Surgical complexity score and role of laparoscopy in women with advanced ovarian cancer treated with neoadjuvant chemotherapy

ObjectivesTo evaluate surgical complexity scores (SCS) and minimally invasive surgery (MIS) at interval debulking surgery (IDS) in advanced epithelial ovarian cancer (EOC) patients receiving neoadjuvant chemotherapy (NACT).MethodsA multi-institutional study of NACT with IDS for advanced EOC was conducted. Demographic data were abstracted and SCS assigned based on IDS findings. Disease-specific overall survival (DSS) was defined as the time from completion of adjuvant chemotherapy to death due to disease. Cox proportional hazards regression models were used for univariate and multivariate survival analyses.Results282 patients were identified; 80.5% had high-grade serous histology and 54.6% were <75 (median 63.9; range 34.1–84.8). Approximately 84% were optimally cytoreduced (61% R0; 23% <1 cm). In multivariate analyses, age 75+ (p ≤ 0.001), residual disease (>1 cm; p = 0.03), and SCS ≥ 3 (p = 0.04) were significantly predictive of worse DSS when morbidity and ASA score were also in the model. When optimally debulked was defined as R0, only age 75+ (<0.001) was significantly associated with decreased DSS. In the R0 cohort, SCS did not significantly predict DSS. However, subset analysis defining optimal ≤1 cm, revealed higher SCS was associated with a 1.6-fold increased risk of death (p = 0.02).Fifty-one patients underwent laparoscopic IDS. Twenty-four (47%) were converted to laparotomy to achieve optimal debulking in 21 patients (87.5%); while 25 had laparoscopic optimal cytoreduction (19/25 [76%] R0).ConclusionsIn women with advanced EOC treated with NACT, older age, SCS ≥ 3, and residual disease >1 cm at IDS were predictors of worse survival. MIS appears safe and feasible with acceptable optimal cytoreduction rates.     

Is training in obstetric critical care adequate? An international comparison

Obstetric critical care is an emerging discipline which cuts across speciality boundaries. We have analysed the training curricula in the three major specialities (obstetrics, anaesthesia and intensive care medicine) likely to be involved in the care of the critically-ill obstetric patient, to assess whether it is adequate to ensure effective training on this subject.     

The Effectiveness of Tranexamic Acid at Reducing Blood Loss and Transfusion Requirement for Women Undergoing Myomectomy: A Systematic Review and Meta-analysis

BackgroundThe surgical removal of fibroids can be associated with excessive blood loss requiring transfusion.ObjectiveThis review sought to determine the effectiveness of tranexamic acid (TA) in reducing perioperative blood loss in women undergoing myomectomy.MethodsElectronic bibliographic databases were searched from inception until June 3, 2017. The review included RCTs of women of reproductive age with uterine fibroids who were undergoing myomectomy and who received TA or a comparator. Two independent reviewers extracted relevant data, and meta-analysis was performed.ResultsThree studies included women undergoing abdominal myomectomy. TA significantly reduced intraoperative blood loss by a mean difference of 213.1 mL (95% CI ?242.4 to ?183.7) and postoperative blood loss by a mean difference of 56.3 mL (95% CI ?67.8 to ?44.8) compared with control arms. However, no significant differences were seen in blood transfusion requirement (relative risk 0.58; 95% CI 0.33–1.00). In one study for women undergoing hysteroscopic myomectomy, TA was not associated with improved outcomes in transfusion requirement and resulted in reduced postoperative hemoglobin levels compared with oxytocin.ConclusionAmong women undergoing abdominal myomectomy, TA is effective at reducing perioperative blood loss compared with no treatment or placebo. For women undergoing hysteroscopic myomectomy, TA compared with oxytocin is not associated with improved outcomes in transfusion requirement and resulted in reduced postoperative hemoglobin levels.     

Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries

ObjectiveThe purpose of this study was to describe associations between episiotomy at the time of forceps or vacuum-assisted delivery and obstetrical anal sphincter injuries (OASIS).MethodsThis population-based retrospective cohort study used delivery information from a provincial perinatal clinical database. Full-term, singleton, in-hospital, operative vaginal deliveries of vertex-presenting infants from April 1, 2006 to March 31, 2016 were identified. Odds ratios (ORs) and 95% confidence intervals (CIs) for associations between episiotomy and third- or fourth-degree lacerations were calculated in multiple logistic regression models (Canadian Task Force Classification II-2).ResultsEpisiotomy was performed in 34% of 52 241 operative vaginal deliveries. OASIS occurred in 21% of forceps deliveries and 7.6% of vacuum deliveries. Episiotomy was associated with increased odds of severe perineal lacerations for vacuum deliveries among women with (OR 2.48; 95% CI 1.96–3.13) and without (OR 1.12; 95% CI 1.02–1.22) a prior vaginal delivery. Among forceps deliveries, episiotomy was associated with increased odds of OASIS for those with a previous vaginal delivery (OR 1.52; 95% CI 1.12–2.06), but it was protective for women with no previous vaginal delivery (OR 0.73; 95% CI 0.67–0.79). Midline compared with mediolateral episiotomy increased the odds of OASIS in forceps deliveries (OR 2.73; 95% CI 2.37–3.13) and vacuum deliveries (OR 1.94; 95% CI 1.65–2.28).ConclusionIn conclusion, results suggest that episiotomy should be used with caution, particularly among women with a previous vaginal delivery and in the setting of vacuum-assisted delivery. Episiotomy may protect against OASIS in forceps-assisted deliveries for women without a prior vaginal delivery.     

Is the anchor matter? A short-term follow-up of the effect of mini-invasive mid urethra sling without anchor for urinary incontinence women

ObjectiveStress urinary incontinence (SUI) is a common disease in aged women, and some of them need surgical correction. Recently, the mid-urethral sling is an accepted surgical approach for SUI. However, complication may occur in this surgery, and some of them are needle-related. Therefore, the needleless system may diminish this-type complication.Materials and methodsWe conducted a retrospective study to evaluate the feasibility of women with SUI undergoing needleless sling surgery in 2017. Assessments were performed by two independent special urogynecologists before, during and post operation periods. We used a category-time-site-pain code following the International Continence Society and International Urogynecological Association (ICS/IUGA) Complication Classification Code (CCC) guidelines.ResultsThirty-eight women were analyzed. The characteristics of the patients were 66.3 ± 12.8 years old (mean ± standard deviation) of age, 2.8 ± 1.2 of parity, and 25.6 ± 4.2 kg/m² of body mass index. All had history of vaginal delivery for term. The objective cure rate at 2- and 4-week follow-up was 97.4% (n = 37) and 94.7% (n = 36), respectively. The subjective cure rate at 2- and 4-week follow-up was both 89.5% (n = 34). Both objective and subjective cure rates remained constant and similar to the end of 4 weeks. There were 6 patients (15.8%) who had complications according to ICS/IUGA CCC guidelines.ConclusionThis needleless mid-urethral sling procedure seemed to be feasible in the management of women with SUI in this small series and short-term follow-up study, suggesting that a further prospective, randomized, comparative study with other tension-free procedures and mini-sling systems can be conducted.     

Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study

Study ObjectiveTo identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingTertiary referral center.PatientsNinety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy.InterventionsSeventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy.Measurements and Main ResultsFactors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (β-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m² was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline β-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy.ConclusionsChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.     

Predictors of Obstetric Fistula Repair Outcomes in Lubango,Angola

ObjectiveObstetric fistulas have a significant physical and social impact on many women in Angola. The majority of the population of this sub-Saharan African nation does not have access to high-quality obstetric care, and this is associated with a risk of prolonged labour and formation of obstetric fistulas. Fistulas are challenging to correct surgically and may require repeated operations. The objective of the study was to determine predictors of successful obstetric fistula repair.MethodsIn this retrospective study, data from all recorded cases of fistula repair performed between July 2011 and December 2016 at the Centro Evangélico de Medicina do Lubango (CEML) hospital located in Lubango, Angola, were reviewed. Analysis of the data was carried out to determine factors affecting the success of fistula repair; parametric and non-parametric tests were used for group comparisons and logistic regression for outcome prediction (Canadian Task Force classification II-2).ResultsA total of 407 operations were performed on 243 women. Of these, 224 women were diagnosed with a vesicovaginal fistula and 19 with a combined vesicovaginal and rectovaginal fistula. The success rate for the attempted repairs was 42%. On multivariate analysis, the success of first surgery was negatively affected by the difficulty of repair (odds ratio 0.28; P < 0.01). For patients requiring repeat surgery, the odds of success were increased with each subsequent operation (odds ratio 5.32; P < 0.01).ConclusionAlthough fistulas rated as difficult to repair had a higher likelihood of initial failure, successive attempts at repair increased the likelihood of a successful outcome.     

Diagnosis and gestational follow-up in a patient with Herlyn-Werner-Wünderlich syndrome,a case report

ObjectiveHerlyn-Werner-Wünderlich syndrome (HWW) is a rare congenital malformation of the urogenital tract due to a fusion failure in the Müllerian ducts. This anomaly consists of a didelphus uterus with obstructed hemivagina and sometimes associated with ipsilateral renal agenesis. The treatment of choice is surgical, it consists of a simple procedure of resection of the vaginal septum and drainage of the obstructed hemivagina and retained collections.Case reportWe report the case of a pregnancy in a 37-year-old woman with SHWW without resection of the vaginal septum.ConclusionsThe early detection is important due to the possible associated complications. Women with uterine defects are subject to an increased risk of complications in pregnancy and childbirth. Therefore, each case must be treated individually.     

Efficacy of a Fibrin Sealant (Tissucol Duo) for the Preventionof Lymphocele after Laparoscopic Pelvic Lymphadenectomy:A Randomized Controlled Trial

Study ObjectiveTo assess the efficacy of Tissucol Duo (Baxter AG, Vienna, Austria) fibrin sealant in decreasing the incidence of lymphocele (LC) after pelvic laparoscopic lymph node dissection using harmonic shears.DesignRandomized controlled trial (Canadian Task Force classification level I).SettingTertiary referral and educational center.PatientsSeventy-four patients randomized to the use of sealant per hemipelvis.InterventionFibrin sealant.Measurements and Main ResultsAfter bilateral pelvic lymphadenectomy a fibrin sealant was used in 1 hemipelvis but not the other, applied in 41 patients (55.4%) to the left and 33 patients (44.6%) to the right hemipelvis. The primary outcome was the incidence of LC after surgery in symptomatic and asymptomatic patients. Imaging (ultrasound, computed tomography, and magnetic resonance) was performed to detect LC at 3, 6, and 12 months after surgery. Overall, 26 patients (35.1%) developed LC, and 4 were symptomatic (5.4%). Allowing patients to serve as their own treatment group and control, the hemipelvis treated with Tissucol Duo corresponding to the treatment group and that not treated to the control group, LCs were found in 17 (23%) and 14 (19%) cases, respectively, but the difference was not significant. The mean initial LC maximum diameter was 27.1 mm (standard deviaiotn, 35.2), and LCs tended to decrease in size during the first year to a mean of 8.7 mm.ConclusionApplication of Tissucol Duo fibrin sealant after laparoscopic pelvic lymphadenectomy using ultrasonic shears does not decrease the occurrence of symptomatic or asymptomatic LC.