Abstract


The development of adhesions after gynecologic surgery is a severe problem with ramifications that go beyond the medical complications patients suffer (which most often include pain, obstruction and infertility), since they also impose a huge financial burden on the health care system and increase the workload of surgeons and all personnel involved in surgical follow-up care. Surgical techniques to avoid adhesion formation have not proven to be sufficient and pharmaceutical approaches for their prevention are even less effective, which means that the use of adhesion prevention devices is essential for achieving decent prophylaxis. This review explores the wide range of adhesion prevention products currently available on the market. Particular emphasis is put on prospective randomized controlled clinical trials that include second-look interventions, as these offer the most solid evidence of efficacy. We focused on adhesion scores, which are the most common way to quantify adhesion formation. This enables a direct comparison of the efficacies of different devices. While the greatest amount of data are available for oxidized regenerated cellulose, the outcomes with this adhesion barrier are mediocre and several studies have shown little efficacy. The best results have been achieved using adhesion barriers based on either modified starch, i.e., 4DryField® PH (PlantTec Medical GmbH, Lüneburg, Germany), or expanded polytetrafluoroethylene, i.e., GoreTex (W.L. Gore & Associates, Inc., Medical Products Division, Flagstaff, AZ), albeit the latter, as a non-resorbable barrier, has a huge disadvantage of having to be surgically removed again. Therefore, 4DryField® PH currently appears to be a promising approach and further studies are recommended.

Abstract


This prospective study aimed to assess the efficacy of a transdermal CO2 gel in promoting regeneration in the vulvovaginal area in postmenopausal women experiencing symptoms as part of genitourinary syndrome of menopause (GSM). Transdermal carboxytherapy refers to the application of CO2 through the skin’s superficial layer, which is intended to increase oxygenation (through the Bohr effect) and angiogenesis, thus helping to reduce symptoms of GSM. In this study, 20 women with moderate or severe signs or symptoms of vulvovaginal atrophy were randomized to receive either transdermal CO2 therapy (n=10) or a placebo gel (ultrasound gel, n=10). The gels (transdermal CO2 gel or the placebo) were applied by the patients at home. The gels were applied in two treatment cycles (10 days of total treatment). Each cycle involved daily applications of the gel to the vulvovaginal area, from Monday to Friday, with no application on weekends. The Female Sexual Function Index (FSFI) and Day-to-Day Impact of Vaginal Aging (DIVA) questionnaires were used to gather standardized information, and biopsy samples were obtained from the vagina and vulva for histological analysis, both on the first day of treatment and 10 days after the final application of gel. Patients who received the transdermal CO2 gel showed significant improvements on the FSFI and DIVA questionnaires and the biopsies revealed that the CO2 gel had a regenerative effect on vulvovaginal tissues.

Abstract


The introduction of the continuous flow gynecologic resectoscope (CFGR) in 1989 revolutionized minimally invasive gynecologic surgery (MIGS) by introducing such intrauterine procedures as hysteroscopic myomectomy, polypectomy, and endometrial ablation. However, with the subsequent introduction of global endometrial ablation (GEA) devices and hysteroscopic morcellators (HMs), the CFGR has fallen into relative disuse—a regrettable situation since it remains ideally suited for accomplishing many procedures that are otherwise not achievable with these newer technologies. Procedures which involve greater precision and control—endomyometrial resection (EMR), hysteroscopic metroplasty, the correction of isthmoceles, the resection of intramural myomas, and the management of late-onset endometrial ablation failure—are only possible with the CFGR. In addition, the CFGR permits a variety of functions that would otherwise require several different disposable platforms.
Despite the benefits of the gynecologic resectoscope, there are clear impediments to its use including a scarcity of educational resources and trained experts, medico-legal concerns, institutional obstacles to organizing an operative team, and the need to develop and maintain an adequate caseload.
In Part I of this three-part series, the author will review why the CFGR remains a relevant and indispensable tool for the minimally invasive gynecologic surgeon, the composition of an operating room team, and the instrumentation and skills necessary to accomplish basic resectoscopic surgery. In Part II, we will describe how ultrasound guidance can be used to assist the execution of more challenging intermediate-level cases. Finally, in Part III, we will discuss the most demanding cases for the resectoscopic surgeon—the treatment of post-ablation failures and the removal of intramural leiomyomas—which are clinical scenarios that require ultrasound guidance and well-honed resectoscopic surgical skills.