Background Vulvar cancer is a rare gynecological malignancy that primarily affects women of postmenopausal age. Treatment is mainly surgical, particularly for vulvar squamous cell carcinoma, the most prevalent histotype. In patients with unifocal tumors with a maximum diameter of <4 cm, in the absence of suspected inguinal lymph nodes, sentinel lymph node (SLN) biopsy is recommended. The use of a radioactive tracer is mandatory; the use of the vital blue dye is optional. Results Two patients diagnosed with vulvar squamous cell carcinoma (FIGO IB stage) underwent bilateral radical vulvectomy, SLN search and removal, and bilateral inguinal lymphadenectomy at the Cannizzaro Hospital Operative Unit of Obstetrics and Gynecology Department (Catania, Italy). Three milliliters of indocyanine green (ICG) 0.5 mg/mL was administered in 3 peritumoral injections under general anesthesia to screen the SLN. The images were acquired using an intraoperative infrared camera system, which allowed intraoperative visualization of the SLN. An SLN was identified for each patient. The lymph nodes examined by the pathologist were negative for metastatic localization of the disease. However, patients underwent bilateral inguinofemoral lymphadenectomy, as this procedure is not currently codified as a gold standard for the detection of SLN in vulvar cancer. All the lymph nodes removed were negative for the localization of vulvar carcinoma metastases. Conclusions The potential of the administration of indocyanine green (ICG) allows the execution of SLN biopsy, avoiding the multiple administrations of radiocolloid in the pre-operative phase, painful for the patient, elimination, and exposure to radioactivity. Therefore, while requiring standardization of the methodology and a large-scale application, this procedure could open a new surgical management perspective in patients with early-stage vulvar cancer.
Background Septate uterus is a common Mullerian ducts anomaly. The aim of our pilot study was the evaluation of diode laser hysteroscopic metroplasty efficacy to increase endometrial volume in women with septate uterus. Results We prospectively enrolled 10 consecutive patients with septate uterus undergoing office hysteroscopic metroplasty with diode laser between February and November 2019. Endometrial volume was evaluated before and 3 months after surgery using 3D transvaginal ultrasound. The surgical procedure was uncomplicated in all patients, the endometrial volume increased at 3 months follow-up (the median increase was 1.9 cm 3 (range 1.7–2.1), and there was a complete removal of septum with no intrauterine synechiae at follow-up hysteroscopy. Conclusions Office hysteroscopic metroplasty with diode laser is a safe procedure and has preliminary showed to increase endometrial volume. The increase in endometrial volume by 3D-TV US could be used as a prognostic factor for the reproductive outcomes.
Background Medical education has recognised the importance of anatomy teaching. Limitations in applied anatomy knowledge exist among obstetrics and gynaecology (O&G) trainees. This study aims to evaluate the knowledge of O&G trainees in applied anatomy and study-associated factors. Materials and methods The questionnaire-based study involved O&G trainees between 1/8/2019 and 1/12/2019. Data collected included age, gender, evaluation of medical school anatomy course, attendance at applied anatomy workshops, operating theatre workload, and senior colleagues' demonstration of anatomy during operating sessions. Results There were 271 trainees recruited with a mean age of 29.3 years, and 80.1% rated the value of medical school anatomy courses as average or above average. Furthermore, 90.8% never attended applied anatomy workshops. In addition, 9.6% and 62% of first- and fifth-year trainees rated their knowledge as either good or very good, and 41.7% reported that anatomy demonstrations by senior doctors happened sometimes. The overall score of applied anatomy knowledge was significantly higher in higher training years, with attendance at applied anatomy lectures, with more operating workloads, and when senior doctors demonstrate anatomy more often during operating sessions. Conclusions Deficiencies in knowledge existed. Factors which may improve knowledge include more applied undergraduate anatomy courses, more frequent operating sessions, attending anatomy workshops, and more senior colleagues' demonstration of anatomy during surgeries.
Background Hysteroscopy training requires the development of specific psychomotor skills. Few validated low-cost models exist in hysteroscopy. The main objective of this study is to determine face, content, and construct validity of a simulator designed for training basic hysteroscopy skills applied to office-based hysteroscopy. Methods Twenty-five hysteroscopy experts and 30 gynecology residents participated in this prospective observational study. The simulator consisted of three color-textured, silicone-coated anthropomorphic 3-dimensional (3-D) printout uterine models inside a box. Each uterine model in the simulator was designed to develop one of the following basic hysteroscopic skills: hysteroscopic navigation, direct biopsy, and foreign body removal. Participants performed five video-recorded simulation attempts on each model. Procedure-specific checklists were used to rate performance. Results Median scores (25th–75th percentiles; p-value) 4 (3–4; p < 0.001) and surgical experience associated to the simulated procedures 4 (3–4; p < 0.001) indicated positive perceptions as to the realism of the internal cavity of the simulator. Median scores of 4 (3–4; p < 0.001) were assigned to the realism and utility of the tasks performed in the simulator for enhancing novice training in hysteroscopy. Expert performance scores were significantly higher and task completion times were significantly lower than those of novices in the navigation exercise ( F (1,53) = 56.66; p < 0.001), the directed biopsy exercise ( F (1,53) = 22.45; p < 0.001), and the foreign body removal exercise ( F (1,53) = 58.51; p < 0.001). Novices’ performance improved on all three exercises: navigation exercise ( F (1,53) = 182.44; p < 0.001), directed endometrial biopsy ( F (1,53) = 110.53; p < 0.001), and foreign body removal ( F (1,53) = 58.62; p < 0.001). Experts’ task completion times were significantly lower when compared to that of novices in the five attempts ( p < 0,001) of the exercises: navigation ( F (1,48) = 25.46; p < 0.001), directed biopsy ( F (1,46 ) = 31.20; p < 0.001), and foreign body removal ( F (1,50) = 69.8; p < 0.001). Novices’ task completion times diminished significantly throughout the sequence of exercises. Conclusions The low-cost simulator designed for the acquisition of basic skills in hysteroscopy demonstrated face, content, and construct validity.
Background One of the major drawbacks of gynecologic laparoscopy is post-laparoscopic shoulder pain (PLSP) that is believed to result from intra-abdominal CO 2 retention leading to peritoneal and diaphragmatic stretching and causing referred pain in C4 dermatome. Several interventions have been applied to prevent and reduce its incidence and severity, with contradictory results. Only pulmonary recruitment maneuver, extended assisted ventilation, and active intra-abdominal gas aspiration have been mentioned to be effective interventions for CO 2 evacuation. However, in our experience, an alternative technique of delayed suprapubic port removal (DSPR) was found to be an effective method in CO 2 expulsion. Therefore, we conducted this randomized trial to determine the effectiveness of the DSPR technique in reducing the incidence and severity of PLSP. The trial was conducted at a single, tertiary hospital between May 2015 and May 2016. Having complied with the criteria, 220 patients scheduled for elective gynecological laparoscopy were randomly allocated into 2 groups after giving informed consent. Laparoscopic procedures were performed through 10-mm umbilical port and at least 2 ancillary, including suprapubic, ports. In conventional group, ancillary ports were removed at the end of surgery leaving only opened umbilical cannula for pneumoperitoneum deflation. Abdominal compression from periphery towards umbilicus was performed to further expel CO 2 before removing the umbilical cannula. In DSPR group, both umbilical and suprapubic cannulas were retained. Two-step abdominal compression was undertaken, primarily towards umbilicus and secondarily towards pelvic cavity, before sequentially removing the umbilical and the suprapubic cannulas. Postoperatively, each patient was asked to rate PLSP level on 100-mm VAS during 0–6, 6–12, 12–24, and 24–48 h, respectively. Statistical analysis was performed to determine both incidence and severity of PLSP during 24- and 48-h post-laparoscopy. Results Patients in DSPR group demonstrated significantly lower incidence of PLSP within 24 h (43.8% vs 59.0%; p = 0.027) and 48 h (43.8% vs 60.0%; p = 0.019), and expressed apparently lower pain scores (0 (0–0) vs 0 (0–8); p = 0.020) during 24–48 h post-surgery. Conclusion DSPR is an effective CO 2 expulsion technique, resulting in significant reduction of both incidence and severity of PLSP within 24–48 h post-laparoscopy. Trial registration Thai Clinical Trials Registry, TCTR20160208003 . Registered 8 February 2016 — retrospectively registered; http://www.thaiclinicaltrials.org/
Background Caesarean scar niche is increasingly being seen due to the rise in the number of caesarean sections worldwide. Indications and the ideal route for niche repair are still being researched. If the residual myometrium is less than 3 mm thick and potential fertility is needed, laparoscopy is the ideal surgical method for caesarean scar niche repair. The aim of this video presentation is to demonstrate techniques of identifying new anatomical landmarks during laparoscopic uterine niche repair. Results As seen in the video, Caesarean scar niche repair can be done in a step-by-step manner, with lateral bands serving as anatomical landmarks. Conclusions Lateral bands are a consistent anatomical landmark which identify the level and width of the uterine niche and thus simplify the laparoscopic repair making this a reproducible technique.
Background This study aimed to determine the possible prognostic factors correlated with the treatment modalities of tubo-ovarian abscesses (TOAs) and thus to assess whether the need for surgery was predictable at the time of initial admission. Materials and methods Between January 2012 and December 2019, patients who were hospitalized with a TOA in our clinic were retrospectively recruited. The age of the patients, clinical and sonographic presentation, pelvic inflammatory risk factors, antibiotic therapy, applied surgical treatment, laboratory infection parameters, and length of hospital stay were recorded. Results The records of 115 patients hospitalized with a prediagnosis of TOA were reviewed for the current study. After hospitalization, TOA was ruled out in 19 patients, and data regarding 96 patients was included for analysis. Twenty-eight (29.2%) patients underwent surgical treatment due to failed antibiotic therapy. Sixty-eight (70.8%) were successfully treated with parenteral antibiotics. Medical treatment failure and need for surgery were more common in patients with a large abscess (volume, > 40 cm 3 , or diameter, > 5 cm). The group treated by surgical intervention was statistically older than the patients receiving medical treatment ( p < 0.05). Conclusions Although the treatment in TOA may vary according to clinical, sonographic, and laboratory findings; age of patients, the abscess size, and volume were seen as the major factors affecting medical treatment failure. Moreover, TOA treatment should be planned on a more individual basis.
Background: to evaluate the impact of lower segment cesarean section (LSCS) on the maternal and fetal outcomes of women with non-adherent placenta previa (PP). Methods: This is a retrospective study of all women who delivered at our hospital by LSCS with non-adherent PP over a period of 10 years. Data were obtained through hospital registry and medical records search. Data were analyzed using the Statistical Package for Social Sciences (SPSS, version 20). The differences in demographic and obstetric characteristics, peripartum complications, and fetal outcomes between women with no previous CS and those with previous CS were analyzed using t test or chi-square test wherever appropriate. A p-value of less than 0.05 was considered statistically significant. Results A total of 90 women with non-adherent placenta were included, 54 women with no previous CS and 36 women with previous CS. Women with previous CS were significantly more likely to experience organ injury ( p -value <0.005), transfusion of ≥ 4 units of PRBC ( p -value = 0.034), transfusion of FFP ( p -value = 0.034), and hysterectomy or other procedure ( B Lynch, Uterine artery ligation) use ( p -value <0.005) Conclusion : There is a significant increase in the incidence of maternal morbidities such as hysterectomy, blood transfusion and organ injury in patients with non-adherent PP with previous CS, with no difference in perinatal outcome in the same group of patients.
Background Five percent of pre-menopausal women experience abnormal uterine bleeding. Endometrial ablation (EA) is one of the treatment options for this common problem. However, this technique shows a decrease in patient satisfaction and treatment efficacy on the long term. Study objective To develop a prediction model to predict surgical re-intervention (for example re-ablation or hysterectomy) within 2 years after endometrial ablation (EA) by using machine learning (ML). The performance of the developed prediction model was compared with a previously published multivariate logistic regression model (LR). Design This retrospective cohort study, with a minimal follow-up time of 2 years, included 446 pre-menopausal women (18+) that underwent an EA for complaints of heavy menstrual bleeding. The performance of the ML and the LR model was compared using the area under the receiving operating characteristic (ROC) curve. Results We found out that the ML model (AUC of 0.65 (95% CI 0.56–0.74)) is not superior compared to the LR model (AUC of 0.71 (95% CI 0.64–0.78)) in predicting the outcome of surgical re-intervention within 2 years after EA. Based on the ML model, dysmenorrhea and duration of menstruation have the highest impact on the surgical re-intervention rate. Conclusion Although machine learning techniques are gaining popularity in development of clinical prediction tools, this study shows that ML is not necessarily superior to the traditional statistical LR techniques. Both techniques should be considered when developing a clinical prediction model. Both models can identify the clinical predictors to surgical re-intervention and contribute to the shared decision-making process in the clinical practice.
Background Pelvic organ prolapse can be repaired vaginally or laparoscopically. Studies comparing vaginal repair with sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (V-USLS) have found no difference in functional or adverse outcomes. Laparoscopic USLS (L-USLS) is becoming a popular treatment for pelvic organ prolapse because it has a low rate of ureteral compromise. To date, no studies have compared perioperative outcomes between L-USLS and SSLF. The objective of this study is to compare the rates of perioperative complications between these two methods. Methods This was a retrospective chart review of 243 consecutive patients who underwent L-USLS or SSLF at one institution between March 2017 and August 2019 for apical pelvic organ prolapse. Descriptive data was analyzed as appropriate with Student’s t tests and chi-square. Univariable logistic regression analysis was performed to assess predictors of perioperative complications. Results Preoperative Pelvic Organ Prolapse Quantification Stage (POP-Q) was similar between the two cohorts ( p = 0.23). After adjusting for confounding factors, L-USLS was associated with a longer operative time (118 vs 142 min, p < 0.01) and shorter length of hospitalization (0.68 vs 1.06 days, p < 0.01). The estimated blood loss between the procedures was not statistically significant after adjusting for confounding factors. There was no difference in perioperative complication rates between L-USLS and SSLF (5% vs 7%, p = 0.55). No clinical risk factors were significantly associated with perioperative complications. Conclusion We did not find a difference in complications between L-USLS and SSLF.
Currently, the intrauterine device (IUD) is one of the most used contraceptive methods worldwide, since it has shown to be effective and reversible. One of its complications is the migration of the device, which can affect close organs by perforating them. We present the case of a patient who presented a colouterine fistula secondary to an IUD migration.
Endometriosis impairs the quality of life (QoL) of many women, including their social relationships, daily activity, productivity at work, and family planning. The aim of this review was to determine the instruments used to examine QoL in previous clinical studies of endometriosis and to evaluate the effect of medical and surgical interventions for endometriosis on QoL. We conducted a systematic search and review of studies published between January 2010 and December 2020 using MEDLINE. Search terms included “endometriosis” and “quality of life.” We only selected studies that used a standardized questionnaire to evaluate QoL before and after medical or surgical interventions. Only articles in the English language were examined. The initial search identified 720 results. After excluding duplicates and applying inclusion criteria, 37 studies were selected for analysis. We found that the two scales most frequently used to measure QoL were the Short Form-36 health survey questionnaire (SF-36) and the Endometriosis Health Profile-30 (EHP-30). Many medical and surgical treatments demonstrated comparable benefits in pain control and QoL improvement. There is no clear answer as to what is the best treatment for improving QoL because each therapy must be personalized for the patient and depends on the woman’s goals. In conclusion, women must be informed about endometriosis and given easily accessible information to improve treatment adherence and their QoL.
Background This study aimed to describe the efficacy of hysteroscopy in the management of women with the persistent gestational trophoblastic disease (PGTD)/GTN to reduce the need for chemotherapy. Materials and methods This prospective, single-arm, clinical trial study was recruited in an educational referral hospital between September 2018 and September 2019. Totally, 30 participants with a history of hydatidiform mole that was managed by uterine evacuation and developed low risk persistent gestational trophoblastic disease were recruited. Hysteroscopy was performed for removal of persisted trophoblastic tissue. Serum beta-hCG titer was measured before and 7 days after the procedure. Results The mean ± SD age of the participants was 31.4 ± 4.6 years. There was a significant difference (p = 0.06) between that mean ± SD of beta-hCG titer before (8168.4 ± 1758) and after (2648.8 ± 5888) hysteroscopy. Only two (6.6%) cases underwent chemotherapy due to no drop in the beta-hCG titer. Conclusion Hysteroscopy may play a significant role in the management of GTN, although it requires validation in larger prospective randomized studies and longer follow-up.
Emergency peripartum hysterectomy is a major operation performed when conservative measures fail to stop life-threatening postpartum hemorrhage. It is associated with a high rate of maternal morbidity among survivors. This work aims to evaluate the incidence, indication, and complications of peripartum hysterectomy at King Abdulla University Hospital over 15 years. A retrospective cohort study of emergency peripartum hysterectomy. The incidence was calculated. Risk factors for abnormally adherent placenta were explored. A comparison between total and subtotal hysterectomy in terms of morbidity outcomes was conducted. The chi-square test, Fisher’s exact, and independent sample T test were used for analysis. Statistical significance was declared at α < 0.05. The incidence of peripartum hysterectomy was 1.38 per 1000 births. Fifty-nine were performed after cesarean section and three were performed after vaginal delivery ( P <0.001). Abnormally adherent placenta (accreta, increta, and percreta) was the main indication (44.06%). The strongest risk factor for abnormally adherent placenta was placenta previa with previous cesarean section ( P =0.001, OR 16.25, 95% CI 1.95-135.01). One maternal and three neonatal deaths were recorded. Urinary bladder injury was the most frequent complication (27.11%). No difference in morbidity was noted between total and subtotal hysterectomy. The incidence of emergency peripartum hysterectomy is increasing steadily over the last two decades in the north of Jordan. Abnormally adherent placenta is the most common indication for emergency peripartum hysterectomy. There is no significant difference between total and subtotal hysterectomy in terms of complications’ development, admission to the intensive care unit, and estimated blood loss. The morbidity associated with emergency peripartum hysterectomy is significant.
The incidence of adnexal masses, due to large use of ultrasound during pregnancy, has considerably increased during last years. Large percentage of ovarian masses found during pregnancy consists in simple cysts and they tend to disappear spontaneously during pregnancy. There are still a percentage of masses that persist in second and third trimester that need to be monitored and, sometimes, surgically removed. If the mass increases in size, sometimes, it is itself an indication for delivery via cesarean section. Keeping in mind that adnexal masses diagnosed in pregnancy are generally benign, it is essential to consider that ovarian cancer still represents the second gynecological tumor for incidence after cervical cancer during pregnancy. Most patients are clinically asymptomatic and diagnosis is often a random finding during scheduled ultrasound for pregnancy follow-up. Sometimes, the finding of an ovarian mass requires other imaging technique such as magnetic resonance imaging. Computed tomography is avoided during pregnancy due to negative effects on fetus. Treatment option should be discussed and a multidisciplinary approach is required to set ad individualized plan, considering both mother and fetus. Sometimes the differential diagnosis between benign masses and malignancy is not feasible only through imaging, so that surgical intervention with histological examination is mandatory, even during pregnancy. Plus, although ovarian cyst torsion, hemorrhage, or rupture is uncommon in pregnancy, some women may require emergency surgery for these complications. Until 90s pregnancy was considered an absolute contraindication for laparoscopy, but nowadays both open surgery and laparoscopy can be performed considering mass diameter, gestational age, and surgical expertise. Emerging data are indeed confirming the advantages of laparoscopic surgery compared with laparotomy in term of recovery and need for medical care. The purpose of this review is to assess the incidence of adnexal masses during pregnancy and examine their impact on obstetric outcomes.
Uterine rupture is a potentially fatal complication during pregnancy, delivery, or postpartum. Women attempting a trial of labor after a cesarean section have an increased risk of a subsequent rupture. We report a case of a 24-year-old woman, gravida 2 para 1 with a previous cesarean section who underwent a trial of labor. During labor she complained of pain while labor progressed rapidly. Because of signs of fetal distress, a vacuum extraction was performed. Two hours after delivery, the patient complained again of severe abdominal pain. Blood accumulated in a previously non-existent area between the serosa and uterine muscle. A dissection of the uterine wall occurred with serious clinical consequences, compatible with a complete uterine rupture. Emergency laparotomy was performed to repair the uterine wall; a hysterectomy was prevented.
Background Femoral nerve injury following gynecologic surgery may be a postoperative complication, leading to medical malpractice claims and litigation. Methods and results A retrospective analysis was performed on data collected from 973 medico-legal reports of suspected malpractice in gynecologic surgery, filed with the Italian Court between 2000 and 2010. Twelve cases were selected for proven negligence, after a blinded investigation conducted by a gynecologist and a medico-legal expert. Surgical data included type of procedure (hysterectomy, salpingectomy, cesarean section, endometriosis excision), duration of procedure, patient position, and use of retractors. For each case, the observed neuropathy, degree of severity, and recovery time after physical therapy were described. Neuropathies were classified into three categories: neuropraxia (three cases), axonotmesis (six cases), and neurotmesis (three cases) with high sensory and motor deficits. Many particular conditions and pre-existing comorbidity were observed. Two neuropraxia cases were associated with the lithotomy position; axonotmesis cases were related to the incorrect use of self-retaining retractors and an inadequate lithotomy position. Conclusions To avoid potential malpractice lawsuits, care must be taken to accurately collect data linked to individual factors and the possible complications of a surgical procedure. A detailed description is required of the patient’s position on the surgical table, the self-retaining retractors selected, length of time they were in use, maximum tractive force exerted, and their inspection or repositioning during the operation.
Background There are a number of techniques documented in the literature to perform laparoscopic hysterectomy, and here, we propose a safe and novel technique that obviates the need for a pelvic assistant, removes the need for a uterine manipulator and can potentially reduce operative duration. Results Total laparoscopic hysterectomy can be approached without the use of uterine manipulator or vaginal tubes using the steps demonstrated. Conclusions This novel technique is safe, efficient and conducive to standardising minimally invasive hysterectomy practices obviating the need for a uterine manipulator and pelvic assistant.
Our objective is to show a feasible approach to the hysteroscopic procedures when the cervical canal has a diameter smaller than the lesion. Our study is designed as a case series and illustration of the surgical hysteroscopic technique. A group of patients (n = 37) underwent office hysteroscopy in Regional Reference Center for Hysteroscopy Service at Palagi Hospital, Florence, Italy, to see and treat an endometrial polyp with unfavorable cervical conditions between January 2019 and December 2019. An office hysteroscopy in outpatient setting with vaginoscopic approach was performed in women with unfavorable cervical conditions. Fiber-based 3.5-mm hysteroscope, with 5F electrosurgery unit and 5F bipolar electrode, was used to perform the cervicoplasty in order to enlarge the cervical canal from internal to external os, following by the removal of the endometrial polyp with the excision of the base only without slicing. After 90 days, a follow-up hysteroscopy was performed. The procedure was performed successfully in 89.2% of patients. The surgical technique of cervicoplastic allows to perform an operative procedure without analgesia/sedation or anesthesia or blind cervical dilation, reducing the risk of complications and costs. Furthermore, cervicoplasty allowed the removal en bloc of the endocavitary lesion in all cases. At the follow-up hysteroscopy, the cervical passage was straight and smooth, without lesions repaired in all patients. Cervicoplasty is a technique which allows to perfume an ease and comfortable hysteroscopic procedure even in patients with unfavorable cervical canal. Due to the widening of the diameter of the cervical canal, intracavitary lesions are removed intact resulting in an optimal pathological evaluation.
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged in China at the end of 2019 has become a pandemic infection that has now involved 200 countries with 465,915 confirmed cases and 21,031 confirmed deaths. Unfortunately, many data have shown that the high number of undocumented infections could have a major role in the rapid diffusion of the disease. In most of the nations involved, non-urgent, non-cancer procedures have been stopped to reallocate medical and paramedical staff to face the emergency. Moreover, concerns have been raised that minimally invasive surgery could be a procedure that carries the risk of virus diffusion in the operating theater during surgery. This paper reports clinical recommendations and scientific studies to assist clinicians in this field.
