Bipedalism and the dawn of uterine fibroids

The high prevalence and burden of uterine fibroids in women raises questions about the origin of these benign growths. Here, we propose that fibroids should be understood in the context of human evolution, specifically the advent of bipedal locomotion in the hominin lineage. Over the ≥7 million years since our arboreal ancestors left their trees, skeletal adaptations ensued, affecting the pelvis, limbs, hands, and feet. By 3.2 million years ago, our ancestors were fully bipedal. A key evolutionary advantage of bipedalism was the freedom to use hands to carry and prepare food and create and use tools which, in turn, led to further evolutionary changes such as brain enlargement (encephalization), including a dramatic increase in the size of the neocortex. Pelvic realignment resulted in narrowing and transformation of the birth canal from a simple cylinder to a convoluted structure with misaligned pelvic inlet, mid-pelvis, and pelvic outlet planes. Neonatal head circumference has increased, greatly complicating parturition in early and modern humans, up to and including our own species. To overcome the so-called obstetric dilemma provoked by bipedal locomotion and encephalization, various compensatory adaptations have occurred affecting human neonatal development. These include adaptations limiting neonatal size, namely altricial birth (delivery of infants at an early neurodevelopmental stage, relative to other primates) and mid-gestation skeletal growth deceleration. Another key adaptation was hyperplasia of the myometrium, specifically the neomyometrium (the outer two-thirds of the myometrium, corresponding to 90% of the uterine musculature), allowing the uterus to more forcefully push the baby through the pelvis during a lengthy parturition. We propose that this hyperplasia of smooth muscle tissue set the stage for highly prevalent uterine fibroids. These fibroids are therefore a consequence of the obstetric dilemma and, ultimately, of the evolution of bipedalism in our hominin ancestors.

Impact of the COVID-19 Pandemic on Access to Fertility Care: A Retrospective Study at a University-Affiliated Fertility Practice

Objective

To elucidate the impact of the COVID-19 pandemic on access to fertility services.

Methods

A retrospective quality improvement study was conducted at a university-affiliated fertility practice in southwestern Ontario. Annual procedural volumes for intrauterine and donor inseminations (IUI/DI), in vitro fertilization and intracytoplasmic sperm injections (IVF/ICSI), and frozen embryo transfers (FET) during the COVID-19–affected year were compared with mean annual volumes from the 2 preceding years. In addition, volumes for the same procedures were compared between the first quarter of 2021 and mean first quarter volumes from 2018 to 2019. Piecewise linear regressions were conducted to evaluate whether any changes in monthly procedural volume were attributable to the COVID-19 pandemic.

Results

In 2020, our fertility practice attained the mean annual volumes of 89.7% for IUI/DI, 69.0% for IVF/ICSI, and 60.6% for FET. In contrast, in 2021, we performed mean first quarter volumes of 130.1% for IUI/DI, 164.3% for IVF/ICSI, and 126.8% for FET. The slopes of the pre- and post–COVID-19 segments of the piecewise linear regressions were significantly different for IUI/DI (P < 0.001) and IVF/ICSI (P = 0.001), but not for FET (P = 0.133).

Conclusion

The COVID-19 pandemic resulted in decreased annual volumes of medically assisted reproductive procedures at a university-affiliated fertility practice in southwestern Ontario. Impact on monthly procedural volume was confirmed for IUI/DI and IVF/ICSI by linear regression. Local adaptations helped compensate and exceed expected volumes in 2021. As a result, the COVID-19 pandemic resulted in a short-lived limitation in access to fertility care.

Uterine kisspeptin receptor critically regulates epithelial estrogen receptor α transcriptional activity at the time of embryo implantation in a mouse model

Embryo implantation failure is a major cause of infertility in women of reproductive age and a better understanding of uterine factors that regulate implantation is required for developing effective treatments for female infertility. This study investigated the role of the uterine kisspeptin receptor (KISS1R) in the molecular regulation of implantation in a mouse model. To conduct this study, a conditional uterine knockout (KO) of Kiss1r was created using the Pgr-Cre (progesterone receptor-CRE recombinase) driver. Reproductive profiling revealed that while KO females exhibited normal ovarian function and mated successfully to stud males, they exhibited significantly fewer implantation sites, reduced litter size and increased neonatal mortality demonstrating that uterine KISS1R is required for embryo implantation and a healthy pregnancy. Strikingly, in the uterus of Kiss1r KO mice on day 4 (D4) of pregnancy, the day of embryo implantation, KO females exhibited aberrantly elevated epithelial ERα (estrogen receptor α) transcriptional activity. This led to the temporal misexpression of several epithelial genes [Cftr (Cystic fibrosis transmembrane conductance regulator), Aqp5 (aquaporin 5), Aqp8 (aquaporin 8) and Cldn7 (claudin 7)] that mediate luminal fluid secretion and luminal opening. As a result, on D4 of pregnancy, the lumen remained open disrupting the final acquisition of endometrial receptivity and likely accounting for the reduction in implantation events. Our data clearly show that uterine KISS1R negatively regulates ERα signaling at the time of implantation, in part by inhibiting ERα overexpression and preventing detrimentally high ERα activity. To date, there are no reports on the regulation of ERα by KISS1R; therefore, this study has uncovered an important and powerful regulator of uterine ERα during early pregnancy.

Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery

OBJECTIVE

To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery.

TARGET POPULATION

All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars.

OUTCOMES

Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery.

EVIDENCE

We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A).

INTENDED AUDIENCE

Surgeons performing laparoscopic gynaecological surgery.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Gonadotropin-Releasing Hormone Agonists Are Effective in Long-term Treatment of Women with Abnormal Uterine Bleeding and Anticoagulant Therapy: Report of 3 Cases and Review of the Literature

Purpose of Review

To evaluate the efficacy of gonadotropin-releasing hormone agonist (GnRHa) in women with abnormal uterine bleeding (AUB) on anticoagulant therapy.

Recent Findings

Prospective observational case series (Canadian Task Force Classification II-3) at University-affiliated teaching hospital. From January 2002 through December 2019, three premenopausal women on warfarin therapy were identified from our clinical practice. After clinical assessment, including Papanicolaou smear, endometrial biopsy, and pelvic sonography, a GnRHa was used to treat their AUB. Two women were receiving warfarin therapy (5–7 mg/day) for previous venous thromboembolism and one for mechanical heart valve replacement associated with Marfan’s syndrome. All patients had additional comorbid conditions and were at high risk for traditional medical or surgical therapies. After treatment with GnRHa, all women reported menstrual reduction at 3 months and remained amenorrheic for 2 to 11 years, two of whom reached menopause.

Summary

In properly assessed and selected premenopausal women with AUB receiving anticoagulant therapy and at high risk for traditional therapies, long-term GnRHa was an effective treatment in 3 patients.

Uterine aquaporin expression is dynamically regulated by estradiol and progesterone and ovarian stimulation disrupts embryo implantation without affecting luminal closure

The study investigated the effect of normal and supraphysiological (resulting from gonadotropin-dependent ovarian stimulation) levels of estradiol (E2) and progesterone (P4) on mouse uterine aquaporin gene/protein (Aqp/AQP) expression on Day 1 (D1) and D4 of pregnancy. The study also examined the effect of ovarian stimulation on uterine luminal closure and uterine receptivity on D4 of pregnancy and embryo implantation on D5 and D7 of pregnancy. These analyses revealed that the expression of Aqp3, Aqp4, Aqp5 and Aqp8 is induced by E2 while the expression of Aqp1 and Aqp11 is induced by P4. Additionally, P4 inhibits E2 induction of Aqp3 and Aqp4 expression while E2 inhibits Aqp1 and Aqp11 expression. Aqp9, however, is constitutively expressed. Ovarian stimulation disrupts Aqp3, Aqp5 and Aqp8 expression on D4 and AQP1, AQP3 and AQP5 spatial expression on both D1 and D4, strikingly so in the myometrium. Interestingly, while ovarian stimulation has no overt effect on luminal closure and uterine receptivity, it reduces implantation events, likely through a disruption in myometrial activity and embryo development. The wider implication of this study is that ovarian stimulation, which results in supraphysiological levels of E2 and P4 and changes (depending on the degree of stimulation) in the E2:P4 ratio, triggers abnormal expression of uterine AQP during pregnancy, and this is associated with implantation failure. These findings lead us to recognize that abnormal expression would also occur under any pathological state (such as endometriosis) that is associated with changes in the normal E2:P4 ratio. Thus, infertility among these patients might in part be linked to abnormal uterine AQP expression.

Complications associated with monopolar resectoscopic surgery

BACKGROUND

Resectoscopic injuries to bowel and/or vessels, although rare, can be catastrophic, resulting in significant patient harm including death and can provoke medicolegal litigation.

OBJECTIVE

To examine indications, preoperative risk factors, perioperative findings and intervention, and clinical outcomes of resectoscopic injuries.

MATERIALS AND METHODS

Eleven cases of resectoscopic complications were reviewed by one author (G.A.V.) for medicolegal purposes. After grouping of the complications, one case for each complication was selected, edited and reconstructed to reflect and highlight all potential complications associated with monopolar resectoscopes (26F, 9-mm) and nonconductive distending medium. Although these cases are reconstructed from actual complications, they do not reflect specific cases of medicolegal opinions and outcomes. Indications for resectoscopic surgery included abnormal uterine bleeding and/or infertility in premenopausal women.

RESULTS

Injuries were associated with uterine perforation resulting in hemorrhage or bowel injury; urinary bladder injury without uterine perforation; and thermal injuries to lower genital tract and dispersive electrode site.

CONCLUSIONS

Resectoscopic complications are associated with any one or a combination of trauma during uterine access or intra-operatively, excessive fluid intravasation of distending medium or thermal injuries from applied energy. Uterine perforation in the presence of distorted anatomy (e.g. uterine fibroids) may be considered as a known and accepted complication. Lower genital tract and dispersive electrode site burn occur due to inherent design of monopolar resectoscopes. Appropriate intra- and post-operative intervention minimizes adverse clinical and medicolegal outcomes. Lack of post-operative vigilance and inappropriate delay in investigation and intervention is associated with adverse clinical and, potentially, unfavourable legal outcomes.

WHAT IS NEW?

Reviewing resectoscopic complications raises awareness; provides insight for avoidance, recognition and timely intervention to minimise adverse clinical and medicolegal outcomes.

Ureteric Injury During Gynaecological Surgery - Lessons from 20 Cases in Canada

BACKGROUND

Ureteric injury is a complication of gynaecological surgery that can cause significant morbidity for the patient and is a leading cause of litigation in many countries.

OBJECTIVES

To determine patient characteristics, peri-operative circumstances and clinical and legal outcomes of ureteral injuries associated with gynaecological surgery.

PATIENTS AND METHODS

This is a retrospective review of 20 cases of ureteric injury during benign gynaecological surgery.

MAIN OUTCOME MEASURES

All cases were assessed for the following variables-patient characteristics, indications for surgery, injury, postoperative symptoms and presentation, and clinical and legal outcomes.

RESULTS

Risk factors associated with ureteric injury included obesity, previous laparotomic pelvic surgery, pelvic adhesions, large pelvic masses and intra-operative bleeding. 70% (14/20) of ureteral injuries were diagnosed after discharge. 50% (10/20) of patients had a complicated post-operative course and 45% (9/20) of cases resulted in unfavourable legal outcomes (settlement or lost at trial) for the surgeon. The conduct of surgery and the failure to act in a timely fashion postoperatively were the most frequent reasons for adverse clinical and unfavourable litigation outcomes for the surgeon.

CONCLUSIONS

Intra-operative surgical consultation and ureteral identification should be considered if there is concern for ureteral involvement in the surgical field. Ureteric injury may not constitute negligence if it is demonstrated that the surgeon provided reasonable care that would be expected during the peri-operative phases.

WHAT IS NEW

This review identifies patient characteristics and peri-operative variables that correlate with poor clinical and legal outcomes after ureteric injury.

Retroperitoneal pelvic tumours in women: diagnostic and therapeutic challenges

BACKGROUND

Gynaecologic pelvic tumours are very common and they can present with a variety of symptoms depending on their size, location, pathophysiology and histogenesis. Infrequently, some pelvic tumours are found in the retroperitoneal space presenting with similar symptoms. Our objective is to present our experience and review of pertinent literature on miscellaneous retroperitoneal tumours.

METHODS

Four women with retroperitoneal tumours (one schwannoma, one granulosa cell tumour and two hindgut (tail gut) cysts)) were encountered during routine laparoscopy (3 cases) and laparotomy (one case). Following multidisciplinary consultation and additional imaging, all tumours were removed by laparotomy with one case provoking litigation due to ureteral and bowel injury.

RESULTS

Using these four cases, and additional cases from the literature, we highlight the potential pitfalls and provide an algorithm to minimize risks and adverse clinical and legal outcomes associated with unexpected retroperitoneal tumours. The algorithm includes resisting the impulse/temptation to remove or biopsy these tumours, requesting intra-operative consultation(s), obtaining additional detailed imaging to characterize these tumours, providing appropriate counselling to patients, obtaining informed consent, and consulting the appropriate surgical teams. At times, an interdisciplinary approach may prove to be the best course of action in order to optimize treatment and ensure patient safety.

CONCLUSION

If a retroperitoneal tumour is unexpectedly encountered, it is imperative to have intra-operative consultation (if available), to not attempt excision or biopsy, and to subsequently obtain post-operative multidisciplinary consultations, specific imaging, and information gathering in order to treat these heterogeneous masses as safely as possible.

Direct Laparoscopic Trocar Insertion: Lessons Learned from Nine Litigated Cases

STUDY OBJECTIVE

To report circumstances and clinical and medicolegal outcomes of 9 litigated cases associated with direct trocar insertion (DTI) injuries to the bowel (7 cases) and major vessel (2 cases) during primary laparoscopic access.

DESIGN

A case series from 1990 through 2015 (Canadian Task Force Classification II-2).

PATIENTS

Nine litigated cases.

INTERVENTIONS

A retrospective review of medical and legal records of litigated cases in Canada reviewed by the primary author (G.A.V.).

MEASUREMENTS AND MAIN RESULTS

The average and range of age and body mass index of the women were 31 years (range, 14-65 years) and 25 kg/m² (range, 20-35 kg/m²), respectively. Indications for laparoscopy included diagnostic (4), laparoscopically assisted vaginal hysterectomy (3), pelvic mass (1), and laparoscopic cholecystectomy (1). DTI was performed with 10-mm trocars (5 shielded, 1 reusable, and 3 unknown). Two complications were experienced by patients of the same male surgeon (cases 2 and 9). Injuries included the small bowel (4 cases), colon (3 cases), and major vessel (2 cases). Vascular injuries resulted in permanent brain damage in 1 and near loss of limb in the other; litigation was favorable to the plaintiff in both cases. All bowel injuries presented with signs and symptoms of peritonitis within 3 postoperative days (PODs) (5 patients on POD 1, 1 patient on POD 2, and 1 patient on POD 3); however, only 2 cases were acted upon and remedied with favorable clinical and medicolegal outcomes. A delayed exploratory laparotomy resulted in significant adverse clinical outcomes (ileostomy/colostomy in 4 patients, multiple surgeries in 7 patients, and 1 death), and in all delayed actions, the medicolegal outcomes were favorable to the plaintiff.

CONCLUSION

During laparoscopic primary peritoneal access using the DTI technique, inadvertent intra-abdominal injury may be significant when major vessels are involved and when intervention is delayed in bowel injuries. These result in significant adverse clinical complications and may provoke higher litigation with more favorable outcomes for the plaintiff.

Postablation Endometrial Carcinoma

BACKGROUND

Many women have undergone both resectoscopic and nonresectoscopic (or global) endometrial ablation (EA) during the past 20 years. These women are now approaching their sixth and seventh decades of life, a time frame in which endometrial carcinoma (EC) is most frequently diagnosed.

DATABASE

In several reports, surgeons have expressed concern that endometrial ablation may leave a sequestered island of EC that may escape detection, possibly delaying its diagnosis or causing it to appear at an advanced stage. Others suggest that EA artifact does not hinder the evaluation and treatment planning in the presence of EC. Data bases used are from Medline and PubMed.

DISCUSSION

We introduce 6 new cases of postablation endometrial carcinoma (PAEC), 4 of which occurred after the introduction of global endometrial ablation (GEA) techniques. In addition, we examine several key questions regarding the impact of EA on the subsequent development of EC, including the manner in which PAEC presents, the efficacy of traditional diagnostic modalities, the ablation-to-cancer interval, and the stage of PAEC at the time of diagnosis. Finally, we explore the use of reoperative hysteroscopic surgery (RHS) as a diagnostic modality and address the possible role ultrasound surveillance as a screening method for women at risk of EC.

Beyond the brain-Peripheral kisspeptin signaling is essential for promoting endometrial gland development and function

Uterine growth and endometrial gland formation (adenogenesis) and function, are essential for fertility and are controlled by estrogens and other regulators, whose nature and physiological relevance are yet to be elucidated. Kisspeptin, which signals via Kiss1r, is essential for fertility, primarily through its central control of the hypothalamic-pituitary-ovarian axis, but also likely through peripheral actions. Using genetically modified mice, we addressed the contributions of central and peripheral kisspeptin signaling in regulating uterine growth and adenogenesis. Global ablation of Kiss1 or Kiss1r dramatically suppressed uterine growth and almost fully prevented adenogenesis. However, while uterine growth was fully rescued by E2 treatment of Kiss1^−/− mice and by genetic restoration of kisspeptin signaling in GnRH neurons in Kiss1r^−/− mice, functional adenogenesis was only marginally restored. Thus, while uterine growth is largely dependent on ovarian E2-output via central kisspeptin signaling, peripheral kisspeptin signaling is indispensable for endometrial adenogenesis and function, essential aspects of reproductive competence.

Burden of symptomatic uterine fibroids in Canadian women: a cohort study

OBJECTIVE

Due to variability in size, number, and location of uterine fibroids (UFs), symptoms can range widely among women. We sought to characterize burden of illness and quality of life (QoL) among women with symptomatic UFs.

RESEARCH DESIGN AND METHODS

An online survey queried the gynecologic health and menstrual cycle of Canadian women aged 20 to 49. Respondents reporting current UFs were assigned an Overall Severity Score based on a validated health-related QoL questionnaire (the UFS-QOL) and were dichotomized as having mild or moderate/severe UF. Subjects with moderate/severe UFs were matched 1:3 to non-UF subjects on age, race, and parity.

RESULTS

Of 9413 women with complete data, 384 (4.1%) reported physician-diagnosed UFs; of these, 50.6% met criteria for moderate/severe symptoms. Compared with matched non-UF respondents, moderate/severe UF respondents reported significantly greater mean menstrual duration (6.2 vs 5.0 days), more healthcare visits (emergency department, walk-in, family doctor, and specialist; total 10.5 vs 4.9 visits/6 months), and greater use of prescription analgesics (47.7% vs 26.7%) and iron supplements (29.7% vs 12.2%) (P < 0.05 for all). They spent more on feminine hygiene products ($32.0 vs $21.6/month) and reported losing nearly a full day of work/month (mean 7.6 hours) due to UFs. Women with moderate/severe UFs also scored lower on all QoL domains, compared to those with mild UF symptoms. Survey responses consistent with moderate/severe UFs were also identified in women who made no report of physician-diagnosed UFs, some of whom may be experiencing substantial burden due to undiagnosed UFs or other gynecologic conditions with related symptoms.

LIMITATIONS

All outcomes recorded in this online survey were based on self-report. Therefore, respondents' claims of medical diagnoses, including medical history, UF status and the presence or absence of potentially confounding comorbidities, could not be confirmed clinically.

CONCLUSIONS

Women experienced significant healthcare utilization, medication use, and financial and QoL burdens as a result of moderate/severe UF symptoms. Prevalence of moderate/severe UFs may be conservatively estimated at 2%, based on this cohort of reproductive-age Canadian women. The extent of UF underdiagnosis in the general population remains to be elucidated.

Post-uterine artery embolization pain and clinical outcomes for symptomatic myomas using gelfoam pledgets alone versus embospheres plus gelfoam pledgets: a comparative pilot study

BACKGROUND

To evaluate the efficacy and post-procedural pain associated with uterine artery embolization (UAE) using Gelfoam alone versus Embospheres plus Gelfoam in women with symptomatic uterine fibroids.

METHOD

We conducted a prospective, non-randomized pilot study. Fluoroscopy-guided trans-femoral artery UAE was performed using Gelfoam pledgets alone or Embospheres (500 to 700 mg) plus Gelfoam under conscious sedation and local anaesthesia. This was followed by patient-controlled analgesia (PCA) using a morphine pump overnight. Post-procedural pain was assessed by the mean amount of self-administered morphine delivered by PCA pump (mL) from 0 to 19 hours in each group. The mean volumes of the uterus and the dominant fibroid were calculated by ultrasound at baseline, three months, six months, and 12 months.

RESULTS

A total of 17 women participated in the study. Bilateral uterine artery occlusion was performed in eight women using Gelfoam alone, and in nine women using Embosphere + Gelfoam. One woman in the Embosphere + Gelfoam group developed a puncture-site hematoma requiring further intervention one week later. The mean (SD) amount of morphine self-administered by PCA pump at time 0, 1, and 2 hours was 3.4 mg (3.1), 2.9 mg (2.2), and 2.4 mg (3.3) in the Gelfoam-only group and 6.1 mg (3.0), 9.6 mg (7.1), and 5.3 mg (4.4) in the Embosphere + Gelfoam group, respectively. After three hours, the amount of morphine used was equal in both groups. The mean (SD) total dose of morphine used was 29.5 mg (18.6) in the Gelfoam group and 41.1 mg (19.3) in the Embosphere + Gelfoam group (P = 0.228). At 12 months, the reduction in median total uterine volume and median dominant fibroid volume in each group was equal.

CONCLUSION

Clinical outcomes were equivalent after uterine artery embolization using Gelfoam alone versus Gelfoam + Embospheres. Although the amount of immediate post-procedure pain may be less with Gelfoam alone, we could not demonstrate this objectively using morphine use as a measure of pain.

Long-term clinical outcomes following resectoscopic endometrial ablation of non-atypical endometrial hyperplasia in women with abnormal uterine bleeding

STUDY OBJECTIVE

To determine the feasibility, efficacy, and long-term clinical outcomes of resectoscopic endometrial ablation as primary treatment of simple endometrial hyperplasia (SH) and complex endometrial hyperplasia (CH) without atypia in women with abnormal uterine bleeding (AUB).

DESIGN

Prospective follow-up study (Canadian Task Force classification II-2).

SETTING

Teaching hospital.

PATIENTS

One hundred sixty-one women with hyperplasia, either SH (n = 107) or CH (n = 54).

INTERVENTIONS

From January 1990 through December 2012, one of us performed 4729 primary resectoscopic endometrial ablation procedures in women with AUB. This group included 161 women with endometrial hyperplasia, identified either at office biopsy (n = 62) or incidentally during routine hysteroscopic endometrial ablation (n = 99). Endometrial tissue obtained at dilation and curettage and/or resected during resectoscopic surgery enabled identification of atypical hyperplasia in 6 patients (4 CH, 2 SH) and 1 patient with adenosarcoma. One patient with atypical CH and the patient with adenosarcoma underwent hysterectomy. The remaining 159 women, including 5 with atypical hyperplasia (3 CH, 2 SH), underwent resectoscopic endometrial ablation (102 SH, 52 CH) as primary treatment. Patient median age was 50 years (range, 30-87 years), and body mass index was 32 (range, 17-59). Comorbidities included hypertension in 25 patients, diabetes in 14, cerebrovascular disease in 3, cardiovascular disease in 7, and hypothyroidism in 8. Office biopsy demonstrated proliferative endometrium in 68 patients, SH in 43, CH in 19, and inadequate findings in 13. In 18 women, we were unable to perform biopsy because of cervical stenosis, morbid obesity, or patient intolerance. Endometrium was resected in 120 patients, electrocoagulated in 34, and a combination of procedures in 5, using a 9-mm (26F) resectoscope, 1.5% glycine, and 120W power. Patients were followed up annually. Three patients were lost to follow-up, and 1 died of an unrelated cause 5 years after surgery.

MEASUREMENTS AND MAIN RESULTS

One uterine perforation occurred, which required no additional treatment. After endometrial ablation, SH was identified in 70 patients, and CH in 35 patients. At a median follow-up of 7 years (range, 1.5-18), 12 patients underwent hysterectomy to treat persistent bleeding (n = 6), benign ovarian cyst (n = 2), pelvic organ prolapse (n = 1), chronic pelvic pain (n = 2), or myomas (n = 1). Uterine histopathology in 11 patients demonstrated no residual endometrial hyperplasia. We were unable to obtain a pathology report for 1 patient. The remaining 138 women were satisfied with the treatment, with no further bleeding or pain in 132 (95.7%). Six patients (4.3%) had monthly spotting.

CONCLUSION

When performed by surgeons experienced in hysteroscopy, resectoscopic endometrial ablation is feasible, safe, and effective for treatment of SH and CH without atypia in women with AUB.

Retroperitoneal pelvic cyst: a diagnostic and therapeutic challenge

BACKGROUND

Retroperitoneal cysts can be asymptomatic or can present with vague symptoms such as abdominal pain or distension. Their clinical implications vary significantly.

CASE

A 45-year-old woman, gravida 2, para 2, presented with vague, non-specific pelvic symptomatology. Imaging indicated a right-sided pelvic cyst 5 cm in diameter. At laparoscopy a retroperitoneal cyst was identified, with a normal pelvis and intra-abdominal organs. No attempt was made at laparoscopy to drain, biopsy, or excise the cyst. CT-guided biopsy of the cyst was performed and small intestine mucosa was identified with goblet cells and smooth muscle. Repeat biopsy confirmed areas of tissue necrosis and small intestine mucosa, with additional tissue containing respiratory epithelium. Following laparotomy and excision of the cyst, the final pathologic diagnosis was benign epithelial cyst consistent with a duplication or hindgut cyst.

CONCLUSION

Although most retroperitoneal cysts are benign, surgical excision is required to rule out malignancy definitively.

Uterine smooth muscle tumors of uncertain malignant potential: diagnostic challenges and therapeutic dilemmas. Report of 2 cases and review of the literature

Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly interpreted and classified as benign or malignant. Because their behavior and clinical prognosis is also uncertain, the World Health Organization has termed these "smooth muscle tumors of uncertain malignant potential" (STUMP). Herein we describe 2 cases, present a review of the literature, and highlight the diagnostic challenges and therapeutic dilemmas associated with uterine STUMP in myomectomy specimens from women who wish to maintain or enhance their fertility. The clinical course of residual STUMP remains speculative.

Granulosa cells in the uterosacral ligament: case report and review of the literature

Granulosa cells are components of the sex cord-stromal cells in the ovary responsible for steroidogenesis. Uncommonly, extraovarian granulosa cells have been reported to be associated with malignant processes of the ovary. We report a unique case of benign granulosa cells, found during routine laparoscopic evaluation, in the uterosacral ligaments in a 20-year-old patient with chronic pelvic pain and infertility. Possible mechanisms include implantation of released granulosa cells from a normal ovary or arising from a focus of müllerianosis. Of note, a focus of endosalpingiosis and endometriosis was also identified within the specimen.

Ureter in histopathologic specimen: a gynecologist's nightmare

An 18-year-old woman presented with a large right-sided ovarian cyst. After further evaluation and counselling, the patient underwent laparotomy and oophorectomy. The pathology report described a large mature cystic teratoma with a tubular structure consistent with a cross-section of ureter. Subsequent evaluation of the urinary tract system was normal indicating that the ureter was an element of the mature cystic teratoma.

Effect of body habitus and parity on insufflated CO2 volume at various intraabdominal pressures during laparoscopic access in women

STUDY OBJECTIVE

To determine height, weight, body mass index (BMI), parity, and age effect on the volume of CO2 pneumoperitoneum during laparoscopic access in women.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University-affiliated teaching hospital.

PATIENTS

From January through June 2004, 100 healthy women underwent operative laparoscopic surgery consecutively by the senior author (GAV). Indications were: chronic pelvic pain (CPP, n = 66), pelvic mass (n = 7), CPP and pelvic mass (n = 4), infertility (n = 23). Median (range) height, weight, BMI, parity and age were 1.65 m (1.45-1.85 m), 70 kg (43-118 kg), 25.5 kg/m2 (17-39 kg/m2), 1.1 (0-5), and 34 years (19-58 years), respectively.

INTERVENTIONS

While in supine position, patients received general endotracheal anesthesia and muscle relaxants. Pneumoperitoneum was established by reusable Veres needle. The insufflated CO2 volume was serially recorded at intraperitoneal insufflation pressures (IPIPs) of 10, 15, 20, 25, and 30 mm Hg. The primary 10-mm trocar was introduced at IPIP of 30 mm Hg. Upon entering the peritoneal cavity, the abdominal contents were visualized with the laparoscope to ensure there was no injury, and the IPIP was immediately reduced back to the operating pressure of 15 mm Hg before switching the patient to the Trendelenburg position.

MEASUREMENTS AND MAIN RESULTS

The mean (SD) insufflated CO2 volumes at 10, 15, 20, 25, and 30 mm Hg were 1.7 (0.74) L, 3.1 (0.9) L, 3.96 (1.05) L, 4.42 (1.1) L and 4.72 (1.14) L, respectively. Using multivariate analysis, we demonstrated that at 20 to 30 mm Hg the insufflated CO2 volume correlated positively with the height, weight and BMI of women. Parity correlated positively at all pressures. There was no correlation with age at any pressure.

CONCLUSIONS

Higher CO2 volume is required to establish appropriate pneumoperitoneum in tall, overweight, and parous women at 20 to 30 mm Hg. Setting the IPIP at 20 to 30 mm Hg before primary trocar insertion eliminates the need to monitor CO2 insufflated volume regardless of women's age, parity, and body habitus.

Administration of goserelin acetate after uterine artery embolization does not change the reduction rate and volume of uterine myomas

OBJECTIVE

To determine if goserelin immediately after uterine artery embolization (UAE) affected myoma reduction.

DESIGN

Randomized pilot study (level 1).

SETTING

Teaching hospital.

PATIENT(S)

Twenty-six women.

INTERVENTION(S)

All patients underwent UAE, and then 12 patients received 10.8 mg of goserelin 24 hours later. The treatment group was 5 years older: 43 versus 37.7 years. Uterine and myoma volumes were measured by ultrasound 2 weeks before UAE and at 3, 6, and 12 months.

MAIN OUTCOME MEASURE(S)

Uterine and fibroid volumes.

RESULT(S)

Pretreatment uterine volume was 477 versus 556 cm3, and dominant fibroid volume was 257 versus 225 cm3 in the control versus goserelin groups. Analysis of variance measurements indicated that the change over time did not significantly differ between the two groups. By 12 months, the control group had a mean uterine volume reduction of 58%, while the goserelin group had a reduction of 45%. Dominant fibroid changes over time did not differ between the two groups. At 12 months, the mean fibroid volume had decreased by 86% and 58% in the control and goserelin groups, respectively.

CONCLUSION(S)

The addition of goserelin therapy to UAE did not alter the reduction rate or volume of uterine myomas.

Effect of body habitus and parity on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women

STUDY OBJECTIVES

Since most gynecologists use the Veres/trocar entry, and because the Veres intraperitoneal (VIP) pressure appears to be the most reliable indicator of correct Veres needle placement, the objective of this study was to determine the effect of height, weight, body mass index (BMI), parity, and age on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University affiliated teaching hospital.

PATIENTS

We prospectively collected data on 356 women undergoing laparoscopy for a variety of indications by the senior author (G.A.V.). The median and (range) for height, weight, BMI, parity, and age were 1.64 m (1.45-1.85 m), 65 kg (40-120 kg), 24.3 kg/m2 (16-47 kg/m2), 1 (0-5) and 34 years (18-87 yrs), respectively.

INTERVENTION

Under general endotracheal anesthesia including muscle relaxants and with the patient in appropriate stirrups in the horizontal position, a nondisposable Veres needle was inserted at the umbilicus or left upper quadrant (Palmer's point) with CO2 flowing at 1 L/min. The initial Veres intraperitoneal insufflation pressure was recorded once the Veres needle was believed to be in the peritoneal cavity.

MEASUREMENTS AND MAIN RESULTS

The mode and the median VIP pressure was 4 mm Hg with a range of 2 to 10 mm Hg. With multivariate analysis, the VIP pressure correlated positively with the weight (r = 0.518, p <.001) and BMI (r = 0.545, p <.001) and negatively with the parity (r = -0.179, p <.001) of women. The correlation of the VIP pressure with height and age was r = 0.029 (p = .591) and r = -0.044 (p = .411), respectively.

CONCLUSION

A VIP pressure < or =10 mm Hg indicates intraperitoneal placement of the Veres needle. The VIP pressure correlates positively with the weight and BMI and negatively with the parity of women. There is no correlation of the VIP pressure with women's height and age.

Characterization and mitigation of stray radiofrequency currents during monopolar resectoscopic electrosurgery

STUDY OBJECTIVE

To determine patterns and range of stray radiofrequency (RF) currents flowing through the working element of monopolar resectoscopes during routine endometrial rollerball ablation or resection; and to determine whether straightforward modifications of the uterine resectoscope and the application of RF monitoring could provide a safe pathway for such currents.

DESIGN

Prospective in vivo measurements (Canadian Task Force classification II-1).

SETTING

University-affiliated teaching hospital.

PATIENTS

Twelve women undergoing resectoscopic surgery.

INTERVENTIONS

During routine resectoscopic surgery using 1.5% glycine irrigant solution, three modified 26F Storz resectoscope working elements (model 27070E) were adapted to be continuously monitored with an Encision AEM device for excessive capacitive coupling and other stray currents from insulation failure. Active electrodes used were 3 mm and 5 mm rollberballs and 8 mm-diameter cutting loops powered by ERBE or Valleylab generators at 120 W. Active and working element currents were monitored by Pearson current transformers followed by root-mean-squared detectors based on the Analog Devices AD-637 integrated circuit. Data were recorded using a Fluke 199C oscilloscope, then serially transferred to a notebook computer and analyzed using Flukeview, Excel, and Minitab software.

RESULTS

Typical values of working element currents ranged from 0.10 to 0.20 A. Active electrode currents were typically in the range of 0.50 to 1.10 A. Frequently, the working element current exceeded the typical values and ranged up to 0.60 A. These current surges produced a heat factor (I(2)t) of 0.45 A(2).sec in a 10-second period.

CONCLUSIONS

During resectoscopic electrosurgery, baseline, most likely capacitive coupled, currents were always present. In addition, high values of working element currents occurred frequently, and they surged up to 0.60 A for significant periods of time. Without the modification of the resectoscopic device, these currents have the capability of flowing through the patient's genital tract and causing burns. Since monopolar electrosurgery remains an integral part of most hysteroscopic procedures, active electrode monitoring may offer a solution in protecting the patient and the surgeon from stray electrosurgical burns.

High-pressure laparoscopic entry does not adversely affect cardiopulmonary function in healthy women

STUDY OBJECTIVE

To determine hemodynamic and pulmonary compliance changes during laparoscopic entry using transient hyperinsufflated pneumoperitoneum.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University-affiliated teaching hospital.

SUBJECTS

From January through June 2004 one hundred healthy women underwent operative laparoscopy consecutively. Indications included chronic pelvic pain (CPP, N=66), pelvic mass (N=7), CPP and pelvic mass (N=4), primary or secondary infertility (N=23). The mean age was 34 years (range, 19-58) and the mean BMI 25.5 kg/m2 (range, 17.1-39.4).

INTERVENTIONS

With the patients under general anesthesia, muscle relaxants, and in supine position, pneumoperitoneum was established using a Veres needle. The following information was prospectively collected at different intraperitoneal insufflation pressures (IPIP): CO2 volume, heart rate, blood pressure, and pulmonary compliance. At IPIP of 30 mm Hg the primary trocar was inserted and the IPIP was immediately reduced back to the operating pressure of 15 mm Hg.

MEASUREMENTS AND MAIN RESULTS

The mean initial IPIP was 4.7 mm Hg (range, 2-9 mm Hg). The mean volume of CO2 at IPIP of 10, 15, 20, 25, and 30 mm Hg was 1.7, 3.1, 4, 4.4, and 4.7 L, respectively. There was no statistically significant change in the heart rate or pulse pressure between IPIP of 15 and 30 mm Hg. The difference in CO2 volume (1.6 L) required to achieve IPIP of 15 and 30 mm Hg was statistically significant (p<0.0001). A statistically significant increase of 7 mm Hg in the mean arterial pressure (MAP) was found between IPIP of 15 & 30 mm Hg (p<0.0001). The additional 21% drop in pulmonary compliance from IPIP 15 to 30 mm Hg was statistically significant (p<0.0001). This decrease in pulmonary compliance was well tolerated by the patients, and the oxygen saturation remained above 92% in all cases. The elevated MAP was not clinically significant.

CONCLUSION

The use of transient hyperinsufflated pneumoperitoneum caused minor hemodynamic alterations which were not clinically significant. The alterations in pulmonary compliance were statistically significant; however, they had no clinical significance and were tolerated well by healthy women.

Safe laparoscopic entry guided by Veress needle CO2 insufflation pressure

Laparoscopy was performed in 259 women. Under general anesthesia, after administering muscle relaxants, and with the patient in stirrups and horizontal position, a nondisposable Veress needle was inserted at the umbilicus or left upper quadrant site with carbon dioxide (CO2) flowing at 1 L/minute. We measured initial intraabdominal pressure in the first 52 women (group 1), pneumoperitoneum pressure (up to 15 mm Hg) at 1-L intervals in the next 102 women (group 2), and CO2 volume required for pressures of 10, 15, 20, and 25 mm Hg in the final 102 women (group 3). In three patients the procedure was abandoned. The primary trocar and laparoscope were introduced at pressure of 25 mm Hg and the entry site and abdominal contents were inspected before desufflation to 15 mm Hg and Trendelenburg position. Medians and means of initial intraabdominal pressure were 4 and 4.09 mm Hg (SD 1.34 mm Hg, range 2-8 mm Hg). This was always below interstitial pressures measured in the abdominal wall and during inadvertent insertion into omentum (5) and colon (2). Correlation between initial intraperitoneal pressure and patients' parity, weight, and body mass index was minimal. Mean CO2 volumes at 10, 15, 20, and 25 mm Hg were 3.7, 5.1, 5.9, and 6.5 L, respectively. No major complications were encountered. An initial intraabdominal pressure of 8 mm Hg or below always indicates correct placement of the Veress needle regardless of the patient's body habitus. Pressures greater than 8 mm Hg indicate interstitial placement including colon. Adequate pneumoperitoneum is determined by CO2 insufflation to a pressure of 25 mm Hg and not by a preconceived volume of CO2.