Background: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a congenital anomaly characterized by uterus didelphys, obstructed hemivagina, and an ipsilateral renal anomaly, most commonly renal agenesis. Most patients become symptomatic after menarche and require surgical treatment. In prepubertal girls, asymptomatic fluid collections are often managed conservatively, whereas symptomatic cases have often prompted concern for ectopic ureter-related urinary accumulation requiring intervention. We report two early-childhood cases to show that integrated assessment of imaging, fluid analysis, and follow-up findings can help clarify the cause of symptomatic fluid collection and thereby guide management. Case Description: Two early-childhood girls with left renal agenesis presented with abnormal genital findings, including a protruding vaginal mass in one case and persistent vaginal discharge in the other. In the first case, imaging revealed a vaginal/paravaginal cystic lesion without definite uterine anomaly, suggesting an OHVIRA-like developmental anomaly rather than classic OHVIRA. Vaginoscopic aspiration was performed; symptoms resolved, and no recurrence was observed during follow-up. In the second case, imaging demonstrated uterine didelphys, obstructed hemivagina, and fluid distension of the left uterine cavity, cervix, and vagina, consistent with OHVIRA. The patient underwent vaginoscopy-guided partial septectomy with no recurrence during follow-up, and fluid analysis supported infected retained secretions rather than ectopic ureter-related urinary accumulation as the likely cause of the early presentation. Conclusions: Symptomatic prepubertal OHVIRA is uncommon and may present with abnormal vaginal discharge. Such cases are not always caused by ectopic ureter-related urinary accumulation; infection may also underlie retained fluid. Integrated assessment can help clarify fluid origin and support individualized management.
Background and Objective:For locally advanced cervical cancer, the typical radiation treatment is a combination of external beam radiation therapy (EBRT) and brachytherapy. However, variation exists in brachytherapy technique selection and implementation, stemming from differences in imaging access, operator experience, and applicator selection. As cervical brachytherapy has evolved from two-dimensional (2D) to more advanced image-guided techniques, clinicians face increasing uncertainty regarding which method of brachytherapy to use in specific clinical scenarios. This narrative review describes the evolution of intracavitary brachytherapy (ICBT), interstitial brachytherapy (ISBT), and hybrid intracavitary/interstitial brachytherapy (hybrid IC/IS-BT) techniques for cervical cancer, as well as their indications, comparative advantages, risks and benefits of each. Methods:A search of the literature was conducted using PubMed from January 1, 2000 through December 31, 2024 to identify the findings of cervical cancer brachytherapy. Only English language publications were considered. Articles were found through the use of key terms and Boolean operators such as ("cervical cancer" AND "brachytherapy" OR "high dose rate brachytherapy") OR ("intracavitary brachytherapy" OR "interstitial brachytherapy" OR "hybrid brachytherapy"). Key Content and Findings:Brachytherapy has evolved from 2D to three-dimensional planning with the advent of image-guided brachytherapy (IGBT). This modern approach encompasses techniques such as ICBT, ISBT and hybrid IC/IS-BT. Various trials, such as EMBRACE-I, indicate that magnetic resonance imaging (MRI)-guided techniques achieve superior local control and lower toxicity compared to 2D older methods. Modality selection is determined not only by tumor size and symmetry, but also by accessibility, parametrial involvement, and the ability to achieve coverage while sparing nearby organs. ICBT remains the most effective for small, centrally located tumors, while ISBT and hybrid IC/IS are preferred for bulky, asymmetric, or parametrially invasive tumors. Conclusions:This review provides an overview of cervical cancer brachytherapy, including recent advances in image-guided brachytherapy-particularly with hybrid IC/IS-BT, allowing for improved tumor coverage and lowered toxicity. By framing the discussion of brachytherapy selection through specific tumor geometry, imaging findings, and resource availability, this review provides an approach for choosing the most appropriate modality. Such insights may improve future clinical practice decisions, research development, and policy efforts to ensure equitable access and training to high-quality brachytherapy.
Background:Transvaginal ultrasound (TVUS) is a guideline-approved stand-alone method to assess the risk of endometrial cancer (EC) for an episode of postmenopausal bleeding (PMB). However, the studies informing this guideline did not assess non-endometrioid histology which have a lower prevalence of abnormally thickened endometrium (EM), or account for uterine fibroids which may disproportionately obscure non-endometrioid histology. This study aims to assess whether fibroids reduce the sensitivity of TVUS for endometrioid and serous EC. Methods:This study is a retrospective cohort of pathology-confirmed endometrioid and serous EC of diagnosed between January 2012 and October 2022 at Montefiore Medical Center, an urban academic hospital system. Univariate analysis was completed with Fisher's exact tests for categorical data and Student's t-test for continuous variables. Multivariate logistic regression was used to model dichotomous outcomes. Results:Of 330 people who met eligibility criteria, 41% of the cohort had serous histology, and 25% had stage III-IV cancer. Large fibroid burden was present in 52% of serous EC vs. 29% of endometrioid EC, and in 55% of Black people vs. 26% of White people. Those with larger fibroid burden had EM visualized 15.9% less (73.8% vs. 89.7%, P<0.001), identification of thickened EM 3.6% less (87.5% vs. 91.1%, P=0.40). They had identification of any TVUS feature suspicious for malignancy 10.9% less (86.1% vs. 97.0%, P<0.001), and identification of focal TVUS features suspicious for malignancy 14.6% less (48.1% vs. 62.7%, P=0.01). Non-visualized EM (16.2% of TVUSs) was associated with total fibroid diameter >5 centimeters [adjusted odds ratio (aOR) 0.99, 95% confidence interval (CI): 0.36-1.61, P=0.002] and inversely associated with body mass index (BMI) ≥35 kg/m2 (aOR -1.15, 95% CI: -2.06 to -0.25, P=0.01). Larger fibroid burden reduced the sensitivity of TVUS to detect any feature suspicious for malignancy 3.2% more for serous than endometrioid histology (P=0.02). Conclusions:Uterine fibroid burden is associated with lower sensitivity of TVUS to detect features of EC, especially for serous than endometrioid histology. This highlights an important limitation to guidelines for the evaluation of PMB.
Surgery serves as a crucial therapeutic modality for gynecological malignancies, occupying a central role in the multimodal treatment framework for common gynecological cancers including cervical cancer, ovarian cancer, endometrial cancer, and vulvar cancer. Its clinical value extends across the early, middle, and advanced stages of tumors, encompassing multiple therapeutic objectives such as radical resection, cytoreductive therapy, and palliative relief. This video showcases the laparoscopic en bloc excision of enlarged obturator lymph nodes, focusing on key technical strategies for safe and effective dissection in the complex pelvic anatomical region-where close proximity to critical structures like the obturator nerve and iliac blood vessels poses inherent risks. The patient was initially planned for laparoscopic total hysterectomy due to cervical intraepithelial neoplasia grade III (CIN III), with no preoperative imaging or clinical indicators suggesting the need for lymphadenectomy. During the procedure, the surgical team unexpectedly identified enlarged, firm obturator lymph nodes, which postoperative pathological analysis confirmed as metastases from urethral squamous cell carcinoma-a known primary tumor prone to pelvic lymph node spread. The surgical approach prioritized meticulous anatomical landmark identification (including the obturator nerve and vascular bundles), strict adherence to fascial plane boundaries, and combined use of blunt dissection and precise suturing. These techniques minimized the risk of vascular injury and nerve palsy, common complications in pelvic lymphadenectomy. This case underscores the feasibility and safety of laparoscopic management for complex pelvic lymphadenopathy when guided by refined surgical skills, leveraging the technology's high-definition visualization advantage. As a medical educational resource, the video aims to equip surgeons with practical insights to enhance their technical proficiency in dissecting lymph nodes within high-risk anatomical areas, supporting improved intraoperative decision-making and patient outcomes.
The pelvic structures are anatomically and functionally interconnected, forming an integrated system. The diagnosis and management of multi-compartment pelvic organ prolapse (POP) often require multidisciplinary collaboration among urogynecologists, colorectal surgeons, and radiologists. Individualized surgical planning should be tailored according to the patient's condition and preferences, aiming to correct all compartmental defects in a single procedure whenever possible. In this study, we report a case of a patient presenting with rectal prolapse, anterior vaginal wall prolapse, and uterine prolapse accompanied by severe constipation, who achieved satisfactory outcomes following laparoscopic lateral suspension (uterus preservation) combined with ventral mesh rectopexy. This combined surgical approach is particularly suitable for patients with multi-compartment POP presenting with rectal prolapse and anterior vaginal or apical prolapse, who also express a desire for uterine preservation and report symptoms of constipation. The key technical considerations involve utilizing lateral suspension to correct anterior vaginal and/or apical prolapse, while employing ventral mesh rectopexy to address rectal prolapse. Compared to the combination of ventral mesh rectopexy and sacrocolpopexy, this procedure is technically simpler and maintains appropriate independence between the posterior vaginal wall and the rectum. It not only achieves favorable outcomes in correcting prolapse across all pelvic compartments but also reduces the risks of mesh-related complications and postoperative constipation. The purpose of this video is to share our experience and insights into the multidisciplinary management of multi-compartment POP.
Background: Maximal sports performance requires sustained physical effort that challenges the structures and functions of the pelvic floor (PF), particularly in high-impact disciplines such as track and field. Despite the specific daily demands faced by female athletes, no studies to date have explored the influence of these habits on PF symptoms. This study aimed to describe the most frequent toileting and training habits related to the PF and to evaluate their association with pelvic floor dysfunctions (PFD) in female athletes. Methods: A total of 281 female track and field athletes participated in this cross-sectional observational study. Between May and August 2023, participants completed an online questionnaire assessing urinary, fecal, and sports training habits, as well as sociodemographic data and symptoms related to PFD. Validated and adapted scales, along with ad hoc items, were used. Results: The most frequent toileting habits were related to premature voiding, such as attempting to urinate before training (>60%) or trying to defecate at home (>75%). During sports training, the most common habit was a healthy practice, being mindful of posture to protect the PF (38.4%). Unhealthy habits related to straining during voiding or defecation, and preferences for specific toileting locations, were more prevalent among athletes with urinary and anal incontinence (AI). However, associations between sports training habits and PFD symptoms were unclear. Conclusions: A high proportion of female athletes report toileting habits considered potentially harmful to PF, mainly involving premature voiding and location preferences. Healthy habits during sports training are infrequent. Habits involving straining and location preferences were more common among athletes with PFD symptoms. Further research is needed to investigate the role of sports-related habits in PF health.
Background: Primary fallopian tube carcinoma (PFTC) is a rare gynecologic malignancy, and isolated colon metastasis as the initial manifestation of PFTC is exceedingly rare. To our knowledge, the present report describes the first case of PFTC presenting as an isolated sigmoid colon metastasis in the setting of completely normal uterine and adnexal imaging and negative serum tumor markers. Case Description: A 52-year-old postmenopausal woman who presented with 3 months of recurrent abdominal pain and diarrhea. Imaging revealed a solitary tumor in the sigmoid colon, while the uterus and bilateral adnexa appeared normal, and serum tumor markers were negative. After tumor resection, histopathological and immunohistochemical analysis confirmed a high-grade serous carcinoma (HGSC) of gynecologic origin. Subsequent laparoscopic hysterectomy and bilateral salpingo-oophorectomy identified a 1 mm lesion of HGSC at the fimbrial end of the fallopian tube. The patient received six cycles of adjuvant chemotherapy with carboplatin 500 mg combined with paclitaxel 80 mg, once every 3 weeks, for a total of six cycles, and achieved complete remission at the 1-year follow-up. Conclusions: This case underscores the crucial role of immunohistochemistry and thorough pathological examination in determining the primary origin of malignancies with atypical presentations. It emphasizes the need for precise diagnosis to inform treatment strategies and enhance prognostic outcomes.
Hysterectomy is a frequent gynecological surgical technique. With the extensive application of robot-assisted laparoscopic surgery, the feasibility of robot-assisted transvaginal natural orifice translumenal endoscopic surgery (v-NOTES) has been demonstrated in various benign gynecologic procedures, including hysterectomy, endometriosis excision, myomectomy, sacrocolpopexy, as well as oncologic surgery. But they are all multi-port straight-arm robots. We report a case of a patient who underwent Single-Port surgical robot-assisted v-NOTES hysterectomy with pneumoperitoneum-free technique to demonstrate its possible advantages over the straight-arm robot. The patient underwent hysterectomy and double salpingectomy because of grade 3 cervical intraepithelial neoplasia (CIN3) and high-grade squamous intraepithelial lesion (HSIL) at the cervical margin. The entire procedure of pneumoperitoneum-free hysterectomy using a Single-Port surgical robot is fully demonstrated in the video. During the operation, transvaginal surgical techniques and v-NOTES techniques were combined with Single-Port robot-assisted and pneumoperitoneum-free devices. The uterosacral main ligament, uterine vessels, broad ligament, inherent ligament of the ovary, round ligament and mesentery of the fallopian tube were treated in sequence. We share this surgical technique, hoping that more gynecologists will learn about this new method. It can effectively avoid the limitations caused by the vaginal anatomy in direct-arm robot surgery. This combination is still in the initial exploration stage and more prospective controlled clinical evaluations are needed before it is widely applied.
Background: Placental thickening is a common clinical abnormality, the definition and clinical guideline for it are not clear. We herein reported two cases of isolated placental thickening (placental thickness >50 mm), with all physical examination findings and laboratory results within normal ranges. Both of the two patients were monitored closely and aggressively treated and led to favorable clinical outcomes. Case Description: One is a 35-year-old gravida 2 para 1 pregnant woman who was first indicated placental thickening at 24 weeks of gestation. She experienced vaginal bleeding with abdominal pain at 38+5 weeks of pregnancy and underwent emergency cesarean sections. The other one is a 32-year-old gravida 2 para 1 pregnant woman who was first indicated placental thickening at 31+1 weeks of gestation. She was found to have persistently low amniotic fluid since 36+6 weeks of pregnancy and an elective cesarean section was performed at 38 weeks. Conclusions: Placental thickening are easily observed clinically, it may be associated with various high-risk pregnancy conditions and adverse perinatal outcomes. However, there's no clear guidelines and only limited insights and data. Accordingly, these cases emphasize the critical clinical implications of placental thickening and proposes that close clinical surveillance is indispensable for improving maternal and fetal prognosis in patients with thickened placentas, with particular relevance to pregnant and postpartum women presenting exclusively with isolated placental thickening and no concurrent obstetric comorbidities.
Background: Pyoderma gangrenosum (PG) is a rare, noninfectious, ulcerative dermatosis that uncommonly affects the genitalia. In patients with PG, trauma from procedural intervention as opposed to conservative management with pharmacologic therapy may cause pathergy and disease exacerbation. We report the unique case of a patient with a remote history of lower extremity PG who later experienced pathergy-induced vulvar PG exacerbated by a vulvar incision and drainage. Case Description: A 67-year-old female with a history of Lyme disease, osteoporosis, and lower extremity PG developed a small pustule on the left labium minus that was incised and drained. She later presented with severe vulvar pain and copious purulent drainage from the incision. Computed tomography (CT) showed no evidence of subcutaneous soft tissue gas or discrete rim-enhancing fluid collection suggestive of an abscess. Laboratory studies showed no leukocytosis, but erythrocyte sedimentation rate and C-reactive protein were elevated. Despite administration of oral doxycycline and metronidazole, the vulvar inflammation rapidly expanded, eventually eroding and ulcerating. Wound and blood cultures were negative, making infectious etiology less likely and raising suspicion for PG triggered by trauma from the incision and drainage. This vulvar PG flare was treated for 8 months with systemic corticosteroids and 6 months of adalimumab, a biologic tumor necrosis factor (TNF) inhibitor. The vulva has healed with residual scar pain managed by daily betamethasone 0.05% ointment. Next follow-up is in 1 year. Conclusions: In patients with a history of PG presenting with vulvar dermatoses, clinicians should consider vulvar PG as a possible diagnosis. Such dermatoses should be conservatively managed to avoid pathergy and minimize disease exacerbation. If procedural intervention is warranted, multidisciplinary discussion with specialists including dermatology and rheumatology should be considered.
Background:Pregnancy represents a significant life event for most women, inducing extensive physiological adaptations. Consequently, it poses additional risks for women with congenital heart disease (CHD), a leading cause of maternal mortality. Isolated right ventricular apical hypoplasia (IRVAH) is a poorly characterized CHD subset, with pregnancy outcomes remaining unreported. Our case of a primigravida with IRVAH underscores the need for heightened monitoring in this population. Case Description:We present a 28-year-old primigravida at 28 gestational weeks referred for structural right heart failure and paroxysmal atrial fibrillation (AF) with no palpitations and dyspnea. Diagnostic evaluation revealed IRVAH on echocardiography, characterized by preserved left ventricular function, severe tricuspid regurgitation, and right ventricular dilation, alongside electrocardiography showing AF; cardiac magnetic resonance imaging (MRI) subsequently confirmed apical right ventricular hypoplasia with no associated structural anomalies. Management was guided by multidisciplinary consensus, initiating stabilization with oral metoprolol (12.5 mg per dose, twice daily) for resting heart rate control (target heart rate <110 bpm). Pregnancy prolongation strategies included weekly fetal growth scans, daily maternal oxygen saturation (SpO2)/blood pressure (BP) monitoring, and steroid coverage at 30 weeks for fetal lung maturation. Due to maternal AF recurrence despite therapy, fetal growth restriction (<10th percentile), and the need to avoid hemodynamic stress from labor, an elective cesarean delivery was scheduled at 32 weeks. A preterm infant (1,580 g, Apgar scores 9/10) was delivered via cesarean section under spinal-epidural anesthesia and transferred to the neonatal intensive care unit (NICU) for recovery. Postoperative AF in the mother was successfully controlled with increased oral metoprolol (25 mg per dose, twice daily). At the 1-, 3-, and 6-month follow-ups, maternal cardiac function remained at New York Heart Association (NYHA) class I, and no developmental delays were observed in the infant. Conclusions:This case demonstrates the critical value of multidisciplinary team collaboration in managing pregnancy complicated by IRVAH, underscoring the need for individualized monitoring and intervention strategies. These findings may serve as a reference for the clinical management of similar cases in the future.
Background:Limb-girdle muscular dystrophy (LGMD) is a rare inherited myopathy characterized by progressive weakness of the shoulder and pelvic girdle muscles. Limb-girdle muscular dystrophy type R2 (LGMD R2) caused by DYSF mutations, often shows early onset. Pregnancy in women with LGMD R2 is uncommon and may aggravate neuromuscular disease while predisposing to serious obstetric complications, including fetal growth restriction (FGR), preeclampsia, and intrahepatic cholestasis of pregnancy (ICP). This case is unique as the first report of two pregnancies in a woman with LGMD R2, highlighting recurrent maternal-fetal complications and postpartum disease progression. Case Description:A 28-year-old Asian woman with genetically confirmed LGMD R2, diagnosed at age 20 year, underwent two pregnancies managed by a multidisciplinary team (genetics, obstetrics, neurology). Management included enoxaparin (40 mg once daily), low-dose aspirin (100 mg daily initiated at 12 weeks), oral antihypertensives (labetalol ≤600 mg/day), and nutritional supplementation with high-protein diet and vitamins. This coordinated multidisciplinary team (MDT) approach ensured comprehensive, individualized, and continuous care throughout the patient's pregnancies. During the first pregnancy, the patient developed hepatic dysfunction [alanine aminotransferase (ALT) 152 U/L, aspartate aminotransferase (AST) 133 U/L], progressive FGR [estimated fetal weight (EFW) <3rd percentile], and pregnancy-induced hypertension (up to 165/102 mmHg), culminating in medically indicated termination at 34+1 weeks. In the second pregnancy, similar complications recurred, including FGR (EFW <5th percentile), severe preeclampsia (up to 167/110 mmHg), and ICP (serum bile acids 48.7 µmol/L, ALT 414 U/L, AST 332 U/L). Cesarean delivery at 36+1 weeks resulted in a liveborn female infant with favorable neonatal outcomes. The mother recovered without major post-cesarean complications but reported accelerated muscle weakness at 6-month follow-up from baseline. Conclusions:LGMD R2 significantly increases the risks of FGR, preeclampsia, and ICP, with FGR representing a key challenge due to its direct impact on fetal outcomes. Successful management requires multidisciplinary coordination, early prophylactic strategies such as aspirin, and vigilant monitoring of fetal growth and placental function. Although LGMD is not an absolute contraindication for pregnancy, women face substantial maternal and fetal risks, and pregnancy may accelerate maternal muscle weakness. Individualized reproductive counseling-including consideration of early delivery or pregnancy termination in severe cases-is essential.
Background:Pelvic organ prolapse (POP) is a common condition in women that negatively impacts the quality of life, including symptoms and effects on body image and sexuality. Robotic-assisted sacrocolpopexy (RASC) is established as a gold-standard treatment for POP, and most published evidence concerns the da Vinci robotic platform. New robotic systems are expanding the technological landscape; the Hugo-RAS platform is one of the most popular of them. Published experience with Hugo-RAS has focus mainly on prostate cancer and typically comes from centers with previous da Vinci experience. RASC articles with Hugo-RAS are very few. Moreover, the implementation of Hugo-RAS in an inexperienced robotics scenario remains unclear. We present our initial series of Hugo-RAS RASC performed by surgeons without prior robotic surgery experience to evaluate the safety, feasibility, and clinical outcomes. Case Description:Between November 2023 and March 2024, eight consecutive patients with symptomatic POP underwent RASC using Hugo-RAS system. The women included have a POP of ≥3 stage based on the POP-quantification (POP-Q). Perioperative parameters, complications, and functional outcomes were prospectively collected. Procedures were performed by a standardized technique including dissection, mesh placement, fixation to the cervix or vaginal vault and promontory, and peritonealization. A gynecological examination was carried out at discharge and at 45 days using the POP-Q system and the Patient Global Impression of Improvement (PGI-I) scale. The median operative time was 230 [interquartile range (IQR), 190-272] minutes, and the median estimated blood loss was 275 (IQR, 147.5-387.5) cc. The intraoperative complications occurred in one patient (opening of the vagina). The postoperative complications occurred in 2 patients and were Clavien-Dindo grade I-II. Median hospital stay was 3 days. At a median follow-up of 15.5 months, all patients showed objective anatomical improvement without recurrences and reported satisfaction with the surgery. Conclusions:In our preliminary series RASC using Hugo-RAS for the treatment of POP is safe, feasible, and provides satisfactory short-term outcomes even by robotic-naive surgeons. More robust and comparative studies are needed to support these results and determine their definitive role in urogynecologic surgery.
Background and Objective:Endometriosis affects approximately 10% of women of reproductive age globally and is a leading cause of chronic pelvic pain and infertility. Accurate classification is essential for preoperative diagnosis, surgical planning, and research. However, systems like the revised American Society for Reproductive Medicine (r-ASRM) rely on intraoperative findings and are not applicable preoperatively. This narrative review addresses this gap by examining three emerging classification systems-#Enzian, American Association of Gynecologic Laparoscopists (AAGL) 2021, and Numerical Multi-Scoring System of Endometriosis (NMS-E)-with a focus on their utility in pre-surgical assessment. Methods:We conducted a narrative literature review using PubMed, Embase, and Scopus covering the period from January 2015 to January 2025. A total of 66 articles related to the #Enzian classification and 19 articles on the AAGL 2021 classification were initially identified. Among them, 7 articles on #Enzian (3 original research articles and 4 reviews) and 5 articles on AAGL (2 original studies and 3 reviews) were selected based on their clinical relevance and methodological rigor. In addition, 5 original studies on the NMS-E system conducted at our institution were included. Further literature related to surgical planning, imaging techniques, and classification validation was also reviewed to support the comparative analysis. Key Content and Findings:The r-ASRM system remains widely used but lacks correlation with deep endometriosis and is not applicable preoperatively. The #Enzian system provides detailed anatomical mapping and is compatible with imaging but lacks scoring for pain and adhesions. It also does not offer a composite severity score or a specific evaluation of pouch of Douglas obliteration. Similarly, the AAGL 2021 classification introduces a surgical complexity score but does not assess pain or adhesions in detail and lacks specific evaluation of uterosacral ligament involvement. The NMS-E system uniquely integrates pelvic examination and ultrasound findings into an E-score reflecting lesion, pain, and adhesion severity. Validation studies demonstrate a strong correlation with surgical duration (r=0.724, P<0.01). Patients with lower NMS-E adhesion scores had better postoperative fertility outcomes (P<0.05). While #Enzian and AAGL 2021 are gaining international adoption, NMS-E remains in the early stages of clinical uptake. Conclusions:Each system contributes to improved preoperative assessment but has limitations. NMS-E adds value by incorporating symptoms and adhesion scoring. No system is yet ideal; further integration and validation across diverse clinical settings are needed. This review provides comparative insights to support classification system refinement and practical application.
Background and Objective:Endometriosis causes infertility and pain and is associated with detriment to quality of life. The aim is to review hormonal and complementary treatments for pain in women with endometriosis. Up until this review was registered on PROSPERO, no other review had focused exclusively on hormonal and complementary treatments for endometriosis. Prior reviews broadly covered surgical, hormonal, and complementary treatments. Methods:This narrative review was carried out by searching the PubMed, Virtual Health Library and Embase databases for publications in English or Portuguese from 2014 to 2024 about hormonal and complementary treatments. Studies were selected if they focused on endometriosis treatment and a pain scale or quality of life questionnaire were specified. Key Content and Findings:A total of 1,201 publications were identified. After excluding duplications and applying inclusion criteria, 48 studies remained, of which 33 were selected for this review. Dienogest is the most studied therapy, with evidence of its use as first-line treatment. Combined oral pills were superior to placebo and have comparable efficacy to dienogest. Gonadotropin-releasing hormone (GnRH) agonists should be prescribed on a short-term basis, as second-line treatment, considering the side effects, impacts on bone mineral density and cardiovascular health. GnRH antagonists represent a promising therapy, due to dose-dependent hypoestrogenism, minimizing side effects compared to agonists. However, they have not been compared to first-line treatments and so far, should be reserved for cases of treatment failure. Findings suggest that complementary therapies seem to have an important role in adjuvant pain control. However, it is difficult to assess the isolated effect of these therapies because the studies involve multiple concurrent interventions and are not placebo-controlled. Conclusions:Progestins and combined oral contraceptive pills are first-line treatments and GnRH analogues are second-line treatments according to studies with good quality evidence. Complementary treatments lack good quality evidence.
Background and Objective:Fistulae are anomalous communications between two epithelial surfaces. Though with a rare incidence, they impose significant burdens on affected women. Fistulae were initially described in 200 A.D., but management has evolved surgically to include more minimally invasive approaches. Minimally invasive techniques have notably decreased morbidity rates for surgical approaches in the past decades. Robotic surgery was born from the desire to overcome laparoscopy limitations while retaining its advantages. When available, robotic surgery provides surgeons with enhanced dexterity, more precise dissection, easier intracorporeal suturing, a shorter surgical learning curve, elimination of the fulcrum effect, and a three-dimensional (3D) perspective, all while maintaining ergonomic comfort. The main objective of this narrative review was to discuss relevant aspects of the vesicovaginal fistula (VVF), vesicouterine fistula (VUF), and ureterovaginal fistula (UVF) and discuss their robotic repair. Methods:A narrative review was conducted utilizing a comprehensive search to identify studies discussing the robotic management of female urinary fistulae. Data from all types of studies were included without restrictions on article type. Only articles in English and Spanish were considered. Searches were performed on 12/12/2020, 04/25/2023, and 09/10/2023 in the electronic database PubMed (1978 to 2023), using free text terms and keywords. Key Content and Findings:Treatment of genitourinary fistulae depends on the size, location, surgeon preference, and underlying cause. A small subset can resolve with conservative management, but more commonly, fistulae are treated surgically. No matter the type of genitourinary fistulae or the surgical approach, there are general surgical principles essential in ensuring successful surgical repair. These include good visualization, adequate exposure, careful dissection, healthy margins, and watertight closure with suture lines that do not overlap. Conclusions:Surgical management is necessary in complicated cases and when conservative measures fail. When available, robotic surgery can aid in repairing the more difficult and complex fistulae, given its advantages of offering a minimally invasive approach with greater dexterity and a tridimensional view.
Background and Objective:Uterine leiomyomas are the most common benign tumors of the female genital tract, affecting approximately 20-40% of women of reproductive age. Clinically, they may present with heavy menstrual bleeding, pelvic pain, pressure symptoms, and infertility. There are different treatment modalities depending on the patient's age and expectations, uterine size, the size and localization of the myoma(s), etc. Myomectomy is a key surgical option, particularly for patients who wish to preserve fertility or maintain the uterus. Although minimally invasive approaches are increasingly used, open (abdominal) myomectomy remains a preferred technique for large, numerous, or deeply located fibroids. The aim of this article is to investigate in which patients open abdominal myomectomy should be preferred. In this context, we will discuss the advantages and disadvantages of the surgical treatment methods of fibroids in patients. Methods:PubMed, Web of Science, and Google Scholar were queried using pertinent keywords to retrieve relevant studies with a particular focus on open abdominal myomectomy, mini-laparotomy, laparoscopic and hysteroscopic myomectomy for uterine fibroids. Key Content and Findings:Myomectomy with laparotomy seems to be more appropriate in the presence of an intramural myoma >10-12 cm in size or multiple myomas (≥4) at different sites in the uterus, requiring numerous incisions. Conclusions:Treatment preferences depend on the patient's age and desire to preserve fertility, as well as the clinical presentation of the myoma such as the size, number and location of fibroids, and also the surgical experience of the gynecologist.
Background and Objective:Although transvaginal mesh surgery (TVM) using polypropylene (PP) mesh is no longer performed worldwide due to a severe warning by the U.S. Food and Drug Administration (FDA) in 2011, TVM surgery has been widely performed in Japan to date because of the availability of polytetrafluoroethylene (PTFE) mesh ORIHIME®. PTFE is a safe material that has been used as a medical material, but its weak adhesion to the surrounding tissue may cause problems in maintaining the position of the mesh in the TVM. The effectiveness and safety of the ORIHIME®, which has been used in Japan since 2019 and has been in use for more than 5 years, need to be verified. Therefore, we aimed to review articles published after 2019 on the outcomes of pelvic organ prolapse (POP) surgery using ORIHIME®. Methods:PubMed and Google Scholar were used for the search, English as the language, with PTFE mesh ORIHIME® and POP as the keywords. The search for papers from January 2019 to July 2025 resulted in a list of 10 papers. One of these papers was on the properties of ORIHIME®, eight were on TVM using ORIHIME®, and one was on laparoscopic sacrocolpopexy (LSC) using ORIHIME®. Key Content and Findings:Regarding the characteristics of ORIHIME®, histopathologically, images of the tissue around the mesh in recurrent cases showed that inflammation around the PTFE mesh was weaker in vivo than in the PP mesh. Although most of the papers on TVM with ORIHIME® have had short-term data up to 1 year, a consensus is emerging that TVM with ORIHIME® is more prone to recurrence than TVM with PP. On the other hand, there seems to be no problem with using ORIHIME® for LSC. Conclusions:TVM with ORIHIME® has a high risk of recurrence when procedure is performed in the same way as TVM with PP due to mesh arm slippage. LSC with ORIHIME® appears to be comparable in performance to LSC with PP mesh. Long-term follow-up data are awaited in both procedures.
