The Journal of Minimally Invasive Gynecology - Articles in Press

Clinical Outcome After Hydrothermal Ablation Treatment of Menorrhagia in Patients With and Without Submucous Myomas - Corrected Proof

Elise Hachmann-Nielsen, Martin Rudnicki — 2012-02-02

Abstract: Study Objective: To analyze the long-term efficacy of hydrothermal ablation (HTA) in women with a normal uterine cavity and submucous uterine myomas.Design: Retrospective study (Canadian Task Force classification II-2).Setting: Roskilde University Hospital surgical daycare unit.Patients: One hundred sixty-six consecutive patients with abnormal uterine bleeding who underwent HTA from 2004 to 2008. All patients were asked to fill out a specific questionnaire that included questions related to postoperative bleeding patterns, complications, and satisfaction with the procedure. One hundred thirty-six patients (81.9%) completed the questionnaire, including 33 women (24.3%) with submucous myomas.Intervention: The HTA procedure was performed in accordance with previous descriptions.Measurements and Main Results: Mean (SD; 95% CI) follow-up was 33 (10.5; 25.5–31.8) months. Amenorrhea was achieved in 57 women with myomas (55.3%) and 17 women (51.5%) without myomas (p = .47). Postoperative light bleeding was reported in 26 women with myomas (25.2%) and 6 women (18.2%) without myomas. During follow-up, 13 women with myomas (12.6%) underwent hysterectomy, compared with 6 women without myomas (18.2%). Postoperatively, the mean (SD; 95% CI) number of days per month with bleeding was reduced in both groups, from 13.62 (7.90; 11.87–15.37) to 1.34 (2.32; 0.84–1.84) days in the group with myomas, and from 14.78 (8.81; 10.97–18.59), to 1.88 (4.38; 0.12–3.65) without myomas. Similarly, both groups reported improved quality of life: 74.8% and 72.7%, respectively (p = .59). Compared with patients with myomas 3 cm or smaller, patients with myomas larger than 3 cm demonstrated a significantly higher rate of severe bleeding postoperatively (p = .02).Conclusion: Our results demonstrate that HTA is associated with a high rate of amenorrhea in patients with or without submucous myomas. However, a significantly lower effect may be observed in patients with myomas larger than 3 cm.

Long-term Outcomes of the Tension-Free Vaginal Tape Procedure for Female Stress Urinary Incontinence: 7-Year Follow-up in China - Corrected Proof

Bin Li, Lan Zhu, Jing-he Lang, Rong Fan, Tao Xu — 2012-01-30

Abstract: Study Objective: To estimate the long-term objective rates of cure, late complications, and satisfaction after tension-free vaginal tape (TVT) procedure.Design: Retrospective study (Canadian Task Force classification II-3).Setting: Single-center.Patients: Fifty-five patients with moderate to severe stress urinary incontinence (SUI) underwent the TVT procedure from May 2002 to March 2005.Intervention: TVT procedure.Measurements and Main Results: Changes in 1-hour pad test results and incontinence quality-of-life (I-QOL) questionnaire scores before surgery and at 1- and 7-year follow-up were compared. Changes in objective rates of cure, late complications, and satisfaction at 1- and 7-year follow-up were also compared. The mean duration of follow-up was 6.80 years. Both the 1-hour pad test results and the I-QOL questionnaire scores improved significantly after surgery (p < .001). The TVT procedure satisfaction rate at 7-year follow-up decreased significantly compared with that at 1-year follow-up (p = .001); however, I-QOL score did not change significantly.Conclusions: The TVT procedure is an effective treatment for SUI in female patients. Despite little persistent or recurrent SUI over 7-year follow-up, satisfaction with the procedure decreases. Therefore, other age-related bladder conditions must be considered when counseling patients about the TVT procedure. Assessment of the efficacy of the TVT procedure should include both objective and subjective standards.

Anatomic and Functional Outcomes with the Prolift Procedure in Elderly Women with Advanced Pelvic Organ Prolapse Who Desire Uterine Preservation - Corrected Proof

2012-01-30

Abstract: Study Objective: To assess the clinical outcomes of total mesh repair with the Prolift technique as treatment of advanced pelvic organ prolapse in elderly patients who desire uterine preservation.Design: Case control series study (Canadian Task Force classification II-2).Setting: Medical school–affiliated hospital.Patients: Sixty-eight patients over the age of 70 years with advanced pelvic organ prolapse, Pelvic Organ Prolapse Quantification stage III (n = 59) or IV (n = 9), underwent a total Prolift procedure and were followed up for a minimum of 2 years.Interventions: Transvaginal pelvic floor repairs were performed with a total Prolift system. The concurrent pelvic surgery included midurethral sling operation with a TVT-O, if indicated. The assessment included intraoperative and postoperative complications, Urogenital Distress Inventory scores, and Incontinence Impact Questionnaire scores.Measurements and Main Results: Objective and subjective data were available for 68 patients. The anatomic success rate was 97.1% after 2 years. Complications included bladder perforation in 1 patient (1.5%), de novo stress urinary incontinence in 20 patients (29.4%), dyspareunia in 4 patients (22.2%), and vaginal erosion in 1 patient (1.5%). The Pelvic Organ Prolapse Quantification stages, Urogenital Distress Inventory scores, and Incontinence Impact Questionnaire scores all improved significantly after surgery.Conclusions: The total Prolift procedure is an alternative surgical option that uses a minimally invasive transvaginal approach to surgically treat elderly patients with advanced pelvic organ prolapse.

Endometriosis after Laparoscopic Supracervical Hysterectomy with Uterine Morcellation: A Case Control Study - Corrected Proof

Mitchell W. Schuster, Thomas L. Wheeler, Holly E. Richter — 2012-01-24

Abstract: Study Objective: To compare the incidence of new-onset endometriosis after laparoscopic supracervical hysterectomy (LSH) with uterine morcellation to traditional routes.Design: Single center case-control study (Canadian Task Force classification II-2) of hysterectomies performed from January 2006 through December 2008.Patients: Two hundred seventy-seven laparoscopic supracervical hysterectomies with morcellation (cases) and 187 transvaginal or abdominal hysterectomies without morcellation (controls) were performed from January 2006 through December 2008.Interventions: A total of 464 women underwent hysterectomy, 277 cases via laparoscopic supracervical approach (LSH) with morcellation and 187 performed either transvaginally or abdominally without morcellation. Repeat operative procedures were performed for other benign indications on 16 of 464 (3.5%) patients who had undergone prior hysterectomy.Measurements and Main Results: One hundred two patients had endometriosis at the time of hysterectomy diagnosed by pathologic evaluation or gross visualization. In those without endometriosis, repeat operative procedures were performed for pain and bleeding in 3.3% (12/362). Sixty percent (3/5) of patients treated with LSH and 28.6% (2/7) of the control group were found to have newly diagnosed endometriosis, conferring a rate of 1.4% (3/217) in the LSH group and 1.4% (2/145) in the control subjects. In patients with endometriosis, repeat operative procedures for pain or bleeding occurred in 2.9% (3/102): 3/60 patients treated with LSH and none in the control group (0/42). Two of these 3 patients undergoing a second surgery had recurrent/continued endometriosis.Conclusion: Newly diagnosed endometriosis was noted in 1.4% of patients after hysterectomy, with a similar incidence between the LSH and control groups. Reoperation for those with endometriosis at the time of LSH with morcellation was infrequent, but endometriosis was usually found. Further research is needed to delineate risk factors for development of de novo endometriosis after hysterectomy.

Randomized Study of Vaginoscopy and H Pipelle vs Traditional Hysteroscopy and Standard Pipelle - Corrected Proof

Siew-Fei Ngu, Vincent Y.T. Cheung, Ting-Chung Pun — 2012-01-24

Abstract: Study Objective: To compare the use of vaginoscopic vs traditional hysteroscopy in evaluation of the endometrial cavity.Design: Prospective, randomized, single blinded, clinical trial (Canadian Task Force classification I).Setting: University-affiliated hospital in Hong Kong.Patients: Ninety women scheduled to undergo diagnostic hysteroscopy without anesthesia.Interventions: Women were randomized to undergo either vaginoscopic hysteroscopy using the H Pipelle for endometrial sampling (n = 45) or traditional hysteroscopy using the standard Pipelle (n = 45). Both procedures were performed without anesthesia and using a rigid 4.5-mm hysteroscope. Main outcome measures analyzed were pain scores using a 10-point visual analog scale during hysteroscopy, endometrial biopsy, and overall pain score of the procedure, success and duration of each procedure, and adequacy of the endometrial sample obtained.Measurements and Main Results: The success rates for vaginoscopic and traditional hysteroscopy were 93.33% and 100%, respectively (p = .24). There was no significant difference in the mean pain score and procedure duration between the 2 hysteroscopic approaches. Endometrial sampling using the H Pipelle was significantly quicker by about 45 seconds compared with use of the standard Pipelle (mean [SD] duration, 1.46 [0.72] min vs 2.20 [1.19] min, respectively; p = .001), with similar biopsy adequacy. Most women (95.5% in both approaches) found the procedure acceptable. There were no intraoperative or postoperative complications.Conclusions: Vaginoscopic and traditional hysteroscopic approaches are similar in safety, feasibility, and associated pain. Although the time needed to obtain an endometrial sample using the H Pipelle was quicker than with the standard Pipelle, there is no difference in overall procedure duration.

Standardizing Pneumoperitoneum for Laparoscopic Entry. Time, Volume, or Pressure: Which Is Best? - Corrected Proof

Angus J.M. Thomson, Mamdouh N. Shoukrey, Isla Gemmell, Jason A. Abbott — 2012-01-16

Abstract: Study Objective: To establish whether time, pressure, or volume is the most reliable indicator of adequate pneumoperitoneum and, hence, the best parameter to use for safe trocar entry.Design: Prospective cohort study (Canadian Task Force classification II-2).Setting: Department of Endogynecology, Royal Hospital for Women, Sydney, Australia.Patients: One hundred thirty-three consecutive patients having gynecologic lararoscopy were recruited for the study. Of these, 100 patients were included in the analysis, and 33 were excluded.Intervention: Laparoscopic surgery.Measurements and Main Results: After umbilical Veress needle entry, pressure and volume were recorded every 20 seconds until insufflation pressure of 20 mm Hg was reached. Following trocar entry, the gas was then expelled with the patient lying flat. The depth of pneumoperitoneum was measured at intra-abdominal pressure of 5, 10, 15, and 20 mm Hg. Random effects models were used to predict the depth of pneumoperitoneum based on pressure, time, and volume. A comparison was made of the standard deviation of pneumoperitoneum distance produced at pressure of 20 mm Hg (8.56 ± 0.59) compared with that produced by a volume of 3 L (4.96 ± 1.13). Compared with volume, pressure was significantly more reliable in estimating depth of pneumoperitoneum (p < .001) because it exhibited the least variance. Further comparison was made of the standard deviation of pneumoperitoneum distance produced at pressure of 20 mm Hg (8.56 ± 0.59) compared with that produced at 3 minutes (7.82 ± 1.19). Compared with time, pressure was significantly more reliable in depth of pneumoperitoneum (p < .001) because it exhibited the least variance. These results demonstrate that, compared with volume and time, pressure is the most reliable predictor of pneumoperitoneum depth because it exhibits the least variance (p < .001).Conclusion: Pressure is the most reliable predictor of pneumoperitoneum before trocar entry in laparoscopic surgery.

Laparoscopic Intracorporeal Cinch Knots: Changing the Square Knot Paradigm - Corrected Proof

Malcolm W. Mackenzie — 2012-01-16

Abstract: Reliable knot tying is a cornerstone of surgical technique, and the square knot and surgeon’s knot constitute the greatest part of most surgeons’ knot-tying skills. Traditionally, laparoscopic intracorporeal knot tying of a square knot or surgeon’s knot is a direct translation from an open instrument tying technique. Given the technical and mechanical challenges imposed by standard laparoscopic instrumentation, performance of such a basic task is sometimes difficult and elusive, even for accomplished surgeons. Consequently, myriad technologies and techniques are used as work-arounds for this basic surgical task. However, the sometimes necessary tying of a snug and reliable intracorporeal knot is unavoidable. That laparoscopic intracorporeal knot tying must be translated from a 2-handed open surgical technique using flat knots deserves reassessment. Cinch knots, with unusual sliding and tightening properties, are currently used in surgery. With apparent complexity and exacting construction requirements, however, primary intracorporeal knot tying has not been described. Described herein is a technique for doing so. Also included is a review of cinch knot mechanics, an understanding of a fundamental scheme for their construction, and basic instrument maneuvers that enable easier intracorporeal tying of a most reliable knot, useful for multiport and, in particular, single-port laparoscopic knot tying.

Laparoscopic Promontofixation for the Treatment of Recurrent Sigmoid Neovaginal Prolapse: Case Report and Systematic Review of the Literature - Corrected Proof

William Kondo, Reitan Ribeiro, Fernanda Keiko Tsumanuma, Monica Tessmann Zomer — 2012-01-16

Abstract: Prolapse of a sigmoid neovagina, created in patients with congenital vaginal aplasia, is rare. In correcting this condition, preservation of coital function and restoration of the vaginal axis should be of primary interest. A 34-year-old woman with vaginal agenesis underwent vaginoplasty using sigmoid colon. Almost 6 years after the initial operation, she started complaining of a bearing-down sensation and an increase in vaginal discharge. She underwent 2 open surgeries and one vaginal surgery to treat the prolapse with no success. She came to our service and at vaginal examination the neovagina protruded approximately 5 cm beyond the hymen. The prolapse was treated successfully using a laparoscopic approach to suspend the neovagina to the sacral promontory (laparoscopic promontofixation). Prolapse of an artificially created vagina is a rare occurrence, without a standard treatment. Laparoscopy may be an alternative approach to restore the neovagina without compromising its function.

What Is the Role of Lymphadenectomy in Surgical Management of Patients With Endometrial Carcinoma? - Corrected Proof

Farr Nezhat, Linus Chang, Solima Eugenio — 2012-01-13

You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-19-2-11-00359

Single-Field Sterile-Scrub, Preparation, and Dwell for Laparoscopic Hysterectomy - Corrected Proof

2012-01-13

Abstract: Type VII laparoscopic hysterectomy is classified as a “clean-contaminated” procedure because the surgery involves contact with both the abdominal and vaginal fields. Because the vulva has traditionally been perceived as a separate but contaminated field, operating room guidelines have evolved to require that surgeons gloved and gowned at the abdominal field either avoid contact with the urethral catheter, the uterine manipulator, and the introitus or change their gloves and even re-gown after any contact with those fields. In the belief that the perception of the vaginal field as contaminated stems from inadequate preoperative preparation instructions, we have developed a rigorous abdomino-perineo-vaginal field preparation technique to improve surgical efficiency and prevent surgical site infections. This thorough scrub, preparation, and dwell technique enables the entire abdomino-perineo-vaginal field to be safely treated as a single sterile field while maintaining a low rate of surgical site infection, and should be further investigated in randomized studies.

Laparoscopic Lymphadenectomy for Isolated Lymph Node Recurrence in Gynecologic Malignancies - Corrected Proof

2011-12-16

Abstract: Study Objective: To assess the feasibility and efficacy of laparoscopic lymphadenectomy in patients with isolated lymph node recurrences (ILNR) who underwent initial surgery because of gynecologic malignancy.Design: Retrospective study (Canadian Task Force classification II-3).Setting: University teaching hospital.Patients: Six patients with ILNR (1 cervical, 4 ovarian, and 1 peritoneal) diagnosed between March 2003 and July 2010.Intervention: Laparoscopic lymphadenectomy.Measurements and Main Results: Median (range) patient age was 59.5 (24–70) years, and body mass index was 21.7 (21.0–24.6). There was no unplanned conversion to laparotomy. Operating time was 337.5 (200–400) minutes, hemoglobin change was 0.9 (0.4–2.6) g/dL, and hospital stay was 8.5 (5–19) days. The number of harvested lymph nodes was 20 (5–27), and of positive lymph nodes was 4 (1–24). One patient had common iliac vein laceration, with complete hemostasis achieved using intracorporeal suture. Postoperative lymphedema occurred in 1 patient, and was managed conservatively. All patients received adjuvant chemotherapy after laparoscopic lymphadenectomy.Conclusion: Laparoscopic lymphadenectomy in patients with ILNR is feasible and might be an alternative therapeutic strategy.

Laparoendoscopic Single-Site Supracervical Hysterectomy With Endocervical Resection - Corrected Proof

Jean-Marie Wenger, Jean-Bernard Dubuisson, Patrick Dällenbach — 2011-11-28

Abstract: Laparoendoscopic single-site surgery is an attempt to enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Total laparoscopic hysterectomy through single-port access has been reported. Supracervical hysterectomy is an alternative to total hysterectomy but requires morcellation, which is challenging through a single umbilical incision. Herein we report and illustrate with a video supracervical hysterectomy performed via single-site laparoscopic surgery with transcervical morcellation after endocervical resection.