Uterine Fibroids - Current Trends and Strategies
Marcel Grube, Medical Doctor (trainee), Felix Neis, MD, Consultant of Operative Gynecology, Sara Y. Brucker, PhD, Professor of Women’s Health and Gynecology, Stefan Kommoss, PhD, Consultant of Operative Gynecology, Jürgen Andress, MD, Consultant of Operative Gynecology, Martin Weiss, MD, Medical Doctor of Women’s Health and Gynecology, Sascha Hoffmann, MD, Medical Doctor of Women’s Health and Gynecology, Florin-Andrei Taran, PhD, Consultant of Operative Gynecology, Bernhard Krämer, PhD, Deputy Medical Director and Senior Consultant Of Operative Gynecology, University of Tübingen, Tübingen, Germany
34/1118
Fibroids are the most common benign tumors in women of childbearing age and can be found in almost 80-90% of all women by age 50 years. They can cause pain, excessive menstrual bleeding or infertility. The development of fibroids increases with age. Since the age of women in industrial countries who are trying to conceive is generally increasing, there has been a growing demand for minimally invasive and uterine-sparing surgical treatment of fibroids. Whereas the main focus of previous surgical techniques for the treatment of fibroids was enucleation of the tumour with subsequent closure of the uterine incision, modern devices developed over the past decade can destroy fibroids by using ultrasound or radio-frequency without incising the uterine wall. Thus, there is no uterine scar, which would impart a risk of rupture during labour or pregnancy.
This article provides an overview of the latest techniques and devices used for uterine-sparing surgical treatment of fibroids. While laparoscopic myomectomy is still the gold standard, novel laparoscopic and transcervical radiofrequency ablation techniques use low-voltage and alternating current to induce heat in the uterine tissue, which triggers necrosis in fibroids. This enables the removal of multiple fibroids without the need for large incisions in the uterine wall. In addition, we address the benefits and potential risks, as well as the impact on fertility and pregnancy, of the different surgical approaches used for the treatment of uterine fibroids.
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Shared Decision-Making to Improve Patient Engagement in Minimally Invasive Hysterectomy
Steven D. McCarus, MD, FACOG, Chief, Division of Gynecologic Surgery, Florida Hospital Celebration Health, Assistant Professor, University of Central Florida, Founder and Director, McCarus Surgical Specialists for Women, Orlando, Florida, Karen Wiercinski, RN, BSN, Women’s Health & CAPPS, Clinical Care Coordinator, Florida Hospital Celebration Health, Celebration, Florida, Natalie Heidrich, MS, Director, Health Economics and Reimbursement, Edwards Lifesciences, Irvine, California
34/1069
Shared decision-making (SDM) between the patient and physician is receiving increased attention as a way to improve patient satisfaction and value of care. Having a readily implemented tool available to inform conversation may enable SDM at a high-volume gynecologic surgery practice. Our objective was to evaluate the impact of an SDM tool on patients’ decision to have minimally invasive gynecology surgery. We conducted a feasibility study using the SDM tool plus a follow-up survey for 100 patients recommended to undergo minimally invasive hysterectomy. Nearly all patients (97%) indicated that they were satisfied with their decision to undergo a minimally invasive procedure, including laparoscopic total and supracervical hysterectomy with or without the aid of the robotic platform. Anecdotally, patients expressed appreciation for the provided materials and the presentation of care options. For the care provider, use of the SDM tool did not add substantial time to the visit. Knowing that comprehensive information was provided to all patients was reassuring. Implementing a shared decision-making model in a gynecological practice is feasible and increases awareness and engagement, as well as satisfaction, among patients electing to have a hysterectomy.
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Use of Growth Factors for Vulvo/Vaginal Bio-Stimulation
Pablo González Isaza, MD,
Head Chief Urogynecology and Minimally Invasive Surgery Unit,
Department of Obstetrics and Gynecology,
Hospital Universitario San Jorge,
Pereira, Colombia
34/1065
Vulvo-vaginal atrophy as a main symptom of the Genito Urinary Syndrome of Menopause (GSM) is a consequence of aging, particularly after menopause as a result of follicular ovarian follicle depletion and consequently low estrogen levels. Anatomical structures derived from the urogenital sinus, such as the distal urethra trigone and vestibule, are the most affected areas because of the high concentrations of alfa- and beta-estrogen receptors. The most common symptoms associated with vulvo-vaginal atrophy are dyspareunia, vaginal dryness, irritation, recurrent urinary tract infection and urinary incontinence, which negatively affect the patient’s quality of life and sexuality. The purpose of this pilot study was to evaluate a protocol with topical growth factors that seeks to activate collagen and elastin at a molecular level, and thus restore all vaginal functions such as secretion, absorption, elasticity, lubrication and vaginal epithelium thickness.
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Endometriosis of the Bladder: Clinical and Surgical Outcomes after Laparoscopic Surgery
Daniela Reis Gonçalves, MD, Resident of Obstetrics and Gynecology, Ana Galvão, MD, Resident of Obstetrics and Gynecology, Marta Moreira, MD, Resident of Obstetrics and Gynecology, Alexandre Morgado, MD, Associate Professor, Miguel Ramos, MD, PhD, Associate Professor, Hélder Ferreira, MD, PhD, Associate Professor, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal, Centro Hospitalar Universitário do Porto, Porto, Portugal
34/1123
Background/Aims: Urinary tract endometriosis is rare. The bladder is the most common site affected. The nonspecific symptoms can make a diagnosis difficult. The aim of this study was to evaluate the clinical and surgical outcomes in women who underwent surgical treatment for bladder endometriosis (BE).
Methods: Ten patients who underwent surgical treatment for BE from January 2012 to November 2016 were retrospectively reviewed. Pre- and postoperative data, intraoperative findings, type of surgical procedure, and intra- and postoperative complications were analyzed.
Results: Two women were treated by laparoscopic shaving of the bladder lesion and 8 underwent laparoscopic partial cystectomy. Simultaneous resection of coexisting pelvic nodules was performed. No conversions to laparotomy were observed. There was only one intraoperative complication. No major or minor postoperative complications were observed and none of the patients required repeated interventions. Improvements in clinical symptoms were reported and there was no increase in long-term urinary frequency after surgery. There was 1 case of urinary symptom recurrence.
Conclusion: Laparoscopic partial cystectomy and shaving of the bladder lesion seem to improve urinary symptoms, with a low rate of intra- and postoperative complications and a low rate of recurrence, without affecting long-term bladder capacity. This surgical approach requires an experienced gynecologist and urologist team.
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Application of Indocyanine Green in Gynecology: Review of the Literature
Helder Ferreira, MD, PhD, Professor, Head of Minimally Invasive Gynecological Surgery Unit of Centro Hospitalar Universitário do Porto, Instituto de Ciências Biomédicas, Abel Salazar Universidade do Porto, Porto, Portugal, Andres Vigeras Smith, MD, Consultant, Minimally Invasive Gynecological Surgery Unit of Centro Hospitalar Universitário do Porto, Porto, Portugal, Arnaud Wattiez, MD, PhD, Professor, University of Strasbourg, Strasbourg, France, Latifa Hospital, Dubai, United Arab Emirates
34/1127
The present review aims to analyze the current data available on the different applications of indocyanine green (ICG) in gynecology. A semantic review of English-language publications was performed by searching for MeSH terms and keywords in the PubMed and Google Scholar databases. The studies were finally selected by one author according to the aim of this review. ICG is a highly water-soluble tricarbocyanine dye that fluoresces in the NIR spectrum. Approved by the FDA in 1959, it can be administered either IV (usual dose of 5 mg) or locally/submucosally (usual dose of 5-6.25 mg) according to the pathology or indication. It is used most often in the setting of oncology, endometriosis and other gynecological conditions. In oncological applications, ICG is used to identify sentinel lymph nodes (SLN) using near-infrared light in endometrial, cervical and vulvar cancers. The main advantages that it offers include a reduction of surgical time, improved SLN detection rates, and the ability to avoid radioactivity. In cases of endometrial (submucosal or hysteroscopic applications) or cervical (intracervical administration) cancer, ICG can detect SLN at an accuracy of 95% to 98%. For vulvar cancer, the SLN detection rate can reach 100%. In endometriosis, the lack of good evidence hinders the final evaluation of this method in both diagnostic and therapeutic scenarios. An analytical, well-designed, prospective study is currently underway.
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Endometrial Ablation: Past, Present, and Future, Part II
Morris Wortman, MD, FACOG, Director and Clinical Associate Professor of Gynecology, Center for Menstrual Disorders, University of Rochester Medical Center, Rochester, New York
33/1052
Endometrial ablation (EA) is the most commonly performed surgical procedure for the management of abnormal uterine bleeding unresponsive to medical therapy. In well-selected subjects, EA provides a safe, inexpensive, and convenient alternative to hysterectomy with a rapid return to normal function.
The first generation of EA techniques were introduced in 1886 by Professor Sneguireff of Moscow. He was the first to apply super-heated steam to the uterine cavity to vaporize the endometrial basalis. This method—known as atmocausis—was refined by Ludwig Pincus of Danzig in 1895, and he went on to perform over 800 procedures. As the 20th century brought forth other energy sources—electricity, X-ray, radium, and even cryogenics—they were each used, in turn, to accomplish endometrial ablation. In 1981, Dr. Milton Goldrath successfully performed EA by co-locating a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser with a rod-lens hysteroscope to achieve photovaporization of the endometrium. The accomplishment of EA under direct visualization defined the second generation of EA. The challenges and risks of second-generation technology, however, were soon apparent, and though this practice continues today, it appears to be confined to a relatively small number of devoted and highly-skilled sub-specialists.
The late 1990s saw increasing interest in safe, affordable, and easily-mastered EA technology. The result was a return to blind technology but modified with a variety of features that brought unprecedented safety to EA, even permitting its selected in-office application. This third generation of EA techniques and devices has propelled the growth of EA in the 21st century.
Although much has been accomplished in the quest for safe, affordable, convenient, and easily-mastered EA, the future requires refinement of patient selection criteria, management strategies for late-onset endometrial ablation failures (LOEAFs), as well as minimally invasive methods for reducing them.
Vol 32.
Endometrial Ablation: Past, Present, and Future, Part I
Morris Wortman, MD, FACOG, Director, Center for Menstrual Disorders, Clinical Associate Professor Gynecology, University of Rochester Medical Center, Rochester, New York
33/987
Endometrial ablation (EA) is a commonly performed minimally invasive technique to manage intractable uterine bleeding that is unresponsive to medical therapy. It originated in ancient times when chemical astringents were used to control uterine hemorrhage associated with childbirth and a variety of other gynecologic conditions. In the late 19th century, the use of astringents and chemical cauterants gave way to the application of a variety of thermal energy technologies to cause selective destruction of the endometrium. These energy sources—steam, electricity, and even gamma rays—were applied blindly and were, by all accounts, quite effective at a time when hysterectomy was unsafe, infrequent, and generally unavailable.
With the emergence of improved optics and laser and video technology in the late 20th century, a resurgence of interest in endometrial ablation began—coinciding with a time when hysterectomy was commonly performed in developed countries. Endometrial ablation underwent a revolutionary change as physicians searched for new techniques to perform selective endometrial destruction under direct visual—hysteroscopic—control. In this first of a two-part series, we will explore the first and second generations of endometrial ablation to understand how this procedure has evolved into its present status and what issues remain to be solved.
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Three Techniques of Contained Morcellation for the Minimally Invasive Gynecologic Surgeon
James Dana Kondrup, MD, Clinical Assistant Professor, Upstate Medical Center, Syracuse, New York, Conor Grey, Medical Student 4th Year, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
33/984
Since 1993 (and prior, WISAP® [WISAP Medical Technology GmbH, Brunnthal, Germany] hand morcellators), laparoscopic power morcellation has been an indispensably employed technique for minimally invasive gynecologic surgery, contributing both to laparoscopic myomectomies and hysterectomies. However, the technique was highlighted with concern by the FDA for the given potential to disseminate neoplastic and non-neoplastic cells by morcellating an unexpected uterine sarcoma (Fig. 1). Given this concern, many gynecologists are either resorting to performing traditional laparotomies or risking dissemination with uncontained power morcellation techniques. The purpose of this article is to address these concerns by illustrating three techniques to perform contained power morcellation, thereby reaping the benefits of the technique without the disadvantage of possible dissemination of neoplastic cells. The techniques outlined in this article include the use of trans-abdominal mini-laparotomy manual contained morcellation, trans-vaginal manual contained morcellation, and the new Contained Tissue Extraction (CTE) System (Olympus America, Inc., Center Valley, Pennsylvania) for power morcellation.
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McCarus Minimally Invasive Hysterectomy: 20 Years’ Experience—Lessons Learned
Steven D. McCarus, MD, FACOG, Chief, Division of Gynecologic Surgery, Florida Hospital Celebration Health, Celebration, Florida
33/1057
The advancement of surgical innovation for both devices and techniques has directly impacted the number of hysterectomy options available to patients. These advancements have led to an expansion of options that has been exceptionally impactful for minimally invasive surgery. For individuals who are diagnosed with a health condition or disease that requires a hysterectomy, these advances allow the surgeon to consider an expanded variety of procedures that may improve patients’ outcomes and accommodate patient preferences. Automated suturing devices, improved energy systems, specialized mini-laparoscopic tissue handling instruments, and novel uterine manipulators, among other devices, all work together to provide hysterectomy options with cosmetically pleasing results from an aesthetic perspective. They also provide excellent medical outcomes from a surgeon’s perspective. Patients are no longer subjected to large incisional scars from total abdominal hysterectomies that were commonly performed 25 years ago.
All gynecological surgeons are obligated to provide patients with improved hysterectomy options that fit the indications and clinical needs of their patients. As the laparoscopic approach to a hysterectomy became the standard of care for many, variations in technique to successfully perform a laparoscopic hysterectomy has become a major limiting factor for generalists to incorporate this skillset into their practice. Maintaining the same procedural steps as the abdominal approach is one of the major hurdles that makes the transition to a laparoscopic approach more treacherous.
Over 20 years of experience has shaped the McCarus hysterectomy technique described here into a safe and reproducible procedure that prioritizes the patient’s aesthetic preferences while also providing optimal patient outcomes. The implementation of unique devices and instruments further expands the surgeon’s technical skills and augments the procedure to make it an effective and preferable choice.
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The Association Between Hospital Surgical Volume and the Uptake of Minimally Invasive Surgical Approach and Outpatient Setting for Hysterectomy
Emad Mikhail, MB, ChB, MD, FACOG, FACS, Assistant Professor/Minimally Invasive Gynecologic Surgeon, Stuart Hart, MD, Voluntary Faculty, University of South Florida/Morsani College of Medicine, Tampa, Florida, Papri Sarkar, MD, Resident Physician, University of South Florida/Morsani College of Medicine, Tampa, Florida, Marilyn Moucharite, MS, Research Manager, Healthcare Economics and Outcomes Research, Medtronic plc, Minneapolis, Minnesota
33/994
Background: There are large variations in the use of minimally invasive surgery (MIS), and outpatient hysterectomy (OP) among Medicare patients according to hospital surgical volume and geographical distribution.
Objective: To explore the changing trend in OP and MIS hysterectomy in the United States. Study Design: We used all Medicare fee-for-service claims data for 2012 and 2014 to determine the incidence of OP and MIS hysterectomy according to hospital surgical volume and geographical distribution. MIS included both laparoscopy and robotic surgery. OP procedures included only same-day discharge hysterectomies.
Results: A total of 55,562 and 53,054 hysterectomies were performed in the years 2012 and 2014, respectively. OP rate in 2014 in high-volume centers (16,828 [47.1%]) exceeded low-volume centers (136 [16%]) by 31.1% (p<0.001). Time trends between 2014 and 2012 show that a rise in OP rate was 17.7% and 7% for high- and low-volume hospitals (p<0.001), respectively. High-volume hospitals showed an increase of 3.1% (p=0.003) in MIS hysterectomy rate in 2014 (69%) as compared to 2012 (65.9%). There was no change in MIS rate among low-volume hospitals.
Conclusion: In the Medicare population, the rate of OP and MIS hysterectomy for high-volume centers is significantly different form low-volume centers. Over the years, outpatient hysterectomy is being practiced widely but an increase in MIS rate is limited to high-volume centers.
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Intrauterine Pressure During Hysteroscopic Morcellation: A Comparison of Three Commercially-Available Devices
Erica Stockwell, DO, MBA, Director of Innovation and Business Education, David L. Howard, MD, PhD Director of Research, Las Vegas Minimally Invasive Surgery , University of Nevada, Las Vegas School of Medicine Las Vegas, Nevada
33/1048
Study objective: Our objective was to compare intrauterine pressures during resection and aspiration modes among three types of commercially-available hysteroscopic morcellators.
Design: This was a benchtop study (Canadian Task Force level II-1). This study cannot feasibly and ethically be done in-vivo, so an ex-vivo study design was chosen.
Setting: A silicone uterine model was attached to a manometer via tubing, with the tip inside the cavity to allow for intracavity pressure measurements. Each hysteroscopic morcellator was then introduced, and intracavity pressures were recorded every one to two seconds in three modes (static, resection, and aspiration) and at three set point pressures (45, 85, and 125 mmHg).
Patients: No human subjects were involved in this study.
Interventions: None.
Measurements and main results: There were a total of 4,872 pressure measurements during this study across the three devices, over the three modes, and at the three set point pressures combined. Using mixed-effects linear regression, the mean observed intracavity pressure was not greater than the set pressure for each of the three devices. This result held true in both aspiration and resection modes. In our statistical models, the coefficient on the terms representing the interaction between device and time were not statistically significant in either resection or aspiration modes. This indicates that, statistically, the change in intracavity pressure over time was not significantly different across the three devices.
Conclusion: In this first of its kind head-to-head benchtop study, we found that all three commercially-available hysteroscopic morcellators appear to be similar to each other in terms of their abilities to maintain intracavity pressure below the set pressure, which is important in avoiding intravasation in-vivo. These findings are important because many gynecologists do not have the ability to choose between the three available devices on the market at their institution.
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Endometrial Ablation: Past, Present, and Future, Part I
Morris Wortman, MD, FACOG, Director, Center for Menstrual Disorders, Clinical Associate Professor Gynecology, University of Rochester Medical Center, Rochester, New York
32/987
Endometrial ablation (EA) is a commonly performed minimally invasive technique to manage intractable uterine bleeding that is unresponsive to medical therapy. It originated in ancient times when chemical astringents were used to control uterine hemorrhage associated with childbirth and a variety of other gynecologic conditions. In the late 19th century, the use of astringents and chemical cauterants gave way to the application of a variety of thermal energy technologies to cause selective destruction of the endometrium. These energy sources—steam, electricity, and even gamma rays—were applied blindly and were, by all accounts, quite effective at a time when hysterectomy was unsafe, infrequent, and generally unavailable.
With the emergence of improved optics and laser and video technology in the late 20th century, a resurgence of interest in endometrial ablation began—coinciding with a time when hysterectomy was commonly performed in developed countries. Endometrial ablation underwent a revolutionary change as physicians searched for new techniques to perform selective endometrial destruction under direct visual—hysteroscopic—control. In this first of a two-part series, we will explore the first and second generations of endometrial ablation to understand how this procedure has evolved into its present status and what issues remain to be solved.
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Total Laparoscopic Hysterectomy in the Setting of Prior Bilateral Renal Transplant, a Case Report and Review of the Literature
Nupur Tamhane, MD, Research Scholar, Entidhar Al Sawah, MD, Assistant Professor, Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, Emad Mikhail, MB, ChB, MD, FACOG, FACS, Assistant Professor, Minimally Invasive Gynecologic Surgeon, Department of Obstetrics and Gynecology, University of South Florida/Morsani College of Medicine, Tampa, Florida
32/974
In recent years, more women are undergoing renal transplantation as a treatment for end-stage renal disease. Women with kidney transplants are prone to certain gynecologic issues which might necessitate hysterectomy. Laparoscopic hysterectomy can safely be performed in patients with prior unilateral or bilateral renal transplantation. Laparoscopy offers magnification of anatomy, decreased wound-related problems, and continuation of immunosuppression therapy. We present a case report and review of the literature for total laparoscopic hysterectomy and bilateral salpingectomy for a patient with prior bilateral renal transplant.
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Evaluation of the Safety and Efficacy of a Novel Radiofrequency Device for
Vaginal Treatment
Jeffrey C. Caruth, MD, Private Practice, Plano Aesthetics, Plano, TX
32/1000
Introduction: Vaginal laxity and atrophy are caused mainly by aging and vaginal childbirth, which lead to a loss of strength and flexibility within the vaginal wall. As a result, women may experience vaginal, pelvic, sexual and urinary symptoms that significantly affect their quality of life.
Objective: The aim of this study was to evaluate the safety and efficacy of a novel radiofrequency (RF) device for internal and external vaginal treatment.
Methods: Thirty women who had been diagnosed with symptoms of vaginal laxity and pelvic relaxation received a single treatment that consisted of continuous RF in the internal genitalia and continuous RF followed by fractional RF in the external vulva. Three different treatment conditions were examined. The results were evaluated by questionnaires and photos at two months post-treatment compared to baseline.
Results: For all parameters that were scored in the questionnaires, including vaginal symptoms, sexual matters, quality of life, pelvic floor impact and Stress Urinary Incontinence, significant improvements were found at a 2-month follow-up, compared to baseline (p<0.001). No significant or unexpected adverse events were noted.
Conclusions: The present results suggest that this novel RF-based device with continuous and fractional RF technologies is useful, safe and effective for treating vaginal relaxation and atrophy symptoms.
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Successful Treatment of Endometriosis-Related Hemorrhagic Ascites: A Report of Three Cases
Sofia Mendes, MD, Chief Resident, Catarina Carvalho, MD, Chief Resident, Gonçalo Rodrigues, MD, Clinical Assistant, Sónia Barata, MD, Clinical Assistant, Centro Hospitalar Lisboa Norte, Hospital Santa Maria, Lisboa, Portugal, Carlos Calhaz-Jorge, PhD, MD, Chief of Gynecology Department, Obstetrics and Gynecology Department, Centro Hospitalar Lisboa Norte, Hospital Santa Maria, Lisboa, Portugal, Faculdade de Medicina de Lisboa, CAML, Centro Académico de Medicina de Lisboa, Lisboa, Portugal, Filipa Osório, MD, Head of Minimally Invasive Surgery Unit, Hospital da Luz, Minimally Invasive Surgery Department/Obstetrics and Gynecology Department, Centro Hospitalar Lisboa Norte - Hospital de Santa Maria, Lisboa, Portugal
32/992
Endometriosis-related ascites is rare and is frequently confused with an ovarian malignancy. Since it affects women in reproductive age, its diagnosis and therapy are even more challenging. These patients usually present with abdominal distension, pelvic pain, and weight loss, but a careful questioning usually reveals the typical endometriosis symptoms—such as dysmenorrhea and dyspareunia. We present three cases of endometriosis-related ascites, one of them with pleural effusion. All cases were associated with extensive disease and required laborious laparoscopic surgery, medical therapy with gonadotropin releasing hormone analogs, and long-term follow-up. One of the patients delivered twins following an in vitro fertilization (IVF) cycle without recurrence of ascites. We aim to raise awareness toward the importance of considering endometriosis in a patient with ascites of unknown origin.
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Surgical Management After Hysteroscopic Sterilization: Minimally Invasive Approach Incorporating Intraoperative Fluoroscopy for Symptomatic Patients with >2 Essure® Devices
E. Scott Sills, MD PhD, Chairman and Medical Director , Reproductive Research Section, Center for Advanced Genetics, Carlsbad, California , Applied Biotechnology Research Group, University of Westminster, London, United Kingdom, Natalie S. Rickers, LVN, Director of Nursing , Reproductive Research Section, Center for Advanced Genetics, Carlsbad, California , Xiang Li, PhD, Director for Patient Services, Asia, Center for Advanced Genetics, Paralian Technologies, Inc., Mission Viejo, California
32/1016
Objective: To describe a non-hysterectomy surgical technique for symptomatic patients with >2 Essure® (Bayer Healthcare, Whippany, New Jersey) devices. Design: Patients (n=4) presented with sharp pelvic pain, irregular vaginal bleeding, dyspareunia, weight gain, hair loss, fatigue, and/or diffuse skin rash, all of which were absent before undergoing hysteroscopic sterilization (HS). Hysterosalpingogram obtained before surgical excision of contraceptive tubal implants confirmed more than two Essure® devices in all patients. Except for HS-associated complaints, all patients were in otherwise good general health and none had any history of prior pelvic pathology. Hysteroscopy was followed by 5mm triple-port laparoscopic cornual dissection, modified partial bilateral salpingectomy, and foreign body removal under fluoroscopy and/or radiographic guidance. Results: In this group, mean±SD patient age was 41±8yrs and interval between HS and device removal was 6.4±2.7yrs. At the conclusion of each case (mean±SD operative time=179±11min), imaging studies were reviewed by an attending radiologist and verified no retained metal in the abdomen. Conversion to laparotomy, hysterectomy, or blood transfusion was unnecessary for any patients, and all were discharged home within three hours. Their postoperative course continues to be satisfactory. Conclusion: Patients with more than two Essure® devices comprise an unusual group with a complex pelvic foreign body presentation. This is the first report on surgical management for such patients, underscoring the importance of localizing these contraceptive devices with careful imaging before, during, and after surgery. Moreover, hysterectomy is not absolutely mandatory in this setting and intraoperative fluoroscopy/radiography can facilitate complete, safe removal of all implants on an out-patient basis. Creation of ICD-10 modifiers for various post-HS complaints would allow for improved surveillance of the Essure® phenomenon.
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A Simplified Novel Approach for Total Laparoendoscopic Single-Site (LESS) Hysterectomy
Emad Mikhail, MB, ChB, MD, FACOG, FACS, Assistant Professor, Minimally Invasive Gynecologic Surgeon, Elisabeth Sappenfield, MD, Assistant Professor, Allison Wyman, MD, FACOG, Assistant Professor, Female Pelvic Medicine and Reconstructive Surgery, Stuart Hart, MD, MBA, MS, FACOG, FACS, Voluntary Faculty, Division of Female Pelvic Medicine and Reconstructive Surgery, University of South Florida/Morsani College of Medicine, Tampa, Florida, Director, Global Medical Affairs, Medical Director, Colorectal & Gynecologic Health, Medtronic PLC, Minneapolis, Minnesota
Total laparoendoscopic single-site (LESS) hysterectomy is a technically challenging minimally-invasive gynecologic procedure. Multiple technological innovations assist surgeons to overcome the challenges that are usually encountered during this advanced approach. Simplifying the steps of this advanced surgery is an invaluable addition in overcoming associated challenges with this procedure. We present our novel technique for a total laparoscopic hysterectomy that will optimize a single-site approach (LESS) for surgeons.
31/903
2-08-2017
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Laparoscopic Excision of an Unusual Presentation of a Nabothian Cyst: Case Report and Review of the Literature
Joseph Nassif, MD, MBA, Associate Professor, Hasan Nahouli, Research Assistant, Faculty of Medicine, Ali Mourad, MD, Resident, Ryan Yammine, BS(C), Ali Khalil, MD, Professor, Obstetrics and Gynecology Department, American University of Beirut Medical Center, Beirut, Lebanon, Sally Khoury, MD, Obstetrician and Gynecologist, Bikhazi Medical Group, Trad Hospital Medical Center, Beirut, Lebanon
Nabothian cysts are mucinous retention cysts formed through the accumulation of cervical mucus inside blocked cervical crypts leading to non-neoplastic mucinous cystic lesion in relation to the uterine cervix. The formation of Nabothian cysts is a common gynecological benign condition in women of reproductive age. While the presence of small-sized Nabothian cysts is usually clinically asymptomatic and requires no treatment or intervention, the diagnosis of larger Nabothian cysts can be mistaken with malignant tumors, including mucin producing carcinomas such as Adenoma malignum.
In this study, we report the case of a large Nabothian cyst that was correctly diagnosed preoperatively using ultrasonography and magnetic resonance imaging (MRI), and successfully treated through laparoscopic excision, avoiding the performance of unnecessary hysterectomy.
A 44-year old Lebanese patient presented with chronic dyspareunia and pelvic pain. An ultrasound was performed and revealed an 8cm multiloculated anechoic pelvic cystic lesion with no solid components. An MRI was performed and showed an 8cm mass lateral to the right vaginal wall, suggestive of a Nabothian cyst. The patient was scheduled for laparoscopic removal of the Nabothian cyst. The patient tolerated the procedure well and was discharged under stable condition a few hours after the operation.
Careful preoperative examination, including the use of imaging methods such as ultrasonogoraphy and MRI, is crucial for diagnosis and differentiation of atypical presentation of benign, but large and complex, Nabothian cysts from other differential conditions of malignancies, consequently avoiding unnecessary hysterectomy. Use of laparoscopy as a minimally-invasive technique to excise such cysts is considered a valid option, allowing for a fast recovery for the patients.
31/907
24-11-2017
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Polypropylene Mesh Sling for Stress Urinary Incontinence: Does Memory Shaping of the Polypropylene Mesh Matter?
Andrew Doering, MD, Obstetrician/Gynecologist, Mt. Carmel Health System, Columbus, Ohio, Ali Azadi, MD, MSc, MBA, Urogynecologist, Pelvic Health Center, St. Vincent Hospital for Women & Children, Evansville, Indiana, David Doering, MD, Assistant Medical Director, Norton Cancer Institute, Louisville, Kentucky, Donald R. Ostergard, MD, Professor-in-Residence, UCLA School of Medicine, Harbor/UCLA Medical Center, Torrance, California
We report a case of a mid-urethral sling (Advantage Fit™, Boston Scientific Corporation, Marlborough, Massachusetts) freshly removed from its original package. Upon removal from the packaging, the sling was noted to have a deformation in positioning at the midpoint, with curvature opposite the natural curve of the sling in the body. The images show the comparison to a sling with the desired positioning. Mid-urethral slings are commonly made from polypropylene mesh which has memory properties. It is important that manufacturers ensure that any steps in the processing or packaging of slings do not result in changes in the shape of the sling that may have unknown impacts on its clinical outcome.
31/941
6-12-2017
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