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   Table of Contents - Current issue
October-December 2022
Volume 11 | Issue 4
Page Nos. 193-258

Online since Monday, November 7, 2022

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How can we improve gynecological surgery webinars during the COVID-19 pandemic? Highly accessed article p. 193
W S Felix Wong, Thomas Kwok To Li
The COVID-19 pandemic prevented doctors from attending surgical meetings or conferences where they learned surgical skills from others and shared surgical experiences. It also resulted in the rapid use of webinars in obstetrics and gynecology meetings. While webinars or virtual meetings enable distance learning and replace face-to-face meetings using various teleconferencing software programs, many attendees are not satisfied and find it difficult to learn surgical techniques using commercially available telecommunication programs. Therefore, dedicated webinars are necessary to present emerging surgical technologies, satisfy the attendees, and achieve a successful outcome. This article reviews the existing telecommunication programs, new presentation technologies, and proposed webinars developments to improve its delivery of surgical techniques and training during the COVID-19 pandemic and in the future.
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Ulipristal acetate in adenomyosis p. 198
Manuel Gonçalves-Henriques, António de Pinho, Marília Freixo, Maria Liz-Coelho, Fabiana Castro, Nathan Ceschin, Pedro Brandão
Adenomyosis is defined as the invasion of the basal endometrium (stroma and glands) into the underlying myometrium. It may lead to abnormal uterine bleeding (AUB), pelvic pain, and infertility. The definitive treatment is hysterectomy. Some conservative measures have been used in patients willing to procreate. Ulipristal acetate is a selective progesterone receptor modulator used to treat AUB caused by leiomyomas. This is a systematic review on the use of ulipristal to treat adenomyosis. Eight eligible articles were retrieved from PubMed, SCOPUS, and Cochrane Library. Only one randomized clinical trial was published until date concerning this matter. It seems that ulipristal acetate induces partial or complete remission of AUB caused by adenomyosis, but the evidence concerning its effect on pelvic pain and the radiologic findings of the disease is conflicting. Nevertheless, given the paucity of data, it is still preliminary to draw any conclusion about the subject.
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Comparative Evaluation of Preoperative Imaging and Postoperative Histopathology in 108 Patients Who Underwent Laparoscopic- or Robot-Assisted Surgery for Endometrial Cancer p. 203
Noriko Terada, Motoki Matsuura, Shoko Kurokawa, Mizue Teramoto, Masamitsu Hanakenaka, Tsuyoshi Saito
Objectives: The aim of this study was to compare preoperative imaging evaluation results and postoperative histopathology examinations of patients who underwent laparoscopic- or robot-assisted surgery for suspected Stage IA endometrial carcinoma. Materials and Methods: There were 298 patients diagnosed with endometrial cancer at our institution between April 2014 and March 2019. Preoperative imaging evaluation based on magnetic resonance imaging (MRI) and computed tomography (CT) revealed 180 patients suspected of having Stage IA disease. Of these, 72 underwent open surgery, 12 underwent robot-assisted surgery, and 96 underwent laparoscopic surgery. In this study, preoperative imaging evaluation results and postoperative histopathology examinations of 108 patients who underwent laparoscopic- or robot-assisted surgery were retrospectively compared. Results: Of the 108 patients, who underwent laparoscopic- or robot-assisted surgery for suspected Stage IA disease, 98 had Stage IA, two had Stage IB, and four had Stages II and III disease. The sensitivity of imaging evaluations based on preoperative MRI and CT was 90.7%. Conclusion: Utilizing preoperative MRI and CT imaging resulted in a high rate of successful diagnosis of Stage IA endometrial carcinoma.
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Intrauterine levobupivacaine instillation for pain control in women undergoing diagnostic hysteroscopy p. 209
Tamer E El-Ghazaly, Ibrahim A Abdelazim, A Elshabrawy
Objectives: Many women experience pain and discomfort after hysteroscopic procedure. Pain and discomfort after hysteroscopic procedures can be explained by the cervical dilatation, intrauterine manipulation, and/or hydrodistension. This study designed to evaluate the efficacy of intrauterine levobupivacaine instillation for pain control in women undergoing diagnostic hysteroscopy. Materials and Methods: One hundred and twenty (120) women scheduled for diagnostic hysteroscopy and endometrial biopsy due to uterine bleeding were included in this study and randomized either to levobupivacaine group or controls. At the end of hysteroscopy, 5 mL of 0.5% levobupivacaine was instilled intrauterine in levobupivacaine group, while 5 mL of 0.9% saline was instilled intrauterine in controls. Participants were kept in the hospital for 12 h after diagnostic hysteroscopy to detect the postoperative (PO) pain intensity using visual analog scale (VAS), and PO required analgesics. Results: The VAS was significantly lower in levobupivacaine group compared to controls 3 h. PO (1.31 ± 1.02 vs. 1.62 ± 0.76, respectively), (P = 0.01), 6 h. PO (0.81 ± 1.24 vs. 1.53 ± 0.88, respectively), (P = 0.004), and 9 h. PO (0.55 ± 1.25 vs. 1.12 ± 0.95, respectively), (P = 0.01). The total PO required analgesics were significantly lower in levobupivacaine group compared to controls (P = 0.005). Conclusion: The intrauterine levobupivacaine instillation was simple, and effective for pain relief after diagnostic hysteroscopy, it significantly decreased pain score assessed by VAS at 3, 6, and 9 h., PO, and it significantly decreased PO required analgesics.
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Feasibility and safety of laparoscopic surgery in large ovarian masses p. 215
Tugba Kinay, Yasemin Kizilkaya, Sadiman Kiykac Altinbas, Omer Lutfi Tapisiz, Yaprak Engin Ustun
Objectives: To evaluate the feasibility and safety of laparoscopic surgery for large ovarian masses with benign features. Materials and Methods: Women who underwent laparoscopic surgery for an ovarian mass with benign features between 2017 and 2019 at a tertiary referral center were included in the retrospective study. Based on the size of the ovarian mass, the women were divided into the case and control groups of ≥10 cm and <10 cm, respectively. Clinical characteristics, operative findings, histopathological results, and complication rates of the groups were compared. Results: A total of 260 women, 64 women with large masses and 196 with small masses were included in the study. The operation time, intraoperative cyst rupture rate, complication rate, and hospital stay were similar in the case and control groups (P > 0.05). The cyst aspiration rate (29.7% vs. 5.1%, P < 0.001) and the unexpected malignancy rate (7.8% vs. 0.0% P = 0.001) were significantly higher in the case group than in the control group. Conclusion: Laparoscopic surgery was found feasible for the treatment of women with large ovarian masses. However, a higher unexpected malignancy rate requires the careful patient selection and appropriate counseling preoperatively in these cases.
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Influence of uterine cavity breach in laparoscopic myomectomy on the risk of obstetric complications p. 221
Shinichiro Wada, Yoshiyuki Fukushi, Yosuke Ono, Hajime Ota, Yoko Tsuzuki, Hideto Yamada
Objectives: Prepregnancy myomectomy is effective for the treatment of infertility or prevention of obstetric complications and is usually performed with laparoscopy. However, pregnancies following myomectomy have risks of obstetric complications, especially in cases with uterine cavity breaches, but the evidence remains unclear. We investigated how uterine cavity breach in laparoscopic myomectomy influenced the occurrence of obstetric complications. Patients and Methods: One hundred and eighty women who underwent a cesarean section from 2014 to 2020 in pregnancies following laparoscopic myomectomy were included. They were divided into two groups: 25 women in the uterine cavity breach group and 155 in the nonbreach group. Obstetric complications, including placenta accreta spectrum (PAS), uterine rupture, placental malposition, abruption placenta, preterm delivery, threatened premature labor, premature rupture of membranes, and massive intrapartum hemorrhage, were assessed. Results: Multivariate analysis revealed that the frequency of PAS in the breach group (24.0%) was statistically significantly higher than in the nonbreach group (5.2%, P < 0.05). Conclusion: This study demonstrated that women who experienced uterine cavity breach in laparoscopic myomectomy had an increased risk of PAS in subsequent pregnancies.
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Is endometriosis telemedicine friendly? p. 224
Burcin Karamustafaoglu Balci
Objectives: Social isolation and lockdowns made telemedicine to gradually penetrate daily practice. Telemedicine has been used successfully in many areas of medicine such as psychiatry but is new in obstetrics and gynecology. This study aimed to investigate whether a telemedicine model would be feasible in choosing patients who needed face-to-face visits during the pandemic. Materials and Methods: Telephone calls were conducted with patients with endometriosis who were admitted to our endometriosis clinic before the pandemic. The primary outcome was to appropriately triage the patients who could postpone their routine visit without any risk and those who needed an in-clinic appointment. Results: Seventy-nine patients were included in the study. Among 58 patients who could be reached, 55 accepted to participate in the study. The mean length of the telephone calls was 8.17 min. Nine patients required an in-clinic appointment (16.4%), whereas 46 (83.6%) patients were managed with the phone call. Compliance with hormonal agents for the treatment of endometriosis-associated pain was 11/17 (64.7%). The most commonly asked questions by patients were about cervical screening, fertility cryopreservation, and the medical treatment options of endometriosis. Conclusion: Telemedicine visits can never replace in-clinic practice but can help with a considerable degree of efficacy in the management of patients with endometriosis.
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Comparative Study of Postoperative Analgesic Effects of Intraoperative Levobupivacaine Local Infiltration Anesthesia and Transversus Abdominis Plane Block Following Gynecologic Laparoscopy p. 231
Akiko Otake, Naoko Sasamoto, Noriko Sato, Ryota Kumasaka, Yoshimitsu Yamamoto, Kazushige Adachi
Objectives: We aim to assess the postoperative analgesic effect of intraoperative levobupivacaine local infiltration anesthesia (LA) and transversus abdominis plane (TAP) block in gynecologic laparoscopy. Materials and Methods: We conducted a retrospective analysis on the data of 260 patients treated by gynecologic laparoscopy (adnexal surgery, hysterectomy, and myomectomy) between January 2019 and December 2020 at Minoh City Hospital, Osaka Japan. Patients were divided into two groups: intraoperative LA group and TAP block group. We assessed clinical characteristics, surgical results, postoperative numerical rating scale (NRS) pain scores, and the frequency of analgesic use up to 24 h after surgery in overall and by each type of surgery. Pearson's χ2 test, Fisher's exact test, and Wilcoxon/Kruskal–Wallis test were used for statistical analysis. Multiple regression analysis was used for multivariate analysis. Results: NRS pain score was statistically significantly higher in the LA group than in the TAP group 1 h after surgery in overall (P = 0.04), with NRS difference of 0.4 which was not clinically significant. No significant differences were observed in NRS pain scores at 3, 6, 12, and 24 h after surgery or in the frequency of analgesic use up to 24 h after surgery in overall and by type of surgery. Endometriosis was associated with increased postoperative pain at 1 h after surgery in adnexal surgeries (P = 0.04) and suggestive for all surgeries. Younger age was related to more frequency of analgesic use up to 24 h after surgery in overall, adnexal surgeries, and hysterectomy. Conclusion: Intraoperative levobupivacaine LA may have similar postoperative analgesic effects as TAP block in gynecologic laparoscopy.
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Oral Gonadotropin-Releasing Hormone Antagonist Relugolix Has the Same Effect as Gonadotropin-Releasing Hormone Agonist Injections in Terms of Preparation for Transcervical Resection Myomectomy p. 238
Mika Ito, Osamu Yoshino, Takehiro Hiraoka, Yosuke Ono, Kouta Tanaka, Shunsuke Iwahata, Masako Honda, Akiko Furue, Junichi Nishijima, Takahito Shimoda, Haruko Iwase, Akinori Miki, Hikaru Tagaya, Shuji Hirata, Nobuya Unno
For preparing the optimal condition in transcervical resection (TCR) surgery, gonadotropin-releasing hormone (GnRH) agonist has been utilized. Recently, an oral GnRH antagonist (relugolix) is available and acts directly on GnRH receptor, avoiding flare up and reducing blood E2 levels rapidly. We retrospectively compared the oral GnRH antagonist (n = 14) effect to that of subcutaneous GnRH agonist (n = 19) for the pretreatment of endometrium in TCR myomectomy. Endometrial thickening was determined by intraoperative videos. The color tone of the endometrium in the normal part was assessed by digital image processing. The median duration of the first GnRH agonist injection and the surgery was 67 days (21–136 days), which is significantly longer than that of the oral GnRH antagonist group, 18.5 days (7–157 days P < 0.01). Both the GnRH agonist and antagonist groups did not exhibit prominence in the endometrium. The GnRH antagonist group showed the same degree of whiteness in the normal endometrium as the GnRH agonist group. The oral GnRH antagonist administration could rapidly atrophy the endometrium and create an optimal surgical field for TCR in a short period.
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Laparoscopic operation under hysteroscopic guidance in management of cesarean scar defect p. 242
Hoang The Dinh, An Nguyen Phuong Tran
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Osseous metaplasia of the endometrium and successful hysteroscopic resection: A video case and review of the literature p. 244
Pinar Kadirogullari, Kerem Doga Seckin, Nura Fitnat Topbas Selcuki
Osseous metaplasia of the endometrium is defined by the presence of mature or immature bone tissue in the endometrium. Most of the cases are associated with secondary infertility after abortion, chronic endometritis, or the presence of foreign bodies in the endometrium. Some cases are asymptomatic; others have menstrual abnormalities such as menorrhagia or oligomenorrhea. Osseous metaplasia is mostly seen after recurrent abortions. Removing the bone tissue helps spontaneous conception. Intrauterine hyperechogenic lesion, suggesting calcification in transvaginal ultrasonography, creates suspicion in diagnosis. Here, we present a patient who underwent dilatation and curettage procedure following a missed abortion, and osseous metaplasia of endometrium was radiologically detected at a 1-month follow-up examination. White bony material was shown in the uterine cavity with hysteroscopy. The lesion was treated by hysteroscopic removal without any complications. Histology confirmed the diagnosis of endometrial osseous metaplasia. Thus, hysteroscopy was effective in the diagnosis and treatment of endometrial osseous metaplasia.
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Choriocarcinoma of the ovary masquerading as ectopic pregnancy p. 247
Roopa Malik, Menka Verma, Meenakshi Chauhan, Pooja Sinha
Choriocarcinoma of ovary is a rare aggressive tumor of ovary. It may be gestational or nongestational tumor. High index of suspicion is required for diagnosis in reproductive age group females. Here, we present a case report of a 30-year-old female who was operated for ectopic pregnancy but was diagnosed as ovarian choriocarcinoma on histopathology. The patient had abnormally high beta-human chorionic gonadotropin levels with history of amenorrhea and negative urine pregnancy test. On laparotomy, a mass of 8 cm × 10 cm was found which was confirmed as choriocarcinoma on histopathological examination. The patient was managed with chemotherapy and responded well to treatment.
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Ovarian Ligament Plication as a Treatment for Patient with Elongated Ovarian Ligament with Recurrent Abdominal Pain in the Absence of Ovarian Torsion p. 250
Rakhi Rai, Kallol Kumar Roy, Rinchen Zangmo, Vinod Nair, Aayush Jain
Elongated ovarian ligament can lead to adnexal torsion. Several cases of ovarian torsion have been reported where the ovarian ligament was elongated, and ovarian detorsion and ovarian ligament plication were done. In our case, a young girl presented with recurrent left lower abdominal pain, especially after exercise, with normal ovaries found on ultrasound. Laparoscopy was performed given recurrent pelvic pain and found elongated left ovarian ligament with normal ovaries. Considering the possibility of recurrent torsion and detorsion of the ovary due to elongated left ovarian ligament, left ovarian ligament plication was done. The patient remained pain-free till 1 year of follow-up. No such case has been reported in the literature where the ovarian ligament plication was performed without torsion. Hence, elongated ovarian ligament could cause recurrent pelvic pain due to possible torsion, and a simple, easy procedure of ovarian ligament plication can help relieve pain.
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The Incidental Aggressive Angiomyxoma of the Vulva: Looks can be Deceptive p. 253
Akanksha Tripathi, Shikha Sharma, Sunil Kanvinde
Aggressive angiomyxoma is a benign, slow-growing, locally aggressive tumor of mesenchymal origin primarily occurring in the pelvic–perineal regions of reproductive age group women and displays a high risk of local recurrence. Lack of specific symptomatology and overlap with other benign and malignant vulval masses makes it a diagnostic challenge. We describe the case of a 32-year-old nulliparous woman with a history of recurrent vulval abscess requiring multiple incision and drainage procedures before she presented to us with an actively draining abscess on the upper third of the left labia majora. She underwent excisional biopsy at our center, the histopathology of which revealed aggressive angiomyxoma with secondary pyogenic slough. The preoperative diagnosis of vulval aggressive angiomyxoma becomes challenging due to the absence of diagnostic features. It ought to be considered a differential in every perineal–pelvic region mass in adult women.
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Uterine teratoma (Dermoid cyst) presenting as an endometrial polyp p. 256
Rebecca Chou, Jessica Robertson, Mujahid Bukhari, Danny Chou
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Salivary proteome profile during the fertile phase of menstrual cycle: Correspondence p. 258
Pathum Sookaromdee, Viroj Wiwanitkit
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