Pediatric and adolescent gynecology: Treatment perspectives in minimally invasive surgery

Minimally invasive surgery (MIS) is widely utilized across multiple surgical disciplines, including gynecology. To date, laparoscopy is considered a common surgical modality in children and adolescents to treat gynecological conditions. Robotic surgical devices were developed to circumvent the limitations of laparoscopy and have expanded the surgical armamentarium with better magnification, dexterity enhanced articulating instruments with 5-7 degrees of freedom, and ability to scale motion thus eliminating physiologic tremor. There are well-documented advantages of MIS over laparotomy, including decreased post-operative pain, shorter recovery times, and better cosmetic results. Indications for MIS in pediatric gynecology are reported in this review and technical considerations are described to highlight new treatment perspectives in children and adolescents, which have already been described in the literature regarding adult patients.

Kuntai Capsule Inhibited Endometriosis via Inducing Apoptosis in a Rat Model

We evaluated the effectiveness of Kuntai Capsule (KTC) for treating endometriosis using rat model and investigated its preliminary mechanism of action involved. SD rats were implanted with endometrial tissues and treated with KTC for three weeks. Then, laparotomy was performed to examine volume changes of the autografts. The serum levels of TNF-α, IL-6, COX-2, E₂, and P4 were measured through ELISA. TUNEL was performed to analyze the apoptosis on ectopic endometrium. Protein levels of caspases 8, 9, and 3 and cytochrome c in the ectopic and eutopic endometrium were measured by western blotting. Results showed that KTC significantly decreased the volumes of ectopic endometrium. The level of TNF-α increased and E₂ decreased in the KTC treatment groups. TUNEL and western blot assay showed that KTC could induce apoptosis of endometriotic tissues, accompanied with the increased protein expression of caspases 8 and 9, activated caspase-3, and cytochrome c in a dose-dependent manner. However, these protein expression profiles were not affected in eutopic endometrium. Our findings suggest that KTC could inhibit the growth of ectopic endometrial tissue through upregulating the level of TNF-α and its downstream signaling, including caspases and cytochrome c.

Anti-Mullerian hormone trend evaluation after laparoscopic surgery of monolateral endometrioma using a new dual wavelengths laser system (DWLS) for hemostasis

Operative laparoscopy is the gold standard in the treatment of endometriotic ovarian cysts. Excisional surgery is the best technique to prevent recurrences and improve symptoms but it may result in ovarian reserve damage due to the removal of healthy ovarian cortex. The aim of this study was to assess the impact on ovarian reserve of the use of dual wavelengths laser system (DWLS) hemostasis after stripping technique of monolateral endometrioma, by dosing the anti-Mullerian hormone (AMH). This prospective study was conducted at the Institute of Obstetrics and Gynecology, University of Foggia, from December 2013 to January 2015. Forty-five women underwent excision of monolateral endometriotic ovarian cyst by stripping without using a bipolar coagulation and performing hemostasis with a DWLS. The AMH serum levels were estimated before the surgery (T0), 4-6 weeks (T1) and 6-9 months (T2) after surgery. Our results suggest that an appropriate surgical technique with the use of laser hemostasis does not determine a significant reduction of ovarian reserve. Laser hemostasis could prevent follicular reserve loss after ovarian endometrioma surgery.

Surgical technique of endometrioma excision impacts on the ovarian reserve. Single-port access laparoscopy versus multiport access laparoscopy: a case control study

Several recent studies report the detrimental effect of endometrioma excision on the ovarian reserve. Surgical technique and the excessive use of bipolar coagulation could be the key factors. Single-port access laparoscopy (SPAL) ovarian cystectomy has been reported as a comparable procedure to conventional laparoscopy in terms of operative outcomes. The aim of this study was to evaluate whether the single-port surgery affects the ovarian reserve whilst performing laparoscopic ovarian cystectomy for unilateral endometrioma. This was a prospective, case-control study of 99 women with unilateral endometrioma. Forty-nine women underwent single-port cystectomy and 50 women underwent multiport laparoscopic (MPL) conventional cystectomy. The primary outcome was the assessment of the ovarian reserve. We evaluated the serum anti-Mullerian hormone (AMH) levels before, 4-6 weeks and 3 months after surgery. At T2 we performed an ultrasound assessment of the antral follicular count (AFC). We have drawn attention to a statistically significant decrease of the mean AMH value and AFC in the SPAL group at the 4-6-week and 3-month follow-up compared to the conventional laparoscopy group. In conclusion, our results suggest that SPAL cystectomy should not be recommended to patients undergoing surgery for endometrioma excision who want to preserve their fertility.

Single-port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study

STUDY OBJECTIVE

The objective was to evaluate the perioperative outcomes, safety, and patient acceptance of single-port access laparoscopic subtotal hysterectomy (SPAL-SH) in comparison with conventional multiport access laparoscopic subtotal hysterectomy (MPAL-SH).

DESIGN

Case-control study. Canadian Task Force Classification II-2.

SETTING

The study was conducted at university hospitals in Cagliari, Italy, and Rouen, France.

PATIENTS

Sixty-one women with metrorrhagia, abnormal uterine bleeding with uterine myomas, or symptomatic adenomyosis were included in the study.

INTERVENTIONS

Thirty-one patients underwent SPAL-SH, and 30 patients underwent conventional MPAL-SH.

MEASUREMENTS AND MAIN RESULTS

We analyzed the data to compare the outcomes of SPAL-SH versus MPAL-SH. Patients in the SPAL-SH group had longer operative times than those in the MPAL-SH group (p < .001) but shorter hospital stays (p < .001). Postoperative pain immediately after surgery, after 6 hours, and after 24 hours were lower in the SPAL-SH group (p < .001). The SPAL-SH group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery (p < .01).

CONCLUSION

We conclude that SPAL-SH is a feasible and safe alternative to standard MPAL-SH in selected patients. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. In addition, SPAL-SH has a definite benefit in relation to body image and cosmesis.

Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis (DIE) vs. incomplete surgical treatment with or without GnRHa administration after surgery

PURPOSE

To evaluate the role of post-surgical medical treatment with GnRHa in patients with DIE (Deep Infiltrating Endometriosis) that received complete or incomplete surgery laparoscopic excision.

METHODS

Hundred fifty-nine patients with deep infiltrating endometriosis of the cul-de-sac and of the rectovaginal septum with pelvic pain undergoing laparoscopic surgery in academic tertiary-care medical center. Eighty patients underwent complete laparoscopic excision of DIE (Arm A) while 79 patients underwent incomplete surgery (Arm B). After surgery each surgical arm was randomized in two groups: no treatment groups 1A [40 pts] and 1B [40 pts] and GnRHa treatment for 6 months groups 2A [40 pts] and 2B [39 pts]. Pain recurrence and quality of life were evaluated in follow-up of 12 months and compared between groups.

RESULTS

No differences were observed between patient groups 1A and 2A. Groups 1A, 2A and 2B obtained significantly lower pain scores than those achieved by the group 1B undergoing incomplete surgical treatment and no post-surgical therapy. At 1-year follow-up patients treated with en-block resection (Groups 1A and 2A) showed the lowest pain scores and the highest quality of life in comparison with the other two groups (Group 1B and 2B).

CONCLUSION

GnRHa administration is followed by a temporary improvement of pain in patients with incomplete surgical treatment. It seems that it has no role on post-surgical pain when the surgeon is able to completely excise DIE implants.

Endometriosis in adolescence

Endometriosis is a common cause of pelvic pain and infertility. The majority of women report symptoms since adolescence, and there are rare cases of endometriosis in premenarchal age patients. Symptoms in adolescence are similar to those in adulthood. Treatment usually consists of oral contraceptives and nonsteroidal anti-inflammatory drugs. In cases where this treatment is not successful, laparoscopy and biopsy of the lesions are necessary for diagnosis. However, emerging new technologies provide new options, in particular the use of serological markers.