The Journal of Minimally Invasive Gynecology - Articles in Press

Trends in Various Types of Surgery for Hysterectomy and Distribution by Patient Age, Surgeon Age, and Hospital Accreditation: 10-Year Population-Based Study in Taiwan - Corrected Proof

Ming-Ping Wu, Kuan-Hui Huang, Cheng-Yu Long, Eing-Mei Tsai, Chao-Hsiun Tang — 2010-07-26

Abstract: Study Objective: To estimate the trends in various types of hysterectomy (abdominal, vaginal, laparoscopic, and subtotal) and their distribution according to patient age, surgeon age, and hospital accreditation in Taiwan.Design: Retrospective cohort study (Canadian Task Force classification II-2).Setting: Population-based National Health Insurance (NHI) database.Patients: Women with NHI in Taiwan undergoing various types of hysterectomy to treat noncancerous lesions.Interventions: Data for this study were obtained from the Inpatient Expenditures by Admissions files of the NHI research database, released by the NHI program in Taiwan for 1996–2005.Measurements and Main Results: A total of 234939 women who underwent various types of hysterectomy were identified for analysis. The number of hysterectomies performed annually remained stationary during the 10-year study. Total abdominal hysterectomies decreased significantly (77.33% in 1996 vs 45.68% in 2005), laparoscopic hysterectomies increased significantly (5.20% vs 40.40%), vaginal hysterectomies decreased (14.70% vs 8.86%), and subtotal abdominal hysterectomies increased (2.76% vs 5.06%). Laparoscopic hysterectomy was more commonly performed in middle-aged women; vaginal hysterectomy was more common in older women; and subtotal abdominal hysterectomy was more common in younger women. Laparoscopic hysterectomy was performed more commonly in regional hospitals (33.11%), followed by medical centers (30.17%) and local hospitals (17.78%). Laparoscopic hysterectomy was performed more commonly in not-for-profit hospitals (30.25%), followed by private hospitals (29.32%) and government-owned hospitals (25.91%).Conclusion: There has been considerable change in the types of surgery used for hysterectomy in Taiwan over the past 10 years. As a minimally invasive approach, laparoscopic hysterectomy represents a profound change for both patients and surgeons.

Review of Intrauterine Adhesions - Corrected Proof

Rebecca Deans, Jason Abbott — 2010-07-26

Abstract: This article has been produced to review the literature on symptomatic and asymptomatic intrauterine adhesions. Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Current Contents, and EMBASE were searched using the Medical Subject Headings (MeSH), including all subheadings, and the keywords “Asherman syndrome,” “Hysteroscopic lysis of adhesions,” “Hysteroscopic synechiolysis,” “Hysteroscopy and adhesion,” “Intrauterine adhesions,” “Intrauterine septum and synechiae,” and “Obstetric outcomes after intrauterine surgery.” The vast majority of evidence in the literature consists of uncontrolled case series, with only intrauterine adhesion barriers being assessed in a randomized controlled format. This article reviews epidemiology, pathologic features, classification systems, and treatments. Seven classification systems are described, with no universal acceptance of any one system and no validation of any of them. Hysteroscopy is the mainstay of both diagnosis and treatment, with medical treatments having no role in management. There is a wide range of treatment techniques with no controlled comparative studies, and assessments are descriptive and report fertility and menstrual outcomes, with more severe adhesions having the worst clinical outcomes. One of the most important features of treatment is prevention of recurrence, with the best available evidence demonstrating that newly developed adhesion barriers such as hyaluronic acid show promise for preventing new adhesions.

Endometriosis of Bladder: Outcomes after Laparoscopic Surgery - Corrected Proof

Elias Kovoor, Joseph Nassif, Ignacio Miranda-Mendoza, Arnaud Wattiez — 2010-07-26

Abstract: Study Objective: To describe outcomes after laparoscopic excision of deep bladder endometriosis.Design: Retrospective study (Canadian Task Force classification II-3).Setting: University hospitals.Patients: Twenty-one consecutive patients with endometriotic nodule on the bladder (infiltrating detrusor muscle) from a series of 169 patients were included in the study. The primary outcome studied was resolution of bladder symptoms. Secondary outcomes included complication rates, recurrence rates, and pregnancy rates after laparoscopic surgery.Interventions: Laparoscopic excision of bladder endometriosis.Measurements and Main Results: Laparoscopy was feasible in all cases without the need for conversion. Median follow-up was 20 months. Ten patients (47.6%) underwent partial cystectomy, and the remaining patients underwent partial-thickness excision of the detrusor muscle. Sixteen patients (76%) had associated deep lesions in the pelvis. The most common associated lesions were rectovaginal nodules (38%) and ureteric lesions (14%), with signs of obstruction. Major complications developed in 3 patients (14%), primarily related to bowel resection. Six patients became pregnant (60%). No patients experienced disease recurrence.Conclusion: Laparoscopic excision is feasible in all types of bladder endometriosis but often involves multiple procedures to manage associated lesions, especially rectovaginal nodules and ureteric lesions. Previous reports have suggested that ureteric lesions are not associated with bladder endometriosis; however, this was not true in our series. Complications are primarily related to severity of the disease and associated procedures. Partial cystectomy is not required in all cases to achieve adequate clearance. Complete excision of the disease is associated with resolution of bladder symptoms and low recurrence rates.

Culdocentesis Followed by Saline Solution–Enhanced Ultrasonography: Technique for Evaluation of Suspected Ectopic Pregnancy - Corrected Proof

Tamer M. Yalcinkaya, Shon P. Rowan, Munire Erman Akar — 2010-07-26

Abstract: Study Objective: To evaluate the use of a technique consisting of culdocentesis followed by saline solution–enhanced pelvic ultrasonography in cases suspect for ectopic pregnancy in which an accurate diagnosis could not be made using routine transvaginal ultrasound.Design: Retrospective clinical study (Canadian Task Force classification III).Setting: Academic medical center.Patients: Twenty patients with an initial diagnosis of pregnancy of unknown location.Interventions: In 20 patients with symptoms of early pregnancy and serum quantitative human chorionic gonadotropin concentration, ectopic pregnancy could not be confirmed or ruled out. Transvaginal ultrasound-guided culdocentesis was performed, and 300 to 400 mL of normal saline solution was injected into the posterior cul-de-sac and pelvis. Transvaginal ultrasound was repeated with particular attention to the floating fallopian tubesMeasurements and Main Results: Using this technique, a tubal pregnancy was visualized in 15 of 20 patients, and ectopic pregnancy was ruled out in 5 patients. In all patients, appropriate management was provided according to the final diagnosis, and consisted of either methotrexate, laparoscopic salpingostomy or salpingectomy, or expectant management in patients with abnormal intrauterine pregnancies.Conclusion: Ultrasound-guided culdocentesis followed by saline solution–enhanced pelvic ultrasound can be considered as a diagnostic tool in patients with suspected ectopic pregnancy in whom other methods fail to demonstrate this diagnosis.

Uterine Artery Pseudoaneurysm after Cesarean Section: Case Report and Literature Review - Corrected Proof

2010-07-26

Abstract: Uterine artery pseudoaneurysm (UAP) occurs rarely and can develop after various gynecologic or obstetric procedures. The delayed diagnosis of this disease often results in life-threatening hemorrhage. Herein is described a case of UAP after cesarean section. The patient visited our emergency outpatient department 99 days after cesarean section because of abnormal uterine bleeding, which was diagnosed as UAP using color Doppler ultrasonography and contrast medium–enhanced computed tomography. Selective transcatheter arterial embolization was performed to resolve the lesion without complications. We also conducted a review to identify the demographic etiology of UAP. A PubMed search yielded 57 cases reported in the English literature. The most frequent cause of UAP was cesarean section, which accounted for 47.4% of all cases. The mean interval between the incident and the symptoms was approximately 2 weeks, regardless of cause. At analysis of 17 cases diagnosed within a day, it became evident that the definitive diagnosis was made at angiography (41.2%), computed tomography (29.4%), or color Doppler ultrasonography (29.4%). Almost all cases (94.1%) were conservatively treated with transcatheter uterine artery embolization. Consideration of UAP in the differential diagnosis is crucial for proper treatment before rupture and to preserve fertility.

Recognition and Management of Major Vessel Injury during Laparoscopy - Corrected Proof

2010-07-26

Abstract: Laparoscopy is one of the most commonly performed procedures in the United States. Injury to a major retroperitoneal vessel occurs in 0.3% to 1.0% of procedures, most commonly during laparoscopic entry while placing the Veress needle or primary trocar. Fatal outcome can be related to massive gas embolism or exsanguination. Recommended treatment for gas embolism can range from supportive measures to external chest compression and insertion of a central line to withdraw gas from the right side of the heart. Recommended treatment of major vessel injury with massive hemorrhage consists of rapid laparotomy and control of hemorrhage using direct pressure until a surgeon experienced in vascular procedures arrives. When a major vessel injury occurs in a surgical facility distant from a medical center and without an available surgeon with vascular experience, based on the trauma literature, we recommend temporary control of blood loss using abdominal packing and closure (i.e., “damage control surgery”) and judicious resuscitation (i.e., “damage control resuscitation”) before transportation to a medical center.

“Iatrogenic” Parasitic Myomas: Unusual Late Complication of Laparoscopic Morcellation Procedures - Corrected Proof

2010-07-23

Abstract: Study Objective: To describe our experience in diagnosing and managing parasitic myomas developing as an unexpected late complication of laparoscopic morcellation.Design: Observational study (Canadian Task Force classification II-3).Setting: University hospital.Patients: Retrospective chart review of all patients found to have parasitic myomas that developed after previous morcellation.Intervention: Laparoscopic morcellation. Review of the recent literature correlated with clinical, surgical, and pathologic features of our cases.Measurements and Main Results: Four patients had heterogeneous pelvic masses after morcellation. In 3 patients, symptoms developed between 2 and 16 years after the primary surgery. One patient had no symptoms, and was referred because of a suspect pelvic mass. Vaginal examination revealed painful pelvic masses in the pouch of Douglas in 2 patients, and painless masses fixed to the vaginal vault and anterior vaginal wall, respectively, in the other 2 patients. Laparoscopic examination confirmed the presence of parasitic masses in 3 patients. In 1 patient, the mass was excised vaginally. Histologic analysis confirmed leiomyoma fragments in all patients. A well-differentiated endometrial carcinoma was incidentally found in 1 patient after hysterectomy.Conclusion: These masses probably resulted from growth of missed fragments of uterine tissue after previous morcellation, culminating in development of symptomatic iatrogenic parasitic myomas. If morcellation is anticipated or required, exclusion of malignancy is mandatory. Meticulous inspection of the abdominal cavity is necessary after morcellation. In patients with a history of morcellation who have pelvic masses, iatrogenic parasitic myomas should be considered in the differential diagnosis.

Laparoscopy and Body Mass Index: Feasibility and Outcome in Obese Patients Treated for Gynecologic Diseases - Corrected Proof

2010-07-09

Abstract: Study Objective: To compare feasibility and surgical outcome of laparoscopic gynecologic surgery between obese, overweight, normal-weight, and underweight women.Design: Retrospective case control study (Canadian Task Force classification II-3).Setting: Surgery Unit of Minimally Invasive Gynaecology.Patients: A total of 503 women who underwent laparoscopic procedures for both benign disease and malignancies.Interventions: Four main categories of gynecologic disease were identified: uterine fibroids, benign adnexal masses, endometriosis, and endometrial cancer (stage I). For each category patients were divided into 4 groups: underweight (BMI <18.5 kg/m2), normal-weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25-29.9 kg/m2), and obese (BMI ≥30 kg/m2).Measurements and Main Results: Selected outcomes were duration of surgery, rate of laparotomy conversion, intraoperative and postoperative complications, and duration of hospital stay. No statistical difference regarding demographic data, surgical and medical history, and intraoperative findings was present between groups. No laparotomy conversion occurred. Regarding duration of surgery, we found no statistical difference among the BMI groups with regard to benign diseases, whereas pelvic lymphadenectomy in obese patients with endometrial cancer had a statistically significant longer duration than in the control group (122 ± 47min vs 65 ± 21 min, p <.001). The postoperative complication rate was 0.01%: 3 cases of blood transfusion and 1 case of hemoperitoneum among myomectomies; 1 ureteral fistula in surgery for pelvic endometriosis; and 1 case of postoperative lymphocele in endometrial cancer group. No statistically significant difference was found in duration of hospital stay among the BMI groups in any of the categories of disease. For each category we conducted an analysis to identify any possible risk factors other than BMI in the surgical outcomes.Conclusion: Laparoscopic approach in the various applications of gynecologic surgery does not appear to be significantly influenced by BMI in terms of surgical outcomes, laparotomy conversion rate, intraoperative and postoperative complications rate, and duration of hospital stay. The technical difficulties can be solved if skilled surgeons and anesthetists are available.

Laparoscopic Extraperitoneal Uterine Suspension to Anterior Abdominal Wall Bilaterally Using Synthetic Mesh to Treat Uterovaginal Prolapse - Corrected Proof

Gang Chen, Bin Ling, Jia Li, Ping Xu, Weiping Hu, Weidong Zhao, Dabao Wu — 2010-07-02

Abstract: Between August 2007 and May 2009, 28 patients with uterovaginal prolapse, stage 2 or greater, and who desired uterine preservation, underwent laparoscopic extraperitoneal uterine suspension to the anterior abdominal wall bilaterally using mesh. The primary outcome was recurrence, which was evaluated using point C. Secondary outcomes were effects on quality of life (Pelvic Floor Distress Inventory [PFDI-20] and Pelvic Floor Impact Questionnaire [PFIQ-7]) and sexual symptom (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12]) scores, operative time, blood loss, duration of hospitalization, and adverse events. After surgery, there was significant improvement in all pelvic organ prolapse quantification (POP-Q) measurements. The POP-Q score for point C was significantly farther from the hymen at 6-months and 1-year follow-up compared with the preoperative value (−7.8 and −8.0 vs 2.6, respectively; p <.001). The objective cure rates at 6 months and 1 year were 96.4% and 94.1%, respectively. There were no major intraoperative or postoperative complications. However, all patients reported postoperative dragging pain at the points of puncture ports where the mesh was fixed to the abdominal wall. The mean visual analog scale decreased from a mean (SD) 3-day score of 2.61 (1.26) to 0 at 1 month follow-up. Baseline PISQ-12 score changed significantly compared with the value at 6 months after operation (28.4 [2.7] vs 29.3 [2.9]; p <.001). The PFDI-20 and PFIQ-7 scores at 6 and 12 months after surgery improved significantly compared with the baseline scores (p <.001). The subjective success rates at 6 months and 1 year were 96.4% and 94.1%. respectively. Laparoscopic extraperitoneal uterine suspension to the anterior abdominal wall using mesh is a simple, safe, and effective procedure for treating uterovaginal prolapse. However, further studies of the long-term efficiency and reliability of this technique are needed to evaluate its value.

Variance in Abdominal Wall Anatomy and Port Placement in Women Undergoing Robotic Gynecologic Surgery - Corrected Proof

Catherine A. Matthews, Christine M. Schubert, Ashley P. Woodward, Edward J. Gill — 2010-07-02

Abstract: Study Objectives: To estimate whether variability in the size and ratios of the lower and upper abdomen exist in women undergoing robotic gynecologic surgery and whether demographic variables are significantly associated, and to determine the association between abdominal wall dimensions and supraumbilical robotic port placement.Design: Prospective cohort study (Canadian Task Force classification II-2).Setting: University teaching hospital.Patients: Seventy-eight women undergoing robotic surgery between May 2008 and March 2009.Intervention: Measurements from the symphysis pubis to the umbilicus (lower abdomen), umbilicus to the xyphoid process (upper abdomen), and distance between the anterior superior iliac crests were obtained at surgery. A multiple linear regression model was created to determine the relationships between abdominal wall measurements, demographic variables, and need for supraumbilical robotic port placement.Measurements and Main Results: Fifty-six white and 22 black women were enrolled. Mean lower abdominal length was significantly affected by body mass index (BMI) (p < .001) and race (p = .006), with white women having longer measurements (17.1 cm vs 15 cm). Mean lower abdominal width was independent of age (p = .95) or race (p = .98), but was significantly correlated with BMI (p < .001). Mean upper abdominal length correlated with BMI (p < .001) and age (p = .03) but not race (p = .13). Ratios of bottom to top were significantly affected by race (p = .002) and age (p = .008) but not BMI (p = .07). Adjustments to port placement above the umbilicus were made in 44 of the 74 women (59.5%). Those who required supraumbilical port placement had a significantly shorter mean (SD) distance between the symphysis pubis and the umbilicus (14.99 [1.36] vs 18.55 [2.21]; p < .001).Conclusions: Significant variability in abdominal wall anatomy exists in women undergoing robotic gynecologic surgery, and the need for supraumbilical robotic port placement is common.

Risk Factors for Uterine Rupture after Laparoscopic Myomectomy - Corrected Proof

William H. Parker, Jon Einarsson, Olav Istre, Jean-Bernard Dubuisson — 2010-06-30

Abstract: Case reports for uterine rupture subsequent to laparoscopic myomectomy were reviewed to determine whether common causal factors could be identified. Published cases were identified via electronic searches of PubMed, Google Scholar, and hand searches of references, and unpublished cases were obtained via E-mail queries to the AAGL membership and AAGL Listserve participants. Nineteen cases of uterine rupture after laparoscopic myomectomy were identified. The removed myomas ranged in size from 1 through 11 cm (mean, 4.5 cm). Only 3 cases involved multilayered closure of uterine defects. Electrosurgery was used for hemostasis in all but 2 cases. No plausible contributing factor could be found. It seems reasonable for surgeons to adhere to techniques developed for abdominal myomectomy including limited use of electrosurgery and multilayered closure of the myometrium. Nevertheless, individual wound healing characteristics may predispose to uterine rupture.

Narrow-Band Imaging in Diagnosis of Endometrial Cancer and Hyperplasia: A New Option? - Corrected Proof

2010-06-28

Abstract: Study Objective: To estimate whether the use of narrow-band imaging (NBI) hysteroscopy increases concordance between visual identification and a histologic diagnosis of endometrial cancer and hyperplasia.Design: Prospective study (Canadian Task Force classification: II-2).Setting: Department of obstetrics and gynecology, University of Eastern Piedmont, Novara, Italy.Patients: 209 consecutive patients with abnormal uterine bleeding.Interventions: White-light hysteroscopy and NBI hysteroscopy followed by direct biopsy.Measurements and Main Results: The sensitivity and specificity of conventional hysteroscopy in predicting a diagnosis of cancer and hyperplasia were, respectively, 84.21% (95% confidence interval [CI], 79.27–89.15) and 99.47% (95% CI, 98.49–100.0), and 64.86% (95% CI, 58.39–71.34) and 98.77% (95% CI, 97.27–100.0), and of NBI hysteroscopy were 94.74% (95% CI, 91.71–97.76) and 97.89% (95% CI, 95.95–99.84), and 78.38% (95% CI, 72.8–83.96) and 97.67% (95% CI, 96.63–99.72). The concordance of conventional and NBI hysteroscopy with the histopathologic findings (measured using the Cohen κ) was, respectively, 88.80% (95% CI, 86.2%–96.3%) and 91.78% (95% CI, 89.6%–98.2%), a difference of 2.98% (95% CI, 0–9) in favor of NBI.Conclusion: Narrow-band imaging hysteroscopy can accurately predict a histologic diagnosis of endometrial cancer or hyperplasia.

Wound Retraction System for Isobaric Laparoendoscopic Single-Site Surgery to Treat Adnexal tumors: Pilot Study - Corrected Proof

Akihiro Takeda, Sanae Imoto, Masahiko Mori, Tomoko Nakano, Hiromi Nakamura — 2010-06-28

Abstract: Transumbilical laparoendoscopic single-site (LESS) surgery is a recent advancement in minimally invasive surgery. However, this procedure usually requires a specialized multichannel port for introducing the laparoscope and instruments under pneumoperitoneum. In an isobaric procedure, a wound retractor alone can conveniently be used for transumbilical single-site access. Fourteen isobaric LESS adnexal surgeries including 1 emergency procedure with adnexal torsion were performed using multiple instruments inserted through the wound retractor. No extraumbilical incisions or conversion to standard multiple-port laparoscopic surgery were required. Port-related complications were not noted, and the cosmetic results were excellent. A wound retractor offers safe and reliable access for isobaric LESS adnexal surgery as an alternative to the current specialized port systems.

Extraperitoneal Laparoscopic Approach for Diagnosis and Treatment of Aortic Lymph Node Recurrence in Gynecologic Malignancy - Corrected Proof

2010-06-28

Abstract: Objective: To estimate the safety and feasibility of extraperitoneal laparoscopic approach for the diagnosis and treatment of paraaortic lymph node recurrence in gynecologic cancers.Material and Methods: Between December 2002 and September 2009, 15 patients underwent extraperitoneal laparoscopic paraaortic lymphadenectomy for suspected isolated lymph node recurrence in the Gynecologic Oncology Unit of Hospital Vall d'Hebron. The suspected diagnosis of recurrence was performed with computed tomography scanning, 18F-fluorodeoxyglucose positron emission tomography scanning, or magnetic resonance imaging.Results: The median age of patients was 63 years (range 42-75). The median body mass index was 28.5 Kg/m2 (range 18-38). The median operative time was 157.5 minutes (range 120-240). The median blood loss was 70 mL (range 30-150). The mean nodal yield was 7.7 ± 5.3 (range 1-16). The median hospital stay was 2 days (range 2-13). There was 1 conversion to laparotomy. There was only 1 postoperative complication, a lymphorrhea that was resolved with drainage. Recurrence was confirmed in the pathologic study in 13 of the 15 patients.Conclusion: The extraperitoneal laparoscopic surgical approach is a feasible and safe procedure for the diagnosis of paraaortic lymph node recurrences of gynecologic cancers. The previous abdominal surgeries or treatment with chemotherapy or radiotherapy and high body mass index are not a problem. The low complication rate, low blood loss and low hospitalization allow a rapid recovery of the patients, which in turn, allows the rapid onset of adjuvant therapy. Complete debulking of suspicious lymphadenopathy offers an exact diagnosis of malignancy, and it may have a therapeutic benefit in the case of being positive.

Iatrogenic Myomas: New Class of Myomas? - Corrected Proof

Ceana Nezhat, Kimberly Kho — 2010-06-28

Abstract: Parasitic myomas, defined as extrauterine seeding of leiomyoma, have been reported since the early 1900s. These myomas were thought to be spontaneously occuring, separate from the uterus but still hormone-dependent and can cause symptoms. What seemed to be a rare disorder developing from the natural history of pedunculated myomas has become increasingly reported over the last decade. Because it is still a rare disorder, the literature is limited to case reports. Herein, we review the literature and provide an analytic review of recent case reports, with emphasis on etiology, trends, and risk factors, to increase awareness of this problematic entity.

Gynecologic Evaluation of Catamenial Pneumothorax Associated with Endometriosis - Corrected Proof

2010-06-28

Abstract: Study Objective: To assess the pathogenesis of catamenial pneumothorax associated with endometriosis from a gynecologic perspective.Design: Retrospective study (Canadian Task Force classification II–2).Setting: University hospital.Patients: Eleven patients with clinically suspected catamenial pneumothorax due to frequently recurrent pneumothorax who underwent thoracoscopy between September 2003 and February 2007 at our hospital.Intervention: Video-assisted thoracoscopy.Measurements and Main Results: Episodes of pneumothorax, coexistence of intrapelvic endometriosis, classification of intrathoracic lesions according to the appearance of pelvic endometriosis using the revised American Society of Reproductive Medicine (re-ASRM) classification, and histopathologic findings in intrathoracic specimens were assessed. A total of 38 episodes of pneumothorax, all on the right side, were documented in 11 patients with catamenial pneumothorax. Median (range) patient age at the initial pneumothorax was 42 (29–47) years. The re-ASRM score in 6 patients in whom pelvic endometriosis was directly observed at laparoscopy and laparotomy was 56 (18–96). We postoperatively reviewed videotape recordings of video-assisted thoracoscopy, and observed superficial thoracic diaphragmatic lesions classified as red (n = 5), black (n = 8), and white (n = 9) with fenestration according to the re-ASRM classifications for pelvic endometriosis. Tissue associated with endometriosis was detected at histopathologic analysis of resected diaphragmatic lesions in 9 patients. No endometriosis was identified at histopathologic analysis of visceral pleural lesions in 7 patients who underwent lung resection.Conclusions: Gynecologic evaluation of catamenial pneumothorax associated with endometriosis is crucial to clarify the unelucidated pathogenesis of the disease.

Human Amnion as a Temporary Biologic Barrier after Hysteroscopic Lysis of Severe Intrauterine Adhesions: Pilot Study - Corrected Proof

2010-06-24

Abstract: Study Objective: To estimate the efficacy of fresh and dried amnion graft after hysteroscopic lysis of severe intrauterine adhesions in decreasing its recurrence and encouraging endometrial regeneration.Design: Pilot prospective randomized comparative study (Canadian Task Force classification I).Setting: Ain Shams Medical School, Cairo, Egypt.Patients: Forty-five patients with severe intrauterine adhesions. Primary symptom was infertility with or without menstrual disorders such as amenorrhea or hypomenorrhea.Interventions: Patients were randomized preoperatively using a computer-generated randomization sheet into 3 groups of 15 patients each. Allocation to any group was concealed in an opaque envelope, which was opened at the time of operation. Hysteroscopic lysis of intrauterine adhesions was followed by insertion of an intrauterine balloon only (group 1) or either fresh amnion graft (group 2) or dried amnion graft (group 3) for 2 weeks. Diagnostic hysteroscopy was performed at 2 to 4 months postoperatively.Measurements and Main Results: Adhesion grade, menstruation, uterine length, complications, and reproductive outcome were determined. There was significant improvement in adhesion grade with amnion graft vs intrauterine balloon alone (p = .003). Improvement was greater with fresh amnion than with dried amnion (p = .01). Normal menstruation occurred in 4 patients (28.6%) in group 1, 5 (35.7%) in group 2, and 7 (46.7%) in group 3. Of 43 patients, 41 (95.3%) were treated in 2 endoscopic sessions (95.3%), and 2 patients (4.7%) were treated in 3 endoscopic sessions. Uterine perforations occurred in 2 patients (4.7%), and cervical tears in 3 (7.0%). Ten patients (23.3%) achieved pregnancy, 8 (80%) after amnion graft and 2 (20%) without amnion. Six of the 10 patients (60%) miscarried, and 4 (40%) were either still pregnant or delivered at term without complications.Conclusion: Hysteroscopic lysis of severe intrauterine adhesions with grafting of either fresh or dried amnion is a promising adjunctive procedure for decreasing recurrence of adhesions and encouraging endometrial regeneration.

Single-Port Laparoscopic Myomectomy Using a New Single-Port Transumbilical Morcellation System: Initial Clinical Study - Corrected Proof

Yong-Wook Kim, Byung-Joon Park, Duck-Yeong Ro, Tae-Eung Kim — 2010-06-24

Abstract: Study Objective: To evaluate the feasibility of single-port laparoscopic myomectomy with transumbilical morcellation and suturing.Design: Continuing prospective study (Canadian Task Force classification II-3).Setting: University hospital.Patients: Fifteen patients who underwent single-port laparoscopic myomectomy between September 2008 and October 2009 to remove single or multiple uterine myomas, at least 1 in each patient measuring greater than 4 cm in diameter.Interventions: All single-port laparoscopic myomectomy procedures were performed by a single surgeon (Dr. Y.W. Kim). Myomas were extracted transumbilically by cutting the myomas into smaller pieces with a knife or a conventional electromechanical morcellator. After making a single 1.5- to 2.0-cm umbilical incision, the single-port system, created with a wound retractor and a surgical glove, was inserted. All operations were performed using conventional rigid straight laparoscopic instruments. Laparoscopic suturing was performed in intramural myomas and some subserosal myomas.Measurements and Main Results: Patient mean (SD; range) age was 38.3 (5.6; 29–49) years. The number of myomas per patient was 1.6 (1.4; 1–6). The diameter of the largest myomas was 6.1 (1.5; 4.2–9.6) cm. In 4 patients, only a knife was required for transumbilical extraction of myomas, and in 11 patients, transumbilical morcellation with an electromechanical morcellator with or without a knife was used. Transumbilical drainage tubes were inserted into the pelvic cavity in 11 of 15 patients. Operative time was 96.7 (33.8; 35–150) minutes. The decrease in postoperative hemoglobin concentration was 1.8 (1.2; 0.4–3.6) g/dL. During the operations, no patients required blood transfusion. No patients developed postoperative fever. Neither bowel injury nor urinary tract injury occurred in any patient. The postoperative hospital stay was 3.1 (0.8; 2–4) days.Conclusion: Single-port transumbilical morcellation using a conventional electromechanical morcellator with or without a knife is feasible. Single-port laparoscopic myomectomy is an alternative method with cosmetic advantage.