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   Table of Contents - Current issue
Coverpage
January-March 2021
Volume 10 | Issue 1
Page Nos. 1-70

Online since Saturday, January 30, 2021

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REVIEW ARTICLE  

Surgical trend and volume effect on the choice of hysterectomy benign gynecologic conditions Highly accessed article p. 1
Chung- Hong Lin, Cheng- Yu Long, Kuan- Hui Huang, Tsia- Shu Lo, Ming- Ping Wu
DOI:10.4103/GMIT.GMIT_68_20  
With the advance of minimally invasive surgery (MIS), the surgical trends of hysterectomy changed significantly during past 2 decades. Total number (age-standardized) of all types of hysterectomy decreased, which may be due to the availability of some other alternatives, e.g. hysteroscopy, laparoscopic myomectomy. However, laparoscopic hysterectomy (LH) still remains the mainstream of surgical treatment. LH significantly increases for benign gynecologic conditions in Taiwan and worldwide. The increase of LH was accompanied with decrease of TAH; VH kept stationary, and SAH increased slightly. The increase in popularity of LH and SAH; provides evidence of surgical trends and a paradigm shift for hysterectomy. This time-frame shift suggests LH has reached a u during the later years. Older patients tend to receive AH, while middle-aged women tend to receive LH. Oder surgeons tend to perform AH, while younger surgeons tend to perform LH. However, all type hysterectomy and LH were more commonly performed by older surgeons aged over 50 years. It means both patients and surgeons became older during the time-frames. The above phenomena may also happen due to less young surgeons entered in the gynecologic practice. Most of the LHs were performed by high-volume surgeons, however, there is a shift from high-volume, to medium- and low-volume surgeons. The above scenario may be due to the wide spread of LH techniques. Surgical volume has important impacts on both complications and costs. The high-volume surgeons have lower complications, which result in lower costs. In the future, how to increase the use of LH, to improve the training and monitoring system deserves more attentions.
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ORIGINAL ARTICLES Top

Feasibility of risk reducing salpingo-oophorectomy at the time of abdominal surgery for correction of pelvic organ prolapse and urinary incontinence Highly accessed article p. 10
Ali Azadi, James A Bradley, Greg J Marchand, Douglas J Lorenz, David Doering, Donald R Ostergard
DOI:10.4103/GMIT.GMIT_21_20  
Objective: The objective of this study is to assess the perioperative outcomes when prophylactic bilateral salpingo-oophorectomy (BSO) is performed concomitantly with surgery to repair pelvic organ prolapse (POP) or stress urinary incontinence (SUI). Materials and Methods: This is a retrospective case–control study of patients who underwent abdominal surgery for the correction of POP and/or SUI with or without concomitant BSO at a tertiary care center. The primary outcome measures were postsurgery length of hospitalization, estimated blood loss, and 30-day readmission rate. The secondary outcome measure was detection of ovarian cancer precursor lesions. Results: We identified 734 patients who had surgery for POP and/or SUI. The control group contained 385 patients, and the BSO group contained 349 patients. There was no difference between the control and BSO groups in the postsurgery length of stay (LOS) (35.2 h vs. 34.1 h; P = 0.49), and all-cause 30-day readmission rate (14.2% vs. 11.6%; P = 0.3085). However, there was decreased blood loss (40.8 ml vs. 67.2 ml, P < 0.0001) in the BSO group compared to the control group. Sub-analysis of primary outcomes in postmenopausal women (age > 55) showed decreased postsurgery LOS (33.4 h vs. 37.4 h; P = 0.0208) and decreased blood loss (35.9 ml vs. 82.7 ml; P < 0.0001) in the BSO group compared to control. Conclusion: Secondary to the lack of additional complications, we recommend surgeons give more consideration to finding appropriate candidates for a risk reducing BSO at time of abdominal surgery to repair POP or SUI.
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Does uterine manipulator type affect surgical outcomes of laparoscopic hysterectomy? Highly accessed article p. 19
Ali Yavuzcan, Raşit Altıntaş, Gazi Yıldız, Alper Başbuğ, Merve Baştan, Mete Çağlar
DOI:10.4103/GMIT.GMIT_65_20  
Objectives: Many surgeons use uterine manipulator (UM) during laparoscopic hysterectomy (LH). In this study, we aimed to compare the outcomes of LH operations performed by using partially reusable UM with the articulated system (artUM) and disposable (dUM) UM without articulation. Materials and Methods: A total of 99 patients underwent the LH operation. This study was carried out with 35 of those 99 Caucasian patients who met the inclusion criteria. Group 1 consisted for 7 LH operations using the articulated RUMI®II/KOH-Efficient™ (Cooper Surgical, Trumbull, CT, USA) system (artUM), while Group II consisted of 28 patients using old-type V Care® (ConMed Endosurgery, Utica, New York, USA) dUM as UM. Results: Mean operation time was found to be 157.1 ± 42.0 min. The operation time was found statistically longer in Group 1, consisted of artUM used patients (P = 0.006 and P < 0.05). No statistically significant difference was found between two groups in terms of surgical results such as, delta hemoglobin value (P = 0.483 and P < 0.05), length of hospital stay (P = 0.138 and P < 0.05), and postoperative maximum body temperature (P = 0.724 and P < 0.05). Conclusion: The UM type did not alter the surgical outcomes except the operating time in our study. According to our results, the surgical technique is a more significant variable than instruments used in LH for normal size uterus. Further prospective, large-scale studies comparing various UM systems are mandatory.
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Abnormal urine outflow from the ureteral orifice on cystoscopy following vaginal stump suture in total laparoscopic hysterectomy p. 25
Hiroharu Kobayashi, Kentaro Iga, Keiichiro Kato, Airi Kato, Koji Otsuka, Eri Soga, Hiroko Konno, Satoru Nakayama, Satoshi Shiojima
DOI:10.4103/GMIT.GMIT_70_19  
Objectives: Ureteral injuries may occur subsequent to abdominal or laparoscopic hysterectomy. In total laparoscopic hysterectomy (TLH), we usually check for ureteral damage by confirming urinary outflow from the bilateral ureteral orifices by cystoscopy after vaginal stump suture. In this work, we investigated the causes of urine outflow disruption after TLH. Materials and Methods: We conducted a retrospective review of all TLHs performed for benign diseases at our hospital from February 2012 to March 2016. There were 11 cases with no or poor urine outflow from the ureteral orifice after vaginal stump suture. For these cases, we assessed the treatment to recover urine outflow and examined the cases with intraoperative manipulation. EZR version 1.25 was used for statistical analysis. Correlation coefficients were calculated with Spearman's rank correlation coefficient test. Results: The abnormality was on the right and left sides in seven and four cases, respectively. In all cases, apart from one, urine outflow was recovered by removing the sutures at the affected side, where the initial suture had included a small amount of the connective tissue near the urinary bladder. It was inferred that ureteral deviation due to vaginal stump sutures that picked up the connective tissue near the ureter caused ureteral peristaltic disorder and abnormal ureteral orifice outflow. Conclusion: TLH without ureter isolation requires sufficient separation of the bladder from the anterior vaginal wall and careful vaginal stump suture without involving the bladder-side tissue to avoid ureteral injury.
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Vaginal-assisted laparoscopic sacrohysteropexy and vaginal hysterectomy with vaginal vault suspension for advanced uterine prolapse: 12-month preliminary results of a randomized controlled study p. 30
Huseyin Cengiz, Sukru Yildiz, Ismail Alay, Cihan Kaya, Ecem Eren, Derya Ece Iliman
DOI:10.4103/GMIT.GMIT_126_19  
Objective: Vaginal-assisted laparoscopic sacrohysteropexy (VALH) is a new modified form of uterine-sparing prolapse surgery using a combined vaginal and laparoscopic approach. We aimed to compare 1 year efficacy and safety of VALH and vaginal hysterectomy with vaginal vault suspension (VH + VVS) in the surgical treatment of apical pelvic organ prolapse (POP). Materials and Methods: Women who requested surgical treatment for stage 2–4 symptomatic uterine prolapse were recommended to participate in one year-long randomized study between July 2017 and January 2019. POP Quantification (POP-Q) examination and validated questionnaires such as International Consultation on Incontinence Questionnaire Vaginal Symptoms (IVIQ-VS) survey, Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire Short Form (IIQ-7), and Patient Global Impression of Improvement (PGI-I) were recorded at baseline and 12 months after surgery. The main primary outcome measure was apical prolapse recurrence. Secondary results were duration of surgery, pain score, blood loss, postoperative hospital stay, and quality of life scores related to prolapse. Results: There were 15 women in VALH and 19 women in the VH + VVS group. ICIQ-VS score, ICIQ-QOL, UDI-6, and IIQ-7 scores were improved for both groups. According to the PGI-I scores, 80% of subjects in the VALH group, and 100% in the VH + VVS group, were “very much better” or “much better” with their prolapse symptoms at their 1-year follow-up. There was no reoperation or operation-related complication in both groups. Conclusion: VALH and VH + VVS have similar 1-year cure rates and patient satisfaction.
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Postlaparoscopic hysterectomy discharge within 24 h in Hospital Putrajaya: A feasibility study p. 37
Nurul Idayu Mohamad Padzil, Emily Christine D'silva, Anis Iryani Safiee, Wan Ahmad Hazim Wan Ghazali
DOI:10.4103/GMIT.GMIT_41_19  
Objective: The study objective was to determine the feasibility and selection criteria for discharge within 24 h posttotal laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy (TLH with or without BSO) in Hospital Putrajaya. Materials and Methods: A total of thirty patients among all gynecology inpatients who were planned for TLH with or without BSO with controlled medical diseases, normal preoperative investigations, and uncomplicated surgery were recruited from January 2014 to December 2016. Data were collected from electronic medical records. Postoperatively, patients who fulfilled the selection criteria were discharged within 24 h and were followed up at 6 weeks and 3 months postsurgery. The results were presented as frequency with percentage and mean standard deviation. Results: All patients who had uncomplicated surgery and blood loss <1 l with no early postoperative complications were discharged within 24 h. They had a pain score of < 3 and were able to ambulate and tolerated orally well. None of these patients who were discharged 24 h postsurgery required readmissions. During follow-up, there were no reported complications such as persistent pain, wound infection, or herniation. Conclusion: Twenty-four hours' discharge post-TLH with or without BSO is feasible and safe if the selection process is adhered to.
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SHORT COMMUNICATIONS Top

Female genital tuberculosis: Five case reports p. 41
Abdurrahman Kaya, Sibel Yildiz Kaya, Esra Zerdali, Ali Can
DOI:10.4103/GMIT.GMIT_25_20  
Female genital tuberculosis (FG-TB) is an important disease leading to substantial morbidity including infertility and abnormal vaginal bleeding. While the incidence of FG-TB is < 1% in a developed area, its incidence is >1% in developing countries. Due to its subtle presentation, many cases are overlooked and diagnosed incidentally. Accordingly, the actual incidence of FG-TB is unknown. The definitive diagnosis of the disease is based on histopathological or microbiological examination but in most cases, the bacteriological test is overlooked. In addition, there is no specific laboratory or imaging evaluation to distinguish FG-TB from others. The first step in the diagnosis of FG-TB is suspicion of the disease. In the case of infertility, FG-TB should be included in the differential diagnosis in developing countries after excluding other common diseases and tissue biopsy should be sent for not only histopathology but also microbiological investigations.
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Assessing the effectiveness of a weight reduction program in hospitalized obese patients undergoing laparoscopic surgery p. 44
Ken Imai, Kenro Chikazawa, Takaki Ito, Azusa Kimura, Hiroyoshi Ko, Yokota Miho, Tomoyuki Kuwata, Ryo Konno
DOI:10.4103/GMIT.GMIT_73_20  
Investigate the efficacy of a hospitalized weight reduction program before laparoscopic surgery among high body mass index (BMI) patients with endometrial cancer. The patients were housed in a shared room, received exercise guidance, and restricted to a total caloric intake of 1200 kcal. A physiotherapist and a dietitian provided pedometer and nutritional guidance, respectively. The primary outcome was weight reduction. Among the 16 patients included, 12 (75%) had Stage I endometrial cancer and 10 (62.5%) underwent laparoscopic surgery. Weight and BMI at first consultation were 88.4±10.4 kg and 34.8±3.9 kg/m2, respectively. The rate of weight reduction was 6.5%±2.5%; on average, BMI decreased by 2.1±1.0 kg/m2. The duration from initial consultation to surgery was 39.1±11.4 days. Hospitalization duration until weight reduction was 20.8±8.0 days; there were no surgical complications. Our hospitalized weight reduction program may be effective for obese endometrial cancer patients.
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CASE REPORTS Top

Laparoscopic wedge resection in a late second trimester cornual pregnancy p. 47
Anis Iryani Safiee, Wan Ahmad Hazim Wan Ghazali
DOI:10.4103/GMIT.GMIT_22_19  
Cornual pregnancy happens when implantation occurs in the cavity of a rudimentary horn of the uterus, which may or may not be communicating with the uterine cavity. The diagnosis of cornual pregnancy remains challenging, and rupture of a cornual pregnancy usually causes massive bleeding. Early diagnosis and treatment, therefore, are very crucial and key to prevent mortality. Historically, the management of cornual pregnancies included wedge resection through open surgery or even hysterectomy. In this case report, we would like to highlight a case of late second trimester cornual pregnancy, at 19-week and 3-day gestation, which was managed laparoscopically.
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Primary ovarian leiomyoma associated with multiple uterine leiomyomas p. 50
Yoshihiro Kitamura, Fumitake Ito, Tetsuya Kokabu, Taisuke Mori, Izumi Kusuki, Jo Kitawaki
DOI:10.4103/GMIT.GMIT_97_19  
Ovarian leiomyomas are very rare. We report the case of a primary ovarian leiomyoma accompanied by multiple uterine leiomyomas. A 50-year-old woman was referred to our department for heavy menstruation, and a hot spot in the uterine lumen was observed on positron emission tomography–computed tomography (PET-CT). Cervical and endometrial cytology and tumor marker tests were negative. Pelvic magnetic resonance imaging revealed an endometrial polyp and submucosal leiomyoma in the uterine lumen and a 5-cm right ovarian tumor. Laparoscopic total hysterectomy, right salpingo-oophorectomy, and left salpingectomy were performed for radical treatment. Histopathology showed that ovarian tumors contained interlacing bundles of fusiform cells encircled by normal ovarian tissue. Immunohistochemical staining showed strong and diffuse positive staining for α-smooth muscle actin. We diagnosed the tumor as a primary ovarian leiomyoma because the leiomyoma was localized in the ovary and was larger than the size of uterine leiomyomas. No metastatic lesion was found on PET-CT. There was no tumor recurrence at the 6-month follow-up.
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Heterotopic pregnancy: Diagnosis and pitfall in ultrasonography p. 53
Achmad Kemal Harzif, Purnomo Hyaswicaksono, Riyan Hari Kurniawan, Budi Wiweko
DOI:10.4103/GMIT.GMIT_92_19  
Heterotopic pregnancy (HP) is the coexistence of extrauterine and intrauterine pregnancies. This case is rare, difficult to diagnose, and threatening if left untreated. Incidental rate is estimated 1 in 30,000 spontaneous pregnancies and higher in assisted reproductive techniques. HP is often missed because of the detection of intrauterine sacs; therefore, comprehensive and systematic ultrasonography (USG) is needed, especially when there is ectopic pregnancy suspicion or when there is free fluid in the pelvis. A 46-year nulligravida with 13-year primary infertility history underwent frozen embryo transfer process with positive beta-human chorionic gonadotropin 2 weeks after the procedure. Clinical pregnancy is expressed by gestational sac findings at 6-week gestation. Two weeks later, she complained of lower right abdominal pain accompanied by spots from the birth canal. USG showed intrauterine pregnancy and sac appropriate to 8-week gestation and adnexal mass accompanied by a ring of fire image. The patient underwent right salpingectomy, recovered well, and continued her pregnancy. In vitro fertilization is the main risk factor for multiple and ectopic pregnancies. Clinical manifestations are similar to pregnancy loss or ectopic pregnancy. Specific risk factor must be acknowledged by the physician prior initial examination to rule out HP. Transvaginal ultrasound is useful in making the diagnosis of HP, especially in early pregnancy.
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A case of heterotopic ovarian pregnancy after in vitro fertilization: early diagnosis and single-port access conservative laparoscopic treatment p. 57
Yeon Hee Hong, Hyojin Kim, Seul Ki Kim, Byung Chul Jee
DOI:10.4103/GMIT.GMIT_117_19  
Here, we reported the case of a 32-year-old pregnant woman who presented with sudden abdominal pain at 5 weeks of gestation and diagnosed as ruptured heterotopic ovarian pregnancy. She was conceived after in vitro fertilization. Right ovarian pregnancy was noticed, and we performed right ovarian wedge resection via single-port access laparoscopic surgery. Intrauterine pregnancy had remained intact, and she delivered a term baby. Rapid diagnosis in early gestation and minimally invasive laparoscopy resulted in a satisfactory pregnancy outcome without other complications. Single-port laparoscopic surgery can be feasible and appears to be a good first treatment option in a ruptured heterotopic ovarian pregnancy.
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Total laparoscopic hysterectomy for anterior cervical myoma: Possible significance of presurgical assessment by magnetic resonance imaging p. 61
Yumi Ishidera, Megumi Furugori, Go Hirata, Reina Wakabayashi, Hiroyuki Shigeta, Hiroshi Yoshida
DOI:10.4103/GMIT.GMIT_104_19  
Hysterectomy for large uterine anterior cervical myoma is a challenging surgical procedure. We summarize our experience in the management of large uterine anterior cervical myoma. Three patients underwent hysterectomy for uterine anterior cervical myoma with similar sizes and different positions treated by laparoscopic surgery. Total laparoscopic hysterectomy (TLH) for cervical myoma is possible by performing ureterolysis and adopting retrograde hysterectomy. Because the position of myoma is important to determine the difficulty of TLH, we propose to measure the axis between the most caudal point of the myoma and external cervical os and pubococcygeal line as a possible useful method in objectively predicting the difficulty of TLH for large anterior cervical myoma.
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CLINICAL IMAGE Top

Laparoscopic management of unruptured interstitial pregnancy using purse-string suture technique p. 65
Mikaela Erlinda Germar Martinez, Regina Paz Airoso Tan-Espiritu
DOI:10.4103/GMIT.GMIT_94_20  
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LETTER TO THE EDITOR Top

Inevitable removal of left accessory ovary p. 67
Ibrahim A Abdelazim, Mohannad AbuFaza, Svetlana Shikanova, Bakyt Karimova
DOI:10.4103/GMIT.GMIT_99_20  
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Gynecological surgeries during COVID-19 pandemic: A laparoscopist's viewpoint p. 69
Kavita Khoiwal, Jaya Chaturvedi
DOI:10.4103/GMIT.GMIT_130_20  
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