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   Table of Contents - Current issue
October-December 2020
Volume 9 | Issue 4
Page Nos. 185-252

Online since Thursday, October 15, 2020

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Gynecological endoscopic society of malaysia statement and recommendations on gynecological laparoscopic surgery during COVID-19 pandemic Highly accessed article p. 185
Wan Ahmad Hazim Wan Ghazali, Pavani Nallaluthan, Raimi Zamriah Hasan, Aizura Syafinaz Adlan, Ng Kwee Boon
Objectives: While the issue of aerosolization of virus from the blood occurs during usage of energy sources scare practitioners, there have been no reported instances of healthcare workers (HCWs) being infected. COVID-19 virus is primarily transmitted via respiratory droplets and contact routes. Therefore, the ultimate decision for surgery, should be based on which is the safest, quickest route and concurrently ensuring that HCWs are protected during these surgeries. During the time of crisis, HCWs need to concentrate and channel resources to the care of those affected by the coronavirus hence judicious allocation of resources is mandatory. We present the guidelines and recommendations on gynecological laparoscopic surgery during this COVID-19 outbreak in Malaysia. Materials and Methods: Thorough search of articles and recommendations were done to look into the characteristics of the virus in terms of transmission and risks during surgery. Smoke plume characteristics, composition and risk of viral transmission were also studied. Search includes The WHO Library, Cochrane Library and electronic databases (PubMed, Google scholar and Science Direct). Conclusion: We concluded that there is no scientific basis of shunning laparoscopic approach in surgical intervention. Ultimately, the guiding principles would be of reducing the anesthetic and surgical duration, the availability of full protective gear for HCWs during the surgery and the status of the patient. It is mandatory for viral swab tests to be done within the shortest window period possible, for all cases planned for surgery.
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Adhesions after laparoscopic myomectomy: Incidence, risk factors, complications, and prevention p. 190
Anja Herrmann, Luz Angela Torres-de la Roche, Harald Krentel, Cristina Cezar, Maya Sophie de Wilde, Rajesh Devassy, Rudy Leon De Wilde
Uterine fibroids or uterine myomas are one of the most common benign diseases of the uterus. Symptoms associated with myomas can make surgical removal of myomas necessary. Besides the traditional abdominal route, laparoscopic myomectomy (LM) has gained more acceptances over the last few decades, and it is anticipated that laparoscopy is associated with lower adhesion development. Therefore, we conducted this review to analyze the evidence on adhesions after LM. The PubMed database was searched using the search terms “myomectomy” alone and in combination with “adhesions,” “infertility OR fertility outcome,” and “laparoscopy” among articles published in English and German. Although the well-known advantages of laparoscopy, for example, less pain, less blood loss, or shorter hospital stay, myomectomy belongs to high-risk operations concerning adhesion formation, with at least every fifth patient developing postsurgical adhesions. In laparoscopic surgery, surgeons´ experience as well tissue trauma, due to desiccation and hypoxia, are the underlying mechanisms leading to adhesion formation. Incisions of the posterior uterus may be associated with a higher rate of adhesions compared to anterior or fundal incisions. Adhesions can be associated with severe complications such as small bowel obstruction, chronic pelvic pain, complications in further operations, or impaired fertility. Tissue trauma and the experience of the surgeon in laparoscopic surgery are most of the influencing factors for adhesion formation after myomectomy. Therefore, every surgeon should adopt strategies to reduce adhesion development in daily routine, especially when it conducted to preserve or restore fertility.
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Comparison of postoperative benign pelvic cysts occurred after gynecologic or gyne-oncologic surgery treated with percutaneous transcatheteric sclerosant alcohol therapy p. 198
Cihan Comba, Aysun Erbahceci Salik, Gokhan Demirayak, Sakir Volkan Erdogan, Filiz Sacan, Isa Aykut Ozdemir
Objectives: Here, we compare the success of percutaneous transcatheter sclerosant alcohol therapy (PTSAT) for the postoperative treatment of benign pelvic cysts that occurred after gynecologic surgery. Materials and Methods: The study is a retrospective case–control trial. Gynecological patients who had symptoms due to postoperative pelvic cysts and received PTSAT after gynecologic surgery, between October 2008 and January 2018, were examined in a single training and research hospital in Turkey. Some factors were investigated for associations with postoperative pelvic cyst formation in patients who underwent gynecologic operations for malignancies or benign conditions. Statistical analysis used: The association between two independent and nonnormally distributed continuous variables was analyzed with the Mann–Whitney U-test. Spearman's rho correlation analysis was conducted to determine the correlation of two nonnormally distributed variables. Chi-square (or Fisher's exact test, when more suitable) was used to examine the correlation between categorical variables. Results: Statistically significant differences were found in terms of the average age was higher in patients with malignancies, and the average postoperative pelvic cyst detection time was higher in patients with benign pelvic cysts. While all patients were treated with PTSAT, repetitive PTSAT was required for seven benign and ten malign cases. Conclusion: Patients with pelvic cysts that occurred after gynecologic surgery for malignant conditions, large volume pelvic cysts and patients with benign cysts who underwent more than one surgery required recurrent PTSAT.
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Effect of pelvic organ prolapse reconstructive mesh surgery on the quality of life of Turkish patients: A prospective study Highly accessed article p. 204
Gokmen Sukgen, Ünal Türkay
Objectives: The purpose of this study was to investigate transvaginal mesh treatment and its effect on the quality of life of Turkish patients with pelvic organ prolapse (POP). Turkish patients with POP were invited to participate in this study, and all the participants underwent prolapse surgery. Materials and Methods: The clinical outcomes, including effectiveness of the treatment and changes in the quality of life, were measured by the short form-36 survey. The data were analyzed using SPSS version 23. To analyze differences in the quality of life at the three aforementioned points in time, a paired sample t-test was used. Results: The results indicated that participants' quality of life increased after surgery. Some quality of life domains (i.e., vitality and mental health) as well as physical and mental health summary scores increased. Overall, transvaginal mesh treatment significantly improved the quality of life of Turkish patients with POP. Conclusion: Women who undergo transvaginal mesh treatment will have positive changes in the quality of life.
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Retrospective cohort study on the symptomatic recurrence pattern after hysteroscopic polypectomy Highly accessed article p. 209
Jorge Cea Garcia, Antonio Jiménez Caraballo, MarÍa del Mar Rios Vallejo, Ignacio Zapardiel
Objectives: The recurrence rate of benign endometrial polyps after a hysteroscopic polypectomy is low, between 0% and 15%. There are limited follow-up duration data on recurrence factors for benign polyps after hysteroscopic polypectomy, including recurrences with Versapoint® versus resectoscope. This study aims to estimate the rate of symptomatic recurrence following hysteroscopic polypectomy and to analyze the possible risk factors involved with Versapoint® versus resectoscope. Materials and Methods: We designed a retrospective cohort study in a tertiary university hospital in Seville (Spain) which looked at the results of polypectomy with a 9-mm resectoscope on 42 women between 2008 and 2015 compared to 151 women using Versapoint® during 2014. Results: The rate of first recurrence was 24.35%. There was a strong positive correlation between the recurrence and the follow-up duration (odds ratio [OR] = 2.58; 95% confidence interval [CI] = 1.68–5.04; P = 0.000), the polyps causing abnormal uterine bleeding (OR = 2.5; 95% CI: 1.1–3; P = 0.04), and a polyp size >15 mm (OR = 1.63; 95% CI = 1.3–3.1; P = 0.02). There were no statistical differences in polyps' recurrence among the types of hysteroscopic polypectomy (P > 0.05). Conclusion: The main risk factors for recurrence were polyps causing abnormal uterine bleeding, size, and follow-up duration.
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Laparoscopic hysterectomy for benign pathology does not yield more perioperative complications than abdominal or vaginal hysterectomies: Our experience in introducing laparoscopic hysterectomy p. 215
Akimasa Takahashi, Mao Uemura, Jun Kitazawa, Mari Nakata, Yoshihiko Hayashi
Objectives: Total laparoscopic hysterectomy (TLH) is increasing as a substitute for total abdominal hysterectomy (TAH) and total vaginal hysterectomy (TVH) with the growing prevalence of laparoscopic surgery. The aim of this study is to assess perioperative complications of the chosen hysterectomy techniques performed for benign indications when started performing TLH. This was retrospective cohort study. This study was conducted at Nagahama City Hospital. Materials and Methods: There were 176 patients who underwent hysterectomy for benign indications from 2013 to 2016. Perioperative and postoperative outcomes were compared for the three different hysterectomy approaches laparoscopic; abdominal; and vaginal. Data were analyzed using the t-test or Chi-square and Fisher's exact test. Results: TAH, TLH, and TVH were performed on 118 patients (67.0%), 32 (18.2%), and 26 (14.8%), respectively. Operation time was significantly longer for the TLH group than for the TAH and TVH groups. Blood loss was lower for the TVH and TLH groups than for the TAH group. Three days after surgery, C-reactive protein was lower in the TVH group than in the TAH group. The average uterus size in the TAH group was larger than in the TVH and TLH groups. Patients undergoing TLH experienced fewer perioperative complications than patients in the TAH and TVH groups; however, this difference was not statistically significant. Conclusion: TLH for benign pathology does not yield more perioperative complications than TAH or TVH. However, vaginal hysterectomy is the least invasive approach. The final choice for the route of hysterectomy depends on many factors, including body mass index, uterus size, and experience of the gynecologist.
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Laparoscopic regional radical hysterectomy showed promising clinical outcomes in early-stage cervical cancer p. 220
Weihong Yang, Rong Chen, Caixia Li, Li Li, Ning Luo, Zhongping Cheng
Objectives: To evaluate the clinical outcomes of standardized and region-specific excision in laparoscopic radical hysterectomy (LRH) for early-stage cervical cancer (ECC). Materials and Methods: This is a retrospective case–controlled study from 2011 to December 2016. A total of 328 women with ECC (IA1, IA2, IB1, or IIA1) underwent primary surgery by laparoscopy or laparotomy in our institute. Women diagnosed as stage IB1 or IIA1 were treated with radical hysterectomy (RH) by open or laparoscopic route. The total parametrium excision in the process of RH was measured and highlighted in the study. Results: A total of 186 patients underwent open surgery and 142 ones were treated with laparoscopic surgery. Laparoscopic surgery was associated with less blood loss (194.43 ± 84.40 ml vs. 362.68 ± 253.36 ml, P < 0.01), shorter hospital stay (11 vs. 14 days, P < 0.01), and lower risk of blood transfusion (2.8% vs. 18.8%, P < 0.01). There was no significant difference in the postoperative complications between two groups (18/142, 12.7% vs. 21/186, 11.3%; P > 0.05). The rate of 5-year overall survival (OS) was 92.8% in laparoscopy group, similar to that of 94.4% in the open group (P = 0.762). Disease-free survival (DFS) rate at 3 years in laparoscopy group was decreased when compared to open group (91.8% vs. 95.0%, P = 0.030), but there was no significant difference in 3-year DFS among the women with tumor size <2 cm (100% vs. 97.0%, P = 0.818). Conclusion: Laparoscopic surgery was associated with better surgical outcomes compared to open surgery in ECC. 5-Year OS was comparable between the groups and cases with tumor size <2 cm showed no difference in 3-year DFS. LRH may be a better fit for women with tumor size <2 cm. Standardized region-specific RH helps to optimize the clinical outcomes of LRH in ECC.
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Natural orifice transluminal endoscopic surgery-assisted vaginal hysterectomy versus total laparoscopic hysterectomy: A single-center retrospective study using propensity score analysis p. 227
Nukun Puisungnoen, Aranya Yantapant, Marut Yanaranop
Objectives: The aim of this study is to evaluate the safety and efficacy of natural orifice transluminal endoscopic surgery-assisted vaginal hysterectomy (NOTES-AVH) compared with total laparoscopic hysterectomy (TLH). Materials and Methods: The population was a cohort of women who underwent NOTES-AVH and TLH for a nonprolapsed uterus and benign gynecological disease between October 2015 and December 2017 at Rajavithi Hospital, Thailand. Study outcomes included operative time, the requirement of blood transfusion, perioperative complications, and postoperative pain. Factors applied for propensity score matching included age, body mass index, parity, underlying disease, previous abdominal surgery, preoperative diagnosis, presence of endometriosis, and uterine weight. Mean difference (MD) and risk ratio with 95% confidence interval (CI) were calculated to represent relative measures of the comparison. Results: Among the 50 pairs, there were no differences in operative time (MD 15.9 min; 95% CI − 9.3–41.1), intraoperative complications (relative risk [RR] 0.33; 95% CI 0.04–3.10) or requirement of blood transfusion (RR 1.50; 95% CI 0.26–8.60) between the NOTES-AVH and TLH groups. NOTES-AVH was associated with lower intensity of postoperative pain (MD − 1.5 at 6-h; 95% CI − 0.8–2.2 and MD − 1.0 at 24-h; 95% CI − 0.4–−1.6) and shorter length of stay (MD − 0.3 day; 95% CI − 0.1–0.7 day). Conclusion: NOTES-AVH was safe and feasible for an alternative approach for hysterectomy. This technique was superior to TLH in that no abdominal incision was required, and postoperative pain was less intense.
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A case of intramural pregnancy: Differential diagnosis for distinguishing from retained products of conception and gestational trophoblastic disease p. 231
Qing- Yun Song, Fan Yang, Hong Luo
Intramural pregnancy refers to the implantation of fertilized eggs in uterine musculature, separated from the uterine cavity and tube. We report a case of intramural pregnancy previously misdiagnosed as retained products of conception and gestational trophoblastic disease. This case highlights the difficulty in the diagnosis of intramural pregnancy. Clinicians should be clear about the risk factors of the disease. Judicious selection of the appropriate imaging modalities is vital to making an accurate diagnosis and providing effective treatment.
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A case report: The third-largest case in the literature of a vulvar lipoma p. 234
Gokmen Sukgen
Lipoma is the most common soft-tissue tumor of mesenchymal tissue origin although very rarely found in the vulva. The present study aims to present a very rare and big lipoma. In this case, the patient was 70 years old and was admitted to our clinic with the complaint of soft vulvar mass, 17 cm × 14 cm × 10 cm in size. The mass appeared about 7 years ago and was growing for the past 2 years and extended to the labium majus from the left inguinal region. The author performed a vulvar reconstruction with total excision of the mass. Pathological examination revealed a lipoma. Vulvar lipoma should be considered in the differential diagnosis of vulvar masses, although lipomatous masses are rarely seen in vulva.
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A case of unsuspected low-grade endometrial stromal sarcoma successfully treated with two minimally invasive surgeries p. 237
Akira Nakabayashi, Kensuke Odaira, Yu Horibe, Toshiyuki Kanno, Yoshika Akizawa, Tsutomu Tabata
It is relatively uncommon to treat patients with a preoperative diagnosis of benign leiomyoma that is then unexpectedly rediagnosed as malignant in postoperative histology. We report the case of a 55-year-old woman with low-grade endometrial stromal sarcoma who had been diagnosed as having uterine leiomyoma with myxoid degeneration by preoperative magnetic resonance imaging (MRI). She underwent a laparoscopic hysterectomy. The uterus, after being placed in a retrieval bag, was transvaginally morcellated to prevent spillage of the contents, as the MRI image appeared somewhat atypical. A retrospective survey of MRI findings affirmed that the muscle tissue had the appearance of a low-intensity band-like structure: bag of worms appearance. She underwent a laparoscopic bilateral salpingo-oophorectomy and remains recurrence-free. With somewhat atypical preoperative MRI, it is essential to prevent the spillage of the tumor content as no definitive preoperative exclusion of unsuspected mesenchymal malignancies is feasible.
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Isolated tubal torsion: A rare cause of acute pelvic/abdominal pain among adolescent females p. 241
Mohamad K Ramadan, Khouloud Demachkie, Amani Mohsen, Loubna Sinno, Janoub Kaza'al
Tubal torsion usually occurs as a part of adnexal torsion that affects an ovary and the adjacent tube; however, isolated tubal torsion is an extremely rare condition. Usually, it presents as acute pelvic/abdominal pain but could also exhibit milder intermittent pain alternating with periods of relief (subacute). This condition has seldom been diagnosed preoperative and commonly results in tubal damage due to delayed management. We hereby, report the findings of two cases managed recently at our center. In both cases, the diagnosis was delayed 2–3 days and was only made intraoperative when the tubes could not be salvaged due to extensive necrosis. The extent of tubal damage is predominantly dependent on the duration of vascular insult; hence, the urgency for affecting early diagnosis and intervention to restore blood supply and preserve tubal integrity and function. We advocate the liberal and early use of laparoscopy in patients presenting with subacute unexplained pelvic/abdominal pain.
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Laparoscopic salpingectomy for an isolated case of left fallopian tube torsion in a premenarcheal 13 years old p. 245
Annabelle Sabu Vadukkut, Abhishek Mangeshikar, Sonam Jadhav, Sushil Kumar
Isolated torsion of the fallopian tube without an ovarian abnormality is an uncommon clinical finding even rarer before menarche and postmenopause, with an incidence of approximately 1 in 1.5 million women. Left fallopian tube torsion is infrequent as compared to right. Here, we report a rare case of a prepubertal girl who presented with acute left abdominal pain. Ultrasound suggested normal ovaries, and a significant left hydrosalpinx and color-Doppler was done, which confirmed signs of left-sided fallopian tube torsion. On laparoscopy, her left fallopian tube was twisted around its axis five times with the signs of necrosis, a laparoscopic salpingectomy was performed. Laparoscopy is the gold standard for the diagnosis and management of this condition. A high index of suspicion is necessary to make an early diagnosis allowing conservative surgical management and hence fertility preservation.
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Successful laparoscopic treatment of small-bowel obstruction in early pregnancy p. 248
Toshihiro Kitai, Eri Yamabe, Aki Isobe, Kanji Masuhara, Mutsumi Fukunaga, Toshikatsu Nobunaga
Small-bowel obstruction (SBO) during pregnancy is uncommon and can be difficult to diagnose. Therefore, the condition is associated with significant maternal and fetal mortality. We report a case of successful laparoscopic treatment of SBO in early pregnancy. A 37-year-old woman presented with diffuse abdominal pain and vomiting at 8 weeks of gestation. She had a history of abdominal surgery. Exploratory laparoscopy was performed by a gastrointestinal surgeon because SBO, and specifically strangulated ileus, was strongly suspected. On entry into the abdomen, dilated small bowel was visible in the pelvis; this was attached to the pelvic wall and twisted near the right adnexa. The small bowel initially appeared dark and congested, but after releasing the adhesions, it regained its normal color, was viable, and peristalsis was observed. Therefore, bowel resection was not required. No recurrence was observed after food ingestion, and the patient was discharged 12 days after surgery.
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Recurrent low-grade endometrial stromal sarcoma presenting as isolated pedunculated vaginal cuff polyp p. 251
Tanitra Tantitamit, Shu- Han Chang, Kuan- Gen Huang
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