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1.

Study Objective

To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy.

Design

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

Setting

A tertiary care academic medical center.

Measurements and Main Results

The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7?±?1.5 vs 38.6?±?1.6 weeks, respectively; p?=?.908) as was preterm labor (5.8% in both groups, p?=?1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25?±?0.1 and 7.26?±?0.08, respectively), and birth weight (3040?±?473?g and 3115?±?584?g, respectively). In the study group, the mean gestational age at surgery was 11.2?±?6 weeks (range, 4–34 weeks). The average operative time was 40.2?±?22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p?=?.012).

Conclusion

Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates.  相似文献   

2.

Study Objective

To compare operative outcomes of single-port laparoscopic myomectomy (SP-LM) vs conventional laparoscopic myomectomy (CLM), including subjective and objective cosmetic aspects.

Design

Prospective randomized controlled trial (Canadian Task Force classification I).

Setting

University hospital.

Patients

Women with uterine myoma scheduled for laparoscopic myomectomy.

Interventions

Sixty-six women were assigned at random to either the SP-LM or CLM group. Surgical outcomes, including patient and observer scar assessments, were evaluated between the groups according to the intention-to-treat principle.

Measurements and Main Results

There were no significant differences in demographic characteristics and properties of myomectomy between the groups. There also were no differences in surgical outcomes, such as operation time, estimated blood loss, and complications, between the 2 groups. The mean total score of the Observer Scar Assessment Scale was lower in the SP-LM group at 1 week (13.0?±?3.2 vs 18.3?±?4.8; p?<?.001) and 8 weeks (9.9?±?3.2 vs 14.3?±?3.8; p?<?.001) after discharge. Similar results were obtained for the Patient Scar Assessment Scale at 1 week (11.6?±?7.2 vs 18.5?±?12.8; p?=?.024) and 8 weeks (9.5?±?6.0 vs 18.8?±?9.1; p?<?.001) after discharge. Postoperative pain and analgesic consumption did not differ between the groups, except in patient-controlled analgesia consumption at 6 hours after operation, which was lower in the SP-LM group (12.7?±?6.3?mL vs 16.4?±?6.2?mL; p?=?.039). Operative outcomes were similar in the 2 groups.

Conclusion

SP-LM is associated with more favorable cosmetic outcomes and better patient satisfaction compared with CLM. There were no differences in operative outcomes and complications between the 2 modalities.  相似文献   

3.

Study Objective

To compare surgical experience at myomectomy between patients with myomas pretreated with ulipristal acetate versus no pretreatment.

Design

A prospective, observational, multicenter study of myomectomy procedures by any route (hysteroscopic, laparoscopic, or laparotomy) (Canadian Task Force classification II-2).

Setting

Five university-affiliated hospitals including tertiary care and community sites.

Patients

Any patient who underwent hysteroscopic, laparotomic, or laparoscopic myomectomy regardless of medical pretreatment.

Interventions

Surgeons completed a Web-based questionnaire after each myomectomy procedure. Surgeons evaluated visualization, the myoma-myometrium relationship, extrusion, fluid deficit, blood loss, and overall ease of hysteroscopic myomectomies. For laparotomic/laparoscopic myomectomies, plane delineation, myoma separation, blood loss, and overall ease were assessed. The total surgical experience score was calculated by summing the values for each subscale.

Measurements and Main Results

A total of 309 myomectomies were evaluated by 52 surgeons (response rate?=?83%) at 5 institutions. Of 140 hysteroscopic myomectomies, 84 (60%) were performed without pretreatment, 29 (21%) after ulipristal acetate pretreatment, and 27 (19%) after pretreatment with gonadotropin-releasing hormone agonist/other. Of 169 laparotomic/laparoscopic myomectomies, 104 (62%) were performed without pretreatment, 46 (27%) after ulipristal acetate, and 19 (11%) after gonadotropin-releasing hormone agonist/other. The mean surgical experience score (±standard deviation) was comparable between the no pretreatment and ulipristal acetate groups for hysteroscopic myomectomies (13.8?±?2.2 vs 13.3?±?2.2, p?=?.35) and laparotomic/laparoscopic myomectomies (12.9?±?4.1 vs 12.1?±?4.2, p?=?.30). Compared with no pretreatment, more laparotomic/laparoscopic myomectomies after ulipristal acetate pretreatment were associated with difficult delineation of surgical planes (22 [47.8%] vs 23 [22.1%], p?=?.002) and difficult myoma separation (20 [43.5%] vs 21 [20.2%], p?=?.003). More myomas were described as soft with ulipristal acetate pretreatment (14 [30.4%] vs 17 [16.4%], p?=?.049). The rates of profuse/abundant endometrium during hysteroscopy were similar between the no pretreatment (21 [25.0%]) and ulipristal acetate (7 [24.1%], p?=?.93) groups.

Conclusion

Despite differences in surgical nuances, the overall myomectomy experience was not negatively affected by ulipristal acetate pretreatment.  相似文献   

4.

Study Objective

To identify predictors of overnight admission after laparoscopic and robot-assisted hysterectomy to improve preoperative counseling and patient optimization.

Design

A single-center retrospective cohort study (Canadian Task Force classification III).

Setting

Academic university hospital.

Patients

Patients undergoing straight-stick laparoscopic and robot-assisted hysterectomy by fellowship-trained minimally invasive gynecologic surgeons for benign indications

Interventions

Straight-stick laparoscopic and robot-assisted hysterectomy.

Measurements and Main Results

Data from 396 consecutive minimally invasive hysterectomy procedures were collected for analysis. Three hundred twelve patients (79%) were discharged the same day, and 84 (21%) were admitted for at least 1 night. Data from the 2 groups were compared. Overnight stay compared with same-day discharge was associated with older age (47.3 vs 43.4 years, p?<?.001), lower preoperation hematocrit (35.8% vs 37.3%, p?=?.035), history of prior laparotomy (31% vs 14.1%, p?=?.003), prolonged operative time (190.5 vs 115.2 minutes, p?<?.001), estimated blood loss (244.6 vs 104.1?mL, p?<?.001), lysis of adhesion (27.4% vs 13.5%), and intraoperative organ injury (17% vs 3%, p?=?.005). Logistic regression analysis, adjusting for all included variables as confounders, showed that hematocrit increments of 5% were protective against any overnight stay (odds ratio, .622; p?=?.015), and a 30-minute increase in operative time increased the odds of an overnight stay by 1.6 (p?<?.001). History of a laparotomy remained a significant predictive factor for an overnight stay (odds ratio, 3.2; p?=?.006). Later surgery end time, in 60-minute increments, increased the odds of an overnight stay by 1.2 (p?<?.01).

Conclusion

Perioperative factors such as age, hematocrit, surgery time, and surgical history as well as intraoperative factors such as prolonged operative time are predictive of overnight hospital stay.  相似文献   

5.

Study Objective

Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications.

Design

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

Setting

Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites.

Patients

Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012.

Intervention

ACS-NSQIP database.

Measurements and Main Results

Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250?g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p?<?.001), urinary tract infection (5.27% vs 2.64%, p?<?.001), and operative time (124.25?±?59.29 minutes vs 88.64?±?50.9 minutes, p?<?.001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25–2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51–2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20–4.15). No differences were observed for other measures of surgical morbidity or mortality.

Conclusion

Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.  相似文献   

6.

Study Objective

To investigate and compare surgical outcomes of the 3 versus 4 robotic arm approaches for robotic surgery in patients with cervical cancer.

Design

A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2).

Setting

An academic tertiary hospital.

Patients

A total of 142 patients with stage 1A1 to IIB cervical carcinoma who underwent robotic surgery were included for analysis. The subjects were divided according to the surgical approach (i.e., the number of robotic arms), and the 2 groups were compared in terms of intraoperative data and postoperative outcomes.

Interventions

Robotic radical hysterectomy (RRH) with lymphadenectomy using 3 robotic arms (n?=?101) versus 4 robotic arms (n?=?41).

Measurements and Main Results

Perioperative surgical outcomes. The 3-arm robotic approach consisted of a camera arm, 2 robotic arms, and 1 conventional assistant port. An additional robotic arm was placed on the right side of the patient's abdomen for the 4-arm robotic approach. The mean age, body mass index, cell type, Fédération Internationale de Gynécologie et d'Obstétrique stage, and type of surgery were not significantly different between the 2 cohorts. The 3-arm approach showed favorable outcomes over the 4-arm approach in terms of postoperative pain at 6 and 24 hours (3.8?±?1.8 vs 4.5?±?1.7 and 2.8?±?1.7 vs 3.4?±?1.6, respectively; p?=?.033 and .049) and postoperative hemoglobin difference (1.8?±?0.9 vs 2.6?±?1.3 and 1.9?±?1.1 vs 2.4?±?0.9 on days 1 and 3, respectively; p?=?.002 and .004). The median length of postoperative hospital stay, total operative time, docking time, lymph node yield, and intraoperative and postoperative complication rates were comparable between the 2 cohorts.

Conclusion

Surgical outcomes and complications rates of RRH for cervical cancer using the 4-arm approach were comparable with that of the 3-arm approach with decreased early postoperative pain in the 3-arm group. Cost-benefit analysis and the impact on surgical training are needed in the future.  相似文献   

7.

Study Objective

To assess clinical pregnancy rate (CPR) and live birth rate (LBR) in the presence of non–cavity-deforming intramural myomas in single fresh blastocyst transfer cycles.

Design

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

Setting

Academic fertility center.

Patients

A total of 929 fresh single blastocyst transfer cycles were included, 94 with only non–cavity-distorting intramural myomas and 764 without myomas. Cleavage embryo transfers were excluded to reduce bias based on embryo quality.

Interventions

None.

Measurements and Main Results

CPR and LBR were assessed. There were no differences noted in gravidity, parity, or body mass index between patients with myomas and those without myomas. Women with myomas required higher doses of gonadotropins (mean, 2653?±?404?IU vs 2350?±?1368?IU; p?=?.04) than women without myomas. However, the total number of mature oocytes collected and the total number of blastocysts created were similar. CPR (47% vs 32%; p?=?.005) and LBR (37.8% vs 25.5%; p?=?.02) were lower in patients who had intramural myomas compared with those without myomas. CPR and LBR were significantly reduced in the presence of even 1 myoma (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33–0.83 and OR, 0.56; 95% CI, 0.35–0.92, respectively). In patients with myomas >1.5?cm, LBR was also significantly reduced, even after adjusting for age, smoking, quality of embryo transferred, antral follicle count, and dose of gonadotropins (OR, 0.53; 95% CI, 0.29–0.97). This LBR finding was not significant if all myomas were included (including those <1.5?cm in diameter), but CPR was still significantly reduced.

Conclusion

Relatively small (>1.5?cm) non–cavity-distorting intramural myomas negatively affect CPR and LBR in in vitro fertilization cycles, even in the presence of only 1 myoma.  相似文献   

8.

Study Objective

To evaluate the association between bladder deep infiltrating endometriosis (DIE) and anterior focal adenomyosis of the outer myometrium (aFAOM) diagnosed by preoperative magnetic resonance imaging (MRI).

Design

An observational, cross-sectional study using prospectively collected data (Canadian Task Force classification II-2).

Setting

Single university tertiary referral center.

Patients

All nonpregnant women younger than 42 years who had undergone complete surgical exeresis of endometriotic lesions. For each patient a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon during the month preceding the surgery. Only women with preoperative standardized uterine MRI were retained for this study.

Interventions

Thirty-nine women with histologically proven bladder DIE and an available preoperative MRI were enrolled in the study. Patients were divided into 2 groups: women with aFAOM (aFAOM (+), n?=?19) and women without aFAOM (aFAOM (–), n?=?20). Both groups were compared for general characteristics, medical history, MRI findings, and disease severity.

Measurements and Main Results

Nineteen patients (48.7%) with bladder DIE had aFAOM at preoperative MRI. The rate of associated diffuse adenomyosis was similar in the 2 groups (63.2% [n?=?12] vs 73.7% [n?=?14]; p?=?.48). The rate of an associated ovarian endometrioma (OMA) was significantly lower in the aFAOM (+) group (10.5% [n?=?2] vs 40.0% [n?=?8]; p?=?.03). There were fewer associated intestinal DIE lesions in the aFAOM (+) group compared with the aFAOM (–) group (26.3% vs 75.0%; p?=?.02), with lower involvement of the pouch of Douglas (26.3% vs 70%; p?<?.01). Total American Society for Reproductive Medicine score was significantly lower in the aFAOM (+) group (13.8?±?12.2 vs 62.2?±?46.2; p?<?.01).

Conclusion

aFAOM is present in only half of women with bladder DIE and appears to be associated with lower associated posterior DIE.  相似文献   

9.

Study Objective

To evaluate the added value of the fluorescence dye indocyanine green (ICG) for sentinel lymph node (SLN) mapping in women with cervical cancer who had undergone previous conization (stage 1A-1B1) by comparing ICG versus Tc99m radiotracer?+?blue dye (BD).

Design

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

Setting

Two European academic medical centers, San Gerardo Hospital, Italy and University of Berne, Switzerland.

Patients

Sixty-five women with early stage (IA-IB1) cervical cancer who had undergone previous conization and who underwent SLN mapping with Tc99m?±?BD (n?=?23) or ICG (n?=?42) followed by pelvic lymphadenectomy and fertility-sparing surgery or hysterectomy were included in this analysis.

Intervention

Overall detection rate and bilateral SLN mapping rates of ICG were compared with those obtained using the standard Tc99m radiocolloid and BD.

Measurement and Main Results

Overall, 220 SLNs were detected. The median number of SLNs per patient in the Tc99m?±?BD group was 2 (range, 1–5) and in the ICG group, 3 (range, 2–15). The detection rate of SLNs was 95.7% in Tc99m?±?BD group and 100% in the ICG group (p?=?.354). The women injected with ICG had a higher rate of bilateral mapping of the SLNs as compared with the Tc99m?±?BD group (95.2% vs 69.6%, p?=?.016%). Only 12% of the patients (8/65) presented metastatic nodes, 2 in the Tc99m?±?BD group and 6 in the ICG group.

Conclusion

In early-stage cervical cancer patients conization had no significant impact on the SLN detection rate using both techniques (ICG and radiotracer?±?BD). In this scenario a higher bilateral mapping rate was confirmed using the fluorescent dye ICG rather than the standard techniques.  相似文献   

10.

Study Objective

To assess the clinical course and surgical and fertility outcomes of patients diagnosed with tubo-ovarian abscess (TOA) after fertility treatment.

Design

Parallel case series over 10 consecutive years (Canadian Task Force classification II-2).

Setting

Tel Aviv Sourasky Medical Center, a tertiary university-affiliated hospital.

Patients

Thirty-seven women who were diagnosed with TOA after fertility treatments (in vitro fertilization and intrauterine insemination) were compared with 313 women who were diagnosed with TOA not associated with fertility treatments during the same time period.

Intervention

Medical records search, chart review, and phone survey were used to assess clinical course and surgical and reproductive outcomes.

Measurements and Main Results

Women with TOA after fertility treatments had significantly higher inflammatory markers upon admission compared with the nonfertility treatment group (mean white blood cell count, 16.1?×?1000/mm3 [standard deviation [SD], ±4.3] vs 13.8?×?1000/mm3 [SD, ±6.3], p?=?.001, respectively; and mean C-reactive protein, 149 mg/L [SD, ±78.3] vs 78.2 mg/L [SD, ±68.5], p?=?.001, respectively). In addition, TOA after fertility treatments was associated with a significantly higher surgical intervention rate and a more complicated clinical course, as evidenced by a shorter time interval from admission to surgery (2.1 days vs 3.2 days, p?=?.01), higher rates of antibiotic failure, higher conversion rate from laparoscopy to laparotomy (14.2% vs 3.2%, p?=?.005), increased perioperative complications rate (25.0% vs 3.8%, p?=?.0001), and a longer hospitalization stay (7.2 days vs 4.8 days, p?=?.01). Clinical pregnancy rate per cycle in women with TOA after fertility treatments was 9%, and 1 case of live birth was recorded.

Conclusions

Our data indicate that TOA after fertility treatment has a substantial effect on the clinical course and surgical outcome. Prophylactic antibiotic treatment before ovum retrieval and deferral of embryo transfer should be considered in patients at risk of infection.  相似文献   

11.

Study Objective

To assess the impact of ovarian endometriomas on endometrial receptivity in frozen embryo transfer (FET) of segmented in vitro fertilization (IVF) cycles.

Design

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

Setting

A single, private assisted-reproduction technology center.

Patients

Thirty patients diagnosed with unilateral or bilateral endometriomas were compared with 60 patients without endometriomas in a population of 1894 patients who underwent segmented IVF treatment between September 2014 and September 2016.

Intervention

Intracytoplasmic sperm injection with blastocyst freeze-all and FET.

Measurements and Main Results

The primary endpoint of the study was a viable pregnancy (>14 weeks). The mean diameter of diagnosed endometriomas was 25.7?±?10.6?mm. The median antral follicle count was significantly lower in the endometrioma group compared with the entire study population (11.5; interquartile range [IQR], 6.0–17.0 vs 14.0; IQR, 9.0–22.0; p?=?.042). The median number of mature ovarian follicles (≥14?mm) per antral follicle that developed during controlled ovarian stimulation was not significantly different between the groups (11.0 [IQR, 5.8–14.3] vs 10.0 [IQR, 6.0–15.8]; p?=?.908); however, the median number of oocytes retrieved was lower in the endometrioma group (11.5 [IQR, 6.0–21.5] vs 13.5 [IQR, 9.0–20.8]; p?=?.373). The biochemical pregnancy, implantation, and ongoing pregnancy rates were not significantly different between the endometrioma and control groups.

Conclusion

Although ovarian endometriomas result in reduced ovarian reserve and oocyte retrieval, their impact on reproductive outcome is limited with FET.  相似文献   

12.

Study Objective

To compare surgical excision and ablation of endometriosis for treatment of chronic pelvic pain.

Design

Randomized clinical trial with 12-month follow-up (Canadian Task Force classification I).

Setting

Single academic tertiary care hospital.

Patients

Women with minimal to mild endometriosis undergoing laparoscopy.

Interventions

Excision or ablation of superficial endometriosis at the time of robot-assisted laparoscopy.

Measurements and Main Results

Primary outcome was visual analog scale (VAS) scoring at baseline and 6 and 12 months for menstrual pain, nonmenstrual pain, dyspareunia, and dyschezia. Secondary outcomes included survey results at baseline and 6 and 12 months from the Short Form Health Survey, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and the International Pelvic Pain Assessment. From December 2013 to October 2014, 73 patients were randomized intraoperatively to excision (n?=?37) or ablation (n?=?36) of endometriosis. Patients were followed at 6 and 12 months to evaluate the above outcomes. After ablation of endometriosis, dyspareunia (VAS scores) improved at 6 months (mean change [MC], ?14.07; 95% confidence interval [CI], ?25.93 to ?2.21; p?=?.02), but improvement was not maintained at 12 months. Dysmenorrhea improved at 6 months (MC, ?26.99; 95% CI, ?41.48 to ?12.50; p?<?.001) and 12 months (MC, ?24.15; 95% CI, 39.62 to ?8.68; p?=?.003) with ablation. No significant changes were seen in VAS scores after excision at 6 or 12 months. When comparing ablation and excision, the only significant difference was a change in dyspareunia at 6 months (MC, ?22.96; 95% CI, ?39.06 to ?6.86; p?=?.01).

Conclusion

Treatment with ablation improved dysmenorrhea at 6 and 12 months and improved dyspareunia at 6 months as compared with preoperative data. However, only dyspareunia demonstrated a significant difference between ablation and excision. Excision and ablation showed similar effectiveness for the treatment of pain associated with superficial endometriosis, with ablation showing more significant individual changes. Careful patient counseling regarding expectations of surgical intervention is vital in the management of endometriosis.  相似文献   

13.

Study Objective

To compare outcomes following umbilical minilaparotomy and suprapubic minilaparotomy for tissue extraction.

Design Classification

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

Setting

Two large academic medical centers.

Patients

Women who underwent a minilaparotomy for tissue extraction following a laparoscopic hysterectomy or myomectomy between 2014 and 2016.

Interventions

Umbilical or suprapubic minilaparotomy for tissue extraction.

Measurements and Main Results

A total of 374 women underwent laparoscopic hysterectomy or myomectomy with minilaparotomy, including 289 (77.3%) with an umbilical minilaparotomy and 85 (22.7%) with a suprapubic minilaparotomy. The 2 groups were similar in terms of age, body mass index, parity, surgical history, procedure type, surgical approach, and surgical indication. The size of the minilaparotomy incision and the specimen weight were significantly smaller in the umbilical minilaparotomy group (mean, 3.3?±?0.8?cm vs 4.2?±?0.6?cm [p?<?.001] and 472.6?±?357.1?g vs 683.0?±?475.7?g [p?<?.001], respectively). Two women in the suprapubic minilaparotomy group sustained a bladder injury during creation of the incision. There were no other complications related to the minilaparotomy in either group. Postoperative outcomes related to the minilaparotomy incision were compiled using the medical record and a follow-up survey. Of the 374 women in this cohort, 163 responded to a detailed survey about their minilaparotomy incision (response rate, 43.5%). With regard to the minilaparotomy, 52.7% of women reported incisional symptoms; 25.9% had increased pain at the incision, 8.3% had an incisional infection, and 2.7% reported an incisional hernia. There was no significant between-group difference in incisional outcomes; however nearly 3 times as many women in the umbilical minilaparotomy group reported concerns about incisional hernia (3.1% vs 1.2%; p?=?.833). These findings were maintained in a multivariable logistic regression analysis. No patient or procedure characteristics were significantly associated with the development of hernia.

Conclusion

There were no significant difference in incisional symptoms, pain, or infection following umbilical minilaparotomy vs a suprapubic minilaparotomy for tissue extraction. Although not statistically significant, the rate of incisional hernia was higher at the umbilical site compared with the suprapubic site.  相似文献   

14.

Study Objective

To demonstrate helpful tips and tricks for the successful use of transvaginal natural orifice transluminal endoscopic surgery (NOTES) for performing sacrocolpopexy and salpingo-oophorectomy surgery. Minimally invasive approaches for treating pelvic organ prolapse via sacrocolpopexy have traditionally included laparoscopy either with or without robotic assistance. Transvaginal NOTES is a novel minimally invasive approach that both avoids abdominal incisions and provides improved visualization; however, it can be technically challenging.

Design

Stepwise demonstration with narrated video footage (Canadian Task Force classification III).

Setting

An academic tertiary care hospital in Guangdong, China.

Patient

A 61-year-old gravida 3, para 3 woman with 3 spontaneous vaginal deliveries and stage III uterine prolapse, stage III cystocele, and stage III rectocele. The preoperative vaginal length was 6?cm.

Intervention

After performing vaginal hysterectomy, we show the usefulness of NOTES for salpingo-oophorectomy. We also demonstrate useful techniques for transvaginal NOTES sacrocolpopexy including hydrodissection, division of the Y mesh, anchoring of the anterior mesh before reducing prolapse, retroperitoneal tunneling, and hand suturing of the mesh and vaginal cuff.

Measurements and Main Results

The procedure was successfully performed in approximately 190 minutes. The postoperative vaginal length was 5?cm. Postoperative pelvic organ prolapse quantification was stage 0.

Conclusion

The transvaginal NOTES approach is feasible and efficient for sacrocolpopexy and salpingo-oophorectomy; additionally, it is a reasonable option for patients who desire a minimally invasive approach with excellent cosmetic results. Surgical techniques that aid in effectively performing transvaginal NOTES sacrocolpopexy include the use of hydrodissection, Y mesh division, anterior mesh anchoring before reducing prolapse, retroperitoneal tunneling, and hand suturing. Using the techniques presented here, we were able to insert the port only 1 time, which improves the efficiency and safety of this surgery.  相似文献   

15.

Study Objective

To compare the accuracy of frozen section diagnosis of borderline ovarian tumors among 3 distinct types of hospital—academic hospital with gynecologic pathologists, academic hospital with nongynecologic pathologists, and community hospital with nongynecologic pathologists—and to determine if surgical staging alters patient care or outcomes for women with a frozen section diagnosis of borderline ovarian tumor.

Design

Retrospective study (Canadian Task Force classification II-1).

Setting

Tertiary care, academic, and community hospitals.

Patients

Women with an intraoperative frozen section diagnosis of borderline ovarian tumor at 1 of 3 types of hospital from April 1998 through June 2016.

Interventions

Comparison of final pathology with intraoperative frozen section diagnosis.

Measurements and Main Results

Two hundred twelve women met the inclusion criteria. The frozen section diagnosis of borderline ovarian tumor correlated with the final pathologic diagnosis in 192 of 212 cases (90.6%), and the rate of correlation did not differ among the 3 hospital types (p?=?.82). Seven tumors (3.3%) were downgraded to benign on final pathologic analysis and 13 (6.1%) upgraded to invasive carcinoma. The 3 hospital types did not differ with respect to the proportion of tumors upgraded to invasive carcinoma (p?=?.62). Mucinous (odds ratio, 7.1; 95% confidence interval, 2.1–23.7; p?=?.002) and endometrioid borderline ovarian tumors (odds ratio, 32.4; 95% confidence interval, 1.8–595.5; p?=?.02) were more likely than serous ovarian tumors to be upgraded to carcinoma. Only 88 patients (41.5%) underwent lymphadenectomy, and only 1 (1.1%) had invasive carcinoma in a lymph node.

Conclusions

A frozen section diagnosis of borderline ovarian tumor correlates with the final pathologic diagnosis in a variety of hospital types.  相似文献   

16.

Study Objective

To investigate the influence of the use of passive instrument positioners (PIPs) on laparoscopic operative outcomes for endometrial cancer relative to other independent variables.

Design

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

Setting

Laparoscopies performed by the author in multiple community hospitals.

Patients

A total of 297 consecutive patients between December 2009 and October 2016 with clinically isolated endometrial cancer or retroperitoneal lymphadenopathy on imaging studies.

Interventions

Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and pelvic/aortic lymph node dissection using passive instrument positioners to secure the laparoscope (PIP group) and using instruments providing exposure and historical control by hand control of all instruments (HC group).

Measurements and Main Results

The overall group mean age was 63.2 years (range, 32.4–90.9 years), and patient characteristics were equivalent in the 2 groups. In the PIP group, 1 procedure was converted to a laparotomy (0.5%), and in the HC group, 6 procedures were converted (5.4%; p?=?.008). The mean operative time was 140.1 minutes for the PIP group and 153.8 minutes for the HC group (p?<?.001). The mean length of hospital stay was 44.8 hours for the PIP group and 58.6 hours for the HC group (p?<?.001). Multivariate analysis confirmed that study group (PIP vs HC; p?=?.014) and the presence vs absence of metastatic disease (p?=?.001) influenced conversion; study group (PIP vs HC; p?<?.001), body mass index (p?<?.001), past surgical history (p?=?.010), and assistant training (p?=?.011) influenced operative time; and study group (PIP vs HC; p?<?.001), Eastern Cooperative Oncology Group performance status (p?<?.001), and operative time (p?=?.051) influenced hospital stay.

Conclusion

For clinically localized endometrial cancer managed laparoscopically, the use of PIPs reduces conversions, operative time, and hospital stay.  相似文献   

17.

Study Objective

The aim of this study was to investigate how steep Trendelenburg positioning with pneumoperitoneum modifies brain oxygenation and autonomic nervous system modulation of heart rate variability during robotic sacrocolpopexy.

Design

Prospective study (Canadian Task Force classification III).

Setting

Rambam Health Care Campus.

Patients

Eighteen women who underwent robotic sacrocolpopexy for treatment of uterovaginal or vaginal apical prolapse.

Interventions

Robotic sacrocolpopexy.

Measurements and Main Results

A 5-minute computerized electrocardiogram, cerebral O2 saturation (cSO2), systemic O2 saturation, heart rate (HR), diastolic blood pressure (BP), systolic BP, and end-tidal CO2 tension were recorded immediately after anesthesia induction (baseline phase) and after alterations in positioning and in intra-abdominal pressure. HR variability was assessed in time and frequency domains. Cerebral oxygenation was measured by the technology of near-infrared spectrometry. cSO2 at baseline was 73%?±?9%, with minor and insignificant elevation during the operation. Mean HR decreased significantly when the steep Trendelenburg position was implemented (66?±?10 vs 55?±?9?bpm, p?<?.05) and returned gradually to baseline with advancement of the operation and the decrease in intra-abdominal pressure. Concomitant with this decrease, the power of both arms of the autonomic nervous system increased significantly (2.8?±?.8 vs 3.3?±?.9?ms2/Hz and 2.5?±?1.2 vs 3.2?±?.9?ms2/Hz, respectively, p?<?.05). All these effects occurred without any significant shifts in systolic or diastolic BP or in systemic or cerebral oxygenation.

Conclusion

This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in HR rate and HR variability.  相似文献   

18.

Study Objective

To evaluate the impact of endometriosis staging and endometriomas on in vitro fertilization (IVF) outcome and to assess the optimal time interval between laparoscopy and IVF.

Design

A retrospective clinical study (Canadian Task Force classification II1).

Setting

A university-affiliated private infertility clinic.

Patients

Two hundred sixteen infertile patients with endometriosis and 209 infertile patients without endometriosis.

Interventions

Laparoscopy, IVF.Measurements and Main Results: Patients with endometriosis were classified according to American Society for Reproductive Medicine criteria; 58, 67, 63, and 28 patients had stages 1 through 4 disease, respectively. Patients with endometriosis had significantly lower estradiol on trigger day (9986?±?6710 vs 12 220?±?9414?pg/mL, respectively) and number of retrieved oocytes (12.7?±?8.6 vs 14.0?±?10, respectively) compared with controls. We found a consistent decline in clinical and ongoing pregnancy rates with increasing stage of endometriosis. The presence of endometrioma in patients with stages 3 and 4 endometriosis did not alter IVF outcome. Patients with a time interval of 7 to 12 and 13 to 25 months after surgery had a favorable outcome.

Conclusion

IVF pregnancy rate was negatively correlated with endometriosis severity. The presence of endometriomas had no impact on IVF clinical outcome. The optimal time to perform IVF appears to be between 7 and 25 months after endometriosis surgery.  相似文献   

19.

Objectives

Insulin resistance (IR) is one of the important factors associated with the clinical signs in patients with the polycystic ovary syndrome (PCOS). There are some studies which report a correlation between insulin resistance and trace elements. The present study primarily focuses on the investigation of serum selenium (Se) and zinc (Zn) levels as well as their relationship with insulin resistance in PCOS patients.

Design

This is a case control study.

Setting

The study was conducted at Fatemeh Zahra Infertility and Reproductive Health Research Center of Babol University of Medical Sciences, Babol, Iran.

Methods

This study includes 60 women with PCOS (20–40?years old) and 90 healthy women. The PCOS group was divided into two sub-groups including insulin-resistant (n?=?36) and non-insulin-resistant (n?=?24) groups. Fasting blood sugar, fasting insulin, insulin resistance indexes and the serum levels of Se and Zn were measured in both groups.

Results

Serum selenium levels were significantly lower in the patient group as compared with the control group (40.42?±?21.12 VS 51.79?±?15.65; p?=?.001). The mean zinc levels were also significantly lower in the PCOS women than in the controls (81.33?±?24.28 VS 108.31?±?63.29; p?=?.022). In addition, Zn levels in PCOS-IR were negatively correlated with the homeostatic model assessment for insulin resistance (r?=??0.332, p?=?.048) and positively correlated with the glucose/insulin ratio (r?=?0.354, p?=?.040) and insulin (r?=?0.429, p?=?.009).

Conclusion

The findings show decreased serum Se and Zn levels in the PCOS patients as compared to the controls. Additionally, the results confirm the correlation between zinc and insulin resistance.  相似文献   

20.

Study Objective

Our primary endpoint was to compare the intra- and postoperative complications, whereas secondary endpoints were the occurrence of voiding dysfunction and evaluation of the quality or life of segmental and discoid resection in patients with colorectal endometriosis.

Design

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

Setting

Tenon University Hospital in Paris.

Patients

Thirty-one 31 patients who underwent a conservative surgery and 31 patients who underwent.

Interventions

The 2 groups were compared using propensity score matching (PSM) analysis, with a median follow-up of 247 days (8.2 months).

Measurements and Main Results

Discoid colorectal resection was associated with a shorter operating time (155 vs 180 minutes, p?=?.03) and hospital stay (7 vs 8 days, p?=?.002) than segmental colorectal resection; however, a similar intra- and postoperative complication rate was found. A higher rate of postoperative voiding dysfunction was observed in the segmental resection group (19% vs 45%, p?=?.03) as well as duration of voiding dysfunction requiring bladder self-catheterization longer than 30 days (0 vs 22%, p?=?.005).

Conclusion

Our PSM analysis suggests the advantages of discoid resection because it results in a similar surgical complication rate to segmental resection but with advantages in operating time, hospital stay, and voiding dysfunction.  相似文献   

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