Myomectomy during pregnancy; diagnostical dilemmas: two case reports and a systematic review of the literature

Myomectomy in pregnancy, until this day, remains very controversial. We present two cases of successful antepartum myomectomies performed in the second trimester of gestation. In both cases, the initial suspected origin of these tumours was the ovaries. However, as it was shortly after confirmed, since both women underwent laparotomy, the diagnosis of these masses was uterine fibroids. Both cases resulted on the live birth of two healthy infants via caesarean section. Secondarily, we conducted a thorough review of current data of myomectomies performed during pregnancy, including the characteristics and diagnosis of the myomas of pregnant women, the surgical details and complications, along with the outcomes of these gestations. Overall, the analysis of cases published in international literature, suggests that the surgical removal of myomas during pregnancy can be considered safe, given certain indications and considerations. Our review comprises of 71 women undergoing excision of fibroids during pregnancy. Only three cases ended in a miscarriage while the remaining 68 resulted in a second or third trimester delivery. However, the data concerning the safety of the procedure are scarce and originate mostly from case reports. Thus, conclusions on the exact maternal and obstetrical complication rates cannot be drawn.

The Role of Laparoscopic Surgery in the Treatment of Advanced Uterine Prolapse: A Systematic Review of the Literature

The aim of this review is to investigate and compare all laparoscopic techniques that can be used in the surgical repair of advanced uterine prolapse. A systematic search of the PubMed, Scopus, Cochrane CENTRAL, and Clinicaltrials.gov databases was performed for articles published up to December 2020, reporting data on the treatment of severe uterine prolapse using laparoscopic procedures. Only studies in the English language, with a patient sample of ≥20 and a follow-up time of ≥12 months were included. The final synthesis of this review consisted of six studies. The main laparoscopic procedures reported were vaginally assisted laparoscopic sacrocolpopexy, vaginally assisted laparoscopic uterine sacropexy, laparoscopic sacrocolpopexy with laparoscopic supracervical hysterectomy, laparoscopic inguinal ligament suspension with uterine preservation, and laparoscopic uterosacral ligament suspension combined with trachelectomy. All procedures involved mesh placement, except for laparoscopic uterosacral ligament suspension. All procedures reported anatomical cure rates > 90%. Vaginally assisted laparoscopic sacrocolpopexy had the largest amount of intraoperative blood loss whilst vaginally assisted laparoscopic uterine sacropexy was associated with bladder injuries intraoperatively. All vaginally assisted procedures reported cases of mesh extrusion postoperatively. Laparoscopic inguinal ligament suspension was the operation with the longest mean operative and hospitalization time. Conversions were not reported. The present study shows that minimally invasive surgery can be used efficiently as an alternative to open surgery in the treatment of severe uterine prolapse.

CO2 laser and the genitourinary syndrome of menopause: a randomized sham-controlled trial

PURPOSE

This study aimed to clarify the efficacy of intravaginal CO₂-laser treatment in postmenopausal women with genitourinary syndrome of menopause (GSM).

MATERIALS AND METHODS

This double-blind, randomized, sham-controlled trial included postmenopausal women diagnosed with GSM and bothersome dryness and dyspareunia. Treatment consisted of three sessions. Active CO₂-laser treatments (active group) were compared to sham treatments (sham group) with the primary endpoints being changes in dryness and dyspareunia intensity, as assessed by the 10-cm visual analog scale. Secondary endpoints were as follows: changes in Female Sexual Function Index (FSFI; total score and all domains), itching, burning, dysuria, and Urogenital Distress Inventory (UDI-6); incidence of symptoms; and presence of adverse events. All outcomes were evaluated at baseline and 4 months post baseline.

RESULTS

Fifty-eight women (28 in the active group and 30 in the sham group) were eligible for inclusion. In the active group, dryness, dyspareunia, FSFI (total score), itching, burning, dysuria, and UDI-6 were significantly improved (mean [standard deviation] -5.6 [2.8], -6 [2.6], 12.3 [8.9], -2.9 [2.8], -2.3 [2.8], -0.9 [2.1], and -8.0 [15.3], respectively). In the sham group, dryness, itching, and burning were significantly improved (-1.9 [2], -1.4 [1.9], and -1 [1.9], respectively). All changes were in favor of the active group. After completion of the protocol, the proportion of participants with dryness, dyspareunia, and sexual dysfunction was significantly lower in the active group compared to those in the sham group (all p < 0.005).

CONCLUSIONS

CO₂ laser could be proposed as an effective alternative treatment for the management of GSM as it is superior to sham treatments.

Can pelvic organ prolapse in postmenopausal women be treated with laser therapy?

PURPOSE

This study aims to assess the effectiveness of the non-ablative photothermal erbium laser (Er:YAG laser) for managing anterior and/or posterior vaginal compartment prolapse.

METHODS

A randomized, single-blind, 1:1 trial was performed comparing Er:YAG laser treatment to watchful waiting in postmenopausal women with symptomatic cystocele and/or rectocele stage 2 or 3 who opted to undergo surgery due to bothersome prolapse symptoms. Three Er:YAG laser treatments at monthly intervals were applied for the Er:YAG laser group, while there was no treatment for the watchful-waiting group. The primary outcome was the proportion of patients with stage 0 or 1 following laser treatment, while secondary outcomes included the Pelvic Organ Prolapse Quantification System (POP-Q points), Pelvic Floor Distress Inventory Questionnaire short-form, Pelvic Floor Impact Questionnaire short-form, and Patients Global Impression of Improvement (PGI-I). All outcomes were evaluated at baseline and 4 months post baseline.

RESULTS

Thirty women (15 vs. 15) were eligible to be included. No participants (0%) in either group had POP-Q stage 0 or 1 at 4 months. Moreover, no change was present in the secondary outcomes. In the PGI-I, 2/15 (14%) and 0/15 (0%) participants declared much better/very much better in the laser and watchful-waiting group, respectively.

CONCLUSIONS

The findings of this study do not support use of the intravaginal Er:YAG laser for treatment of the anterior/posterior vaginal wall. Clinical trial identification number: NCT03714607.

The Genitourinary Syndrome of Menopause: An Overview of the Recent Data

The genitourinary syndrome of menopause (GSM) is a relatively new term for the condition previously known as vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. The term was first introduced in 2014. GSM is a chronic, progressive, vulvovaginal, sexual, and lower urinary tract condition characterized by a broad spectrum of signs and symptoms. Most of these symptoms can be attributed to the lack of estrogen that characterizes menopause. Even though the condition mainly affects postmenopausal women, it is seen in many premenopausal women as well. The hypoestrogenic state results in hormonal and anatomical changes in the genitourinary tract, with vaginal dryness, dyspareunia, and reduced lubrication being the most prevalent and bothersome symptoms. These can have a great impact on the quality of life (QOL) of the affected women, especially those who are sexually active. The primary goal of the treatment of GSM is to achieve the relief of symptoms. First-line treatment consists of non-hormonal therapies such as lubricants and moisturizers, while hormonal therapy with local estrogen products is generally considered the “gold standard’’. Newer therapeutic approaches with selective estrogen receptor modulators (SERMs) or laser technologies can be employed as alternative options, but further research is required to investigate the viability and scope of their implementation in day-to-day clinical practice.

The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women

OBJECTIVES

To assess the effect of microablative fractional CO2 laser (MFCO2-Laser) therapy on the vaginal microenvironment of postmenopausal women.

METHODS

Three laser therapies at monthly intervals were applied in postmenopausal women with moderate to severe symptoms of genitourinary syndrome of menopause, pH of vaginal fluid >4.5 and superficial epithelial cells on vaginal smear <5%. Vaginal fluid pH values, fresh wet mount microscopy, Gram stain and aerobic and anaerobic cultures were evaluated at baseline and 1 month after each subsequent therapy. Nugent score and Hay-Ison criteria were used to evaluate vaginal flora.

RESULTS

Fifty-three women (mean age 57.2 ± 5.4 years) participated and completed this study. MFCO2-Laser therapy increased Lactobacillus (p < 0.001) and normal flora (p < 0.001) after the completion of the therapeutic protocol, which decreased vaginal pH from a mean of 5.5 ± 0.8 (initial value) to 4.7 ± 0.5 (p < 0.001). The prevalence of Lactobacillus changed from 30% initially to 79% after the last treatment. Clinical signs and symptoms of bacterial vaginosis, aerobic vaginitis or candidiasis did not appear in any participant.

CONCLUSION

MFCO2-Laser therapy is a promising treatment for improving the vaginal health of postmenopausal women by helping repopulate the vagina with normally existing Lactobacillus species and reconstituting the normal flora to premenopausal status.

Complete longitudinal vaginal septum resection. Description of a bloodless new technique

PURPOSE OF INVESTIGATION

To describe a novel approach for longitudinal vaginal septum (LVS) resection. Materials and Methods: Two cases of young girls with a uterus didelphys and a longitudinal vaginal septum. The technique consisted in grasping the vaginal septum with a laparoscopic 33-cm long bipolar cutting forceps, five-mm in diameter, and divided it to its midportion towards the two cervices.

RESULTS

In both cases, the procedure was straightforward, uncomplicated, completed within three minutes and the patients were discharged four hours later. It was associated with minimal blood loss, short recovery time, absence of local ischemia, and optimum healing process.

CONCLUSION

The authors believe that surgical safety, efficacy and operative result make bipolar cutting forceps a tailored option for LVS resection.

Breast disorders in girls and adolescents. Is there a need for a specialized service?

INTRODUCTION

Minor breast concerns in childhood and adolescence are common and lead to increased anxiety among young patients and their families, particularly due to high correlation with breast cancer. However, most breast services aim at managing adults and triaging patients with breast cancer, whereas adolescent medicine specialists or pediatricians are usually not appropriately trained to identify and treat breast pathology.

METHODS

We reviewed hospital records of all patients attending a pediatric and adolescent gynecology or breast clinic of a tertiary referral hospital, with a breast related symptom, between January 2009 and December 2011. We collected information regarding age at presentation, age at menarche, diagnosis, management and outcome.

RESULTS

We identified 81 patients of which 11 presented with an abnormal nipple or areolar secretion, 33 had a palpable lump, 20 had mastitis, and 16 had unequal breast development. One patient presented with virginal breast hypertrophy. Three out of 11 of the patients with an abnormal secretion had a cyst identified on ultrasonography. Out of the palpable lumps 12 were fibroadenomas, 3 were phyllodes tumors, and 14 were cystic in nature. The phyllodes tumors and half of the fibroadenomas were removed. The remaining fibroadenomas remain under regular ultrasonographic follow-up. All cases of mastitis were treated conservatively and resolved with broad spectrum antibiotic treatment.

CONCLUSION

In our series, no malignancies were identified. Although 8 patients required surgical treatment, the majority of cases were treated conservatively.

Safety of hormone replacement therapy in gynaecological cancer survivors

Therapy for endometrial, ovarian and cervical cancer in young women can cause sudden onset of intense menopausal symptoms, such as hot flushes, emotional disorders and sexual dysfunction. In order to overcome these unpleasant and sometimes severe symptoms, hormone replacement therapy (HRT) has proven to be very effective. However, its safety remains controversial. We reviewed English literature and examined whether administration of HRT in this specific population is related with more recurrences and worse prognosis. Current scientific data, comprising mainly retrospective studies, suggest that recurrence rates and survival are comparable between HRT users and non-users. However, large randomised trials are missing and definitive conclusions cannot be drawn. Gynaecological cancer survivors using HRT, although they seem to have little if any risk for recurrence, should be correctly informed about the lack of strong evidence.

[Ischemic mitral regurgitation]

Mitral regurgitation (MR) is a serious complication of coronary heart disease. The functional form is the most frequent, often presenting with a dynamic character. The presence, and in particular the severity of MR and its dynamic character have a major impact on the medium and long term prognosis. The mechanisms responsible for MR are complex and occur in a state of disequilibrium between traction forces and closing forces, for which the significance is partly affected by the presence of asynchrony in left ventricular contraction. The therapeutic management of these patients is difficult. In cases of proven asynchrony, implantation of a biventricular pacemaker is justified. A mitral surgical procedure may be envisaged in cases of severe MR where bypass surgery is planned. In cases of moderate MR at rest, an evaluation of its dynamic character on effort can assist with the decision to undertake combined surgery. Mitral regurgitation (MR) is a common and serious complication of ischemic heart disease. Three general forms are distinguished: MR related to acute rupture of the mitral pillar, ischemic MR and functional MR.