Gynecological Surgery

The aim of this retrospective clinical study was to compare the effectiveness and long-term anatomic and functional results of the modified laparoscopic Vecchietti and modified McIndoe techniques used to treat Rokitansky syndrome. Neovaginas were created either with the modified laparoscopic Vecchietti technique or with the modified McIndoe technique in 21 patients with Rokitansky syndrome aged between 17 and 40 years (mean 23 years) who wished to begin sexual intercourse. Anatomic success was defined as a neovagina longer than 6 cm and the easy introduction of two fingers. Functional success was achieved if the patient reported satisfactory sexual intercourse starting from 6 months after surgery. The performance of both techniques was efficacious. However, the postoperative hospital stay and operation times of the modified laparoscopic Vecchietti technique were shorter than those of the modified McIndoe technique and the modified laparoscopic Vecchietti technique was less painful than the modified McIndoe technique.

In this paper, we aim to describe the clinical features and treatment outcome following the laparoscopic treatment of endometriosis in teenagers and adolescents. This is a retrospective review of girls aged 21 and below who underwent operative laparoscopy for endometriosis. We identified two groups: (1) the EMAT group, being those who underwent their primary laparoscopic surgery under the Endometriosis and Minimal Access Therapy team (EMAT), and (2) the non-EMAT group, consisting of those referred to the EMAT team with recurrent symptoms following primary operative laparoscopy by other gynaecologists. Symptom recurrence and the need for re-operation was compared between the two groups. Twenty-eight girls, age range 15–21 years, were identified. All had pelvic pain unresponsive to the pill and non-steroidal anti-inflammatory drugs (NSAIDs). Most disease was atypical, with the uterosacral ligaments and ovarian fossae being the most common sites. The re-operation rate per surgical team at 24 months was 14.2% for the EMAT group vs. 42.8% for the non-EMAT group. All recurrences in the non-EMAT group coincided with the location of primary disease. Disease recurrence occurred most commonly in the uterosacral ligaments. Endometriosis in teenagers is mainly atypical and, in our series, commonly affects the uterosacral ligaments. Disease in this location is deeply infiltrating and is usually not amenable to electrocoagulation. We advocate disease resection to minimise recurrence.

The incidence of adnexal masses, due to large use of ultrasound during pregnancy, has considerably increased during last years. Large percentage of ovarian masses found during pregnancy consists in simple cysts and they tend to disappear spontaneously during pregnancy. There are still a percentage of masses that persist in second and third trimester that need to be monitored and, sometimes, surgically removed. If the mass increases in size, sometimes, it is itself an indication for delivery via cesarean section. Keeping in mind that adnexal masses diagnosed in pregnancy are generally benign, it is essential to consider that ovarian cancer still represents the second gynecological tumor for incidence after cervical cancer during pregnancy. Most patients are clinically asymptomatic and diagnosis is often a random finding during scheduled ultrasound for pregnancy follow-up. Sometimes, the finding of an ovarian mass requires other imaging technique such as magnetic resonance imaging. Computed tomography is avoided during pregnancy due to negative effects on fetus. Treatment option should be discussed and a multidisciplinary approach is required to set ad individualized plan, considering both mother and fetus. Sometimes the differential diagnosis between benign masses and malignancy is not feasible only through imaging, so that surgical intervention with histological examination is mandatory, even during pregnancy. Plus, although ovarian cyst torsion, hemorrhage, or rupture is uncommon in pregnancy, some women may require emergency surgery for these complications. Until 90s pregnancy was considered an absolute contraindication for laparoscopy, but nowadays both open surgery and laparoscopy can be performed considering mass diameter, gestational age, and surgical expertise. Emerging data are indeed confirming the advantages of laparoscopic surgery compared with laparotomy in term of recovery and need for medical care. The purpose of this review is to assess the incidence of adnexal masses during pregnancy and examine their impact on obstetric outcomes.

Congenital uterine anomalies may cause various reproductive problems, including difficulty performing vaginal surgical termination of pregnancy (TOP). We report the case of a 35-year-old woman with a uterus bicornis bicollis (a double, partially fused uterus with two cervices and a vaginal septum), who was requesting termination of pregnancy following two failed attempts at vacuum aspiration. Flexible hysteroscopy, in combination with trans-abdominal ultrasound, was used to facilitate the correct passage of the dilators during a successful dilatation and evacuation (D&E) followed by insertion of intra-uterine progestogen-only contraceptive system (‘Mirena’). On review of the literature, we found no similar cases reported.

This study aims to estimate the safety, efficacy, and patient acceptability of adding vaginoscopic office hysteroscopy (VOH) to the routine infertility diagnostic work-up for evaluation of the endometrial cavity. This study is a prospective comparative diagnostic trial. This study was conducted in a tertiary care referral facility and university hospital. This study comprised a total of 156 infertile patients scheduled for laparoscopy. Seventy-eight patients had VOH on one stop bases in addition to the usual infertility work-up and were assigned as group B while a similar number was examined by the usual diagnostic work-up and assigned as group A. The main outcome measure is the diagnostic accuracy of VOH alone in comparison to hysterosalpingography (HSG) and diagnostic laparoscopy (DL) and assessment of combined VOH and HSG in diagnosing intrauterine abnormalities. There was insignificant difference between both groups regarding socio-demographic and HSG data. Abnormal DL findings were more significant in group A. VOH detected 50 % abnormal endometrial cavity in group B with a significant superiority over HSG. There was a high percentage of agreement in the diagnosis of uterine abnormalities between HSG and VOH (96 %). Generally, VOH was an acceptable procedure with mild pain and feasible in most cases. Adding VOH to the routine diagnostic work-up of infertile couples prior to laparoscopy seems to be a feasible, safe, simple, tolerable, and quick outpatient procedure. It can diagnose intrauterine abnormalities in about a quarter of infertile women with normal HSG. VOH has an additional value to HSG and DL in diagnosing uterine. Nevertheless, whether its use would increase pregnancy rate among infertile women requires a further longitudinal comparative study.

This was a single-site cohort study to evaluate the safety of a new transcervical device (VizAblate™) combining real-time intrauterine sonography with radiofrequency (RF) ablation for the treatment of fibroids. Nineteen women with uterine fibroids received treatment with the VizAblate System in a closed abdomen setting prior to hysterectomy. Twelve of these subjects underwent an immediate abdominal hysterectomy after radiofrequency ablation (acute group), while the remaining seven underwent hysterectomy on post-ablation days 16 and 17 (subacute group). Uteri were sectioned and stained with the viability stain triphenyltetrazolium chloride (TTC) to quantify fibroid ablation dimensions and assess the serosa for thermal injury. Subjects in the subacute group were treated with the VizAblate System under conscious sedation; they provided pain and tolerability data for the interval from ablation through hysterectomy, and indicated overall procedural satisfaction. Twenty-two ablations ranging from 1.8 to 36.2 cm3 were created among 19 subjects within 20 fibroids and one region of adenomyosis. There were no complications or thermal serosal injury. For subjects in the subacute group receiving one ablation, the mean total procedure time was 25.8 ± 6.0 min (range 18–32 min). All subjects in the subacute group were discharged within 2 h of the VizAblate procedure. For fibroids ≤ 5 cm, 67.2% ± 27.0% of the fibroid volume was ablated (range 15–100%; median 75%). Transcervical RF ablation of fibroids under intrauterine sonographic guidance with the VizAblate system can be accomplished with a high degree of reliability and without adverse events.

In April 2004 junior members of the British Society for Gynaecological Endoscopy met in Gloucester to discuss training in miminal access surgery in the United Kingdom. The following letter is a consensus of the trainees’ opinions.