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1.
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2.

Study Objective

To introduce an effective assisted method using the hysteroscopy transmittance test and a Foley catheter to repair previous cesarean scar defect (PCSD) by laparoscopy.

Design

A step-by-step explanation of the surgery using video.

Setting

A university hospital.

Patients

A young woman with abnormal uterine bleeding.

Interventions

First, we inspected the pelvic cavity and detached the adhesion, opened the uterovesical peritoneal reflection, and pushed down the bladder. Then, the hysteroscopy transmittance test was used to confirm the site and the size of the PCSD. Next, a Foley catheter was inserted into the diverticulum through the cervical canal, and then we removed the diverticulum along the outer edge 1, 2, 3, 4. The myometrium and the serosal layer were sutured continuously with absorbable sutures. At this point, a second hysteroscopy transmittance test was performed to verify the repair effect. Finally, we placed antiadhesive film.

Measurements and Main Results

The location, size, and boundary of the PCSD can be exactly marked by this method. The operative time was 68 minutes, blood loss was 20mL, and no complications occurred.

Conclusion

This surgical method has the following benefits: the resection of the diverticulum is complete, and the suture is exact; it is suitable for patients with a thin diverticulum wall, large diverticulum cavity, and a long duration of bleeding after menstruation; the hysteroscopy transmittance test was used to confirm the site of the PCSD and verify the repair effect; and the Foley catheter can marker the resection site, prevent gas leakage, and stop bleeding by local compression.  相似文献   

3.

Study Objective

To examine the potential beneficial effect of platelet-rich plasma (PRP) and fibrin sealant (TISSEEL; Baxter Healthcare Corporation, Deerfield, IL) on bowel wound healing after shaving of an experimentally induced endometriotic lesion.

Design

A single-blind, randomized study (Canadian Task Force classification I).

Setting

A certified animal research facility.

Animals

Thirty female Sprague-Dawley rats.

Interventions

Experimental colonic endometriosis was induced by transplanting endometrial tissue to all animals (first surgery). Thirty rats were then randomized to 1 of 3 groups according to treatment; PRP (group 1, n?=?10), fibrin sealant (group 2, n?=?10), or no agent (group 3, n?=?10) was applied after shaving of the endometriotic nodule (second surgery).

Measurements and Main Results

Colonic endometriosis was successfully induced in all subjects. Four days after the second surgery, the animals were euthanized, and microscopic evaluation was performed. The pathologist was blinded to the treatment method. Histopathologic analysis revealed that compared with the control group, collagen disposition was found in a significantly higher expression in both the PRP and fibrin sealant groups (p?=?.011 and p?=?.011, respectively). Distortion of the integrity of the colon layers was statistically more pronounced in the control group compared with the fibrin sealant group (p?=?.033), whereas greater new blood vessel formation was observed in the fibrin sealant group compared with the control (p?=?.023). No histologic evidence of residual or recurrent disease was detected.

Conclusion

Both PRP and fibrin sealant appear to be safe and associated with improved tissue healing during shaving for the excision of colonic endometriosis, attributed to the enhanced collagen disposition, neovascularization, and protection of the integrity of colon layers. Clinical trials are warranted to confirm the feasibility of PRP and fibrin sealant in the clinical setting.  相似文献   

4.

Study Objective

To evaluate the safety and effectiveness of hysteroscopic myomectomy after uterine artery embolization (UAE) for the treatment of large-sized submucosal myomas with deep intramural invasion that are difficult to treat with 1-step hysteroscopy.

Design

A retrospective cohort study (Canadian Task Force classification II-2).

Setting

An academic university hospital.

Patients

Eight premenopausal patients with symptomatic submucosal myomas with intramural invasion.

Interventions

All of the patients after bilateral UAE underwent subsequent hysteroscopic operation 3 to 15 months after UAE.

Measurements and Main Results

A total of 8 patients who had a large-sized submucosal myoma with deep myometrial invasion were included. The average volume of the submucosal myomas was 87.7±39.9 cm3 as confirmed by magnetic resonance imaging, and the average patient age was 37.6 years. The mean volume reduction of the submucosal myomas was 83.3±16.4% after UAE, and no immediate complications were observed. One-step hysteroscopic myomectomy after UAE was successfully performed in all patients. Leiomyomas with hyaline degeneration were pathologically confirmed. All women showed improved symptoms, and there was no evidence of recurrence 1 year later. One patient conceived naturally and delivered a full-term baby.

Conclusion

In premenopausal women with large-sized symptomatic submucosal myomas with deep myometrial invasion, hysteroscopic myomectomy after UAE is very effective and safe.  相似文献   

5.

Study Objective

To evaluate the effect of intraoperative superior hypogastric blocks on postoperative pain management.

Design

Prospective observational cohort study (Canadian Task Force classification II-2).

Setting

Kocaeli Derince Training and Research Hospital, University of Health Sciences, Department of Anesthesiology and Reanimation, Department of Gynecology and Obstetrics, Kocaeli, Turkey.

Patients

Sixty female patients who underwent elective laparoscopic hysterectomy were included in this study. Patients were divided into 2 groups: those who had intraoperative superior hypogastric plexus (SHP) block (Hypo; n?=?30) and those who did not have intraoperative SHP block (No-Hypo; n?=?30).

Interventions

Intraoperative SHP blocks were performed with the modified laparoscopic technique previously described by us.

Measurements and Main Results

Rescue analgesic time was calculated in minutes as the time interval between the last administration of analgesic in the operating room or postanesthesia care unit and the first analgesic demand in the surgical ward. Rescue analgesic times were found to be significantly higher in the Hypo group. Nonsteroidal anti-inflammatory drugs and opioid requirements in the postanesthesia care unit and in the surgical ward were significantly lower in the Hypo group. There was no difference between groups in postoperative nausea and vomiting.

Conclusions

Intraoperative SHP block is a preferable modality for postoperative analgesia in patients undergoing hysterectomy. The surgical laparoscopic modified anterior approach we describe is an uncomplicated and easily applicable method. More effective results would be seen if used together with wound site local anesthetic infiltration or abdominal wall plane blocks. (Clinical trial registration no. NCT03427840.)  相似文献   

6.

Study Objective

To analyze and investigate reports associated with uterine artery embolization used for treatment of myomas using this database.

Design

A retrospective review of the Manufacturer and User Facility Device Experience (MAUDE) database for events related to uterine artery embolization (Canadian Task Force Classification III).

Setting

The MAUDE database was accessed online.

Patients

Patients with myomas undergoing uterine artery embolization.

Interventions

The MAUDE database was accessed online and searched for events related to uterine artery embolization reported between 1998 and 2018. These reports were reviewed and analyzed, reported events were categorized, and other relevant information was collected and tabulated.

Measurements and Main Results

A total of 193 reports published during the study period were identified. Pain was the most frequently reported event (68 events; 35.2%), followed by vaginal discharge (45 events; 23.3%), operational misfire (37 events; 19.2%), and fever or infectious complications (36 events; 18.7%). A surgical procedure was required in 27 events (14.0%), with hysterectomy reported in 7.8% of the events. Death following this procedure was mentioned in 5 events (2.6%).

Conclusion

The MAUDE database may be useful for clinicians using a Food and Drug Administration–approved medical device to identify the occurrence of adverse events and complications. A variety of adverse events associated with the use of uterine artery embolization were reported to the MAUDE database related to its use in the treatment of uterine myomas. We encourage physicians to review the MAUDE database when using medical devices, because this is an important tool to assess uncommon but major problems that could be associated with a medical device.  相似文献   

7.

Study Objective

To investigate ethnic differences for moderate-to-severe endometriosis.

Design

Analysis of a prospective registry (Canadian Task Force classification II-2).

Setting

Tertiary referral center.

Patients

A total of 1594 women with pelvic pain and/or endometriosis.

Interventions

None

Measurements and Main Results

On logistic regression, adjusting for potential confounders, East/South East Asians were 8.3 times more likely than whites to have a previous diagnosis of stage III/IV endometriosis before referral (adjusted odds ratio [aOR], 8.33; 95% confidence interval [CI], 3.74–18.57), 2.7 times more likely to have a palpable nodule (aOR, 2.66; 95% CI, 1.57–4.52), 4.1 times more likely to have an endometrioma on ultrasound (aOR, 4.10; 95% CI, 2.68–6.26), and 10.9 times more likely to have stage III/IV endometriosis at the time of surgery at our center (aOR, 10.87; 95% CI, 4.34–27.21).

Conclusion

Moderate-to-severe endometriosis was more common in women with East or South East Asian ethnicity in our tertiary referral center.  This could be explained by East/South East Asians with minimal to mild disease being less likely to seek care or genetic/environmental differences that increase the risk of more severe disease among East/South East Asians. (ClinicalTrials.gov, NCT02911090.)  相似文献   

8.

Study Objective

To evaluate the risk of endometrial cancer (REC) scoring system for the prediction of high and low probability of endometrial cancer (EC) in women with postmenopausal bleeding (PMB).

Design

A prospective study (Canadian Task Force classification II-1).

Setting

An academic hospital.

Patients

Nine hundred fifty consecutive patients with PMB underwent transvaginal ultrasonography (TVS) and REC scoring between November 2013 and December 2015.

Interventions

Obstetrics and gynecology residents supervised by trained physicians scored endometrial patterns according to the previously established REC scoring system. The reference standard was endometrial samples, endometrial thickness (ET, 4–4.9 mm), operative hysteroscopy or hysterectomy (ET ≥5 mm), and 1-year follow-up in all patients presenting with ET <4 mm. Diagnostic performance for the prediction of probability of malignancy was assessed using the REC scoring system.

Measurements and Main Results

The area under the receiver operating characteristic curve of the TVS REC scoring system was 97% (95% confidence interval [CI], 95%–98%) for the prediction of malignancy. In 656 patients with ET ≥4 mm, REC scoring effectively predicted a high probability of malignancy with sensitivity (95% confidence interval) of 92% (95% CI, 87%–95%) and specificity of 94% (95% CI, 91%–96%). An REC score of 0 was present in 206 (32%) patients with ET ≥4 mm and was associated with a low negative likelihood ratio of 0.026 for EC. There were only 7 patients with EC/atypical hyperplasia among these 206 patients.

Conclusion

The REC scoring system identified or ruled out most ECs, clearly showing that more specific image analysis at first-line TVS can accelerate the diagnosis of EC in patients with PMB and may allow for improved selection of second-line strategies in patients with ET ≥4 mm.  相似文献   

9.

Study Objective

To evaluate the long-term safety and efficacy of tension-free vaginal tape (TVT).

Design

Prospective observational study (Canadian Task Force classification II-2).

Setting

Tertiary referral center in China.

Patients

Between January 2004 and December 2005, 85 consecutive patients who underwent the TVT procedure were included. Patients with mixed incontinence or pelvic organ prolapse requiring surgery were excluded.

Interventions

TVT procedure.

Measurements and Main Results

The primary outcomes were long-term postoperative complications. The secondary outcomes included long-term subjective satisfaction (Patient Global Impression of Improvement), objective cure rate (stress test), quality of life, and sexual function. At the 13-year follow-up, 70 patients (82%) were available for evaluation. De novo overactive bladder was observed in 15.7% of patients, and voiding symptoms were found in 17.1% of patients. None of the patients reported voiding dysfunction that needed treatment with tape removal or catheterization. Tape exposure occurred in 2.9% of patients. The subjective satisfaction rate and objective cure rate were 78.6% and 81.4%, respectively.

Conclusion

TVT is a safe and effective treatment for stress urinary incontinence, even at the 13-year follow-up. The prevalence rates of overactive bladder and voiding symptoms are increased with advancing age and should not be considered long-term postoperative complications.  相似文献   

10.

Study Objective

To compare the efficacy of oral diclofenac potassium versus hyoscine-N-butyl bromide (HBB) in reducing pain perception in patients undergoing diagnostic office hysteroscopy (OH).

Design

A randomized double-blind placebo-controlled trial (Canadian Task Force classification I).

Setting

A university hospital.

Interventions

One-hundred twenty-nine patients were divided randomly into 3 groups (n?=?43 in each group); group 1 received 50mg diclofenac potassium, group 2 received 20mg HBB, and group 3 received placebo tablets. All tablets were taken orally 1hour before OH. The primary outcome was the participant's self-rated pain perception using the 10-point visual analog scale during the procedure. The secondary outcomes included the visual analog scale score 30 minutes after OH, ease of OH assessment using a 10-cm scale, duration of OH, and adverse effects of the study medications.

Measurements and Main Results

Both the diclofenac and HBB groups showed significant pain score reduction compared with the placebo group (p?=?.001). The mean pain score in the diclofenac group was significantly lower than the HBB group (2.12 ± 1.03vs 3.02 ± 1.55, respectively; p?=?.002). The pain scores in the diclofenac and HBB groups immediately after OH were significantly lower than the placebo group (p?=?.001), and the mean pain score in the diclofenac group was significantly lower than the HBB group (1.23 ± 0.57vs 1.56 ± 0.73, respectively; p?=?.024). The ease of procedure score was significantly lower in the diclofenac and HBB groups than the placebo group (p?=?.003 and p?=?.005, respectively). The mean duration of the procedure was significantly less in the diclofenac group (p?=?.01). Fourteen women (32.6%) in the HBB group experienced dizziness and 2 women (4.6%) had nausea, whereas only 4 women (9.3%) in the diclofenac group had dizziness and 2 women (4.6%) had vomiting.

Conclusion

Oral diclofenac potassium administration 1hour before diagnostic OH reduces the procedure pain with subsequent easier and shorter OH duration. Oral HBB is less effective than diclofenac potassium with more adverse effects.  相似文献   

11.

Study Objective

To investigate whether there are left–right asymmetries, factors affecting lateral dominance, and clinical feature differences in the left and right sides of tubal pregnancy (TP).

Design

Retrospective study (Canadian Task Force classification II-2).

Setting

International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University.

Patients

Patients (n?=?6186) with TP treated surgically.

Interventions

We used data from the digital medical records system of the hospital. Women diagnosed with ectopic pregnancy(EP) between January 2005 and December 2016 in the inpatient department of gynecology were included. All data from the medical files were obtained retrospectively, including demographic characteristics; reproductive, gynecologic, and surgical history; clinical features; and treatment. Patients who were previously treated by salpingectomy or nonsurgical management and those with unknown-site EP or non-TPs were excluded.

Measurements and Main Results

The overall frequency of right-sided TP was 54.48% (3370/6186), which is significantly higher than 50% (p < .001, binominal test). The proportion of right-sided TPs decreased with age (p for trend?=?.007) and from the proximal (interstitial) end to the distal (fimbrial) end of the tube (p for trend?=?.017). Of the TP patients with a corpus luteum, we found the corpus luteum was more frequently located in the right ovary (p < .001) and in the contralateral ovary to the TP side in 41.38% of cases. However, tubal rupture was more frequent in left TP than the in right TP (p?=?.005).

Conclusion

The left–right asymmetries of TP include right-side dominance and the clinical feature differences between the 2sides of TP.  相似文献   

12.

Study Objective

To assess the usefulness of narrowband imaging (NBI) to detect additional areas of endometriosis not identified by standard white light in patients undergoing laparoscopy for the investigation of pelvic pain.

Design

A prospective cohort trial (Canadian Task Force classification II). Evidence obtained from a well-designed cohort study.

Setting

A tertiary laparoscopic subspecialty unit in Melbourne, Australia.

Patients

Fifty-seven patients undergoing laparoscopy for the investigation of pelvic pain were recruited. Fifty-three patients were eligible for analysis.

Interventions

Patients underwent standard white-light laparoscopy of the pelvis followed by NBI survey to assess for any additional areas suspicious for endometriosis.

Measurements and Main Results

All identified areas of possible endometriosis were resected and sent for blinded histopathological analysis. The additional predictive value of NBI was 0% if the preceding white-light survey was negative and 86% if the preceding white-light survey was positive.

Conclusion

The use of NBI at laparoscopy for the investigation of pelvic pain is beneficial in finding additional areas of endometriosis if endometriosis is already suspected after white-light survey in a tertiary laparoscopic unit. Further research in nonspecialized units may show additional benefit and requires further research. NBI may also be useful as a diagnostic aid for trainees.  相似文献   

13.

Study Objective

To demonstrate a safe laparoscopic procedure for diaphragmatic infiltrative endometriosis.

Design

Video case

Setting

Teaching hospital (Canadian Task Force classification III).

Patients

One patient presenting deep and severe diaphragmatic endometriosis.

Intervention

Laparoscopic cure of diaphragmatic endometriosis.

Measurements and Main Results

Throughout this video, which was approved by the institutional board review, we demonstrate safe and complete surgical treatment of a patient suffering severe pelvic and diaphragmatic endometriosis. The patient complained of menstrual dyspnea and shoulder pain persisting despite hormonal treatment, associated with persistent dyspareunia and pelvic pain despite a previous laparoscopic surgery. Patient positioning and anesthesia were adapted to the special requirements of the surgical technique and the expected risks. The operation consisted of the exposure of the right diaphragm by mobilization of the liver, CO2 laser vaporization of left and right diaphragmatic lesions, nerve-sparing excision of infiltrating nodules, and pleural exploration. Finally, we performed an excision of pelvic endometriosis. Participation of 3 surgical teams to this procedure allowed a safe and complete laparoscopic treatment with resolution of pain symptoms at a 1- and 3-month follow-up.

Conclusion

Laparoscopic treatment allows a safe and complete treatment of diaphragmatic endometriosis.  相似文献   

14.

Study Objective

To evaluate the safety and effectiveness of the AEGEA Vapor System (Aegea Medical System, Menlo Park, CA) for the treatment of heavy menstrual bleeding (HMB).

Design

A prospective, multicenter, single-arm, open-label, clinical trial. Follow-up assessments were conducted at 24 hours; 2 weeks; and 3, 6, and 12 months after the endometrial ablation procedure (Canadian Task Force Classification II-1).

Setting

A private practice and outpatient and hospital settings at 15 sites in the United States, Canada, Mexico, and the Netherlands.

Patients

One hundred fifty-five premenopausal women aged 30 to 50years with HMB as determined by a pictorial blood loss assessment score ≥150. Preoperative evaluation included ultrasound, sonohysterography or hysteroscopy, and endometrial biopsy. Screening inclusion allowed treatment of up to 12-cm uterine sound lengths and nonobstructing myomata.

Interventions

Endometrial ablation (120-second treatment time) was performed under varying anesthesia regimens using the vapor system from September 2014 to May 2015.

Measurements and Main Results

The primary effectiveness end point was the reduction of menstrual blood loss to a pictorial blood loss assessment score ≤75. Success was judged based on the Food and Drug Administration's objective performance criteria, derived from the success rates of the first 5 global endometrial ablation pivotal clinical trials. The secondary effectiveness end points included quality of life and patient satisfaction as assessed using the Menorrhagia Impact Questionnaire and the Aberdeen Menorrhagia Severity Score as well as the need for surgical or medical intervention to treat abnormal bleeding at any time within the first 12 months after treatment. All adverse events, including device- and procedure-related events, were recorded. At 12 months, the primary effectiveness end point was achieved in 78.7% of subjects exceeding the OPC (p?=?.0004); 90.8% of subjects were satisfied or very satisfied with the treatment. Ninety-nine percent of subjects showed improvement in quality of life scores with an average decrease in the Menorrhagia Impact Questionnaire score by 8.1, 72% had less dysmenorrhea, and 85% of women whose sex lives were affected by their menses reported improvement in their sex lives. There were no reported serious adverse device effects or any reported serious adverse events that were procedure related.

Conclusion

The AEGEA Vapor System is a safe, effective, and minimally invasive option for performing in-office endometrial ablation under minimal anesthesia for the purpose of treating women who suffer from HMB.  相似文献   

15.

Objective

To review the evidence and provide an opinion as to whether universal cervical length screening to prevent preterm birth should be adopted across Canada.

Outcomes

Outcomes evaluated include prevention of preterm birth.

Evidence

Literature searches using Knowledge Finder, Medline and Cochrane databases were searched for articles published up to April 2018 on cervical length screening for prevention of preterm birth.

Values

The evidence obtained was reviewed and evaluated by the Diagnostic Imaging Committee of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

Benefits, Harms, and Costs

The prevention of preterm birth in a cost-effective manner is of significant importance to the health of mothers and their families. This committee opinion will summarize the current evidence for universal cervical length screening to prevent preterm birth in Canada, determine whether it meets the Junger and Wilson criteria for screening tests, and make recommendations as to its use in Canada.

Validation

These guidelines have been reviewed and approved by the Diagnostic Imaging Committee of the SOGC and The Society of Obstetricians and Gynaecologists of Canada (SOGC).

Sponsors

The Society of Obstetricians and Gynaecologists of Canada (SOGC).  相似文献   

16.

Study Objective

To evaluate serial generation of microparticles (MPs) after laparoscopic stripping or CO2 laser vaporization in the surgical treatment of patients with ovarian endometrioma (OE).

Design

A prospective, randomized, blinded, pilot study (Canadian Task Force classification I).

Setting

Tertiary care university hospital from December 2014 to July 2016.

Patients

Thirty women with unilateral OE undergoing laparoscopic surgery.

Intervention

Patients were randomly selected to undergo either CO2 laser vaporization (L group) or laparoscopic stripping (S group) of OE.

Measurements and Main Results

Blood samples were collected before surgery and at 2 hours, 24 hours, 1 month, and 3 months after surgery. An MP generation curve after OE surgery was created. MP generation was greater in the S group than in the L group at all time points evaluated. The MP generation curve showed a significantly higher area under the curve after excisional surgery (p <.05).

Conclusion

The higher MP levels in the S group suggest an increased inflammation and procoagulant response after this procedure.  相似文献   

17.

Study Objective

To compare fetal, maternal, and operative outcomes of laparoscopic surgery versus laparotomy for major benign diseases including appendicitis, cholecystitis, adnexal masses, and uterine myoma during pregnancy.

Design

Retrospective cohort study (Canadian Task Force classification II-2).

Setting

The Diagnosis Procedure Combination database, a national inpatient database for acute care inpatients in Japan.

Patients

Eligible patients (n?=?6018) underwent abdominal surgery (4047 laparotomy and 1971 laparoscopy patients) from July 2010 through March 2016.

Interventions

The 2 groups were compared using propensity score matching analysis.

Measurements and Main Results

The primary outcome was fetal adverse events, including abortion or stillbirth within 7 days after surgery and premature delivery during hospitalization. Secondary outcomes were operative time, blood transfusion, and length of hospital stay after surgery. Propensity score matching created 740 pairs. Significant difference was observed in the primary outcome between propensity score–matched patients in the laparotomy versus laparoscopy group (1.8% vs .41%, respectively; risk difference, ?1.4%; 95% confidence interval, ?2.4 to ?.30; p?=?.01). Compared with the laparotomy group, the laparoscopy group had a significantly lower incidence of blood transfusion (2.3% vs .41%, p = .002), shorter operative time (115 vs 95 minutes, p <.001), and shorter hospital stay (9.2 vs 5.9 days, p <.001).

Conclusion

Our current study using propensity score matching suggests the advantages of laparoscopic surgery for benign diseases compared with laparotomy because laparoscopic surgery had advantages in short-term fetal adverse events, incidence of blood transfusion, operative time, and hospital stay.  相似文献   

18.

Study Objective

To evaluate the feasibility of an en-bloc salpingectomy at the time of vaginal hysterectomy for removal of Essure inserts.

Design

Prospective observational study (Canadian Task Force classification II-1).

Setting

Monocenter study at the Conception University Hospital Center, Marseille, France.

Patients

Women seeking removal of the Essure device and candidate for vaginal hysterectomy from January 1, 2017 to January 31, 2018.

Interventions

Patient underwent a total hysterectomy and bilateral salpingectomy by the vaginal route (VH-S) with en-bloc removal of each hemiuterus with the ipsilateral fallopian tube, thereby allowing for removal of the Essure inserts without fragmentation.

Measurements and Main Results

Twenty-six VH-S were performed. There was no converted case to laparoscopy or laparotomy because of issues regarding feasibility or complications. Removal of each hemiuterus with the ipsilateral tube as a single unit was feasible in all cases. There was 1 Clavien-Dindo grade 1 perioperative complication: a bladder injury that required 10days of urinary catheterization. There were 2 grade 2 postoperative complications: 1 case of metrorrhagia of a granuloma on the vaginal fundus that was treated with silver nitrate and 1 case of acute urinary retention that required urinary catheterization for 24hours.

Conclusion

Performing a VH-S with en-bloc removal of the hemiuterus with the ipsilateral tube without fragmentation orsectioning of the Essure inserts appears to be feasible. The vaginal route can hence be an approach for women who undergo hysterectomy during Essure insert surgery removal.  相似文献   

19.

Study Objective

We sought to estimate the impact of sentinel nodes in gynecologic oncology on fellowship training and discuss potential solutions.

Design

Retrospective multi-institution cohort (Canadian Task Force classification II-2).

Setting

Three tertiary cancer referral cancer centers.

Patients

Patients with endometrial and vulvar cancer undergoing lymph node evaluation.

Interventions

Patient history and fellow case volumes were evaluated retrospectively for type of lymph node assessment.

Measurements and Main Results

Minimally invasive endometrial cancer and vulvar cancer fellow case volumes in 3 large institutions were reviewed and average annual volumes calculated for each clinical gynecologic oncology fellow. For vulvar cancer, probabilities of sentinel lymph node mapping and laterality of lesions were estimated from the literature. For endometrial cancer, estimates of lymphadenectomy rates were determined using probabilities calculated from our historic database and from review of the literature. Modeling the approaches to lymphadenectomy in endometrial cancer (full, selective, and sentinel), 100% versus 68% versus 24%, respectively, of patients would require complete pelvic lymphadenectomy and 100% versus 34% versus 12% would require para-aortic lymphadenectomy. In vulvar cancer, rates of inguinal femoral lymphadenectomy are expected to drop from 81% of unilateral groins to only 12% of groins.

Conclusions

Sentinel lymph node biopsy for endometrial and vulvar cancer will play an increasing role in practice, and coincident with this will be a dramatic decrease in pelvic, para-aortic, and inguinal femoral lymphadenectomies. The declining numbers will require new strategies to maintain competency in our specialty. New approaches to surgical training and continued medical education will be necessary to ensure adequate training for fellows and young faculty across gynecologic surgery.  相似文献   

20.

Study Objective

To evaluate safety and effectiveness of the combination of hysteroscopic endometrial focal resection with levonorgestrel-releasing intrauterine device (LNG-IUD) for International Federation of Gynecology and Obstetrics stage IA G1 early endometrial cancer (EEC) and atypical endometrial hyperplasia (AEH) in young women to preserve their fertility.

Design

Retrospective case series (Canadian Task Force classification II-3).

Setting

University Federico II, Naples, Italy.

Patients

The medical records of 69 consecutive patients treated from 2007 to 2017 with diagnosis of EEC (n?=?14) or AEH (n?=?55) meeting inclusion criteria were reviewed.

Interventions

Patients with focal EEC were treated by hysteroscopic resection of the lesion according to Mazzon's technique; patients with AEH were treated by superficial endometrial resection, preserving the basal layer of the endometrium. An LNG-IUD was inserted in all patients after surgery. Patients were followed for 24 months with serial hysteroscopic biopsies.

Measurements and Main Results

Rates of response, live birth, and recurrence were assessed. Of the 14 patients with EEC, 11 (78.6%) achieved a complete response, 2 (18.2%) of whom had subsequent relapse, 1 (7.1%) showed partial response, whereas 2 (14.3%) were nonresponders (1 stable disease and 1 progression). Of the 55 patients with AEH, 51 (92.7%) achieved a complete response, 2 (3.9%) of whom had subsequent relapse, 3 (5.5%) showed partial response, whereas only 1 (1.8%) was nonresponder with stable disease. Among 25 patients who had removed the LNG-IUD, 10 (40%) gave birth after natural conception in the last 12 months of follow-up.

Conclusion

The combination of hysteroscopic resection with an LNG-IUD as fertility-sparing treatment of EEC and AEH showed similar response and live birth rates compared with those reported in literature for progestins alone, but with considerably lower relapse rate. We advocate the use of this combined approach as an alternative fertility-sparing option in patients with ECC and AEH.  相似文献   

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