Hysteroscopic myomectomy using bipolar energy: a gold standard?

In recent years, hysteroscopic resection has become the treatment of choice for submucous fibroids. Technological advances enabled the use of bipolar resectoscopes, in the same way as new bipolar instruments used in laparoscopy or open surgery. Bipolar systems would be expected to eliminate the risks of hyponatremia and electrical burns. In evaluation studies, bipolar energy used in operative hysteroscopy is as effective in comparison with the unipolar system. However, no clinical study has yet shown increased reliability of bipolar resection to consider their use as a gold standard. Outpatient operative hysteroscopy is now developing rapidly with the introduction of bipolar energy and small-diameter endoscopes. Although the financial impact is unknown, It allows time saving with maximal safety, avoiding cervical dilatation and anesthetic procedures.     

Is three-dimensional ultrasonography of additional value in the assessment of adnexal masses?

OBJECTIVE: Patient characteristics, CA125 level and two-dimensional (2D) ultrasonography can be used to predict the probability of malignancy of an ovarian mass. Three-dimensional (3D) ultrasonography might also contribute to the prediction of malignancy. We evaluated whether addition of 3D features to a diagnostic model could improve the discriminative capacity of the model. METHODS: This multicenter prospective study was approved by the institutional review board. Women with an adnexal mass scheduled for surgery underwent 2D and 3D ultrasonographic examination in the week prior to surgery. Stepwise logistic regression was used to construct two models for the prediction of malignancy: a model based on patient characteristics, level of CA125 and 2D ultrasonography and a second model based on patient characteristics, level of CA125, 2D and 3D ultrasonography. Receiver operator characteristic (ROC) curve analysis was used to compare the capacity of the two models to discriminate between benign and malignant adnexal masses. RESULTS: We included 181 women with an adnexal mass, of which144 were benign and 37 showed malignancy on histopathology. The 3D model discriminated better between benign and malignant adnexal masses than the 2D model (areas under the ROC curve of 0.92 and 0.82, respectively, p=0.02). The calibration of both models was good. CONCLUSION: In the assessment of the ovarian mass, the use of 3D ultrasonography significantly improves the prediction of malignancy as compared to patient characteristics and 2D ultrasonography.     

Should adnexal mass size influence surgical approach? A series of 186 laparoscopically managed large adnexal masses

Objective  To evaluate the feasibility and safety of laparoscopic management of adnexal masses ≥10 cm in size.
Design  Prospective cohort study.
Setting  Two Gynecology Departments of University Hospitals.
Population  All women presenting with an adnexal mass ≥10 cm in diameter were candidates for laparoscopic management. Women were excluded from laparoscopic approach if there was evidence of ascites or gross metastatic disease. Neither the sonographic features of the cyst nor elevated serum CA125 level was used to exclude women from having a laparoscopic approach.
Methods  A single operative protocol was followed for all women. All removed specimens were sent for immediate pathological evaluation.
Main outcome measures  Rate of conversion to laparotomy, incidence of cancer encountered, and operative complications.
Results  One hundred and eighty-six women underwent laparoscopic evaluation for an adnexal mass of 10 cm or larger in size. The average preoperative mass size was 12.1 ± 4.9 cm. A benign pathological condition was found in 86.6% (161/186) of the women, primary ovarian cancer in 16 (8.6%) women, a metastatic tumour of gastrointestinal origin in 1 (0.5%) woman, and a low malignant potential ovarian tumour in 8 (4.3%) women. Laparoscopic management was successful for 174 (93.5%) women. Reasons for conversion to laparotomy included anticipated technical difficulty ( n = 7) and malignancy ( n = 5). No intraoperative complications occurred in the entire study group.
Conclusions  The vast majority of large adnexal masses can be safely resected laparoscopically, provided that there is expertise in laparoscopic surgery, immediate access to frozen section diagnosis, and preparation of patient to receive an adequate cancer surgery where indicated.     

Recombinant follicle-stimulating hormone: gold standard or not?

Recombinant follicle stimulating hormone has been available now for almost 10 years and many couples have benefited from its use. Its clinical efficacy, purity and safety profile have been extensively documented in numerous publications. Because of growing public concerns on the safety of gonadotrophins extracted from human urine, the future will lie in the recombinant technology, which will also enable the design of more convenient tailor-made gonadotrophins.     

Laparoscopic management of a pelvic retroperitoneal leiomyoma—case report

Leiomyomas are benign tumors frequently found in the fourth and fifth decades of life. Although the uterus is the most common site of origin of leiomyomas, they can develop at any site where there is smooth muscle cell. Extrauterine leiomyomas are not common and usually their diagnostic are more challenging. In this paper, we report one case of pelvic retroperitoneal leiomyoma associated to vulvar/perineal leiomyomas. A 47-year-old female patient presented with a 6-month history of deep dyspareunia, abdominal pain, dysuria, and pain during defecation. She had a previous history of two open myomectomies, a supracervical hysterectomy associated to the exeresis of a vulvar leiomyoma, and a left salpingo-oophorectomy. On vaginal examination, there was a tender and firm mass at the vaginal vault and along the posterior vaginal wall. There was another tumor at the left vulvar/perineal region measuring around 6 cm. Magnetic resonance imaging demonstrated the presence of a mass at the Douglas pouch measuring 14 × 10 × 10 cm suggestive of uterine leiomyomatosis. She underwent a successful laparoscopic resection of the pelvic tumor with an operative time of 210 min. The vulvar/perineal lesions were resected by vaginal approach. She presented an uneventful postoperative course and was discharged home 3 days after surgery. Histopathology confirmed the diagnosis of leiomyomas. Laparoscopic approach for pelvic retroperitoneal leiomyoma is feasible. It is important to keep in mind the possibility of this entity as a differential diagnosis of retroperitoneal masses in women.     

Should we consider integrated approach for endometriosis-associated infertility as gold standard management? Rationale and results from a large cohort analysis

Purpose

To evaluate reproductive and maternal–fetal outcomes after integrated approach for endometriosis-associated infertility (EAI).

Methods

We retrospectively analyzed reproductive and maternal–fetal outcomes of 277 women affected by EAI, subdividing patients in two groups: in the first one (surgery group), we included all women who underwent laparoscopic surgery for EAI; in the second one (integrated group), we included women who failed to conceive spontaneously after surgery within 6–12 months and underwent in vitro fertilization and embryo transfer (IVF). We evaluated delivery rate (DR), maternal and neonatal outcomes of the first pregnancies, and, finally, the type (spontaneous or IVF) of subsequent pregnancies.

Results

We did not find significant difference regarding DR between surgery and integrated groups. We found significantly lower birth weight (p < 0.001) and gestational age at delivery (p < 0.001) in integrated group respect to surgery group; conversely, we found higher rate of preterm birth (p < 0.001), small for gestational age (p = 0.003), and admission to the neonatal intensive care unit (p < 0.001) respect to surgery group. Finally, 92 women became pregnant for the second time: 8% were spontaneous and 20% were IVF pregnancies.

Conclusions

We suggest the integrated approach as gold standard treatment for carefully selected patients (young, good ovarian reserve, partner with normal semen parameters) affected by EAI. As consequence, IVF should be reserved as the secondary treatment for women who fail to conceive spontaneously after surgery within 6–12 months, since it is able to increase DR significantly.

     

Is intrapartum fetal blood sampling a gold standard diagnostic tool for fetal distress?

Objective

To assess the impact of pre-pregnancy counselling (PPC) on the health of diabetic women in early pregnancy as compared to their health at the time of PPC.

Study design

Retrospective cohort study involving all the diabetic women who attended PPC and subsequently become pregnant in the decade 1997-2007. The proforma had two sections: one for the PPC visit and one for the booking visit. Details on demographic factors, control and complications of diabetes, folic acid, current medication, weight, contraception, smoking and alcohol consumption were documented.

Results

Fifty-seven women who became pregnant after PPC were studied. There was optimisation of diabetic control with a significant reduction in HbA1c levels at booking as compared to PPC (7.5% vs 8.8%, p < 0.0001). Diabetic surveillance (retinopathy and nephropathy screening) was up to date at the time of booking in >80% of the cases. Alteration of insulin regimes was undertaken in ∼1 in 5 women. Folic acid was taken by most patients (48/54) at booking. There was no significant reduction in the number of women who smoked at booking compared to PPC.

Conclusion

The effect of PPC was evident in the improvements in the markers of health of diabetic women in early pregnancy compared to at the time of PPC.     

Laparoscopic management of ectopic pregnancies: a comparison between interstitial and “more distal” tubal pregnancies

Background/aims

Laparoscopy is an established, safe, and feasible management option for tubal pregnancies, even in women with significant hemoperitoneum. In case of interstitial pregnancy, however, a laparoscopic surgical approach is still a matter of debate. The objective of this study is to evaluate the safety and feasibility of a laparoscopic approach to interstitial pregnancies.

Methods

A total of 92 women with ectopic pregnancy who underwent a surgical management from April 2009 to August 2015 were reviewed. Clinical and surgical outcomes of confirmed interstitial pregnancies (n = 10) (IP group) were compared with those of “more distal” tubal pregnancies (n = 79) (TP group).

Results

Although there were no differences between the two groups in gestational age, ß-hCG values were significantly higher in the IP group (p = 0.005). All patients with IP were treated by laparoscopic wedge resection. The rate of surgical complications (p = 0.413) and subsequent MTX treatment (p = 0.531) were not significantly different between groups. Operating room (OR) time (p = 0.007) was higher in the IP than in the TP group. After stratification for the presence of hemoperitoneum this difference remained, with patients in the IP group having longer OR time (p = 0.034) and additionally higher intra-operative blood loss (EBL) (p = 0.013). On the other hand, in the absence of hemoperitoneum no differences between the two groups were observed.

Conclusions

In experienced hands, the laparoscopic management of interstitial pregnancies seems to be as safe and feasible as that of other tubal pregnancies. However, it could be technically more challenging, especially in case of hemoperitoneum.

     

What is the gold standard for intrapartum fetal monitoring?

The health authorities of Stockholm county recently published a Health Technology Assessment report: "Fetal monitoring with computerized STAN analysis during labor - a systematic review" with the aim to ensure that high quality research information on costs, effectiveness and broader impact of health technologies is analysed and presented in the most efficient way for those who use, manage and work in this field. The report claims to analyse available research in relation to ST interval analysis of fetal electrocardiogram (STAN) and concludes that scientific evidence for advantages of the STAN technology for maternal and fetal outcome was insufficient and that clinical use cannot be recommended and should be restricted to research protocols. The Norwegian reference group for fetal surveillance points out that the report suffers from two insufficiencies: selection bias by not providing a complete collection of the evidence for the clinical performance of the STAN technology and, secondly, that it does not provide evidence-based alternative methods.     

Laparoscopic excision of ovarian cysts: is the stripping technique a tissue-sparing procedure?

OBJECTIVE: To determine whether the stripping technique by laparoscopy is a tissue-sparing procedure. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Forty-two women, 21 to 35 years of age, who had a unilateral ovarian cyst (26 endometriomas, 7 serous, 6 dermoid, and 3 mucinous cysts). INTERVENTION(S): Laparoscopic excision of ovarian cysts by using the stripping technique. MAIN OUTCOME MEASURE(S): Histologic analysis of the excised specimens was done to evaluate the presence and nature of ovarian tissue adjacent to the cyst wall. RESULT(S): Recognizable ovarian tissue adjacent to the cyst wall was present in 15 of 42 excised specimens (36%). A significant difference was present for endometriomas versus non-endometriosis cysts (ovarian tissue was present in 14 of 26 specimens [54%] vs. 1 of 16 specimens [6%]; P<.005). No specimen showed the normal follicular pattern observed in healthy ovaries. CONCLUSION(S): The stripping technique appears to be a tissue-sparing procedure. In 36% of the cysts, ovarian tissue is excised together with the cyst wall, but this tissue does not show the morphologic characteristics observed in normal ovarian tissue.