Risk of uterine niche following single-layer locked versus unlocked uterine closure: a randomized study

INTRODUCTION

The primary objective of the present study is to evaluate the effect of single-layer locked versus single-layer unlocked uterine closure techniques on the development of uterine niche. The secondary objective is to evaluate the effect of the ratio of lower uterine segment (LUS) to upper uterine segment (UUS) on the development of uterine niche, which was not previously investigated in literature but which the authors consider to be a major risk factor for the development of uterine niche.

METHODS

Included in this randomized study were 194 patients who were admitted to the Department of Obstetrics and Gynecology at Health Sciences University Antalya Training and Research Hospital and who underwent cesarean section (CS) due to any reason between October 2017 and May 2018. Two different techniques were used in the closure of hysterotomy: Single-layer locked continuous suturing (Group 1) and single-layer unlocked continuous suturing (Group 2). During surgery, the thicknesses of the LUS and UUS were measured using a sterile scale prior to hysterotomy closure. The patients were evaluated for the development of uterine niche at postoperative six months by transvaginal ultrasound.

RESULTS

Control transvaginal ultrasound performed at six months after surgery revealed uterine niches in 58 out of 194 patients (29.29%; 34 patients in Group 1 [34.3%] and 24 patients in Group 2 [25.3%]). No significant difference was noted in terms of the development of uterine niche between the two groups (p = .167). The mean LUS and UUS in patients without uterine niche development were 6.81 ± 1.26 mm and 9.38 ± 1.26 mm, whereas the mean LUS and UUS in patients with uterine niche development were 4.24 ± 1.15 mm and 9.21 ± 2.15, respectively (p = .001 and p = .236). The mean UUS/LUS ratio is 1.4 ± 0.16 among patients without uterine niche and 2.21 ± 0.31 in patients with uterine niche (p < .001).

CONCLUSIONS

The present study found no statistically significant difference in niche size between the two groups. However, the study reports that the ratio of upper to lower uterine segment that was not previously investigated in literature is a major risk factor for the development of uterine niche.

Comparison of the effects of bilateral and unilateral laparoscopic ovarian drilling on pregnancy rates in infertile patients with polycystic ovary syndrome

AIM

This study aims to investigate the effects of unilateral and bilateral laparoscopic ovarian drilling (LOD) on pregnancy rates in patients with clomiphene citrate (CC) resistant infertile polycystic ovary syndrome.

METHODS

This prospective cohort study included 75 patients who were admitted to the Department of Obstetrics and Gynecology of the Antalya Training and Research Hospital between July 2016 and December 2017 and underwent LOD operation. Among these patients, 37 underwent unilateral laparoscopic ovarian drilling (ULOD) and 38 underwent bilateral laparoscopic ovarian drilling (BLOD). The drilling procedure was carried out using the following equation: Number of punctures (np) = 60 J/cm³ /30 watt × 4 s by selecting the larger ovary in the patients who underwent ULOD and by taking the ovarian volume of each ovary in the BLOD group.

RESULTS

During the 1-year follow-up, 20 of the ULOD patients (54.1%) and 13 of the BLOD patients (34.2%) were observed to be pregnant. Although a higher number of pregnancies were obtained in the ULOD group, no statistically significant difference was found between the two groups (P = 0.083). The pregnancies occurred more in the first 6 months during the postoperative follow-ups of the patients. A total of 14 (70%) of the 20 pregnancies in the ULOD group and 9 (69.2%) of the 13 pregnancies in the BLOD group occurred in the first 6 months.

CONCLUSION

ULOD with respect to a larger ovarian volume should be preferred to BLOD for CC-resistant PCOS patients because of the high pregnancy rates and fewer potential side effects.

Laparoscopic lateral suspension to treat neovaginal prolapse in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome: A rare case report

Various methods have been described to treat neovaginal prolapse in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. In this case report, we describe neovaginal prolapse of a 21-year-old patient with MRKH syndrome which had been created by sexual intercourse dilation. Herein, the laparoscopic lateral suspension was performed for the surgical correction of neovaginal prolapse which is not available in the literature as far as we search. Prolapse was successfully corrected and vaginal length was provided at a sufficient length of 7 cm. Since after 1-year of operation, she has remained satisfied with her surgical outcome anatomically, sexually and psychologically. Laparoscopic lateral suspension is a safe and effective treatment in a patient who has neovaginal prolapse with MRKH syndrome and also can be used as a potentially alternative management in the treatment of neovaginal prolapse in patients with MRKH syndrome.

The rectal vaginal opacification with water and the antiperistaltic agent in magnetic resonance scanning of the intestinal endometriosis

The diagnosis of deep intestinal endometriosis is mandatory to plan treatment and for follow-up; however, there is no consensus worldwide in the use of rectal/ vaginal opacification and anti-peristaltic agents for magnetic resonance imaging (MRI) scanning, being defined as an option for the examination. The transvaginal ultrasound images of previous MRI with the standard protocol, and recent MRI in our institution with rectal/vaginal opacification with water and the anti-peristaltic agent are presented in four cases for comparison, respectively. The technique in our institution seems to be more effective than routine pelvic MRI scans in the intestinal endometriosis.

Comparison of the efficacy and safety of two advanced vessel sealing technologies in total laparoscopic hysterectomy

AIM

Adequately powered, randomized controlled studies evaluating efficacy and safety of advanced bipolar energy devices in gynecologic laparoscopic surgery are very few. We aimed to compare the two most commonly used devices in total laparoscopic hysterectomy.

METHODS

This randomized controlled trial was carried out in the department of obstetrics and gynecology in an education and research hospital. One hundred thirty-two women who underwent total laparoscopic hysterectomy for benign indications were included. Women with age younger than 18 years, suspected malignancy, stage 3-4 endometriosis and cervical/intraligamentary leiomyoma were excluded. Patients were randomized preoperatively to LigaSure or Articulating Enseal. One experienced surgeon performed all operations.

RESULTS

LigaSure was used in 67 patients and Enseal was used in 65 patients. Primary outcomes of the study were operative time (time from start of sealing and transection of the round ligament until completion of colpotomy) and total operative time (time from skin incision to skin closure). Secondary outcomes were intraoperative blood loss (blood lost during operative time period) and perioperative complications. Operative time was significantly shorter in LigaSure group (P = 0.001). Total operative time, intraoperative blood loss and perioperative complications were similar. When two groups were further classified according to uterine weight taking 300 g as cut-off value, operative time was significantly shorter in LigaSure group in both subgroups (P = 0.003 and P = 0.007).

CONCLUSION

LigaSure use in total laparoscopic hysterectomy shortens operative time when compared with Enseal; without an apparent increase in intraoperative blood loss and perioperative complications. On the other side, total operative time remains unaffected.

Modified Laparoscopic Lateral Suspension: The Mulayim Technique

STUDY OBJECTIVE

To demonstrate a modified technique of laparoscopic lateral suspension for pelvic organ prolapse (POP).

DESIGN

A video illustrating this modified technique of laparoscopic lateral suspension (Canadian Task Force classification III).

SETTING

The benign gynecology department at a university hospital.

INTERVENTIONS

Laparoscopic lateral suspension using mesh is a minimally invasive technique that effectively treats POP [1-4]. We present a modified technique of laparoscopic lateral suspension that differs from previously described methods [1-4]. The prominent differences are as follows: first, our modified technique uses Mersilene tape on a 48-mm round-bodied needle (Ethicon Inc, Somerville, NJ,USA). We suspend the vaginal vault, taking a double bite using Mersilene tape without knotting placed as a transversal hammock. Thanks to the Mersilene tape, meshes, sutures, tackers, or fasteners are not needed. Mersilene tape ensures much easier suturing and an inexpensive artificial material. The second difference is that port placement sites (Fig. 1). The third difference is the number of incisions we make (Fig. 1). We do not need 2 additional incisions as used in previously described methods references [1-4]. We use the same incision for lateral trocar insertion and for pulling out the distal end of the Mersilene tape, which is 2 cm above the iliac crest and 4 cm posterior to the anterior superior iliac spine (Fig. 1). Our technique has the potential to be easier, shorter, more cost-efficient, less invasive, and safer when compared with previously described methods.

CONCLUSION

Modified laparoscopic lateral suspension, the so-called Mulayim technique, might be considered as an alternative treatment for POP surgery; however, studies should be conducted in a larger number of patients with longer postoperative follow-up periods (Fig. 1).

Pubertal failure and primary amenorrhea with uterine hypotrophy due to hypogonadotropic hypogonadism

BACKGROUND

Primary amenorrhea can be a sign of either delayed puberty or Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.

CASE

A virgin 27-year-old woman with pubertal failure, primary amenorrhea, and uterine hypotrophy due to hypogonadotropic hypogonadism sought treatment at our institution. She was diagnosed as having MRKH syndrome 10 years ago at another institution after pelvic ultrasonography revealed no uterus or ovaries. Unfortunately, no further investigations had been made or treatments implemented during the ensuing decade.

SUMMARY AND CONCLUSION

In female patients in whom the uterus cannot be visualized with ultrasonography, magnetic resonance imaging and/or laparoscopy should be considered to ensure that the diagnosis is correct. Besides further imaging, hormonal assessment and breast development should always be initially considered for the diagnosis of delayed puberty and MRKH syndrome.

Sublingual misoprostol after surgical management of early termination of pregnancy

OBJECTIVE

To assess the efficacy of sublingual misoprostol after surgical management of early termination of pregnancy (ETP) regarding duration and amount of bleeding, presence of retained products of conception (RPOC), and endometrial thickness.

DESIGN

Prospective, randomized clinical trial.

SETTING

University hospital.

PATIENT(S)

One hundred five patients admitted for possible management of early pregnancy failure and unwanted pregnancy.

INTERVENTION(S)

Manual vacuum aspiration (control and study groups) plus 400 microg sublingual misoprostol (study group) at pregnancy termination, and transvaginal ultrasonography (both groups) 10 days after the procedure.

MAIN OUTCOME MEASURE(S)

Duration and amount of bleeding and presence of RPOC and endometrial thickness 10 days after the procedure.

RESULT(S)

Bleeding lasted 3.2 and 5.1 days in the study and control groups. Severe vaginal bleeding occurred in two patients in the study group and in six patients in the control group. Mean endometrial thickness was 5.5 mm in the study group and 6.9 mm in the control group. These differences were statistically significant. No cases of RPOC occurred in the study group; two cases occurred in the control group.

CONCLUSION(S)

In countries in which surgical management of ETP is still done, using sublingual misoprostol postoperatively may reduce the duration and amount of bleeding.

The prenatal diagnosis of cloacal dysgenesis sequence in six cases: can the termination of pregnancy always be the first choice?

OBJECTIVE

Cloacal dysgenesis sequence is a lethal malformation, which usually requires termination. In this study, our aim was to evaluate the prenatal and postnatal diagnostic features of cloacal dysgenesis sequence and review the management of the patients.

MATERIAL AND METHODS

The data of six cases of cloacal dysgenesis sequences were collected from the ultrasonography and neonatal records. The findings were evaluated in prenatal and postnatal periods. Chromosomal analysis was performed in all the cases. The evaluation of primary and secondary malformations was done. Coexisting anomalies were searched for by radiology and histopathology.

RESULTS

Malformations in six cases (two females and four males) were described. The absence of anal, genital, and urinary openings with intact perineum covered by smooth skin were common findings. These features were considered as primary malformations for cloacal dysgenesis sequence. Secondary anomalies (urinary and gastrointestinal system malformations, pulmonary hypoplasia, and other coexisting anomalies) were evaluated.

CONCLUSION

The prenatal differential diagnosis of cloacal dysgenesis sequence from other urinary obstructive diseases was essential regarding fetal prognosis, prenatal, and neonatal management. The bladder outlet obstruction and pulmonary hypoplasia due to reduced amniotic fluid and/or kidney disease were considered prognostic factors for neonatal death. Termination of pregnancy is almost always recommended instead of intrauterine shunt procedures; but if we take into consideration one of our cases and a few reported cases who survived in the neonatal period, the prenatal management of these pregnancies needs to be reevaluated.

The role of inhibin B as a basal determinant of ovarian reserve

Our objective was to compare inhibin B and conventional basal determinants in designating the ovarian reserve in patients receiving assisted reproductive treatment. A total of 58 women, aged 19-47 years, who were accepted for assisted reproductive treatment at the Zeynep Kamil Women and Children's Hospital, Department of Assisted Reproductive Technologies, were included in the study. The age, body mass index, basal levels of follicle stimulating hormone, estradiol and inhibin B, volume of the ovary and number of antral follicles were compared prospectively. When the number of oocytes collected was > or = 5, this was accepted as a sufficient ovarian response. Serum inhibin B (cut-off level 56 pg/ml), as a basal determinant of ovarian reserve, had the highest sensitivity (81%) and specificity (81%). The usefulness of serum inhibin B measurement as a basal determinant of ovarian reserve is supported.