Intermittent Self-catheterization for Bladder Dysfunction After Deep Endometriosis Surgery: Duration and Factors that Might Affect the Recovery Process

STUDY OBJECTIVE

To assess the duration needed for regaining normal bladder voiding function in patients with postoperative bladder dysfunction requiring intermittent self-catheterization after deep endometriosis surgery and identify risk factors that might affect the recovery process.

DESIGN

Retrospective study based on data recorded in a large prospective database.

SETTING

Endometriosis referral center.

PATIENTS

From September 2018 to June 2022, 1900 patients underwent excision of deep endometriosis in our center; 61 patients were discharged with recommendation for intermittent self-catheterization and were thus included in the study.

INTERVENTIONS

Intermittent self-catheterization after endometriosis surgery.

MEASUREMENTS AND MAIN RESULTS

A total of 43 patients (70.5%) stopped self-catheterization during the follow-up period. Median follow-up was 25 weeks (range, 7-223 wk). Surgery was performed laparoscopically in 48 patients (78.7%) and robotically in 13 (21.3%); 47 patients (77%) had nodules involving the digestive tract, 11 (18%) had urinary tract involvement, 29 had parametrial nodules (47.5%), and 13 (21.3%) had sacral plexus involvement. The probability of bladder voiding function recovery and arrest of self-catheterization was 24.5%, 54%, 59%, 72%, and 77% at 4, 8, 12, 52, and 78 weeks, respectively. Cox's multivariate model identified preoperative bladder dysfunction as the only statistically significant independent predictor for arrest of self-catheterization (hazard ratio, 0.36; 95% confidence interval, 0.15-0.83).

CONCLUSION

Patients requiring intermittent self-catheterization for bladder dysfunction after deep endometriosis excision may spontaneously recover bladder function in 77% of cases. Symptoms suggesting preoperative bladder voiding dysfunction should be reviewed before planning surgery, and patients should be informed of the higher postoperative risk of long-term bladder voiding dysfunction.

Combined Cystoscopic-Abdominal Versus Abdominal-Only Route for Complete Excision of Large Deep Endometriosis Nodules Infiltrating the Supratrigonal Area of the Bladder: A Comparative Study

STUDY OBJECTIVE

Surgical excision of large deep endometriosis nodules infiltrating the bladder may be challenging, particularly when the nodule limits are close to the trigone and ureteral orifice. Bladder nodules have classically been approached abdominally. However, combining a cystoscopic with an abdominal approach may help to better identify the mucosal borders of the lesion to ensure complete excision without unnecessary resection of healthy bladder. This study aimed to compare classical excision of large bladder nodules by abdominal route with a combined cystoscopic-abdominal approach.

DESIGN

Retrospective comparative study on data prospectively recorded in a database. Patients were managed from September 2009 to June 2022.

SETTING

Two tertiary referral endometriosis centers.

PATIENTS

A total of 175 patients with deep endometriosis infiltrating the bladder more than 2 cm undergoing surgical excision of bladder nodules.

INTERVENTIONS

Excision of bladder nodules by either abdominal or combined cystoscopic-abdominal approaches.

MEASUREMENTS AND MAIN RESULTS

A total of 141 women (80.6%) were managed by abdominal route and 34 women (19.4%) underwent a combined cystoscopic-abdominal approach. In 99.4% of patients, the approach was minimally invasive. Patients with nodules requiring the combined approach had a lower American Fertility Society revised score and endometriosis stage and less associated digestive tract nodules, but larger bladder nodules. They were less frequently associated with colorectal resection and preventive stoma. Operative time was comparable. The rate of early postoperative complications was comparable (8.8% vs 22%), as were the rates of ureteral fistula (2.2% vs 2.9%), bladder fistula (2.2% vs 0), and vesicovaginal fistula (0.7% vs 2.9%).

CONCLUSION

In our opinion, the combined cystoscopic-abdominal approach is useful in patients with large bladder nodules with limits close to the trigone and ureteral orifice. These large deep bladder nodules seemed paradoxically associated to less nodules on the digestive tract, resulting in an overall comparable total operative time and complication rate.

Robotic Surgery for Severe Endometriosis: A Preliminary Comparative Study of Cost Estimation

STUDY OBJECTIVE

To compare the postoperative outcomes and the overall expenses between conventional laparoscopy and robotic surgery, in a series of consecutive patients managed for only severe endometriosis in our institute.

DESIGN

A cohort comparative study.

SETTING

Center of Excellence in Multidisciplinary Endometriosis Care.

PATIENTS

A total of 175 symptomatic patients undergoing surgery for only severe endometriosis from March 2021 to August 2022.

INTERVENTIONS

We treated patients with endometriosis involving the digestive tract such as rectum, sigmoid colon, and ileocecal junction by rectal shaving, discoid resection, or segmental resection (141 surgeries) with or without bladder (23 surgeries), sacral plexus (19 surgeries), and diaphragm involvements (14 surgeries).

MEASUREMENTS AND MAIN RESULTS

Postoperative outcomes were evaluated in terms of total surgical time (total surgical room occupancy time and total operating time), hospitalization period, postoperative complications, rehospitalization, and second surgical procedures. A statistically higher total surgical room occupancy (203 minutes vs 151 minutes) and operating time (150 minutes vs 105 minutes) were observed in the robotic group (p = .001). No differences in terms of mean hospital stay (p = .06), postoperative complications (p = .91), rehospitalization (p = .48), and secondary surgical treatment (p = .78) were identified. Concerning the cost analysis only for disposable supply, the cost of colorectal resection was totaled at 2604 euros for the laparoscopic conventional approach vs 2957 euros for the robotic approach (+352.6 euros, +14%). The cost of rectal disc excision was 1527 euros for the laparoscopic conventional approach vs 1905.85 euros (+378 euros, +25%).

CONCLUSIONS

Our study confirms the feasibility of the robotic approach for the treatment of severe endometriosis, with however a higher cost of robotic approach. Next studies should identify specific indications for robotic surgery, where technical advantages provided by the technology are followed by objective improvement of patients' outcomes.

Ventrofixed Uterus: Unfreezing the Uterus in 6 Standardized Steps

Objective

This article presents a 6-step laparoscopic technique for dissecting a central uterine band in a ventrofixed uterus, in order to minimize injury to adjacent structures during such procedures as repeat cesarean sections and hysterectomy.

Methods

The description of this laparoscopic surgical technique shows how the anatomically consistent avascular space beneath the uterine band was accessed via lateral dissection. An online video demonstrating the anatomy, anatomical free space, and secure dissection techniques is included.

Results

The proposed technique enables safe dissection of the uterine band and reduces the risk of bladder injury during uterine-preserving procedures. Accessing the anatomical free space via lateral dissection results in a safer operative field, decreased blood loss, and preserved myometrium during uterine-preserving procedures.

Conclusions

The anatomically consistent avascular space beneath the uterine band is accessible via lateral dissection, enabling secure dissection of the uterine band. This technique can be used in both laparoscopic and open procedures, such as repeat cesarean sections. Familiarity with the anatomy of the central uterine-adhesion band can ensure a safe operation and reduce the risk of bladder injury. (J GYNECOL SURG 39:220).

Primary Umbilical endometriosis - case series and review of clinical presentation, diagnosis and management

Introduction

Umbilical endometriosis is the most common cutaneous form and is seen mostly secondary to surgical scar and rarely occurs as primary umbilical endometriosis. The objective of this retrospective case series evaluation is to report the presentation, diagnosis, and management of patients with primary umbilical endometriosis.

Presentation of cases

We present a retrospective, observational and descriptive review of cases presenting with primary umbilical endometriosis among Indian women managed in two private tertiary care centres between 2018 and 2020. Patients were assessed at the gynaecological outpatient department. We analysed age, parity, presenting symptoms and duration, associated symptoms, imaging, size of the lesion, associated pelvic endometriosis or any pelvic pathology, management, and histopathological diagnosis for confirmation in all four patients.

Discussion

The patients were aged between 25 and 31 years with an average of 28 years with no previous history of any abdominal surgeries. The mean duration of the symptoms presented in these cases was 25.5 months, with a range from 18 to 48 months. The diagnosis was made by clinical examination supported by imaging followed by complete surgical excision and confirmation on histopathology.

Conclusion

Primary umbilical endometriosis is a rare disease with a limited number of cases reported in the literature and should be included in the differential diagnosis if women present with umbilical lesions with cyclical pain. Diagnosis is clinical but can be aided by high resolution imaging such as Ultrasound (US) and Magnetic Resonance Imaging (MRI). Complete surgical excision is the treatment of choice.

•

Primary umbilical endometriosis should be considered in cases of umbilical nodule with cyclical pain

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High resolution imaging to differentiate from other umbilical nodules and avoid delay in diagnosis and management

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Complete surgical excision is the treatment of choice

Novel Anastomotic Technique for Uterine Transplant Using Utero-ovarian Veins for Venous Drainage and Internal Iliac Arteries for Perfusion in Two Laparoscopically Harvested Uteri

STUDY OBJECTIVE

To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically.

DESIGN

Case study (Canadian Task Force Classification III).

SETTING

An urban, private, tertiary care hospital.

PATIENTS

Two patients, ages 30 and 24years, diagnosed with absolute uterine factor infertility secondary to Mayer-Rokitansky-Küster-Hauser syndrome underwent related living donor uterine transplants; donors were their mothers with normal menses.

INTERVENTIONS

Retrieval of organs through minilaparotomy and laparoscopic harvest of donor internal iliac arteries and ovarian veins.

MEASUREMENTS AND MAIN RESULTS

Anastomosis was completed with bilateral donor internal iliac arteries to recipient internal iliac arteries in an end-to-end manner and with bilateral donor ovarian veins to recipient external iliac veins in an end-to-side manner. The lengths of utero-ovarian veins of both donors were 11 and 11cm on both sides; the lengths of the internal iliac arteries of both donors were 10 and 7.5cm on the left side and 10 and 6cm on the right side. The operative times for harvest surgery, bench surgery and transplant surgery were 2:40 and 3:20 hours, 34:32 and 33:30 min and 4:00 and 4:30 hours respectively for recipients 1 and 2. Daily postoperative uterine Doppler was completed through day 8 and then every other day and showed good intrauterine blood flow (i.e., low resistance arcuate vessel flow; resistance index < .5). Cervical biopsies on postoperative days 7 and 14 showed no evidence of rejection in either recipient. Both recipients started menstruating within 2 months of surgery.

CONCLUSION

By using ovarian veins as outflow channels, the challenges involved in dissection along the internal iliac vein are avoided, and harvesting the donor internal iliac artery reduces the tension on vascular anastomosis. The selection of vessels to be harvested could make the technique reproducible, although larger studies are warranted to confirm results.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant: Our Experience of Two Patients

STUDY OBJECTIVE

To report the first ever laparoscopic-assisted live donor uterus retrieval in 2 patients for uterus transplant.

DESIGN

Case study (Canadian Task Force classification III).

SETTING

Galaxy CARE Laparoscopy Institute, Pune, India.

PATIENTS

Two patients with absolute uterine factor infertility with their mothers as donors.

INTERVENTIONS

In vitro fertilization and uterine transplant.

MEASUREMENTS AND MAIN RESULTS

A 12-member team was formed, and approval for transplant was obtained from the institutional review board. Pretransplant, in vitro fertilization for both patients was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus and harvested vessels were retrieved by a small abdominal incision to prevent injury and infection. The uterus was transplanted in the recipients by end to side anastomosis of the harvested vessels to external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 6 months were measured. Operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. Recipient surgery time was 4 hours. There were no intraoperative or immediate postoperative complications. Both the recipients started menstruating after 34 days and 48 days, respectively, and have had 6 cycles of menses at regular intervals. Uterine artery Doppler showed good flow in both patients. Hysteroscopy-guided cervical biopsies were used as a method of surveillance of graft rejection after uterine transplant. Office hysteroscopy was done after 2 months in both patients, and hysteroscopy-guided endometrial and cervical biopsies were taken. Minimal slough was seen on the endometrium in the patient with Mayer-Rokitansky-Küster-Hauser syndrome, which was removed. Repeat hysteroscopy after 10 days showed a healthy endometrium.

CONCLUSIONS

Laparoscopic-assisted uterus donor retrieval is feasible and affords all the advantages of a minimally invasive technique, thereby reducing the morbidity of the procedure. It helps in better dissection of the vessels, shortens the operative time, and helps to minimize tissue handling of the harvested uterus and vessels.

Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant

STUDY OBJECTIVE

The authors present the first ever laparoscopic-assisted uterus retrieval in a live donor for uterus transplant.

DESIGN

A step-by-step surgical demonstration.

SETTING

Galaxy CARE Laparoscopy Institute, Pune, India.

PATIENTS

Two patients, ages 21 and 26 years, with Mayer-Rokitansky-Küster-Hauser syndrome and Asherman syndrome, respectively, with their mothers as donors.

INTERVENTIONS

A 12-member team was formed. After a review of the available literature on uterine transplant, a protocol was formulated and submitted to the Institutional Review Board (IRB). Approval from the Institutional Review Board was obtained. Thorough screening of the candidates was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus was retrieved through a small abdominal incision, to prevent any injury to the uterus and harvested vessels. Uterus was transplanted in the recipients by end-to-side anastomosis of the harvested vessels to the external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients.

MEASUREMENTS AND MAIN RESULTS

Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 4 months. The operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. The recipient surgery was completed in 4 hours. There were no intraoperative or immediate postoperative complications. Both recipients started menstruating after 34 days and 48 days, respectively, and have had 3 cycles of menses at regular intervals to date. After discharge, follow-up cervical biopsies at 3 weekly intervals showed no signs of rejection. Uterine artery Doppler ultrasound showed good flow in both patients.

CONCLUSION

Laparoscopic-assisted donor retrieval is feasible and affords all advantages of a minimally invasive technique. It helps in better dissection of vessels, shortens the operative time, and helps minimize tissue handling, thereby reducing the morbidity of the procedure.

A case of late-onset, thymoma-associated myasthenia gravis with ryanodine receptor and titin antibodies and concomitant granulomatous myositis

BACKGROUND

Myasthenia gravis is an autoimmune neuromuscular disorder, which has only rarely been reported to co-manifest with myositis. The diagnosis of concomitant myositis in patients with myasthenia gravis is clinically challenging, and requires targeted investigations for the differential diagnosis, including EMG, autoantibody assays, muscle biopsy and, importantly, imaging of the mediastinum for thymoma screening.

CASE PRESENTATION

This report presents a case-vignette of a 72-year-old woman with progressive proximal muscle weakness and myalgias, diagnosed with thymoma-associated myasthenia and bioptically verified granulomatous myositis, with positive autoantibody status for ryanodine receptor and titin antibodies.

CONCLUSIONS

The diagnosis of concurrent myositis and myasthenia gravis, especially in the presence of ryanodine receptor and titin antibodies, should lead neurologists to adopt different treatment strategies compared to those applied in myasthenia or myositis alone. Moreover, further evidence is warranted that titin and, particularly, ryanodine receptor antibodies may co-occur or be pathophysiologically involved in myasthenia-myositis cases.