Objectives: Tubal infertility accounts for approximately 30% of infertility cases in women. Falloposcopic tuboplasty (FT) is used in women with proximal tubal obstruction. However, it is technically challenging because of difficulties in locating the tubal ostium and confirming success. To address these challenges, we developed a hysteroscopically assisted FT (HA-FT). This study aimed to evaluate the efficacy of HA-FT in women with tubal infertility. Materials and Methods: This prospective unblinded study included infertile women with proximal tubal obstruction who desired a natural conception. HA-FT was performed under either intravenous or general anesthesia. Postoperative hysterosalpingography was performed in an operating room to confirm success. Success and pregnancy rates of HA-FT were compared with those of regular FT (Reg-FT). Results: Regular FT (n = 73; 119 tubes) was performed before 2013, and HA-FT (n = 72; 136 tubes) was introduced thereafter. Patient characteristics were similar between the two groups. Operative time was not significantly different (Reg-FT: 37.7 ± 18.7 min vs. HA-FT: 44.3 ± 18.2 min). The success rate per patient was significantly higher in a HA-FT group (72/72,100%) than that in a Reg-FT group (63/73, 86.3%, P < 0.05). Similarly, success rate per tube was significantly higher for HA-FT (135/136, 99.3%) than that for Reg-FT (95/119, 79.8%; P < 0.01). Natural pregnancy rates were similar between the groups (HA-FT: 20/58, 34.4%; Reg-FT: 20/61, 32.7%). Conclusion: HA-FT is a safe, effective, and reliable method for the treatment of proximal tubal obstruction. Its natural pregnancy rates are acceptable, making it a promising option for women with tubal infertility.
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting women everywhere. PCOS without insulin resistance (IR) is much less severe than PCOS with IR, and the severity is less in the nonobese. Management and treatment of IR are imperative in PCOS management. As a major cause of female fertility issues, PCOS is yet to be fully understood. The symptoms of PCOS create a mental burden on the patient, which needs to be taken care of. Management of IR has significantly helped in reducing the symptoms of PCOS. Many studies have shown that there is no one solution to IR and PCOS. In this review, we examine the various pathophysiological processes, clinical impacts, and management of PCOS and IR. We also focus on how the combination of lifestyle changes, such as improving activity levels, consuming nutrient-rich whole foods, maintaining good mental health, quality sleep, pharmaceutical support and dietary supplements, is currently recognized as the management of IR and PCOS.
Objectives:Laparoscopy is a minimally invasive surgical approach that can reduce morbidity compared with open surgery in appropriately selected patients. However, patients with a history of intra-abdominal solid organ transplantation may have postoperative adhesions and altered anatomy, leading to more complex and variable anatomy. It remains unclear whether prior transplantation increases the risk of complications during laparoscopy. This study aimed to evaluate the incidence of complications in patients undergoing laparoscopy following intra-abdominal solid organ transplantation. Materials and Methods:A systematic search of PubMed, EMBASE, and Google Scholar was conducted through October 2023 to identify studies on laparoscopy in postintra-abdominal solid organ transplant recipients. Two independent reviewers identified 30 relevant articles, of which 19 (including case reports, case-control, and cohort studies) met the inclusion criteria. Risk of bias was assessed using the Newcastle-Ottawa scale by two independent reviewers. The study protocol was registered with PROSPERO (CRD42023477254). Results:Four studies included direct comparisons between transplant and nontransplant patients. The mean postoperative length of stay was 3.5 days among 1402 transplant patients, compared with 2.3 days among 2,640,340 nontransplant patients. Two studies reported a lower rate of wound infection in nontransplant patients compared with posttransplant patients (1.7% vs. 4.8%). Rates of other infections, seroma formation, ileus, and disease recurrence were comparable between groups, although each was reported by only one small study. Two of the four studies were assessed as having a low risk of bias. Conclusion:Direct comparisons between patients with and without a history of intra-abdominal solid organ transplantation suggest that laparoscopy is generally safe, with a modest increase in hospital stay and wound infection risk in posttransplant patients.
Laparoscopic myomectomy is increasingly used for uterine fibroid excision in women needing fertility preservation. However, as complex laparoscopic procedures become common and widespread, new and novel complications are being reported. Retained fibroid pieces are an uncommon but possibly dangerous consequence. We describe a case of laparoscopic myomectomy involving multiple fibroids of varying sizes which were enucleated and electrosurgically cut into smaller pieces. This case is unique because a residual fibroid fragment got buried in the mesentery causing early postoperative intestinal obstruction. The diagnosis was confirmed by a follow-up laparoscopy, and full healing resulted from surgically removing that fibroid segment. In order to prevent such difficulties, this article highlights how crucial it is to carefully remove all myoma fragments during laparoscopy.
Utero-cutaneous fistula (UCF) is a rare complication after a cesarean section which is mostly managed surgically. There is only one reported case of laparoscopic management of UCF. Our patient, a para one lady, presented after cesarean section with bloody discharge from the cesarean wound ever since her surgery, which, on contrast-enhanced computed tomography was confirmed to be a UCF. She was managed successfully with laparoscopic fistula tract excision followed by debridement of the necrotic uterine wall and repair of both uterine and bladder defects. This case highlights that minimally invasive route is a feasible and reasonable option for a UCF repair. UCF may be difficult to suspect and diagnose leading to a delay in the diagnosis in most cases. Nevertheless, it warrants an arduous work up and meticulous management, whether medical or surgical to ensure the good quality of life to the patient.
Objectives: To investigate the underlying risk factors, clinical value, usefulness, and outcome of laparoscopic management of urinary tract injuries. Materials and Methods: A retrospective cohort study including 25 patients of a case of urinary tract injuries in duration from January 1, 2015 to May 31, 2023 was conducted at tertiary care hospital from Central India after the approval from the institutional ethics committee was obtained. All the cases were managed by laparoscopic route by a single surgeon with more than 15 years of experience. Results: A total of 25 patients were operated for urinary tract injuries at our hospital during the study period. All cases were managed laparoscopically. All patients showed complete recovery. The major risk factors for injury were adhesions, previous lower segment cesarean section, and endometriosis. The most of injuries occurred during hysterectomy, with few of them during cesarean section. Ten cases of bladder injuries were identified intraoperatively and managed by bladder repair in two layers. Four cases with ureteric injuries were managed by ureteric catheterization. In ureterovaginal fistula group, 5 cases were managed by ureteric re-implantation uretero-neocystotomy whereas, 1 case was managed by ureteric catheterization. Five cases with vesicovaginal fistula (VVF) were managed by VVF repair. Conclusion: The sound anatomical knowledge of pelvic anatomy, risk factors associated with urinary tract injury, and meticulous operative procedure is important for the prevention and early identification of the injuries if any to minimize the morbidity postoperatively. With technical advances and surgical expertise urinary tract injuries can be managed by laparoscopy with excellent outcome.
Objectives:To compare the treatment failure rates in patients with adenomyosis who underwent transcervical resection of the endometrium (TCRE) and levonorgestrel intrauterine device (LNG-IUD) insertion versus those with LNG-IUD insertion alone. Materials and Methods:One hundred and forty-six women with adenomyosis and heavy menstrual bleeding (HMB) or dysmenorrhea were enrolled in this randomized controlled clinical trial (CTRI/2020/09/027592). One group had TCRE with LNG-IUD insertion and the other group had only LNG-IUD insertion. Baseline assessment included quality of life score (World Health Organisation quality of life-BREF [WHO QOL-BREF]), and menorrhagia multi-attribute scale (MMAS) score. The patients in both the treatment arms were followed up for 12 months. The scores were reassessed at 12 months along with LNG-IUD expulsion rates and treatment failure, which included any of the following: hysterectomy for adenomyosis, persistent HMB, or persistent dysmenorrhea. Results:The primary outcome of treatment failure was significantly lower in the TCRE + LNG-IUD group (7.14% vs. 25%, P = 0.01; Risk ratio 3.45, 95% Confidence interval (1.35-8.83). The quality-of-life (WHO QOL-BREF) and MMAS scores at 12 months were also significantly better in the TCRE + LNG-IUD arm. None of the women in the combined TCRE and LNG-IUD group had LNG-IUD expulsion at 12 months compared to the LNG-IUD expulsion rate of 8.8% in the LNG-IUD alone group (P = 0.013). Conclusion:A combination of TCRE with LNG-IUD had a lower failure rate at 12 months in women with adenomyosis compared to LNG-IUD alone. This combination also resulted in better quality of life and lowered the chance of LNG-IUD expulsion at 12 months.
Objectives:This study evaluated the safety and feasibility of a simplified intra-ureteral indocyanine green (ICG) injection technique performed by gynecologists during complex laparoscopic surgeries. Materials and Methods:A retrospective analysis of 110 cases performed from March 2023 to March 2024 was conducted. A set of hysteroscope (Karl Storz), a set of epidural catheter, a vial of ICG (25 mg), and a Near-Infrared (NIR) three-dimensional (3D) RUBINA camera system were used. A hysteroscope was used to inspect the bladder and identify the ureteral openings. Epidural catheter was inserted into the operating channel of the hysteroscope and advanced into the ureteral orifice up to 150-200 mm from the ureteral opening. Approximately 2.5 ml of ICG was injected into each ureter from the outer end of the epidural catheter. The planned 3D laparoscopic procedures were then followed. The ICG highlighted the ureters, and their course was observed and visualized in real-time under NIR light as desired. Results:Among the 110 cases, 62 involved severe endometriosis, 40 had large uterine masses, 8 involved malignancy, and 48 had prior pelvic surgeries. ICG injection was successfully performed in 107 cases (97%) with a mean time of 2.2 min. Three near-miss ureteral injuries were prevented with real-time visualization. Mean operative time was 210.8 min, the mean estimated blood loss was 198 ml, and the mean hospital stay was 2.8 days. No adverse events were reported. Conclusion:The simplified "EP Method" for intra-ureteral ICG injection is safe, feasible, cost-effective, and time-saving. It prevents ureteral injuries and can be performed independently by gynecologists without urologist assistance.
Objectives: The purpose of this study was to determine if urine epidermal growth factor (EGF) levels can be used to distinguish between overactive bladder (OAB) and recurrent lower urinary tract infection (UTI). Materials and Methods: This was a prospective study conducted at a single tertiary medical center, using medical records and biospecimens collected from premenopausal women with OAB, recurrent lower UTI, and healthy controls without urinary tract conditions. Patients with OAB were treated with either mirabegron (Betmiga®) or solifenacin succinate (Vesicare®) for 3 months. Urinary EGF and creatinine levels were measured at baseline and posttreatment. Symptom changes were assessed using voiding diaries and the OAB Symptom Score (OABSS) questionnaire. Results: A total of 61 women were included in the study: 21 with OAB, 20 with recurrent lower UTI, and 20 healthy control women. There was no significant difference in the urine EGF/creatinine ratio between the OAB, recurrent lower UTI, and control groups (3212.7 [2592.2, 3909.6] and 3362.3 [2374.7, 4632.3] vs. 3402.3 [2700.1, 4568.9], P = 0.895). Both medications were effective in relieving symptoms of OAB, but solifenacin was associated with a significantly higher rate of dry mouth (60% vs. 0%, P = 0.045). Conclusion: No significant difference in urine EGF/creatinine ratio was observed between control subjects and patients with OAB or recurrent lower UTI. Thus, urine EGF is not likely a useful marker for distinguishing between OAB and recurrent lower UTI.
Objectives:This study aimed to compare the efficacy of rectal misoprostol combined with intramyometrial normal saline versus intramyometrial vasopressin in reducing blood loss during laparoscopic myomectomy. Materials and Methods:This was a randomized, double blind, controlled trial (CTRI/2023/05/053204). A total of 70 women scheduled for laparoscopic myomectomy were enrolled and equally randomized into two groups: Group I (received rectal misoprostol 400 µg 1 h before surgery) and Group II (received intramyometrial vasopressin 20 IU in 200 ml NS dilution). Final analysis was conducted on 64 patients due to missing data (4 in Group I and 2 in Group II). The primary outcome was intraoperative blood loss. Results:Baseline clinical characteristics were similar between the groups. Intraoperative blood loss was significantly higher in the misoprostol Group I compared to the vasopressin Group II (320.9 ± 131.9 mL vs. 246 ± 119.3 mL; P = 0.02). Similarly, the mean drop in hemoglobin was greater in Group I (2.38 ± 1 g/dL) than in Group II (1.5 ± 1.2 g/dL; P = 0.02). Although operative time was longer in Group I (median [95% confidence interval]: 120 [90-158.2] min vs. 96 [90-135.89] min), the difference was not statistically significant (P = 0.49). Blood transfusion was required in 4 patients in Group I and 1 patient in Group II. Intraoperative mean arterial pressure was significantly higher in Group II (110 ± 13.3 mmHg vs. 101 ± 13.7 mmHg; P = 0.02). Postoperative complications were comparable, with low rates of fever in both groups. Conclusion:Vasopressin was more effective than misoprostol in reducing intraoperative blood loss and postoperative hemoglobin drop during laparoscopic myomectomy.
Laparoscopy for intramural uterine myomas lacking serosal protrusion or hysteroscopic accessibility remains surgically challenging due to limited visualization and precise localization. This prospective case series evaluated the efficacy of intraoperative transvaginal ultrasonographic guidance in augmenting laparoscopic excision of occult intramural fibroids. Fifteen patients underwent laparoscopy with concurrent transvaginal ultrasound-guided needle localization, utilizing a 17- or 18-gauge single-lumen needle affixed to a transvaginal probe. The needle, introduced via the vaginal fornix, facilitated real-time intrauterine mapping to pinpoint myoma boundaries and optimize serosal incision placement. Complete enucleation was achieved in all cases. This technique enhanced intraoperative precision by integrating dynamic imaging to overcome visual constraints inherent in conventional laparoscopy, minimizing collateral tissue disruption and hemorrhage through targeted incision planning. The findings underscore the adjunctive role of transvaginal ultrasonography in optimizing minimally invasive myomectomy for complex intramural fibroids, offering a reproducible strategy to improve surgical accuracy, completeness of resection, and hemostatic control.
Ultrasound-guided transvaginal ethanol sclerotherapy belongs to one of the minimally invasive methods for endometrioma management. Nevertheless, some reports suggested a possible link between the method and the presence of pelvic adhesions. Therefore, our study aimed to describe ultrasound-guided transvaginal sclerotherapy with high-percentage ethanol, which resulted in the preservation of normal anatomy of the minor pelvis and the normal appearance of affected ovaries in the laparoscopic images obtained during postsclerotherapy surgeries. We present four cases of patients who underwent laparoscopic surgeries several months after ethanol sclerotherapies for ovarian endometriomas. During sclerotherapies, cyst fluid was aspirated under ultrasound guidance, cyst cavities were flushed with saline, and then filled with 96% ethanol to 60% of their initial volume for 10 min. The reported cases demonstrate that ultrasound-guided transvaginal ethanol sclerotherapy did not cause excessive adhesion formation or affect ovarian morphology. Therefore, it seems that this treatment method does not adversely affect fertility.
Abstract Objectives: Patients with pelvic organ prolapse (POP) tend to have a reduced quality of life (QOL) because of voiding symptoms. To assess the severity of POP, the Prolapse Quality-of-Life Questionnaire (P-QOL) is used; however, it is unclear whether P-QOL can evaluate voiding conditions. In the present study, we examined patients with POP to determine whether the P-QOL could be used as an assessment questionnaire for voiding dysfunction. Materials and Methods: The study enrolled 98 patients who underwent LSC at our institution. The correlation between the selected P-QOL component question scores and the International Prostate Symptom Score (IPSS) plus the QOL score was evaluated, and the Kruskal–Wallis test was used to compare the differences in the selected component question scores of the P-QOL between the IPSS ≥8 and ≤7 groups and between the QOL ≥4 and ≤3 groups before and after surgery. Results: The Spearman’s correlation coefficient by rank test between the total of the selected component question P-QOL scores and the IPSS plus QOL score revealed significant preoperative and postoperative correlations. Box plots also showed a significant difference in the total selected component question P-QOL scores between the IPSS ≥8 and ≤7 groups and between the QOL ≥4 and ≤3 groups preoperation and 3, 6, and 12 months postoperation. Conclusion: The P-QOL can provide relatively accurate information regarding preoperative and postoperative voiding conditions. The P-QOL can be a substitute for the IPSS plus QOL score in patients with POP.
Abstract Objectives: In the preoperative period, patients with pelvic organ prolapse (POP) frequently experience overactive bladder (OAB) symptoms, and transvaginal mesh surgery (TVM) is an effective approach for POP treatment, but postoperative symptoms may persist even in patients who underwent repair surgery for POP. We here investigated patients with POP who underwent TVM at our institution to determine the factors causing postoperative OAB symptoms following TVM. Materials and Methods: The study enrolled 132 patients who underwent TVM at our hospital between June 2016 and September 2023. To determine the independent factors contributing to postoperative OAB symptoms or OAB improvement, the Pearson Chi-square test and multiple logistic regression analysis were employed. To assess the change in OAB symptoms, we used the OAB symptom score (OABSS). Results: Correlation analyses revealed that ORIHIME ® with the adjustment of the mesh size (AMS) beneath the bladder was significantly associated with decreased postoperative OAB symptoms and OAB improvement (both P < 0.05). Multiple logistic regression analyses showed that an independent contributor to the postoperative decline of OAB symptoms and postoperative OAB improvement was ORIHIME ® with AMS beneath the bladder. Furthermore, box plots showed a significant decrease in OABSS at 3–12 months postoperatively in the group that used ORIHIME ® with AMS beneath the bladder. Conclusion: Adjusting the mesh size beneath the bladder can lead to postoperative OAB symptom alleviation or improvement. In TVM using ORIHIME ® , the mesh size should match the bladder size to reduce postoperative OAB symptoms.
