associated with endometrial ablation

OBJECTIVE

To evaluate the feasibility and the outcome of Essure sterilization associated with different techniques of endometrial ablation.

METHOD

Retrospective study conducted among 23 women with confirmed menometrorrhagia and with the desire for or the medical need for permanent tubal sterilization. Patients underwent combined hysteroscopic placement of Essure and hysteroscopic endometrial resection procedures: ThermaChoice (n=14), NovaSure (n=4), Hydrothermablator (n=2) and endometrial resection using monopolar energy (n=1), or bipolar energy (n=2).

RESULTS

Fallopian tubes were successfully cannulated bilaterally in 87% of the cases (20/23). No adverse event was reported. Adequate bilateral occlusion was confirmed for all patients (20/20) by 3D ultrasound and pelvic X-ray at a 3-month follow-up. Furthermore, 85% of these patients were satisfied with the results of the procedure, all experiencing a significant reduction in menstrual blood loss (Higham blood loss score).

CONCLUSION

Combining EA and hysteroscopic sterilization seems to be feasible and efficient in patients with menometrorrhagia.

Laparoscopic hysterectomy with retroperitoneal uterine artery sealing using LigaSure: Gazi hospital experience

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of laparoscopic hysterectomy by retroperitoneal sealing of the uterine arteries with LigaSure.

METHODS

Laparoscopic hysterectomy by retroperitoneal uterine artery sealing with LigaSure was performed by four-puncture laparoscopy in 50 women with various indications for hysterectomy. The mean operation time, amount of intraoperative bleeding, drop in hemoglobin concentration, weight of removed uterus, major and minor per-post operative complications, and the rate of conversion to classical abdominal approach were analyzed prospectively.

RESULTS

The mean operation time was 85 min (range 60-125 min). The mean weight of removed uterus was 180 g (range 60-650 g). There was one major complication; one patient had cystotomy due to difficulty in dissecting severe adhesions because of two previous cesarean sections that were repaired laparoscopically. Only one patient converted to laparotomy because of severe bowel adhesions due to rectovaginal endometriosis. All patients were discharged on the first postoperative day. No minor complications occurred. Hemoglobin decreased a mean of 0.4 g/dl (range 0.2-1.4 g/dl) by postoperative day 1.

CONCLUSION

Laparoscopic hysterectomy by retroperitoneal uterine artery sealing with LigaSure is an effective, safe, and fast procedure with less intra operative bleeding, short operation time and hospital stay.

Surgical adhesions: a timely update, a great challenge for the future

Damage to the peritoneum during abdominal surgery triggers a cascade of events aimed at repairing the damage. As part of this process, fibrin is deposited, which is the precursor to the formation of an adhesion between 2 damaged peritoneal surfaces. This can have a significant impact on morbidity and even mortality as well as large cost implications. Strategies to reduce adhesion formation include improving surgical techniques, optimizing laparoscopy conditions, using pharmacologic interventions targeted at the inflammatory response and/or fibrin deposition, and using agents that provide a physical barrier to adhesion formation. While these strategies have provided some success, none have yet proved totally successful in abolishing adhesions. Further research to ensure that adhesion prevention is optimal is therefore essential.

[Laparoscopic management of occult cervical cancer discovered after simple hysterectomy]

OBJECTIVES

To assess the feasibility and morbidity of surgical management by combined laparoscopic and vaginal approach after cervical cancer diagnosed at the time of simple hysterectomy.

PATIENTS AND METHODS

From 2000 to 2005, 10 patients were referred with occult cervical cancer discovered after simple hysterectomy. All these patients had laparoscopy for surgical staging.

RESULTS

Eight on ten patients had complete laparoscopic staging: pelvic lymphadenectomy (N=8), radical colpectomy (N=5). Operative time, pelvic lymph nodes resected, postoperative stay were respectively 261.3 minutes (200-400), 27 (23-38), 4.4 days. There were 2 symptomatic lymphocysts. Pelvic lymph nodes were positive for 1 patient with negative paraaortic nodes. Residual disease was present in 2 cases: 1 parametrial and vaginal involvement, 1 ovarian metastasis. 5 patients had adjuvant treatment: 2 combined pelvic external radiotherapy and brachytherapy, 1 pelvic external radiotherapy, 1 pelvic concurrent chemoradiation and 1 brachytherapy only. Two on ten patients needed a laparoconversion, one for ovarian involvement and one for technical failure. With a median follow-up of 29.7 months (4-63), 3 patients recurred. 3 patients recurred above 5 patients with pelvic lymphadenectomy but without parametrectomy versus no recurrence above 5 patients with pelvic lymphadenectomy and parametrectomy.

DISCUSSION AND CONCLUSION

Surgical staging of occult cervical cancer discovered after simple hysterectomy is necessary for indication of adjuvant treatment. Laparoscopy combined with vaginal surgery is feasible and safe, inducing fewer adhesions which is important for adjuvant radiotherapy. The realization of a radical parametrectomy seems to offer a local control of the disease and a decrease in the risk of recurrence, which need to be confirmed by conducting a study with more patients. This emphasize the necessity of creating a national record to register all women managed for occult cervical cancer.

Prise en charge du placenta accreta

Placenta accreta occurs when a defect of the decidua basalis results in abnormally invasive placental implantation. Main risk factors include placenta previa and previous caesarean section. The conventional sonographic criteria for abnormally adherent placenta have a good diagnostic value that has to be assessed. MRI should improve the diagnosis when sonography is inconclusive. The choice of the treatment results of medical staff and the women's choice. It implies centers with adequate equipment and resources. Radical strategy consists in caesarean hysterectomy according to American recommendations or in an attempt of complete placental delivery associated with trial haemostasis and hysterectomy if this fails. A conservative approach whereby the placenta is left in place may however be proposed in selected cases if the woman wishes to continue to be fertile. This strategy needs a rigorous follow-up until complete resorption of the placenta. In case of major hemorrhage, hysterectomy should not be delayed to prevent major maternal complications or even maternal death.

Hysteroscopic surgery does not adversely affect the long-term prognosis of women with endometrial adenocarcinoma

STUDY OBJECTIVE

To determine the effect of hysteroscopic surgery on the long-term clinical outcome of women diagnosed with endometrial cancer.

DESIGN

Prospective cohort study (Canadian Task Force classification II-3).

SETTING

University-affiliated teaching hospital.

PATIENTS

From January 1990 through December 2005, the principal author (GAV) performed primary hysteroscopic surgery in 3401 women with abnormal uterine bleeding. Among these women, there were 16 occult and 3 known endometrial cancers.

INTERVENTIONS

All women underwent hysteroscopic evaluation and partial (n = 8) or complete (n = 11) rollerball electrocoagulation and/or endomyometrial resection. After diagnosis of endometrial malignancy, women were counseled regarding their disease and management, in accordance with established clinical practice guidelines. Follow-up ranged from 1 to 14 years and was conducted by office visits and telephone interviews.

MEASUREMENTS AND MAIN RESULTS

Among the 3401 women, there were 19 women with endometrial adenocarcinoma, 3 of whom were known to harbor cancer before hysteroscopic surgery. One woman refused hysterectomy and remains alive and well 5 years after total hysteroscopic endomyometrial resection. Two women wished to maintain fertility; 1 consented to hysterectomy after incomplete resection of her lesion. The other was treated with progestins. Her cancer reverted to complex hyperplasia, and she requested hysterectomy 4 years later. No residual cancer was found. After 5 years of follow-up, 1 patient died from carcinoma of the gallbladder (2 years), and 2 died at 4 years; 1 at the age of 87 years of natural causes and the other at the age of 86 years from acute renal failure unrelated to her cancer. Fourteen women remain alive and well at 5 to 14 years of follow-up. Two additional women remain alive and well at 1 and 4 years of follow-up.

CONCLUSION

Resectoscopic surgery did not adversely affect the 5-year survival and the long-term prognosis in 14 women with endometrial cancer.

Wound retraction system for gasless laparoscopic-assisted myomectomy with a subcutaneous abdominal wall-lift method

Over the course of 4 years we evaluated 209 women using gasless laparoscopic-assisted myomectomy and a wound retractor. Three were no significant differences in blood loss or surgical duration despite myoma size or location. Gasless laparoscopic-assisted myomectomy utilizing a wound retractor is an effective procedure for women desiring uterine preservation without significantly longer surgery duration.

Transcervical Sterilization: Past, Present, and Future

After multiple attempts at developing transcervical sterilization techniques over the past 150 years, United States women now have the option of a transcervical method, which can be performed without an incision under local anesthesia. It is feasible in most patients and highly effective once occlusion has been confirmed with hysterosalpingogram. Another method is likely to be approved and enter the market in the near future. Expanded choices for sterilization are a positive development for women's health because more options may decrease unintended pregnancy.

Complications of hysteroscopic surgery: “Beyond the learning curve”

STUDY OBJECTIVE

To investigate the actual complication rate of hysteroscopic surgery performed by experienced endoscopic surgeons in a single medical center.

DESIGN

A prospective descriptive study (Canadian Task Force classification III).

SETTING

An endoscopic gynecology unit at a tertiary care university hospital.

PATIENTS

Women from 21 to 82 (median 45.0) years, undergoing operative hysteroscopy for uterine disease.

INTERVENTION

Operative hysteroscopy with glycine or saline solution used as an irrigation medium.

MEASUREMENTS AND MAIN RESULTS

Data of short-term complications were prospectively collected during surgery and at the 2-week follow-up visit. Six hundred procedures were investigated. The total complication rate was 3%, with 1% of uterine perforations. Two-thirds of the complications were related to cervical dilation or uterine entry, and infertility was found to be a risk factor.

CONCLUSIONS

Hysteroscopic surgery, performed by a well-trained hysteroscopic surgeon, is a safe procedure with an overall complication rate of 3%. Most complications are related to cervical dilation or uterine entry techniques. Efforts therefore should be focused on identifying the patients at risk and finding novel techniques for cervical priming.

Robotic surgery in gynecologic oncology: evolution of a new surgical paradigm

Robotic surgical platforms were first developed with telesurgery in mind. Conceptualized by NASA and the military to provide surgical expertise to remote locations, some telesurgical success has been documented, but progress has been held back by communication bandwidth limitations. Telepresence surgery, where the surgeon is in proximity to the patient but is provided with an ergonomic console equipped with three-dimensional vision and autonomous control of wristed laparoscopic surgical instruments and energy sources, has shown efficacy first in cardiac and then urologic cancer surgery. Interest is currently focused on the application of this technology in the field of gynecology, with techniques being described to perform simple hysterectomy, myomectomy, tubal anastomosis, and pelvic reconstruction procedures. This article will review the application of robotic- and computer-assisted surgery in the specialty of gynecologic oncology.

Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis

BACKGROUND

We compared the accuracy of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) for the diagnosis of deep pelvic endometriosis (DPE), with respect to surgical and histological findings.

METHODS

Longitudinal study of 88 consecutive patients referred for surgical management of DPE, who underwent both MRI and RES pre operatively. The diagnostic criteria were identical for MRI and RES and were based on visualization of hypointense/hypoechoic areas in specific locations. DPE was diagnosed when at least one site was involved. We calculated the sensitivity, specificity, predictive values, accuracy and 95% confidence interval of MRI and RES for DPE.

RESULTS

DPE and endometriomas were present in 97.7 and 39.7% of women, respectively. The sensitivity, specificity and positive and negative predictive values of MRI and RES, respectively, were 84.8 and 45.6%, 88.8 and 40%, 98.5 and 87.8% and 40 and 8.5% for uterosacral endometriosis; 77.7 and 7.4%, 70% and 100, 85.3 and 100% and 89.7 and 70.9% for vaginal endometriosis and 88.3 and 90%, 92.8 and 89.3%, 96.4 and 94.7% and 78.8 and 80.6% for colorectal endometriosis.

CONCLUSIONS

MRI is more accurate than RES for the diagnosis of uterosacral and vaginal endometriosis, whereas the two methods are similarly accurate for colorectal endometriosis.

Prediction of operation time for laparoscopic myomectomy by ultrasound measurements

BACKGROUND

This study aimed to develop a regression-based prediction equation for operation time for laparoscopic myomectomy (LM) using ultrasound measurement.

METHODS

Patients who were to undergo laparoscopic myomectomy from March 2003 to December 2005 were enrolled prospectively in a tertiary institution. Ultrasound was performed before operation. The myoma weights were calculated and converted into mass units (g) by an assumed smooth muscle density of 1.04 g/cm3. Myomas were weighed immediately after operation, and the correlation between these two weights was assessed by linear regression and limits of agreement. A multivariate linear regression model was fitted to the ultrasound parameters and clinical variables to predict operation time.

RESULTS

Of 109 patients, 203 myomas were removed laparoscopically with a mean ultrasound-measured myoma weight of 137.9 (100.7) g, a diameter of the dominant myoma of 6.30 (1.92) cm, and an operation time of 125 (41) min. Strong correlations were observed between the ultrasound-measured and operated myoma weights. A predictive model, in which operation time = 0.14 x ultrasound-measured myoma weight + 1.68 x BMI + 5.21 x operated myoma number + 0.06 x (ultrasound-measured myoma weight x operated myoma number) + 43.97, was developed.

CONCLUSIONS

Operation time was significantly related to the myoma weight measured by ultrasound. The ultrasound-derived prediction equation is valid and reliable in predicting operation time for LM.

Laparoscopic subtotal hysterectomy using the plasma kinetic and lap loop systems: an alternative approach in the surgical management of women with uterine fibroids

OBJECTIVE

To evaluate the safety and applicability of laparoscopic subtotal hysterectomy (LSH) using the plasma kinetic (PK) and lap loop systems as an alternative surgical approach in the management of uterine fibroids in women who have completed their families.

STUDY DESIGN

Sixty-two consecutive LSH were performed during this prospective study from March 2003 to March 2005 at Princess Royal University Hospital, Kent, UK.

RESULTS

All study patients had menorrhagia resistant to at least one form of therapy, with a mean duration of symptoms of 3.5 years. In addition, four patients had previous myomectomy. The mean number of fibroids removed was 2.7. The mean weight of the uterus was 141.9 g. The mean operative time was 46.8 min, and the mean blood loss was 126.6 mL. The overall perioperative complication rate was 4.8% with no visceral injury, or return to theatre. At follow-up, all patients were satisfied with surgery.

CONCLUSION

The study describes the first application of the PK and Lap Loop systems in LSH for the surgical management of uterine fibroids in women in whom fertility is not an issue, and its findings suggest that this minimally invasive technique is a safe, and valid alternative. Larger adequately-powered studies are however still required.

A preclinical study of nonsurgical radiofrequency collagen remodeling for the treatment of stress urinary incontinence

Many women with stress urinary incontinence seek a nonsurgical, well-tolerated, effective and durable treatment that is associated with a rapid recovery and improvement in quality of life. However, the nonsurgical options available, such as pelvic floor exercises or behavioral therapy, are typically not effective; thus, many women with the condition remain untreated. A new nonsurgical treatment, transurethral radiofrequency collagen remodeling, offers many patient-desired treatment characteristics. This prospective, controlled animal study was performed to evaluate the safety, gross and histological impact, and physiological effect of transurethral radiofrequency collagen remodeling. The outcomes served as the basis for initial and subsequent clinical trials in women.

Conservative surgical management of endometriosis in women with pelvic pain

Endometriosis is a common cause of pelvic pain in women. This article addresses the conservative surgical treatment of endometriosis for this indication.