Diagnostic minihysteroscopy with vaginoscopic approach: rationale and advantages

Diagnostic hysteroscopy still is considered an invasive and painful technique. In recent years, a new technique based on the employment of minihysteroscopes with fluid distention and vaginoscopic approach has been proposed in order to improve feasibility and reduce pain and side effects. Size reduction of the hysteroscope is of greatest importance for reducing pain and risk of vasovagal reaction. In conclusion, the best approach in terms of ease, reliability, acceptability, and safety to patients in whom intrauterine exploration is indicated should be simple diagnostic hysteroscopy using a small-diameter, rod lens hysteroscope with a single-flow diagnostic sheath, vaginoscopic approach, and fluid distention. In this way in about 90% of patients, a correct diagnosis and proper choice for eventual subsequent operative strategy can be obtained, without discomfort and risk.     

Laparoscopic myomectomy: feasibility and safety—a retrospective study of 762 cases

The objective of this retrospective study of a case series was to evaluate patients with symptomatic uterine myomas managed by laparoscopic myomectomy—the clinical features, operative techniques, and intraoperative and postoperative morbidity. The subjects consisted of a total of 762 women who underwent endoscopic surgery for uterine leiomyomas at a private advanced endoscopy and assisted reproductive technology centre over a 13-year period. Data were collected on baseline clinical characteristics, details of surgery, intraoperative and postoperative complications, and hospital stay. A total of 1,375 myomas were removed; the most common indication was infertility (50.9%), and the majority of myomas (49.52%) were intramural. The mean duration of surgery was 95 min, and the average blood loss was 250.5 ml. The average hospital stay was 1.3 days. Major complications included an unexplained postoperative death and one laparotomy for postoperative bleeding. We conclude that laparoscopic myomectomy is a relatively safe procedure. Most cases can be completed by a laparoscopic approach, and the remaining may require a laparoscopic-assisted myomectomy. The risk of complications is comparable to that with the open procedure, whereas morbidity and length of hospital stay are much lower.     

腹腔镜在附件包块治疗中的价值和安全性(附2083例报道)

目的:评价腹腔镜在附件包块治疗中的价值及安全性。方法:回顾分析2000年1月至2003年12月北京协和医院术前诊断为良性附件包块2083例的腹腔镜手术治疗情况。患者平均33.4±8.9岁,绝经后妇女占1.8%。术中怀疑卵巢恶性肿瘤者送冰冻病理检查。计算腹腔镜术中诊断卵巢恶性肿瘤的敏感性(SEN)、特异性(SPE)、阳性预测值(PPV)及阴性预测值(NPV)。结果:2 083例患者中,2 067例为良性肿瘤,16例(0.77%)患者为卵巢交界性肿瘤(LMP)或卵巢癌,其中14例LMP及卵巢癌在术中确诊,2例卵巢癌术后确诊。55例(2.6%)患者术中可疑恶性送冰冻病理检查,检查结果为良性肿瘤41例(74.5%),LMP 8例(14.5%),卵巢癌6例(10.9%)。术后病理结果:良性肿瘤41例(74.5%),LMP 7例(12.7%),卵巢癌7例(12.7%)。术中冰冻与术后病理的符合率为98.2%。腹腔镜诊断卵巢恶性肿瘤的SEN为87.5%、SPE为98%、PPV为25.5%、NPV为99.9%。卵巢良性肿瘤2 067例,均进行了卵巢囊肿剔除术、附件切除术等。无中转开腹或围手术期并发症。16例LMP或卵巢癌患者中,7例行腹腔镜手术包括3例腹腔镜分期手术。16例患者术后平均随诊17.3月。1例LMP一侧附件切除术后4年对侧卵巢出现交界性肿瘤,行腹腔镜囊肿剔除术,其余病例均无复发征象。结论:腹腔镜可作为术前诊断为良性的附件包块的首选手术方式,术中意外发现卵巢LMP或者恶性肿瘤的机会较低。对可疑恶性的卵巢肿瘤,术中应进行冰冻病理检查。     

Temporary, transvaginal occlusion of the uterine arteries: a feasibility and safety study

A Doppler-guided, transvaginally applied paracervical clamp safely and effectively occluded the uterine arteries in 10 women. Following closure of the clamp, blood flow through the uterine arteries stopped; flow returned immediately upon clamp release. Average time of clamp closure was 26 minutes (range 10-59 min). No ureter was obstructed by clamp closure.     

浅谈阴道内镜技术的发展与临床应用#br#

正适龄妇女定期子宫颈癌筛查,并对筛查异常者进行进一步管理,最大限度地检出及治疗子宫颈癌前病变,是预防子宫颈浸润癌的首要目标。但在临床上管理筛查异常者时,需对筛查低级别异常及高级别异常实施分层管理,由此产生的复杂性可能会导致临床医生管理认识上的混乱[1],往往存在着对低级别异常者管理过度或对高级别异常者管理不足问题,均不利于子宫颈癌的防控。为此,近年来世界卫生组织及各国阴道镜和子宫颈病理学会(Society for Colposcopy and Cervical Pathology, SCCP),     

Applying experience sampling methods to partner violence research: safety and feasibility in a 90-day study of community women

An experience sampling method (ESM) rarely has been applied in studies of intimate partner violence (IPV) despite the benefits to be gained. Because ESM approaches and women who experience IPV present unique challenges for data collection, an empirical question exists: Is it safe and feasible to apply ESM to community women who currently are experiencing IPV? A 90-day, design-driven feasibility study examined daily telephone data collection, daily paper diaries, and monthly retrospective semistructured interview methods among a community sample of 123 women currently experiencing IPV to study within-person relationships between IPV and substance use. Findings suggest that ESM is a promising method for collecting data among this population and can elucidate daily dynamics of victimization as well as associated behaviors and experiences. Lessons learned from the application of ESM to this population are also discussed.     

Minimally invasive approach to cases of lost intra-uterine device: a 7-year experience

Objectives

To evaluate the effectiveness of hysteroscopy and laparoscopy for diagnosis and treatment in women with lost intra-uterine devices (IUDs), and to elucidate the most common extra-uterine locations of lost IUDs.

Study design

Retrospective clinical study at Atatürk University Hospital, Erzurum, Turkey. Women with lost IUDs presenting in the last 7 years were referred to the obstetrics and gynaecology clinics. Women whose lost IUDs were removed using a Novak curette were excluded from the study.

Results

Of the 55 cases studied, 29 (52.7%) lost IUDs were located inside the uterine cavity, 23 (41.8%) were located outside the uterine cavity, and three (5.5%) were embedded in the myometrium. The most common extra-uterine location of lost IUDs was around the uterosacral ligaments (n = 8, 34.7%). Considerable association was found between the position of the uterus and the extra-uterine location of lost IUDs. In all eight cases where the lost IUD was located around the uterosacral ligaments, the uterine position was anteverted and perforation was found on the posterior side of the uterus. IUD removal was performed successfully in 46 women (83.6%) by either hysteroscopy or laparoscopy.

Conclusions

Lost IUDs inside or outside the uterine cavity can be managed by minimally invasive approaches. If an anteverted uterus is seen on laparoscopy, the initial exploration for the lost IUD should be made around the uterosacral ligaments.     

Preliminary experience of ovarian tissue cryopreservation procedure: alternatives, perspectives and feasibility

Chemotherapy and radiotherapy induce premature ovarian failure in many patients treated for oncological or benign diseases. The present paper reviews the risk of developing premature ovarian failure according to the type of treatment and the different options to preserve fertility, focusing on the cryopreservation of ovarian tissue. This technique constitutes a promising approach to preserve the fertility of young patients and offers the advantage of storing a large number of follicles that could be subsequently transplanted or cultured in vitro to obtain mature oocytes. Based on 34 requests, from which 19 were performed, the feasibility of the ovarian cryopreservation procedure is evaluated. The medical and ethical approaches of this protocol are also discussed. Cryopreservation of ovarian tissue constitutes new hope for many patients, but must still be kept for selected cases, with a significant risk of premature ovarian failure after treatments such as bone marrow transplantation.     

Tolerability and cardiovascular complications of outpatient diagnostic minihysteroscopy compared with conventional hysteroscopy

STUDY OBJECTIVE: To assess acceptability and cardiovascular complications of hysteroscopy performed with minihysteroscopes compared with those performed with conventional hysteroscopes. DESIGN: Prospective, randomized clinical trial (Canadian Task Force classification I). SETTING: Academic research center. PATIENTS: One hundred women with abnormal uterine bleeding. INTERVENTIONS: Hysteroscopy with a 3.5-mm minihysteroscope or conventional 5-mm endoscope with no anesthesia. MEASUREMENTS AND MAIN RESULTS: Duration of examinations, pain, and occurrence of vasovagal reactions were recorded. Pain was assessed by visual analog scale ranging from zero to 20 before (pain expectancy) and at the end of the procedure. Occurrence of vasovagal reactions was assessed by monitoring blood pressure and pulse rate at 1-minute intervals during the procedure. A heart rate of less than 60/minute or a reduction greater than 20% compared with baseline was considered a vasovagal reaction; similarly, a reduction in blood pressure exceeding baseline value by 20% was considered a result of vagal stimulation. Mean duration was shorter for minihysteroscopy than for conventional hysteroscopy. The mean (SD) level of pain experienced during minihysteroscopy also was significantly lower (0.76 +/- 0.65 vs 1.46 +/- 0.86, 95% CI-1.0-0.4, p <0.0001). The number of instrumentally recorded (1 vs 11 cases) and clinical vasovagal reactions (0 vs 6 cases) was also significantly lower in the minihysteroscopy group than in the conventional hysteroscopy group (p <0.002 and <0.02, respectively). CONCLUSION: New-generation minihysteroscopes make hysteroscopy easier and less painful, and carry a lower risk of vasovagal reactions than hysteroscopy performed with conventional instruments. In our experience, minihysteroscopy with vaginoscopic approach and saline distention is well tolerated, effective, and a true outpatient procedure.     

Feasibility, morbidity, and safety of total laparoscopic radical hysterectomy with lymphadenectomy: our experience

STUDY OBJECTIVE: The purpose of this study was to retrospectively evaluate, in a series of 65 patients, the feasibility, morbidity, and safety of total laparoscopic radical hysterectomy with lymphadenectomy for early cervical carcinoma. DESIGN: Retrospective, nonrandomized study (Canadian Task Force classification II-2). SETTING: Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy. PATIENTS: Sixty-five nonconsecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage Ia1 with lymphvascular space involvement, Ia2, and Ib1 early cervical cancer. INTERVENTION: Fourteen patients underwent a laparoscopic class II procedure, and 51 patients underwent a class III procedure according to the Piver classification. All the patients underwent total laparoscopic radical hysterectomy with pelvic lymphadenectomy during the study period, and none of the surgeries required conversion to laparotomy. Paraaortic lymphadenectomy is not routinely performed unless suspicious pelvic lymph nodes are confirmed to have metastatic disease on frozen section evaluation. MEASUREMENTS AND MAIN RESULTS: Fifty-six patients had squamous cell carcinoma; 7 patients had adenocarcinomas, and 2 had adenosquamous carcinoma. The mean age was 40.5 years (95% CI 27.7-69.1) and the SD was +/- 7.5. The median weight was 56.2 kg (range 44-75 kg). The median operative time was 196 minutes (range 182-240 minutes), and the surgical margins were free of disease in all cases. The median blood loss was 55 mL (range 30-80 mL). No patient required an intraoperative blood transfusion. The median length of hospital stay was 4 days (range 3-7 days). CONCLUSION: Laparoscopic treatment of cervical cancer offers patients the potential benefits of decreased discomfort with decreased convalescence time, but it should be reserved for oncologic surgeons trained in extensive laparoscopic procedures.     

Office vaginoscopic treatment of an isolated longitudinal vaginal septum: a case report

This case report describes a new treatment of an isolated longitudinal vaginal septum (LVS) by office operative vaginoscopy with a 4-mm rigid hysteroscope in a 27-year-old virgin who reported leukorrhea and recurrent vaginal infections. This technique might represent an effective treatment of an LVS, mostly in patients with an intact hymen. This could allow the inclusion of vaginal lesions among the indications for office endoscopic procedures performed using operative hysteroscopes.     

A randomised comparison of vaginoscopic office hysteroscopy and saline infusion sonography: a patient compliance study

Objective  The purpose of this study was to compare patient discomfort during saline infusion sonography (SIS) and office hysteroscopy performed according to a vaginoscopic approach.
Design  Randomised controlled trial.
Setting  University hospital.
Population  Women with an indication for further investigation of the uterine cavity.
Methods  A total of 100 women randomly allocated to either SIS or vaginoscopic office hysteroscopy in an outpatient clinic.
Main outcome measures  Scores on a visual analogue scale (VAS) for pain and a present pain intensity (PPI) scale, conclusiveness and success rate.
Results  The patients' pain scores on both the VAS and the PPI were lower for SIS when compared with office hysteroscopy ( P < 0.05). However, in cases of severe pain (VAS > 7 or PPI > 2), there was no statistically significant difference between both groups. The success rate, defined as adequate inspection of the cervical canal and uterine cavity, was 94% for SIS compared with 92% for office hysteroscopy ( P = 0.633). SIS, multiparity, shorter procedure time and position of the uterus in anteversion decreased pain scores among women studied.
Conclusions  Both SIS and office hysteroscopy are successful procedures and well tolerated by women. SIS induces significantly less discomfort than office hysteroscopy and should therefore be considered the method of choice.     

Feasibility,accuracy and safety of chorionic villus sampling: a report of 10741 cases

OBJECTIVES: To evaluate the feasibility, accuracy and safety of chorionic villus sampling (CVS). METHODS: Ten thousand seven hundred and forty one singleton pregnancies at risk of chromosome abnormalities (96.3%) and gene disorders (2.8%) were referred from 1990 to 1999 to the fetal medicine unit of a teaching hospital. CVS was performed transabdominally after 11 weeks, using a modified freehand ultrasonographically guided technique by 5 operators. Fetal karyotyping was obtained using a direct method before 1995 and was completed by cell culture after 1996. Failed results, feto-placental discrepancy and fetal loss were assessed. RESULTS: Villi were sampled using extra-amniotic puncture (89.4%) and one sampling-device insertion (92.3%). The mean weight of the specimen was 15.2 +/- 6.0 mg. All attempts at sampling were successful, except eight (0.07%). The number of failed results following direct preparation, cell culture and both methods was 20 (0.19%), 23 (0.21%) and 2 (0.02%), respectively. Light maternal cell contamination occurred in less than 1% of the samplings after microscopic selection of the villi, and never interfered with the assessment of karyotyping. All 3 false-negative results (0.03%) were recorded after direct preparation and 2 were corrected by culture. The rate of chromosomal abnormalities confined to the placenta decreased from 1.08% before 1995 to 0.73% after 1996. True fetal mosaicisms were recorded in 7 cases (0.06%). The rate of fetal loss at <28 weeks was 1.64% in all pregnancies and 1.92% when CVS was performed before 13 weeks. Advanced maternal age was the single factor significantly associated with fetal loss. CONCLUSIONS: CVS was feasible, accurate and safe in our institution, as a result of the increasing experience of the operators and the cytogeneticists.     

Laparoscopic methotrexate treatment of ectopic pregnancy: feasibility, efficacy, safety and intrauterine pregnancy rates.

We set out to investigate efficacy, methotrexate (MTX) plasma concentrations, and toxicity following a single injection of MTX into the gestational site in the treatment of ectopic pregnancy. This was a non-randomised, non-blinded prospective clinical trial. Eighteen women with unruptured tubal pregnancies and in stable haemodynamic condition were studied. MTX 1 mg/kg was injected into the ectopic pregnancy guided by laparoscopy. Serum betahCG levels were estimated before MTX treatment and on days 1, 4 and 13. In 14 patients plasma MTX was determined 1 h and 6 h after the injection. We found an adequate decline in betahCG was achieved in 17 (94%) patients, and tubal surgery avoided in 15 (83%). At 6 hours following drug administration, mean plasma MTX concentration (0.36+/-0.21 microM) was only 12% of mean peak level (3.1+/-1.0 microM). Six (39%) demonstrated slightly elevated, but completely reversible liver enzymes. None reported any subjective adverse effects. At the 4-7 year follow-up nine of 12 (75%) women had delivered healthy babies. It is concluded that intratubal injection of 1 mg/kg MTX appears to be an effective and safe treatment of ectopic pregnancy.     

Posterior IVS: feasibility and preliminary results in a continuous series of 108 cases

OBJECTIVE: We present a continuous series of 108 patients operated for genital prolapse by vaginal route using the Posterior Intravaginal Slingplasty (PIVS) technique (IVS 02 Tyco Healthcare, polypropylene multifilament band), associated to prosthetic repair of cystocele and/or rectocele if present by interposition of a mesh (Surgipro Mesh Tyco Healthcare). PATIENTS AND METHODS: Inclusion criteria were C and/or D point superior to -1 cm. The main criterion is the assessment of feasibility, morbidity and anatomical results obtained for the treatment of level 1 genital prolapse with an average follow-up of 19 months. The secondary criterion is to assess the same elements for the treatment of associated cystocele and rectocele. RESULTS: Seventy-three patients presented with a cystocele (Ba>-1 cm) and eighty-seven with a rectocele (Bp>-1 cm). Nineteen patients had a hysterectomy, twenty had amputation of the cervix and forty-nine were treated for stress urinary incontinence by anterior IVS. Perioperative complications consisted of seven bladder injuries, one injury to the lower rectum during dissection. Postoperative complications were: a loss more than 2 g haemoglobin for seven patients, two haematomas in the cave of Retzius, one haematoma of the pararectal fossa with secondary superinfection requiring mesh removal. Three erosions occurred: two in front of the vesicovaginal prosthesis and one in front of the recto-vaginal prosthesis. The latter became secondarily super infected and had to be removed. With regard to the anatomical result, one failure was noted for the Posterior IVS excluding the two patients in whom the prosthetic material had to be removed. For the anterior compartment, eight failures occurred. From a functional perspective, we noted one case of dyspareunia due to fibrous retraction and seven patients complained of de novo stress urinary incontinence and eight of moderate voiding obstruction. DISCUSSION AND CONCLUSIONS: The technical feasibility is excellent. Feasibility of level 2 repair, anterior or posterior, but results on cystocele are insufficient in case of lateral defect.     

Focused ultrasound treatment of uterine fibroid tumors: safety and feasibility of a noninvasive thermoablative technique

OBJECTIVE: The purpose of this study was to determine the safety and efficacy of focused ultrasound surgery with magnetic resonance imaging guidance for the noninvasive treatment of uterine leiomyomas. STUDY DESIGN: Fifty-five women with clinically significant uterine leiomyomas were treated. Pain and complications were assessed prospectively, and posttreatment magnetic resonance imaging was used to measure the treatment effects. Patients in three of the five centers underwent planned hysterectomy after treatment, which provided pathologic correlation of treatment. RESULTS: Seventy-six percent of the enrolled patients completed the full treatment session. All treatments were conducted in an outpatient setting with minimal discomfort for subjects and no major complications. Pathologic examination of the uterus confirmed that magnetic resonance imaging guidance provides the safe and accurate delivery of effective levels of thermal energy with a 3-fold increase in volume of histologically documented necrosis, compared with treatment volume (6.6 +/- 0.8 vs 18.4 +/- 3.9 mL, P <.005). CONCLUSION: Magnetic resonance imaging-guided focused ultrasound surgery appears to be a well-tolerated treatment for uterine leiomyomas.     

Tibolone in the treatment of menopause: compliance, efficacy and safety in a ten year experience

AIM: To assess tibolone compliance, efficacy and safety in everyday clinical practice a non-randomized, prospective, cohort clinical study was carried out. METHODS: One hundred and fifty post-menopausal women aged 48 to 73 years were prescribed tibolone: 72 of them were treated for 36.4 months, 55 terminated treatment after less than 1 year, while 23 never took the tablets after seeking for menopause counseling and having agreed upon the treatment. We examined: endometrial thickness and histology, total cholesterol, triglycerides, fibrinogen, AST, ALT, gamma-gt, and the body weight. RESULTS: Side effects were the main causes of withdrawal (32%), and insufficient therapeutic effect and adverse events for a small number of cases (5.5% and 4.7% respectively), while various causes (fear of cancer, missing tablets, family doctor or other specialist's advice, remission of symptoms) were responsible for terminating treatment after extended periods. Laboratory findings showed a favorable trend; only the (GT showed slightly higher mean values, although within a normal range. On average, weight during treatment increased of 1.5 kg, and endometrial thickness grew of 1.3 mm in a mean time of 34.5 months of observation. An average of 2.3%/year increase of bone mineral density was reported, though bone mass didn't improve in some patients. CONCLUSIONS: Different causes of terminating treatment are related to the length of treatment, side effects being the main reason for early withdrawals, efficacy on symptoms or medical advice or fear of treatment for extended periods of time. Effectiveness on bone mass, safety as resulting from endometrial thickness and laboratory measures are confirmed. It is suggested to enhance follow-up accuracy and reinforce counseling as measures to improve compliance.