Incidence of trocar site herniation following robotic gynecologic surgery

Objective

Trocar site herniation is a recognized complication of minimally invasive surgery, but published data on trocar site herniation after robotic surgery are scarce. We sought to determine the incidence of trocar site herniation in women undergoing robotic surgery for gynecologic disease.

Methods

A retrospective review of robotic surgeries performed from January 1, 2006, through December 31, 2012, was conducted. Postoperative trocar site herniations were identified, along with time to presentation, location of herniation, and management. Patients were excluded if surgery was converted to laparotomy or traditional laparoscopy. The Wilcoxon rank-sum test was used to compare patients with and without herniation with respect to continuous variables, and Fisher's exact test was used to compare these 2 groups with respect to categorical variables.

Results

The study included 500 patients, 3 of whom experienced herniation at a single trocar site. The patients with and without herniation did not differ with respect to age, body mass index, smoking status, medical comorbidities, operating time, or estimated blood loss. All 3 herniations occurred at 12-mm trocar sites. Two herniations occurred at assistant port sites, and 1 occurred at the umbilical camera port site. The median time to herniation was 21 days (range, 8–38 days). One patient required immediate surgical intervention; the other 2 patients had conservative management.

Conclusions

Trocar site herniation is a rare complication following robotic surgery. The most important risk factor for trocar site herniation appears to be larger trocar size, as all herniations occurred at 12-mm port sites.     

Robotic single-site pelvic lymphadenectomy

Objective

: To examine the feasibility of performing pelvic lymphadenectomy with robotic single site approach. Recent papers described the feasibility of robotic-single site hysterectomy [,  and ] for benign and malign pathologies but only with the development of new single site 5 mm instruments as the bipolar forceps, robotic single site platform can be safely utilized also for lymphadenectomy.

Methods

: A 65 year-old, multiparous patient with a body mass index of 22.5 and diagnosed with well differentiated adenocarcinoma of the endometrium underwent a robotic single-site peritoneal washing, total hysterectomy, bilateral adnexectomy and pelvic lymphadenectomy. The procedure was performed using the da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA) through a single 2,5 cm umbilical incision, with a multi-channel system and two single site robotic 5 mm instruments. A 3-dimensional, HD 8.5 mm endoscope and a 5 mm accessory instrument were also utilized.

Results

: Type I lymphonodes dissection for external iliac and obturator regions was performed [4]. Total operative time was 210 min; incision, trocar placement and docking time occurring in 12 min. Total console time was 183 min, estimated blood loss was 50 ml, no intra-operative or post-operative complications occurred. Hospital discharge occurred on post operative day 2 and total number of lymphnodes removed was 33. Difficulties in term of instrument's clashing and awkward motions have been encountered.

Conclusion

: Robotic single-site pelvic lymphadenectomy using bipolar forceps and monopolar hook is feasible. New developments are needed to improve surgical ergonomics and additional studies should be performed to explore possible benefits of this procedure.     

Predictive factors of recurrence following adjuvant vaginal cuff brachytherapy alone for stage I endometrial cancer

Purpose

The purpose of this study is to identify risk factors for recurrence in a cohort of stage I endometrial cancer patients treated with vaginal cuff brachytherapy at a single academic institution.

Methods and materials

From 1989 to 2011, 424 patients with stage I endometrial cancer underwent total hysterectomy and bilateral salpingo-oophorectomy, with or without lymphadenectomy (LND), followed by high-dose-rate vaginal cuff brachytherapy (VCB) to patients felt to be high or intermediate risk FIGO stage IA and IB disease. Covariates included: 2009 FIGO stage, age, grade, histology, presence of lymphovascular space invasion, LND, and receipt of chemotherapy.

Results

With a median follow-up of 3.7 years, the 5 and 10-year disease free survival were 98.4% and 95.9%, respectively. A total of 30 patients developed recurrence, with the predominant pattern of isolated distant recurrence (57.0%). On multivariate analysis, grade 3 (p = 0.039) and LND (p = 0.048) independently predicted of increased recurrence risk. χ² analysis suggested that higher-risk patients were selected for LND, with significant differences in age, stage, and grade noted between cohorts. Distant metastatic rate was significantly higher for patients who qualified for GOG 0249 at 23.1% (95% CI 10.7–35.5%) compared to those who did not at 6.8% (95% CI 1.8–11.8%, p < 0.001).

Conclusion

Overall disease-free survival for this cohort of patients was > 95% at 10 years. Univariate analysis confirmed previously identified risk factors as predictors for recurrence. Multivariate analysis found that grade 3 and LND correlated with risk for recurrence. Of those that did recur, the initial site of relapse included distant metastasis in most cases.     

Single port gasless laparoscopy-assisted mini-laparotomic ovarian resection (SP-GLAMOR): Reasonable treatment for large cystic ovarian tumors with suspicion of malignancy

Objectives

Recent improvements to both optical and laparoscopic instruments have enabled the use of laparoscopic surgery for gynecological procedures as opposed to open abdominal surgery. However, laparoscopic surgery has several potential limitations, including tumor rupture, spillage, incomplete resection of lesions, and trocar insertion site metastasis in surgeries involving large ovarian masses with suspicion of malignancy.Here, we report a case series of large ovarian cystic tumors that were successfully removed by single port gasless laparoscopy assisted mini-laparotomic ovarian resection (SP-GLAMOR), the limitations of which were successfully addressed.

Methods

We reviewed the medical records of 31 women who visited St. Vincent Hospital from April 2006 until April 2011 and were diagnosed with a large cystic ovarian mass with suspicion of malignancy based on imaging studies and tumor markers. After diagnosis, all of the women underwent SP-GLAMOR.

Results

The median maximal diameter of cysts, median incision size, median surgical duration and median volume of blood loss were 20 cm (range 10.7–45 cm), 3 cm (range 2.5–4 cm), 100 min (range 45–270 min) and 100 mL (range 30–500 mL), respectively. Four cases were diagnosed as malignant disease on frozen sections obtained during the operation, and were converted to open abdominal surgery. No major complications were observed. The four patients diagnosed with malignant disease also underwent adjuvant chemotherapy. All patients were followed up to the time of this report.

Conclusions

The results of our study suggest that the SP-GLAMOR procedure is feasible, with potentially decreased perioperative morbidity and blood loss, faster recovery and better cosmetic results.     

Risk-scoring system for the individualized prediction of lymphatic dissemination in patients with endometrioid endometrial cancer

Objective

To develop a risk-scoring system (RSS) for the prediction of lymphatic dissemination after hysterectomy in endometrioid endometrial carcinoma (EC).

Methods

Patients who underwent surgery from 1/1/1999-12/31/2008 were evaluated. Patients with non-endometrioid histology, stage IV with macroscopic extrauterine disease, or receiving adjuvant therapy (excluding brachytherapy) without pelvic and/or paraaortic (P/PA) lymphadenectomy (LND) were excluded. Lymph node dissemination was defined as nodal metastasis when P/PA LND was performed or P/PA lymph node recurrence after negative LND or when LND was not performed. Logistic regression analysis was used to identify predictors for lymphatic dissemination and develop a RSS and nomogram. The RSS was assessed for calibration and verified for discrimination.

Results

Overall, 883 patients were assessed of which 521 (59.0%) underwent P/PA LND and 57 (10.9%) had positive lymph nodes. Of patients who did not undergo P/PA LND (N = 362) or had negative nodes (N = 464), 10 (1.2%) patients had P/PA lymph node recurrence. Myometrial invasion, tumor diameter (TD), FIGO grade, cervical stromal invasion and lymphovascular space invasion were significant on univariable analysis. All preceding variables were included in a multivariable logistic model. A parsimonious model and an alternative full model not including TD were considered. The full model with TD (illustrated in nomogram) had the highest predictive ability (concordance index 0.88).

Conclusion

Our RSS allows accurate quantification of the probability of lymphatic dissemination and can be used as an adjunct to clinical decision-making after hysterectomy in the absence of staging. TD is an important component of the RSS and should be routinely assessed.     

A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial

Objective

Laparoscopic entry techniques vary and still remain debated. We conducted a randomized control trial to compare three entry techniques.Study design: Women aged 18–70 years, nominated for laparoscopic surgery at University of Rome Campus Bio-Medico, were randomized into three different groups: Veress needle (VER), Direct trocar insertion (DIR) and Open technique (OP). For each group, minor complications (extra-peritoneal insufflation, trocar site bleeding, omental injury and surgical site infection), failed entry and time of entry of the main trocar were evaluated. Major complications were also considered. Between-group comparisons were performed using chi-square test. Significance P value was <0.05.

Results

A series of 595 consecutive procedures were included: 193 in the VER group, 187 in the DIR group and 215 in the OP group. Minor complications occurred in 36 cases: extraperitoneal insufflation (n = 6) in the VER group only, site bleeding (n = 2 in the VER group, n = 2 in the DIR group and n = 1 in the OP group), site infection (n = 5 in the VER and n = 6 in OP group), and omental injury (n = 6 in the VER group and n = 3 in the DIR group). Failed entry occurred in 4 cases of the VER group and 1 case of the DIR group. Mean time of entry was 212.4, 71.4 and 161.7 s for the VER, DIR and OP groups respectively. Among major complications, one bowel injury resulted following the Veress technique.

Conclusions

In our series, DIR and OP entry presented a lower risk of minor complications compared with VER. In addition, time of entry was shorter in DIR than with OP entry.     

A novel modification of conventional laparoscopic myomectomy using manual assistance for multiple uterine myomas

Objectives

To evaluate the efficacy and feasibility of finger-assisted laparoscopic myomectomy for multiple myomas.

Study design

A total of 565 patients with symptomatic myomas underwent finger-assisted laparoscopic myomectomy between January 2006 and March 2011 to remove multiple myomas at our center. Laparoscopic myomectomy technique was modified, and involved the insertion of two fingers into the vagina to elevate the uterus, while one or two fingers of the other hand were inserted into the abdomen through a suprapubic 15-mm trocar port for palpation of small myomas, which did not distort the uterine contour.

Results

The mean (SD; range) patient age was 38.26 years (5.84; 25–48 years). The diameter of the largest myoma in each case was 6.13 cm (1.21; 4–15 cm). The total number of myomas enucleated in the initial enucleation was 2228. There were 597 additional myomas enucleated with finger-assisted guidance. The mean diameter of the additionally enucleated myomas was 1.1 cm (range, 0.2–2.5 cm), which was significantly smaller than those of the initially enucleated myomas (p = 0.002). The mean operative time was 97.1 min (30.2; 35–180 min). The decrease in postoperative hemoglobin concentration was 1.6 g/dL (0.7; 0.4–3.2 g/dL). During the operation, no patients required a blood transfusion. Six patients developed postoperative fever. There was no occurrence of bowel or urinary tract injury. The mean postoperative hospital stay was 3.2 days (0.9; 2–6 d). All procedures were successfully completed without the need for laparotomy.

Conclusions

Finger-assisted laparoscopic myomectomy is a feasible and safe approach in the surgical treatment of multiple myomas.     

Laparoscopic radiofrequency volumetric thermal ablation of fibroids versus laparoscopic myomectomy

Objective

To compare the mean hospital discharge times and perioperative outcomes for radiofrequency volumetric thermal ablation (RFVTA) of fibroids and laparoscopic myomectomy (LM).

Methods

The present postmarket, randomized, prospective, single-center, longitudinal, comparative study, conducted in Tübingen, Germany, evaluated the outcomes of RFVTA and the current standard of care (LM) for symptomatic uterine fibroids in women who desired uterine conservation. The surgeons were blinded to the treatment until all fibroids had been mapped by laparoscopic ultrasound.

Results

The mean hospitalization times were 10.0 ± 5.5 (median 7.8 [range 4.2–25.5]) hours for the RFVTA group and 29.9 ± 14.2 (median 22.6 [range 16.1–68.1]) hours for the LM group (P < 0.001, Wilcoxon test). Intraoperative blood loss was 16 ± 9 (median 20 [range: 0–30]) mL for the RFVTA procedures and 51 ± 57 (median 35 [range 10–300]) mL for the LM procedures. The percentage of fibroids imaged by laparoscopic ultrasound that were treated/excised was 98.6% for RFVTA and 80.3% for LM. Two complications were reported: vertigo (n = 1; RFVTA) and port site hematoma (n = 1; LM).

Conclusion

Radiofrequency volumetric thermal ablation resulted in the treatment of more fibroids, a significantly shorter hospital stay, and less intraoperative blood loss than laparoscopic myomectomy.ClinicalTrials.gov:NCT01750008     

How much is another randomized trial of lymph node dissection in endometrial cancer worth? A value of information analysis

Objective

This study aimed to assess the value of a randomized controlled trial (RCT) of lymph node dissection (LND) at the time of hysterectomy for high-risk subsets of women with endometrial cancer.

Methods

A modified Markov decision model compared routine LND to no LND for women with grade 3 or grades 2–3 endometrial cancer. Inputs were modeled as distributions for Monte Carlo probabilistic sensitivity and value of information (VOI) analyses. Survival without LND was modeled from Surveillance, Epidemiology and End Results program data. A hazard ratio (HR) describing survival in the high-risk group undergoing LND (estimate 0.9, 95% CI 0.6–1.1), adverse event rates, probability and type of adjuvant therapy were modeled from published RCTs. Costs were obtained from national reimbursement data. VOI estimated the value of reducing uncertainty regarding the survival benefit of LND.

Results

For grade 3, LND had an incremental cost-effectiveness ratio of $40,183/quality-adjusted life year (QALY) compared to no LND. Acceptability curves revealed considerable uncertainty, with an expected value of perfect information of $4,195 per patient at societal willingness to pay of $50,000/QALY. The estimated value of partial perfect information regarding the HR was $3,702 per patient. Assuming 8,000 individuals annually with grade 3 endometrial cancer in the US, the upper limit of VOI for the HR was $29.6 million annually. For grades 2 and 3 combined, analysis revealed a much lower likelihood of finding LND cost-effective.

Conclusion

A clinical trial defining the survival effect of LND in women with grade 3 endometrial cancer is a worthwhile use of resources.     

Successful incorporation of robotic surgery into gynecologic oncology fellowship training

Background

The increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons.

Methods

A prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared.

Results

Times were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p < 0.001), BSO 7% to 75% (p = 0.005), right PLND 4% to 44% (p < 0.001), left PLND 0% to 56% (p < 0.001), and VCC 59% to 82% (p = 0.024). Console times (min) were similar for SH (60 vs. 63, p = 0.73), BSO (48 vs. 43, p = 0.55), and VCC (20 vs. 22, p = 0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p = 0.04, left 23 vs. 27, p = 0.02). Nodal counts were not significantly different (right 7 vs. 8, p = 0.17 or left 7 vs. 7, p = 0.87).

Conclusions

Robotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons.     

Endometrial echo complex thickness in postmenopausal endometrial cancer

Objective

To determine the preoperative pelvic ultrasonographic characteristics of postmenopausal women diagnosed with endometrial cancer (EC) at our institution.

Methods

Postmenopausal women with EC who underwent preoperative transvaginal pelvic ultrasound from 1999–2009 were identified from our institutional database. The histologic diagnosis was based on pathologic findings in the hysterectomy specimen. Endometrial echo complex (EEC) thickness was abstracted from ultrasound reports. In all instances, ultrasound preceded the biopsy by a maximum of 3 months. Means with standard deviations were calculated for all categorical data. Differences between type 1 and type 2 ECs were determined using Mann–Whitney U tests and Chi squared/Fisher's exact tests, as appropriate. A p-value of < 0.05 was considered statistically significant.

Results

Among 250 patients with postmenopausal EC, 156 had type 1 EC while 94 had type 2 EC. Thirty-six percent of the cohort had an EEC ≤ 4 mm, including 37% of patients with type 1 EC and 34% of patients with type 2 EC (p = 0.63). There were no significant differences between type 1 and type 2 ECs in any demographic characteristic, other than likelihood of postmenopausal bleeding.

Conclusions

Current expert opinion recommends no further diagnostic procedure in a woman with postmenopausal bleeding and an EEC ≤ 4 mm. These results indicate that a sizable proportion of women with EC have EECs ≤ 4 mm during their initial evaluation. An EEC ≤ 4 mm does not completely rule out endometrial cancer and cannot supplant histologic evaluation.     

Minimal cold knife conization height for high-grade cervical squamous intraepithelial lesion treatment

Objectives

To assess the relationship between cold-knife conization specimen height, cervical intraepithelial neoplasia (CIN II/III) size and endocervical margin involvement by CIN II/II.

Study design

A cross-sectional study was performed. Cold knife cone specimens with a diagnosis of CIN II/III were selected. Epidemiological data and pathology reports were obtained through a chart review. All samples from each cone specimen showing CIN II/III and the squamocolumnar junction were selected. Cone height (mean ± standard deviation), intraepithelial lesion size, and size of endocervical surgical margins were measured.

Results

Four hundred and forty-seven samples were analyzed from 97 cone specimens. Section size ranged from 3.4 to 29.7 mm, tumor size from 0.3 to 17.5 mm, and tumor distance from the endocervical margin, from 0.0 to 22.0 mm. Age and parity were similar in the positive vs. negative margin groups (37.6 ± 10.0 years vs. 37.7 ± 11.9 years respectively, p = 0.952, and 2.2 ± 1.7 births vs. 2.6 ± 1.9 births respectively, p = 0.804), whereas cone height (22.4 ± 6.9 mm vs. 17.1 ± 5.6 mm, p = 0.013) and tumor size (6.12 ± 3.25 mm vs. 10.6 ± 4.45 mm, p < 0.001) were significantly different in negative vs. positive margin groups respectively.

Conclusions

Use of cone height to identify the likelihood of negative margins enables better estimation of the risk–benefit ratio of greater risks of bleeding, stenosis, and obstetric complications (cervical incompetence) versus greater risks of residual and recurrent disease.     

Five minutes of extended assisted ventilation with an open umbilical trocar valve significantly reduces postoperative abdominal and shoulder pain in patients undergoing laparoscopic hysterectomy

Objective

Residual carbon dioxide contributes substantially to pain following laparoscopic surgery. We evaluated the effects of extended assisted ventilation (EAV) with an open umbilical trocar valve for five additional minutes following laparoscopic hysterectomy on postoperative abdominal and shoulder pain levels. We also examined whether a combination of EAV and trocar site infiltration (TSI) with lidocaine could further reduce postoperative pain levels.

Study design

In this prospective randomized trial, the effectiveness of EAV and EAV/TSI in reducing postoperative abdominal and shoulder pain were compared with that of a standard treatment regime in 283 patients undergoing laparoscopic hysterectomy (total or supracervical). Pain levels were evaluated by self-assessment questionnaire using a numeric rating scale (NRS) and by postoperative piritramid requirement, a surrogate parameter for postoperative analgesic drug requirement. The incidence of nausea and vomiting was also assessed.

Results

Compared with the standard treatment regime, EAV reduced abdominal pain levels significantly at 3 h (NRS score, 3.21 ± 1.56 vs. 4.73 ± 1.71) and 24 h (3.82 ± 1.49 vs. 4.95 ± 1.68) postoperatively (both p < 0.01). EAV also significantly reduced shoulder pain at 24 h (EAV vs. control, 4.28 ± 1.51 vs. 5.14 ± 1.49) and 48 h (3.64 ± 1.66 vs. 4.22 ± 1.43) postoperatively (both p < 0.01). Patients in the EAV group had significantly lower piritramid requirements compared with standard treatment at 3 h post-operatively (4.28 ± 2.09 mg vs. 6.31 ± 2.21 mg; p < 0.01). EAV/TSI showed no additional benefit in terms of pain reduction compared with EAV alone. Incidences of postoperative nausea and vomiting were not reduced by EAV or EAV/TSI.

Conclusion

EAV was found to be an effective and safe method to reduce postoperative pain levels in patients undergoing laparoscopic hysterectomy.     

Valores de referencia de la translucencia intracraneal

Objective

To determine reference ranges for intracranial translucency (ICT) in our population.

Material and methods

To assess the relationship between crown-rump length (CRL) and ICT, we performed a linear regression analysis of 471 singleton pregnancies without associated anomalies.

Results

ICT was measured in 98.9%. ICT had a normal distribution with a standard deviation of 0.4139. The mean was 2.0502 mm (0,9-3.6 mm), and the 5% and 95% percentiles corresponded to 1.4 mm and 2.7 mm. ICT had a linear correlation with CRL (ICT: 0.0125 + 1.2628 * CRL; R2: 0,055 P <.0001). The estimated ICT was calculated for the 5th percentile (1.2628 + 0.0125 * LCC) − 0.6505. The intraclass correlation coefficient was 0,816 (0606-0921 CI: 95%).

Conclusions

Measurement of the fourth ventricle during first trimester ultrasound examination is feasible and is simple to perform. An extended neurological evaluation should be carried out if measurements are above the 95th percentile or below the 9th percentile.     

A phase II trial of a surgical protocol to decrease the incidence of wound complications in obese gynecologic oncology patients

Objectives

Obese women have a high incidence of wound separation after gynecologic surgery. We explored the effect of a prospective care pathway on the incidence of wound complications.

Methods

Women with a body mass index (BMI) ≥ 30 kg/m² undergoing a gynecologic procedure by a gynecologic oncologist via a vertical abdominal incision were eligible. The surgical protocol required: skin and subcutaneous tissues to be incised using a scalpel or cutting electrocautery, fascial closure using #1 polydioxanone suture, placement of a 7 mm Jackson-Pratt drain below Camper's fascia, closure of Camper's fascia with 3-0 plain catgut suture and skin closure with staples.Wound complication was defined as the presence of either a wound infection or any separation. Demographic and perioperative data were analyzed using contingency tables. Univariable and multivariable regression models were used to identify predictors of wound complications. Patients were compared using a multivariable model to a historical group of obese patients to assess the efficacy of the care pathway.

Results

105 women were enrolled with a median BMI of 38.1. Overall, 39 (37%) had a wound complication. Women with a BMI of 30–39.9 kg/m² had a significantly lower risk of wound complication as compared to those with a BMI > 40 kg/m² (23% vs 59%, p < 0.001). After controlling for factors associated with wound complications the prospective care pathway was associated with a significantly decreased wound complication rate in women with BMI < 40 kg/m² (OR 0.40, 95% C.I.: 0.18–0.89).

Conclusion

This surgical protocol leads to a decreased rate of wound complications among women with a BMI of 30–39.9 kg/m².     

Feasibility of a new two-step procedure for office hysteroscopic resection of submucous myomas: results of a pilot study

Objective

To assess the feasibility of a new two-step technique for office hysteroscopic resection of submucous myomas.

Study design

Between January 2010 and December 2011, all consecutive patients of reproductive age with symptomatic lesions sonographically diagnosed as single mainly intracavitary (G1 or G2) myoma ≤4.0 cm were eligible to participate in a prospective study. They underwent a two-step hysteroscopic procedure, which included preparation of partially intramural myomas with incision of the endometrial mucosa and the pseudocapsule covering the myoma in the first step, and excision of the myoma by means of diode laser four weeks later. All procedures were performed on an outpatient basis and without anesthesia.

Results

A total of 43 women (mean age 36.7 years) were included. The two-step myomectomy technique was successfully performed in 34 (79.1%) patients. All myomas ≤18 mm were successfully enucleated as compared with 85% of 19–30 mm, and 0% of ≥30 mm (P < 0.001). Also, myomas located in the anterior/posterior walls and those located in the fundus/lateral walls were enucleated in 87.9% and 50% of cases, respectively (P = 0.020). Success of surgery was not influenced by the initial type of myoma.

Conclusion

The new two-step hysteroscopic myomectomy carried out as an outpatient procedure and without anesthesia is feasible for the excision of symptomatic submucous fibroids.     

Hydrosonographic assessment of the effects of 2 different suturing techniques on healing of the uterine scar after cesarean delivery

Objective

To compare the effects of 2 suturing techniques (single versus double layer) on healing of the uterine scar after a cesarean delivery.

Methods

In the present randomized, prospective study, 36 women with a term pregnancy who had an elective cesarean delivery were randomly assigned to closure of the uterine incision with a single-layer locked suture or with a double-layer locked/unlocked suture. Six months after the operation, the integrity of the cesarean scar at the uterine incision site was assessed by hydrosonography. The healing ratio and the thickness of the residual myometrium covering the defect were calculated as markers of uterine scar healing.

Results

There were no significant differences between the groups in terms of estimated blood loss, operation time, or additional hemostatic suture. However, the mean thickness of the residual myometrium covering the defect was 9.95 ± 1.94 mm after a double-layer closure and 7.53 ± 2.54 mm after a single-layer closure (P = 0.005). The mean healing ratio was significantly higher after a double-layer closure (0.83 ± 0.10) than after a single-layer closure (0.67 ± 0.15; P = 0.004).

Conclusion

A double-layer locked/unlocked closure of the uterine incision at cesarean delivery decreases the risk of poor uterine scar healing.     

Enfermedad renal: urinoma. A propósito de un caso

Objective

Fetal ultrasound enables us to diagnose and follow the progress of obstructive uropathies including the occurrence of fetal urinomas.

Subject and methods

We report a case of hydronephrosis diagnosed in the second trimester with evolution urinoma.

Results

Patient at 21.4 weeks’ gestation showed in fetal ultrasound a left hydronephrosis grade II. At 27.5w showed a left hydronephrosis with a retroperitoneal fluid collection perirenal 40 × 50 × 30 mm and distortion of the kidney morphology compatible with urinoma.

Conclusions

the prenatal occurrence of an urinoma is often associated with the postnatal absence of function of the involved kidney.     

The value of serial cervical length measurements for the prediction of threatened preterm labour

Objectives

To assess the predictive performance of cervical length measurement at presentation and 24 h later in women with symptoms of preterm labour.

Study design

Cervical length was measured transvaginally at presentation and 24 hours later in 122 women presenting with threatened preterm labour between 23 and 33 + 6 gestational weeks.

Results

Six women delivered within 1 week of presentation. The sensitivity and specificity of a cervical length <15 mm at admission for delivery within one week was 83.3 and 95.8%, respectively. A reduction of >20% in cervical length 24 h after admission predicted 50% of preterm deliveries within 1 week, with a specificity of 92.7%; in combination with cervical length at presentation it did not improve the prediction. The same was observed for birth before 32 weeks (N = 9) and birth before 35 weeks (N = 15).

Conclusions

Women with threatened preterm labour and a cervical length of <15 mm at presentation are at high risk of delivering preterm. Cervical change in the following 24 hours does not seem to improve the prediction.     

Early versus late hCG administration to trigger ovulation in mild stimulated IUI cycles: a randomized clinical trial

Objectives

To verify non-inferiority of the clinical pregnancy rate of Early hCG administration (leading follicle sizes within 16.0–16.9 mm in diameter) compared to Late hCG administration (leading follicle sizes within 18.0–18.9 mm in diameter).

Study design

Prospective randomized trial. Six hundred and twelve infertile women candidates for intrauterine insemination (IUI) received HP-hMG 75 IU/day SC from cycle days 4 to 8 and then as per ovarian response. Ovulation was randomly triggered (hCG 5000 IU, IM) when the leading follicle diameter ranged between either 16.0 and 16.9 mm (Early hCG group, n = 227) or 18.0 and 18.9 mm (Late hCG group, n = 207) and IUI was performed approximately 36 h later.

Results

Whereas population and sperm characteristics were comparable in both groups, the number of follicles ≥14 mm in diameter (P < 0.007) and serum estradiol levels (P < 0.001) on the day of hCG were lower in the Early versus the Late hCG groups. Clinical (11.9% versus 12.1%) and ongoing (11.0% versus 8.6%) pregnancy rates per randomized women were similar in the two groups and statistical non-inferiority of clinical and ongoing pregnancy rates was demonstrated.

Conclusion

These results suggest that hCG administered when the largest follicle size reaches 16.0–16.9 mm leads to similar clinical and ongoing pregnancy rates as when it reaches 18.0–18.9 mm in IUI cycles.