The Journal of Minimally Invasive Gynecology

Cover 1

2012-01-01

The Food and Drug Administration’s 2011 Warning Regarding Adverse Effects Related to Mesh Implants for Pelvic Floor Reconstruction—Personal Perspectives

Menahem Neuman — 2012-01-01

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-19-2-11-00439

AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Endometrial Polyps

AAGL Advancing Minimally Invasive Gynecology Worldwide — 2012-01-01

Abstract: Endometrial polyps are a common gynecologic disease that may be symptomatic, with abnormal vaginal bleeding being the most common presentation. They may be found incidentally in symptom-free women investigated for other indications. Increasing age is the most important risk factor, with medications such as tamixifen also implicated. Specific populations at risk include women with infertility. Malignancy arising in polyps is uncommon, and specific risks for malignancy include increasing age and postmenopausal bleeding. Management may be conservative, with up to 25% of polyps regressing, particularly if less than 10 mm in size. Hysteroscopic polypectomy remains the mainstay of management, and there are no differences for outcomes in the modality of hysteroscopic removal. Symptomatic postmenopausal polyps should be excised for histologic assessment, and removal of polyps in infertile women improves fertility outcomes. Blind removal is not indicated where instrumentation for guided removal is available. Surgical risks associated with hysteroscopic polypectomy are low.

Partial Constriction of Left Infundibulopelvic Ligament

Cristo Papasakelariou, Tamika Sea, Eugene C. Toy — 2012-01-01

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-19-1-1711

Utero-Ovarian Vessel after Uterine Artery Embolization

Lydia Garcia, Keith Isaacson — 2012-01-01

You can discuss this case report with its authors and with other AAGL members at http://www.AAGL.org/jmig-19-1-11-00248

A Systematic Review Comparing Hysterectomy with Less-Invasive Treatments for Abnormal Uterine Bleeding

2011-11-14

Abstract: Study Objective: To compare hysterectomy with less-invasive alternatives for abnormal uterine bleeding (AUB) in 7 clinically important domains.Design: Systematic review.Setting: Randomized clinical trials comparing bleeding, quality of life, pain, sexual health, satisfaction, need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options.Patients: Women with AUB, predominantly from ovulatory disorders and endometrial causes.Interventions: Systematic review of the literature (from inception to January 2011) comparing hysterectomy with alternatives for AUB treatment. Eligible trials were extracted into standardized forms. Trials were graded with a predefined 3-level rating, and the strengths of evidence for each outcome were evaluated with the Grades for Recommendation, Assessment, Development and Evaluation system.Measurements and Main Results: Nine randomized clinical trials (18 articles) were eligible. Endometrial ablation, levonorgestrel intrauterine system, and medications were associated with lower risk of adverse events but higher risk of additional treatments than hysterectomy. Compared to ablation, hysterectomy had superior long-term pain and bleeding control. Compared with the levonorgestrel intrauterine system, hysterectomy had superior control of bleeding. No other differences between treatments were found.Conclusion: Less-invasive treatment options for AUB result in improvement in quality of life but carry significant risk of retreatment caused by unsatisfactory results. Although hysterectomy is the most effective treatment for AUB, it carries the highest risk for adverse events.

Risk Factors, Symptoms, and Treatment of Ovarian Torsion in Children: The Twelve-Year Experience of One Center

2011-10-20

Abstract: Objective: To assess risk factors, clinical findings and mode of diagnosis and treatment in premenarchal children with surgically verified ovarian torsion (OT).Study Design: A retrospective case review (Canadian Task Force Classification II-2).Setting: Teaching and research hospital, a tertiary center.Patients: Premenarchal children with surgically verified OT.Interventions: Patients underwent either laparoscopy or laparotomy.Results: Twenty-two cases of OT in 20 premenarchal girls (median age 12 years) were identified. Three cases involved recurrent torsion after detorsion without cystectomy. The main presenting symptoms were sudden pain and vomiting. Six patients underwent Doppler examinations, and all demonstrated an abnormal flow. Seventeen interventions were by laparoscopy. Conservative management, mainly detorsion with additional cyst drainage or cystectomy, was performed in 19 cases (86.4%). Oophoropexy was performed in 3 cases (13.6%). Pathologic examination demonstrated 5 simple cysts and 1 dermoid cyst.Conclusions: Ovarian torsion in premenarchal girls usually presents with intermittent abdominal pain and abdominal tenderness. Other signs and symptoms are nonspecific. When performed, Doppler imaging may assist in diagnosing ovarian torsion in children. Detorsion followed by cystectomy may prevent recurrence.

Treatment of Twenty-Two Patients with Complete Uterine and Vaginal Septum

2011-10-24

Abstract: Study Objective: To assess the fertility and obstetric outcome after surgical treatment of complete uterine and vaginal septum.Design: Retrospective study (Canadian Task Force Classification II-2).Setting: Teaching hospital in France.Patients: Twenty-two women who have experienced infertility, pregnancy losses, dyspareunia, or dysmenorrhea.Intervention: Hysteroscopic section of complete uterine septum and resection of longitudinal vaginal septum.Measurements and Main Results: Improvement of dyspareunia or dysmenorrhea and obstetric outcome, focusing on the miscarriage rate, obstetric complications, and the gestational age at delivery were assessed. Overall, 20 women had conceived a total of 37 pregnancies, with 10 and 8 deliveries before and after metroplasty, respectively. Median gestational age at delivery was not significantly different in both groups (36.5 [33–39.5] vs 38.0 weeks’ gestation [35–40], respectively). Preterm delivery occurred in 4 cases (25%) before the surgery and in 3 cases (14%) after (p = .44). The live birth rate was also not significantly different before and after surgery (62.5% and 38%, respectively) (p = .19). There was a decrease of caesarean section and significantly fewer breech deliveries after metroplasty (p = .01). A decrease in the prevalence of dyspareunia or dysmenorrhea was observed after metroplasty in the 19 patients originally displaying these symptoms. No perioperative complications were observed in this series.Conclusion: Resection of vaginal septum and hysteroscopic metroplasty for complete uterine septum with resection of the cervical septum is a safe procedure that may improve dyspareunia and dysmenorrhea when present. Reproductive and obstetric outcomes after this procedure do not appear to be compromised, even though a relatively high miscarriage rate remains after metroplasty, questioning its systematic practice in symptom-free women without any previous obstetric history.

The Risk of Umbilical Hernia and Other Complications with Laparoendoscopic Single-Site Surgery

2011-10-28

Abstract: Study Objective: To estimate the risk of umbilical hernia and other latent complications in women who underwent laparoendoscopic single-site surgery (LESS) for a gynecologic indication.Design: Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2).Setting: Four tertiary care academic medical centers.Patients: Women undergoing LESS for a benign or malignant gynecologic indication from 2009 to 2011.Interventions: A total of 211 women underwent LESS via a single 1.5- to 2.0-cm umbilical incision. All surgeries were performed by advanced gynecologic laparoscopists. Incisions were repaired with a running, delayed absorbable suture. Subject demographics and clinical variables were collected and surgical outcomes analyzed.Measurements and Main Results: Median age and body mass index were 45 years and 30 kg/m2, respectively. Approximately half of study subjects underwent a hysterectomy with or without salpingo-oophorectomy, and 15% had a diagnosis of cancer. Overall, 0.9% of women were diagnosed with a preoperative umbilical hernia, and 2.4% of women experienced a major perioperative complication. After a median postoperative follow-up time of 16 months, 2.4% had development of an umbilical hernia. However, 4/5 of these women had significant risk factors for fascial weakening independent of LESS, including requirement for a second abdominal surgery in 1 subject and a cancer diagnosis with postoperative chemotherapy administration in 2 subjects. When these subjects deemed “high risk” for incisional disruption were excluded from the analysis, the umbilical hernia rate was 0.5% (1/207). On univariable analysis, obesity was the only factor associated with complications (p = .04).Conclusion: When performed by advanced laparoscopic surgeons, laparoendoscopic single-site gynecologic surgery is associated with a low risk of major adverse events. Additionally, the overall umbilical hernia rate was 2.4% and was lower (0.5%) in subjects without significant comorbidities.

Endometriosis of the Round Ligament of the Uterus

2011-11-17

Abstract: Study Objective: To demonstrate the prevalence of endometriosis in the intrapelvic portion of the round ligaments of the uterus (RLUs) and to propose criteria for their excision.Design: Retrospective case series analysis of women undergoing laparoscopy for the treatment of deep infiltrating endometriosis (Canadian Task Force classification II-3).Setting: Tertiary referral hospital.Patients: We evaluated 174 patients who underwent laparoscopy for the treatment of deep infiltrating endometriosis (DIE) between April 2006 and May 2009.Interventions: All patients underwent laparoscopy for the treatment of DIE and had their RLUs removed when there was shortening, deviation, or thickening. After removal, the RLUs were sent for histopathologic analysis to verify the presence or absence of endometriosis.Measurements and Main Results: The prevalence of endometriosis in the RLUs and the association between the macroscopic alterations and the anatomic pathology results were determined. After the identification of macroscopic alterations, 1 or both RLUs (for a total of 42) were removed from 27 of the 174 patients who underwent laparoscopy. The positive predictive value (PPV) of the macroscopic criteria proposed for endometriosis of the RLU was 83.3% (95% confidence interval [CI] = 72.1%–94.5%), with 35 positive RLUs out of the 42 that were excised. The prevalence of endometriosis of the RLU was 13.8% (95% CI = 8.7%–18.9%), with 24 patients having a positive histopathologic examination result for endometriosis.Conclusions: The prevalence of RLU endometriosis in patients with DIE was 13.8%, which emphasizes that a rigorous evaluation of this structure must be part of the routine surgical treatment of patients with endometriosis.

Cost Analysis of Abdominal, Laparoscopic, and Robotic-Assisted Myomectomies

2011-11-21

Abstract: Study Objective: To perform a cost-minimization analysis of abdominal, traditional laparoscopic and robotic-assisted myomectomy.Design: Cost analysis (Canadian Task Force Classification III).Setting: Academic medical center.Patients: Women undergoing myomectomy by various surgical approaches.Interventions: We developed a decision model to compare the costs ($2009) of different approaches to myomectomy from a healthcare system perspective. The model included operative time, conversion risk, transfusion risk, and length of stay (LOS) for each modality. Baseline estimates and ranges were based on reported values extracted from existing literature. We analyzed two different models: #1) Existing Robot model and #2) Robot Purchase model.Measurements and Main Results: In the baseline analysis for the Existing Robot model, abdominal myomectomy (AM) was the least expensive at $4937 compared with laparoscopic myomectomy (LM) at $6219 and robotic-assisted laparoscopic myomectomy (RM) at $7299. The abdominal route remained the least expensive when varying all parameters and costs except for two cases in which LM became least expensive: 1) If AM length of stay was greater than 4.6 days, and 2) If the surgeon’s fee for AM was greater than $2410. When comparing LM to RM, the cost of RM was consistently higher unless the robotic disposable equipment costs were less than $1400. In the Robot Purchase model, only the RM costs increased while AM and LM costs remained the same.Conclusion: In this cost-minimization analysis, abdominal myomectomy is the least expensive approach when compared to laparoscopy and robotic-assisted laparoscopy.

Predictors of Successful Salpingo-Oophorectomy at the Time of Vaginal Hysterectomy

2011-11-07

Abstract: Study Objective: To determine prognostic factors related to successful salpingo-oophorectomy in menopausal women at the time of vaginal hysterectomy.Design: Retrospective cohort study (Canadian Task Force Classification II-2).Setting: Tertiary care center.Patients: A total of 309 postmenopausal ≥60 years old with pelvic floor disorders.Interventions: Vaginal hysterectomy with attempted prophylactic salpingo-oophorectomy.Measurements: Factors associated with ability to achieve vaginal salpingo-oophorectomy.Main Results: 203 (65.7%) achieved successful removal of 1 or both ovaries, and 106 (34.3%) were not amenable to removal. Younger age and shorter cervical length were predictors of salpingo-oophorectomy. Cervical elongation of ≥7 cm, exteriorized cervical/uterine prolapse, and anterior vaginal wall prolapse beyond the hymen were associated with lower likelihood of achieving salpingo-oophorectomy.Conclusions: Patient age and cervical length are independent factors that influence the success of accomplishing salpingo-oophorectomy at the time of vaginal hysterectomy.

Myomectomy Decreases Abnormal Uterine Peristalsis and Increases Pregnancy Rate

2011-11-10

Abstract: Background: The relationship between fibroids and infertility remains a critical and unresolved question. During the implantation phase, it is known that uterine peristalsis is dramatically reduced, which is thought to facilitate implantation of the embryo to the endometrium. In the previous study, using a cine MRI mode, we found that less than half of the patients with intramural fibroids exhibited abnormal uterine peristalsis during the mid-luteal phase. In the present study, we further investigated whether myomectomy for patients in the high peristalsis group is a constructive method to normalize uterine peristalsis.Methods: The frequency of junctional zone movement was evaluated using a cine MRI mode during the mid-luteal phase. Fifteen infertility patients, who had intramural myomas and exhibited abnormal uterine peristalsis (≥2 times/3 min) in their first MRI, underwent myomectomy and a second MRI. After receiving the second MRI, patients underwent infertility treatment for at least 8 months, and pregnancy rate was evaluated prospectively.Results: Among 15 patients, the frequency of uterine peristalsis was normalized (0 or 1 time/3min) in 14 patients. Following myomectomy and second MRI test, 6 of the 15 patients achieved pregnancy (n = 15, pregnancy rate: 40%).Conclusions: The presence of uterine fibroids might induce abnormal uterine peristalsis in some patients, leading to infertility, and myomectomy may improve fertility in these patients.

Outcome of Laparoscopic Repair of Ureteral Injury: Follow-up of Twelve Cases

2011-11-21

Abstract: Study Objective: To review the feasibility of laparoscopic repair in cases of ureteral injuries occurring during gynecologic laparoscopy.Design: Retrospective study (Canadian Task Force classification II-3).Setting: Institution-specific retrospective review of data from a tertiary referral medical center.Patients: Patients suffering from iatrogenic ureteral injuries diagnosed during or after surgery, and cases with deliberate ureteral resection and repair because of underlying disease.Measurements and Main Results: We conducted a retrospective review of all (10 345) laparoscopic gynecologic surgeries performed in our institute between February 2004 and November 2008. Twelve cases (median: 45.5 years, range: 27–63) of ureter transections were diagnosed and repaired laparoscopically by endoscopists. Of these, 10 had previous surgeries, pelvic adhesions, or a large pelvic-abdominal mass. One patient had undergone a segmental resection and laparoscopic ureteroureterostomy for deep infiltrative endometriosis. Of the remaining 11 iatrogenic ureteral transections, 10 were repaired via laparoscopic ureteroureterostomy, whereas 1 had undergone a laparoscopic ureteroneocystostomy. One injury was recognized on the second postoperative day, but intraoperative recognition was attained in 11 cases. The median duration of double J stenting was 73 days. Three patients had development of strictures (between 42 and 79 days after surgery) treated with restenting, but 1 had to undergo an ureteroneocystostomy for ureter disruption when trying to restent. One patient had development of leakage of the anastomotic site but recovered with a change of the double J stent. Only 1 case required another laparotomy for ureteroneocystostomy. Laparoscopic primary repair of ureteral injury was successful for 11 of 12 patients. All the patients were well and symptom free at the conclusion of the study period.Conclusion: Early recognition and treatment of ureteral injuries are important to prevent morbidity. Laparoscopic ureteroureterostomy could be considered in transections of the ureter where technical expertise is available. To the best of our knowledge, this is the largest series, to date, of ureteral repairs via laparoscopy.

Bladder Dysfunction after Gynecologic Laparoscopic Surgery for Benign Disease

Ha Ryun Won, Peta Maley, Naven Chetty, Karen Chan, Jason Abbott — 2011-11-28

Abstract: Study Objective: To estimate the incidence of and factors leading to bladder dysfunction after laparoscopic gynecological surgery for benign disorders.Design: Prospective observational study (Canadian Task Force Classification II-3).Setting: Tertiary referral hospital in Sydney, Australia.Patients: One hundred eight women undergoing elective laparoscopic surgery for benign gynecological disease.Intervention: Prospective assessment bladder function. Data were collected with respect to preoperative baseline bladder function, demographic, intraoperative and postoperative data and bladder function and time to discharge.Measurements and Main Results: Postoperative bladder dysfunction was defined as a residual of >100 mL after a void of >150 mL on more than 1 occasion or a bladder volume >600 mL with no urge to void, with 20/102 (19.6%) women having postoperative bladder dysfunction. There was no statistically significant difference in baseline bladder function, mean operative time, anatomic site of surgery, number of operative sites, type of disease, duration of catheterization, or units of morphine required during hospitalization for women with or without bladder dysfunction. Women with dysfunction had a statistically significant greater length of stay from removal of catheter to discharge (28 vs 44 hours; p =.04).Conclusion: Postoperative bladder dysfunction appears idiosyncratic, with no single factor predictive of this problem. Possibilities for the demonstrated rate of dysfunction include normal bladder behavior, unmasking future bladder dysfunction, response to drugs, or neurologic issues. The implications of postoperative bladder dysfunction may have consequences for health care resource use and allocation, acute patient management, and possible long-term urinary function consequences and are worthy of further study.

Clinical Practice Guideline for Abnormal Uterine Bleeding: Hysterectomy versus Alternative Therapy

2011-11-14

Abstract: Study Objective: To develop recommendations in selecting treatments for abnormal uterine bleeding (AUB).Design: Clinical practice guidelines.Setting: Randomized clinical trials compared bleeding, quality of life, pain, sexual health, satisfaction, the need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options.Patients: Women with AUB, predominantly from ovulatory disorders and endometrial causes.Interventions: On the basis of findings from a systematic review, clinical practice guidelines were developed. Rating the quality of evidence and the strength of recommendations followed the Grades for Recommendation Assessment, Development, and Evaluation system.Measurements and Main Results: This paper identified few high-quality studies that directly compared uterus-preserving treatments (endometrial ablation, levonorgestrel intrauterine system and systemically administered medications) with hysterectomy. The evidence from these randomized clinical trials demonstrated that there are trade-offs between hysterectomy and uterus-preserving treatments in terms of efficacy and adverse events.Conclusion: Selecting an appropriate treatment for AUB requires identifying a woman’s most burdensome symptoms and incorporating her values and preferences when weighing the relative benefits and harms of hysterectomy versus other treatment options.

Comparison of Laparoscopically Assisted Vaginal Hysterectomy and Abdominal Hysterectomy: A Randomized Controlled Trial

Kiattisak Kongwattanakul, Kovit Khampitak — 2011-12-02

Abstract: Objective: To compare intraoperative hemorrhage and other operative parameters after laparoscopically assisted vaginal hysterectomy (LAVH) versus total abdominal hysterectomy (TAH) for benign gynecologic conditions.Design: A prospective, randomized, controlled trial.Materials and Methods: Between April 2010 and March 2011, 50 Thai patients with strong indications for hysterectomy—with uterine sizes ≤16 weeks of gravid uterus and with no contraindications for open or laparoscopic surgeries—were randomly assigned for LAVH or TAH.Main Outcome Measures: Intraoperative blood loss, operating time, postoperative analgesic requirements, perioperative complications, and duration of hospitalization.Results: Intraoperative blood loss was significantly less in the LAVH group (median 120 mL [range 50–300]) than in the TAH group (median 250 mL [105–800]) (median difference 130 mL, p <.001, 95% confidence interval [CI] 55–200). The LAVH group required significantly less postoperative morphine sulfate administration (median 3 mg [range 0–12]) than the TAH group (15 mg [6–24]) (median difference 9 mg, p <.001, 95% CI 9–12). The hospital stay for the LAVH group (median 3 days; range 2–7) was significantly shorter than that of the TAH group (median 4 days; range 4–5) (median difference 2 days, p <.001, 95% CI 1–2). The operating time was comparable between the 2 groups (median 100 minutes; range 50–240) for the LAVH and 115 minutes (range 60–200) for the TAH group (median difference 5 minutes, p =.592, 95% CI −15–25). There were no conversions from a LAVH to a laparotomy.Conclusions: The LAVH has advantages over the TAH in that in the former there is less intraoperative blood loss, less postoperative morphine requirement, and a shorter duration of postoperative hospital stays.

Laparoscopic Surgery for Endometrial Cancer: Why Don’t All Patients Go Home the Day After Surgery?

2012-01-01

Abstract: Study Objective: To identify risk factors for hospital length of stay (LOS) longer than 1 postoperative day in patients undergoing laparoscopic hysterectomy because of endometrial cancer.Design: Retrospective observational study (Canadian Task Force classification II-2).Setting: Tertiary-care university hospital.Patients: One hundred thirty-three patients undergoing laparoscopic hysterectomy because of endometrial cancer between August 2006 and August 2010.Interventions: One hundred thirty-three women underwent traditional laparoscopy. In 101 of these patients, lymph node sampling was performed.Measurements and Main Outcomes: Seventy-four women (55%) were discharged on postoperative day 1. The percentage of women discharged on postoperative day 1 (POD1) vs after POD 1 did not differ by extent of staging. Risk of perioperative complications was associated with hospital LOS longer than POD1 (odds ratio [OR], 11.45; 95% confidence interval [CI], 1.40–94.39). Procedure start time after 3:00 pm (OR, 3.20; 95% CI, 1.14–9.04) and procedure end time after 5:00 pm (OR, 2.47; 95% CI, 1.17–5.20) were independent factors associated with hospital LOS beyond POD1. There was a nonsignificant tendency toward later hospital discharge with administration of intravenous narcotic agents.Conclusions: Laparoscopic surgery to treat endometrial cancer should be preferentially scheduled early in the day to facilitate discharge on POD1. The extent of staging lymphadenectomy performed does not increase hospital stay beyond POD1.

Accuracy of Three-Dimensional Ultrasonography in Differential Diagnosis of Septate and Bicornuate Uterus Compared with Office Hysteroscopy and Pelvic Magnetic Resonance Imaging

2011-10-24

Abstract: Study Objective: To estimate the accuracy of 3-dimensional (3-D) ultrasonography in the differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging (MRI).Design: Prospective cohort study (Canadian Task Force Classification II-2).Setting: University hospital.Patients: Thirty-one patients referred with a suspected diagnosis of septate (n = 20) or bicornuate (n = 11) uterus.Interventions: All patients underwent 3-D ultrasonography displaying the rebuilt coronal view of the uterus, office hysteroscopy, and pelvic MRI. Operative hysteroscopic assessment and treatment was performed in case of sonographically diagnosed septate uterus. Bicornuate uterus was confirmed by laparoscopy.Main Outcomes Measures: Concordance between suspected diagnosis with 3-D ultrasonography, hysteroscopy, and pelvic MRI and final diagnosis.Results: A septate uterus was diagnosed with 3-D ultrasonography in 29 patients and bicornuate uterus in 2 patients. Hysteroscopic transcervical section of the uterine septum was achieved in the 29 patients. Bicornuate uterus was laparoscopically confirmed in the 2 patients. Concordance between ultrasonography and operative hysteroscopy or laparoscopy was verified in all 31 cases. Twenty-five uterine septa and 5 bicornuate uteri were diagnosed by hysteroscopy (3 false-positive diagnoses of bicornuate uterus, 1 unfeasible hysteroscopy). Hysteroscopic diagnosis was correct in 27/30 patients. Twenty-four septate uteri and 7 bicornuate uteri were diagnosed by MRI (5 false-positive diagnoses of bicornuate uterus). Two complete septate uteri diagnosed by MRI were finally confirmed as incomplete septate uteri after 3-D ultrasonography and operative hysteroscopy. MRI diagnosis was correct in 24/31 patients.Conclusion: Transvaginal 3-D ultrasonography appears to be extremely accurate for the diagnosis and classification of congenital uterine anomalies, more than office hysteroscopy and MRI. It may conveniently become the only mandatory step in the assessment of the uterine cavity in patients with a suspected septate or bicornuate uterus.

Low-Dose Spinal Anesthesia with Hyperbaric Bupivacaine with Intrathecal Fentanyl for Operative Hysteroscopy: A Case Series Study

2011-11-10

Abstract: Study Objective: To estimate the efficacy and tolerability of low dose spinal anesthesia during operative hysteroscopy in a group of patients with high surgical risks.Design: Case series study (Canadian Task Force Classification II-2).Setting: Tertiary centers for women health care.Patients: A total of 47 women affected by endometrial polyps (n = 32), myomas (n = 8), and abnormal uterine bleeding (n = 7) scheduled for inpatient operative hysteroscopy.Interventions: Transvaginal ultrasonography; office diagnostic hysteroscopy; preoperative evaluation of American Society of Anesthesiologist (ASA) classification; inpatient operative hysteroscopy; low-dose spinal anesthesia with hyperbaric bupivacaine; compilation of a questionnaire.Main Outcome Measures: Practicability and patients’ subjective experiences with spinal anesthesia; duration of cervical dilation and for operative hysteroscopy; infusion volume needed; incidence of surgical complications.Results: Resectoscopy was performed in all patients, with the exception of 1 woman (2.1%) in which spinal anesthesia was unsuccessful. No statistically significant differences were noted among groups in terms of intra- and peri-operative findings. Sensory block induced by spinal anesthesia was suitable for surgery in all patients, and side effects occurred far less frequently than mentioned in the literature. Data reported in the questionnaire revealed that 93.5% of women would choose a spinal anesthesia again for a potential operative hysteroscopy in the future, since for 89.1% of them long lasting anesthesia is of relevance.Conclusions: Low-dose spinal anesthesia is a feasible technique in the inpatient setting for operative hysteroscopy in women with high surgical risks.

Laparoscopic Extramucosal Partial Bladder Resection in a Patient with Symptomatic Deep-Infiltrating Endometriosis of the Bladder

Martina Prager, Tina Wilson, Karsten Krüger, Andreas D. Ebert — 2012-01-01

Abstract: Endometriosis is a complex disease, affecting the urinary tract, mainly the bladder, in 1% to 2% of cases. Thus far, partial cystectomy has been the treatment of choice for long-term relief of symptoms. Here, we describe the case of a 26-year-old patient with deep-infiltrating bladder endometriosis who was completely cured by laparoscopic extramucosal bladder resection. Diagnostic standards and factors affecting the rate of success for this additional option in endometriosis surgery are discussed.

Colouterine Fistula Complicating Diverticulitis Diagnosed at Hysteroscopy: Case Report

2012-01-01

Abstract: Since Noecker first reported a colouterine fistula secondary to diverticulitis in 1929, about 20 cases have been reported in the literature. Methods for diagnosis have yet to be established. Herein we report the first case of a colouterine fistula at the level of the isthmus diagnosed at hysteroscopy. Diagnostic hysteroscopy enabled rapid diagnosis of the colouterine fistula. Diagnostic hysteroscopy is the first-choice diagnostic tool for investigation of any abnormal vaginal discharge such as blood or stool because it enables direct vision and biopsy of the lesions of the lower genital tract quickly and at low cost.

Laparoscopic Management of Internal Hernia of Small Intestine through a Broad Ligament Defect

Roopa Bangari, Dhiraj Uchil — 2012-01-01

Abstract: Internal herniation through a defect in the broad ligament is a rare condition. A 42-year-old multiparous woman presented with a long-standing history of right-sided abdominal pain. Laparoscopy revealed herniation of small bowel through a defect in the right broad ligament. The hernia was reduced, and the defect was corrected laparoscopically. The postoperative recovery was uneventful, and the previously persistent abdominal pain has resolved.

Lymphatic-Venous Anastomosis for the Radical Cure of a Large Pelvic Lymphocyst

2012-01-01

Abstract: Therapeutic efficacy of lymphatic-venous anastomosis (LVA) has been shown, but expansion of the indication is desirable because LVA is a procedure with low invasiveness and is applicable over a wide area. This is the first reported case of intractable pelvic lymphocyst for which LVA was effective. LVA may be useful for pelvic lymphocyst at an early stage after cancer resection and lymph node dissection.

Uterine Artery Embolization Complicated by Uterine Perforation at the Site of Previous Myomectomy

2012-01-01

Abstract: A 46-year-old woman had an unusual complication from uterine myoma embolization by development of extensive necrosis with subsequent uterine perforation at the location of a previous myomectomy. We suggest that a scarred uterus may be a risk factor for uterine fibroid embolization complications, such as uterine necrosis.

Leiomyoma Recurrent at the Cervical Stump: Report of Two Cases

2012-01-01

Abstract: Although supracervical hysterectomy is an increasingly popular modality for surgical management of benign uterine conditions data exploring all of its consequences are still forth coming. This case report will discuss the scenario of leiomyoma recurrence at the cervical stump after supracervical hysterectomy. After supracervical hysterectomy, the remnant cervix has the potential for leiomyoma formation. Surgeons performing supracervical hysterectomy should be aware of this possible outcome.

Letter to the Editor

James A. Greenberg — 2012-01-01

I was interested to read Donnellan and Mansuria’s recent case report involving a small bowel obstruction and barbed suture . As an early advocate of the use of barbed suture in laparoscopy , I have followed this technology for some time and try keep “an ear to the ground” to best understand how the use of this type of suture is advancing and what may be some of its limitations. The authors’ report of a small bowel obstruction in a case in which barbed suture was used does not come as a surprise to me, and I agree that reporting it in this format is a good way of raising consciousness about a potential complication. That said, I was disappointed by the authors’ descriptions of their techniques and respectfully suggest that it was not the barbed suture per se that led to the complication but rather, perhaps, their use of it.

Reply

Nicole M. Donnellan, Suketu M. Mansuria — 2012-01-01

Thank you for your letter regarding our case report entitled “Small Bowel Obstruction Resulting from Laparoscopic Vaginal Cuff Closure with a Barbed Suture” . Although we appreciate your comments on our surgical technique, we are afraid that you missed the primary intent of our case report. Our intent was not to describe a surgical technique but rather to disseminate knowledge regarding a potential complication of a relatively new suture material used in our field in the hopes that this complication can be averted in the future.

Fertility Performance and Obstetrical Outcomes Among Women With Previous Cesarean Scar Pregnancies

Frances Batzer — 2012-01-01

With the rising incidence of cesarean section deliveries has come an increase in the incidence of cesarean scar ectopic pregnancies. This report form the Sachler Faculty of Medicine, Tel-Aviv University, on the fertility performance and obstetrical outcome in women with a history of previous cesarean scar ectopic pregnancy is important.

Erratum

2012-01-01

In the case report by Qiong et al (Volume 18, Number 6, page 766), one of the coauthor’s names is misrepresented. The author name Deep Jagat Prasad should in fact read as Jagat Prasad Deep.

Meetings Calendar/Masthead

2012-01-01

Society Affiliations

2012-01-01

Editorial Board

2012-01-01

Board of Trustees

2012-01-01

The Journal of Minimally Invasive Gynecology

Cover 1

The Food and Drug Administration’s 2011 Warning Regarding Adverse Effects Related to Mesh Implants for Pelvic Floor Reconstruction—Personal Perspectives

AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Endometrial Polyps

Partial Constriction of Left Infundibulopelvic Ligament

Utero-Ovarian Vessel after Uterine Artery Embolization

A Systematic Review Comparing Hysterectomy with Less-Invasive Treatments for Abnormal Uterine Bleeding

Risk Factors, Symptoms, and Treatment of Ovarian Torsion in Children: The Twelve-Year Experience of One Center

Treatment of Twenty-Two Patients with Complete Uterine and Vaginal Septum

The Risk of Umbilical Hernia and Other Complications with Laparoendoscopic Single-Site Surgery

Endometriosis of the Round Ligament of the Uterus

Cost Analysis of Abdominal, Laparoscopic, and Robotic-Assisted Myomectomies

Predictors of Successful Salpingo-Oophorectomy at the Time of Vaginal Hysterectomy

Myomectomy Decreases Abnormal Uterine Peristalsis and Increases Pregnancy Rate

Outcome of Laparoscopic Repair of Ureteral Injury: Follow-up of Twelve Cases

Bladder Dysfunction after Gynecologic Laparoscopic Surgery for Benign Disease

Clinical Practice Guideline for Abnormal Uterine Bleeding: Hysterectomy versus Alternative Therapy

Comparison of Laparoscopically Assisted Vaginal Hysterectomy and Abdominal Hysterectomy: A Randomized Controlled Trial

Laparoscopic Surgery for Endometrial Cancer: Why Don’t All Patients Go Home the Day After Surgery?

Accuracy of Three-Dimensional Ultrasonography in Differential Diagnosis of Septate and Bicornuate Uterus Compared with Office Hysteroscopy and Pelvic Magnetic Resonance Imaging

Low-Dose Spinal Anesthesia with Hyperbaric Bupivacaine with Intrathecal Fentanyl for Operative Hysteroscopy: A Case Series Study

Laparoscopic Extramucosal Partial Bladder Resection in a Patient with Symptomatic Deep-Infiltrating Endometriosis of the Bladder

Colouterine Fistula Complicating Diverticulitis Diagnosed at Hysteroscopy: Case Report

Laparoscopic Management of Internal Hernia of Small Intestine through a Broad Ligament Defect

Lymphatic-Venous Anastomosis for the Radical Cure of a Large Pelvic Lymphocyst

Uterine Artery Embolization Complicated by Uterine Perforation at the Site of Previous Myomectomy

Leiomyoma Recurrent at the Cervical Stump: Report of Two Cases

Letter to the Editor

Reply

Fertility Performance and Obstetrical Outcomes Among Women With Previous Cesarean Scar Pregnancies

Erratum

Meetings Calendar/Masthead

Society Affiliations

Editorial Board

Board of Trustees

Table of Contents