Laparoscopically Assisted Vaginal Hysterectomy—A Pilot Project

Endoscopic gynaecologic procedures have undergone a meteoric rise in popularity. This rapid adoption of untested endoscopic surgical procedures has prompted a growing concern among physicians who point to the present Jack of stringent training guidelines and clearly defined indications for laparoscopic surgery.Laparoscopically assisted vaginal hysterectomy (LAVH), first described by Reich et al. in 1989, was developed to convert an inevitable abdominal hysterectomy into a vaginal procedure, thus avoiding the postoperative morbidity and hospital stay associated with laparotomy. Early reports have suggested that LAVH can reduce postoperative morbidity successfully and shorten hospital stay. This pilot project of LAVH was conducted under the auspices of the Provincial Department of Health. The peri-operative outcomes were compared to cohorts of patients who underwent either a vaginal or abdominal hysterectomy performed by the same surgeons.In this study, LAVH resulted in a higher rate of peri-operative complications. Postoperative hospital stay was comparable to patients who underwent vaginal hysterectomy. The reduction in hospital stay compensated for the increased cost of disposable surgical instruments and resulted in a net cost comparable to the abdominal hysterectomy. Larger studies are needed to evaluate the safety of LAVH and to define better the indications for this surgical procedure.     

Assisted Reproductive Technologies—A Primer for Canadian Physicians

Objective: to describe the indications for and availability of various assisted reproductive techniques in Canada, in addition to their associated costs and waiting lists.Methods: fourteen in vitro fertilization (IVF) programmes in Canada (out of 15 functioning programmes) completed a questionnaire regarding availability, costs, and waiting lists for assisted reproduction services.Results: fourteen programmes offer standard IVF treatment, with waiting lists ranging from zero to 12 months. The cost to the patient is $0 to $4,500 per cycle (excluding medications), depending on provincial funding. Ontario is the sole province to provide medical coverage for IVF, but only for women with tubal obstruction and only for three cycles. The IVF eligibility criteria vary throughout the country for women over 40 and single women. All programmes offer or can arrange for embryo and sperm freezing. Eight clinics offer donor oocyte programmes. For treatment of severe male factor infertility, or a combination of severe male and female factor infertility, twelve programmes offer donor sperm in conjunction with IVF, while eleven programmes have introduced intracytoplasmic sperm injection (ICSI).Conclusions: a variety of assisted reproductive technologies is available througjn at least 14 clinics in five provinces across Canada. The remaining five provinces and two territories have access to assisted reproduction only through satellite clinics and travel to distant centres. This primer is intended as a practical guide to aid community physicians with preliminary counselling and appropriate referral of complex infertility patients.     

Clinical Assisted Reproduction: An Analysis of Spontaneous Hatching in a Human Endometrial Epithelial Coculture System: Is Assisted Hatching Justified?

Purpose: To evaluate spontaneous embryo hatching in an endometrial epithelial coculture system, and compare it with cases where coculture was performed because of maternal age, previous repeated implantation failures, or both. To clarify in which cases assisted hatching would be appropriate.Methods: Individual human embryos were cocultured on an endometrial epithelial cell monolayer until Day 6.Results: Blastocyst hatching rate at Day 6, depending on maternal age, was 9.1% (age <37 years) and 3.4% (age 37 years). However, blastocyst hatching rates depending on number of previous IVF failures were similar.Conclusions: Maternal age and previous implantation failures are factors affecting the ability of human embryos to reach the blastocyst stage in coculture. However, assisted hatching is not justified in these populations because of the absence of hatching rate differences between blastocysts obtained from these two groups and the control group.     

Do Lunar Phases Affect Conception Rates in Assisted Reproduction?

Objectives: To assess the effect of the phases of the moon on pregnancy rates in humans following in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment.Design: Retrospective, observational study.Setting: Reproductive Medicine Unit, Liverpool Womens Hospital.Patient: Complete data for all women undergoing assisted conception procedures over a period of 13 years (1995–2002).Intervention: Assisted conception procedures-IVF and ICSI.Main outcome measures: Biochemical pregnancy that is positive pregnancy test result following embryo transfer.Results: There was no significant effect of any lunar phase on the incidence of biochemical pregnancy (p-value 0.71). Age of the woman significantly affects the chances of pregnancy, (OR 0.95, 95% CI 0.91, 0.998, and p-value 0.04). The chances of pregnancy rises significantly with increase in the number of embryos replaced from 1 to 2 (OR 2.97, CI 1.36, 6.48, and p-value 0.01).Conclusion: Pregnancy rates in humans, following assisted conception, appears to be independent of the effect of the lunar phase during which embryo transfer is carried out.     

Preimplantation Genetic Diagnosis—An Integral Part of Assisted Reproduction

Conference Report

Preimplantation Genetic Diagnosis—An Integral Part of Assisted Reproduction     

What is the Learning Curve for Robotic Assisted Gynecologic Surgery?

STUDY OBJECTIVE: The purpose of this study was to estimate the learning curve when using the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in benign gynecologic cases by a team of 2 gynecologic laparoscopists. DESIGN: Retrospective case series (Canadian Task Force classification II-1). SETTING: A private practice obstetrics/gynecology clinic. PATIENTS: Patients requiring major benign gynecologic surgery who were candidates for a laparoscopic approach. INTERVENTION: All patients who would have otherwise been offered a transabdominal or conventional laparoscopic procedure were offered the option of having their procedure performed laparoscopically with robotic assistance. Data that were collected included robot set-up times by the operative room staff, operative times for use of robot, total operative times, and perioperative outcome. We analyzed the learning curve defined as the number of cases required to stabilize operative time to perform the various procedures. MEASUREMENTS AND MAIN RESULTS: One hundred thirteen patients were treated over a 22-month period with the da Vinci Surgical System. Most procedures were hysterectomies, whereas other gynecologic procedures included supracervical hysterectomy, laparoscopic vaginal assisted hysterectomy, myomectomy, sacrocolpopexy, and oophorectomy. Total operative times for hysterectomies studied sequentially stabilized at approximately 95minutes after 50 cases. The decrease in robotic time did not depend on uterine size. The mean length of hospital stay was 24hours, and return to normal activities averaged 2.8 weeks. CONCLUSIONS: Robotic assisted surgery is an enabling technology that allows gynecologic surgeons the ability to offer laparoscopic procedures to most of their patients. In the hands of surgeons with advanced laparoscopic skills, the learning curve to stabilize operative times for the various surgical procedures in women requiring benign gynecolologic interventions is 50 cases.     

Myomas and Assisted Reproductive Technologies: When and How to Act?

The effect of myomas on reproductive outcome has been the subject of many studies; however, a definitive answer is still missing. Therefore, the authors have tried to outline some guidelines for the management of women who have uterine myomas and desire to conceive.The location and size of the myomas are the two parameters that influence the success of a future pregnancy. Subserosal myomas seem to have little, if any,effect on reproductive outcome, especially if they are up to 5 to 7 cm in diameter.Intramural myomas that do not encroach upon the endometrium also can be considered to be relatively harmless to reproduction, if they are smaller than 4 to 5 cm in diameter. This is the ambiguous gray zone of the subject, and where research should be focused before a consensus can be established. Myomas that compress the uterine cavity with an intramural portion (submucous myoma type II) and submucous myomas significantly reduce pregnancy rates, and should be removed before assisted reproductive techniques are used.Hysteroscopic myomectomy is the gold standard for the treatment of submucous myomas. For other myomas, abdominal myomectomy, or laparoscopic myomectomy--when the experience of the surgeon and the facilities are sufficient--are the best alternatives. In most of the literature, the pregnancy rates were increased and the miscarriage rates were decreased after surgery with these two techniques. Other alternative treatment modalities, such as CUV, laparoscopic myolysis, or MRI-guided focused ultrasound, are to be monitored and evaluated thoroughly before they are applied as routine procedures.     

Natural Orifice–Assisted Laparoscopic Meckel Diverticulectomy Incidentally Found During Para-Aortic Mass Resection

Study Objective

To show a surgical video in which an incidentally found Meckel diverticulum was resected with a natural orifice–assisted laparoscopic approach during para-aortic resection of a retroperitoneal schwannoma.

Robot‐Assisted Laparoscopic Prostatectomy in Patients with Preexisting Three‐Piece Inflatable Penile Prosthesis

IntroductionRobotic‐assisted laparoscopic radical prostatectomy (RARP) is becoming the preferred surgical treatment option for management of organ‐confined prostate cancer. Although not a contraindication, previous pelvic surgery can make RARP challenging. Presence of a three‐piece inflatable penile prosthesis, with a perivesical pelvic reservoir, has the potential to induce steric hindrance making RARP difficult.AimThe main purpose of this publication is to report our experience with RARP in patients with previously inserted three‐piece inflatable penile prostheses.MethodsTwo patients with previously inserted AMS 700 penile prosthesis and with organ‐confined, biopsy proven adenocarcinoma of the prostate underwent RARP. We describe intraoperative findings, surgical technique, oncologic and functional outcomes.ResultsBoth patients underwent safe and successful RARP with out any complications. Surgical margins were not affected with pelvic reservoir‐sparing technique. In both patients, the penile prosthesis remained functional postoperatively.ConclusionsRARP can be safely performed in patients with previously inserted three‐piece inflatable penile prosthesis. Nontraumatic handling of the pelvic reservoir is mandatory to preserve prosthesis' integrity. Erdeljan P, Brock G, and Pautler SE. Robot‐assisted laparoscopic prostatectomy in patients with preexisting three‐piece inflatable penile prosthesis. J Sex Med 2011;8:306–309.     

Is blood really thicker than water? Assisted reproduction and its impact on our thinking about family

The traditional notion that a family is built around and based on blood or genetic ties is challenged when assisted human reproduction utilizing donor gametes is used. A focus on the family--in contrast to the individual--requires from medicine an extension of thinking in which a model that incorporates treating infertility and building a family becomes the norm. Such a model will require that attention is given to the psychological and social needs of the would-be parents, thus enabling them to approach their family building with confidence. This confidence is expected to carry through to their sharing with their offspring the nature of their family building and thus avoid the stigma that leads to secrecy. Research relating to dimensions of family building when donor insemination has been used is reviewed. The impact of professional attitudes, along with the policies adopted by governments concerning access to genetic information for offspring, significantly influences the families built with assistance of donor gametes or embryos. The evolution of professional thinking in this area is reviewed, along with the increasing involvement of governments.     

Assisted reproduction in women over 40 years of age: how old is too old?

Women’s fertility progressively declines with advanced age due to depletion of the ovarian follicular reserve and poorer oocyte quality. However, many women of advanced age are eager to conceive from their own ova. The aim of the present study was to evaluate the outcome of IVF cycles among older patients. All IVF retrievals performed in the unit in patients ?42 years old between 1998 and 2006 were retrospectively analysed. Data were compared with patients <35 years old treated in the unit during the same time period. A total of 843 IVF retrievals in 459 patients ?42 years old were assessed. Clinical pregnancy rates per cycle were 7.7%, 5.4% and 1.9% for 42, 43 and 44 years old, respectively. Only one IVF cycle in patients aged 44 years resulted in delivery. None of the 54 cycles performed in women of 45 years or older resulted in a pregnancy. A marked decline in clinical pregnancy and delivery rates, accompanied by an increase in spontaneous abortion rates, was found in patients ?42 years old. In view of these results and as the option of egg donation is a promising alternative with delivery rates close to 50%, it appears that IVF treatment should be limited to patients not older than 43 years old with adequate ovarian response.