There is a balance between procedural success and patient acceptability in outpatient hysteroscopy. Reporting either outcome alone inadequately reflects how well the procedure was conducted. A new metric is proposed: the "Clark ratio", defined as patient acceptability divided by procedural failure, to capture this trade-off. Higher ratios indicate better performance. The limitations of data from randomised controlled trials and need for real-world evidence and standardised outcome measures to validate feasibility and patient experience is discussed. The Clark ratio is a new concept and could potentially be adopted, if found to be valid and useful, as a simple, easily interpretable, pragmatic benchmark for quality assurance and outcome in research for outpatient hysteroscopic procedures.
Background:Previous retropubic surgery, such as laparoscopic Burch colpo-suspension, can significantly alter the anatomy of the space of Retzius due to fibrosis and scarring. These changes increase the technical difficulty and risk of complications during subsequent retropubic procedures, particularly midurethral sling placement. Objectives:To demonstrate the feasibility and safety of laparoscopic-assisted tension-free vaginal tape (TVT) placement in a patient with recurrent stress urinary incontinence (SUI) following prior colpo-suspension. Participant:A 74-year-old woman with recurrent SUI following laparoscopic Burch colpo-suspension performed five years previously. Intervention:Retropubic TVT placement was performed under simultaneous laparoscopic guidance at a tertiary gynaecological centre. Intraoperative laparoscopy enabled visualisation of the retropubic space, revealing significant fibrosis and distorted anatomy. Needle passage and sling positioning were performed under direct visualisation. Because extensive retropubic dissection reduced the usual tissue support of the tape, it was temporarily secured with a rapidly absorbable suture to maintain its position without increasing suburethral tension. Conclusions:Laparoscopic-assisted TVT placement is a feasible and safe approach in patients with prior retropubic surgery. Direct visualisation allows identification of altered anatomical planes, facilitating controlled needle passage and potentially reducing the risk of complications. What is New?:This video demonstrates the importance of avoiding blind needle insertion in patients with prior colposuspension and highlights laparoscopic guidance as a valuable strategy to improve safety during retropubic sling procedures.
Background:Consensus is lacking regarding the relative safety and oncological outcomes of minimally invasive compared to abdominal hysterectomy. Objectives:To estimate complications and survival rates of minimally invasive hysterectomy (MIH) (i.e., laparoscopic or robotic assisted) compared to total abdominal hysterectomy (TAH) for endometrial and cervical cancer. Methods:A systematic quantitative review of randomised controlled trials (RCTs) comparing MIH with TAH for the treatment of endometrial or cervical cancer. Medline-PubMed, Cochrane Library, Scopus, ongoing clinical trials and the grey literature were searched until December 1, 2024. Main Outcome Measures:Complications, overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) rates. Results:Twenty-nine RCTs enrolling 6,127 patients were included. The risk of bladder injury was higher in the MIH group [risk ratio (RR): 1.84, 95% confidence interval: (CI): 1.03-3.29, I2: 0%), as was the risk of vaginal injury (RR: 12.39, 95% CI: 1.61-95.29, P=0.02, I2: 0%) but the risk of wound dehiscence was lower (RR: 0.32, 95% CI: 0.13-0.83, P=0.02, I2: 13%) compared to abdominal hysterectomy. Among cervical cancer patients, the risk for blood transfusion was significantly lower with the MIH (RR: 0.42, 95% CI: 0.21-0.84, P=0.01, I2: 0%). Among endometrial cancer patients, the OS, DFS, and DSS were comparable between routes of hysterectomy. In contrast, the overall the OS and DFS rates were lower for minimally invasive compared to abdominal hysterectomy (0.94, 95% CI: 0.90-0.98, P=0.005, I2:0 %) and (0.89, 95% CI: 0.84-0.94, P<0.001, I2: 0%) respectively. Conclusions:Bladder and vaginal injuries are higher with minimally invasive compared to abdominal hysterectomy. Survival rates for endometrial cancer are comparable but for cervical cancer, minimally invasive hysterectomy is associated with poorer survival outcomes and this should be taken into account when counselling patients and deciding upon the route of hysterectomy. What is New?:TAH has superior survival outcomes compared to minimally invasive hysterectomy.
Background:Interstitial thermal ablation represents a uterine-sparing alternative for symptomatic fibroid management. Transvaginal ultrasound-guided myolysis enables precise targeting and real-time monitoring of the ablation zone. Objectives:To illustrate the feasibility and immediate intraoperative response of transvaginal ultrasound-guided interstitial myolysis for the treatment of uterine fibroids. Participant:A 36-year-old multiparous woman with persistent abnormal uterine bleeding and pelvic pain related to a known uterine fibroid seeking a uterus-preserving treatment. Previous treatments, including levonorgestrel-releasing intrauterine system and oral therapy with relugolix, estradiol, and norethisterone had failed. Intervention:Transvaginal ultrasound revealed a retroverted, enlarged uterus with a posterior type 2-5 fibroid measuring 45×37×49 mm (volume: 42.4 cm³). Under conscious sedation, a 16G-27 cm microwave antenna was transvaginally inserted and repositioned within the fibroid under continuous ultrasound guidance. Ablation was delivered in four cycles at 20 W for a total duration of 194 seconds, with a cumulative net energy delivered of 3.3 kJ calculated by the device, while continuously assessing safety margins and tissue response. Immediate ultrasound evaluation showed a 42.7% volume reduction (from 42.4 to 24.3 cm³), loss of fibroid definition, and partial collapse, consistent with effective devascularisation. No complications occurred, and the patient was discharged the same day. At 4-month follow-up, fibroid volume reduction was sustained (41.7%), with complete symptom control under the previously ineffective hormonal therapy. Conclusions:Transvaginal interstitial myolysis offers a minimally invasive, uterine-sparing treatment option for selected patients with symptomatic fibroids. Real-time ultrasound monitoring enables precise ablation and immediate confirmation of treatment efficacy. What is New?:This video documents the immediate volumetric response of a uterine fibroid following transvaginal ultrasound-guided myolysis.
Caesarean scar defects, known as isthmocele, are increasingly recognized in women with secondary infertility, yet hysterosalpingographic (HSG) criteria remain poorly defined. We describe a reproducible HSG feature, the “pocket sign,” observed in seven women with prior caesarean delivery. This finding appears as contrast pooling in the anterior lower uterine segment near the internal cervical os. In all cases, it correlated with transvaginal ultrasound and hysteroscopic findings. Although non-specific and not diagnostic, the pocket sign may serve as an adjunctive indicator prompting further evaluation. Given anatomical variability and intrinsic limitations of HSG, multimodal imaging remains essential.
