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Urology Feb 2024Endometriosis is a chronic, debilitating condition affecting up to 10% of reproductive-age women. Urinary tract endometriosis is found in 1%-6% of women diagnosed with...
BACKGROUND
Endometriosis is a chronic, debilitating condition affecting up to 10% of reproductive-age women. Urinary tract endometriosis is found in 1%-6% of women diagnosed with pelvic endometriosis, with the most common sites being the bladder (70%-85%), ureter (9%-23%), and kidney (4%). Patients typically present with symptoms such as lower abdominal pain, dysuria, and urgency. Unfortunately, urinary tract endometriosis is often asymptomatic, potentially leading to silent obstructive uropathy and kidney failure.
OBJECTIVE
To demonstrate a step-by-step approach for the surgical management of urinary tract endometriosis using conventional laparoscopy for partial cystectomy and robotic-assisted laparoscopy for ureteroneocystostomy.
MATERIAL AND METHOD
Surgical video of 2 cases managed in an academic tertiary referral center for endometriosis. The first case was a 38-year-old Gravida 3, Para 3 with a history of hysterectomy who had an MRI which revealed a T2 hypointense bladder nodule consistent with endometriosis. Patient had significant urinary urgency, dysuria, and suprapubpic pain that improved but did not disappear after starting oral progestin therapy (5 mg of norethindrone). A cystoscopy was first performed to confirm MRI findings of bladder lesion and to delineate borders and depth of invasion. The second case was a 35-year-old nulliparous woman with chronic pelvic pain and primary infertility. The patient had a history of stage IV endometriosis with deep endometriosis into the bowel and extrinsic encasement of the ureters causing subsequent hydronephrosis requiring bilateral ureteral stents. She had continued daily pelvic pain despite of being on oral contraceptives for medical management of endometriosis. She subsequently underwent bilateral percutaneous nephrostomy tube placement to allow for ureteral rest prior to surgery.
RESULTS
In the first case, conventional laparoscopy was utilized to perform bilateral ureterolysis, bladder mobilization, partial cystectomy for complete excision of the lesion, and 2-layered bladder closure. Use of indigo carmine assisted with ureteral orifice identification. In the second case, a cystoscopy was performed with injection of Indocyanine green to assist with ureteral identification. After ureterolysis, distal ureteric obstruction due to extensive disease was confirmed on laparoscopy and ureteroscopy. Bilateral ureteroneocystostomy with placement of Double-J ureteral stents was performed using a robotic-assisted approach. Each patient had an indwelling Foley catheter for bladder decompression during recovery. Pathology in both cases revealed endometriosis. Both patients had an uneventful postoperative course. A postoperative retrograde cystogram confirmed adequate repair prior to removal of each Foley catheter. Patient 2 had uncomplicated office stent removal 6 weeks postoperatively and had a normal renal ultrasound with no hydronephrosis 6 months postoperatively.
CONCLUSION
Endometriosis is an increasingly common condition. It is important for gynecological surgeons to have the proper understanding of anatomy, surgical technique, and multidisciplinary care needed with urology for safe and complete excision of bladder and ureter endometriosis.
Topics: Humans; Female; Adult; Urinary Bladder; Ureter; Endometriosis; Dysuria; Hydronephrosis; Pelvic Pain
PubMed: 38072247
DOI: 10.1016/j.urology.2023.11.029 -
The Journal of Obstetrics and... Mar 2022Laparoscopic hysterectomy (LH) have been frequently used because of low complication rates and short duration of hospital stay. Elevated intracranial pressure (ICP), a...
BACKGROUND AND AIM
Laparoscopic hysterectomy (LH) have been frequently used because of low complication rates and short duration of hospital stay. Elevated intracranial pressure (ICP), a disadvantage of laparoscopic surgery, is caused by the Trendelenburg position (TP) and CO pneumoperitoneum (PP). This study aimed to evaluate TP and PP associated changes in ICP by ONSD measurements during LH. The intra-and inter-observer consistency and reliability of ONSD measurements were also investigated.
METHODS
Sixty patients with were enrolled into this prospective study. ONSD for each patient was measured by three anesthesiologists at T0, T1, T2, and T3 time points. ONSD, mean arterial pressure (MAP), end tidal CO (EtCO ), and arterial blood CO partial pressure values (PaCO ) were measured at T0: baseline, T1: 10 min after introducing 20 mmHg PP, T2: 10 min after placing the patient in TP and 15 mmHg PP and, T3: 10 min after PP deflation.
RESULTS
The ONSD measured at T1 (5.97 ± 0.49 cm) and T2 (5.95 ± 0.57 cm) were higher than T0 (5.63 ± 0.53 cm) and T3 (5.72 ± 0.47 cm) (p < 0.05). There were no correlations between MAP and ONSD, and also between PaCO , EtCO , and ONSD measurements at any time points. Inter-observer intraclass correlation coefficient (ICC) values of ONSD measurements by all examiners had moderate (at T1) to good (at T0, T2, T3) reliability. Intra-observer agreements were reasonable for each observer.
CONCLUSION
ONSD measurements increase with CO PP and TP in patients undergoing LH. Transorbital sonography is a reliable method to monitor intraoperative changes in ONSDs. This study underlines the need for careful training and the importance of standardization in order to obtain reliable results in the examination technique of ONSD measurements.
Topics: Female; Head-Down Tilt; Humans; Hysterectomy; Laparoscopy; Male; Optic Nerve; Pneumoperitoneum; Prospective Studies; Prostatectomy; Reproducibility of Results; Ultrasonography
PubMed: 35048472
DOI: 10.1111/jog.15147 -
JAMA Oncology Jun 2024Poor performance of the transvaginal ultrasonography triage strategy has been suggested as a contributor to racial disparity between Black individuals and White...
IMPORTANCE
Poor performance of the transvaginal ultrasonography triage strategy has been suggested as a contributor to racial disparity between Black individuals and White individuals in endometrial cancer (EC) stage at diagnosis in population-level simulation analyses.
OBJECTIVES
To examine the false-negative probability using ultrasonography-measured endometrial thickness (ET) thresholds as triage for EC diagnosis among Black individuals and assess whether known risk factors of EC modify ET triage performance.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective diagnostic study of merged abstracted electronic health record data and secondary administrative data (January 1, 2014, to December 31, 2020) from the Guidelines for Transvaginal Ultrasound in the Detection of Early Endometrial Cancer sample assessed Black individuals who underwent hysterectomy in a 10-hospital academic-affiliated health care system and affiliated outpatient practices. Data analysis was performed from January 31, 2023, to November 30, 2023.
EXPOSURE
Pelvic ultrasonography within 24 months before hysterectomy.
MAIN OUTCOME AND MEASURES
Ultrasonography performed before hysterectomy as well as demographic and clinical data on symptom presentation, endometrial characterization, and final EC diagnosis were abstracted. Endometrial thickness thresholds were examined for accuracy in ruling out EC diagnosis by using sensitivity, specificity, and negative predictive value. False-negative probability was defined as 1 - sensitivity. Accuracy measures were stratified by risk factors for EC and by factors hypothesized to influence ET measurement quality.
RESULTS
A total of 1494 individuals with a uterus (median [IQR] age, 46.1 [41.1-54.0] years) comprised the sample, and 210 had EC. Fibroids (1167 [78.1%]), vaginal bleeding (1067 [71.4%]), and pelvic pain (857 [57.4%]) were the most common presenting diagnoses within 30 days of ultrasonography. Applying the less than 5-mm ET threshold, there was an 11.4% probability that someone with EC would be classified as not having EC (n = 24). At the 4-mm (cumulative) threshold, the probability was 9.5%, and at 3 mm, it was 3.8%. False-negative probability at the 5-mm threshold was similar among EC risk factor groups: postmenopausal bleeding (12.4%; 95% CI, 7.8%-18.5%), body mass index greater than 40 (9.3%; 95% CI, 3.1%-20.3%); and age 50 years or older (12.8%; 95% CI, 8.4%-18.5%). False-negative probability was also similar among those with fibroids on ultrasonography (11.8%; 95% CI, 6.9%-18.4%) but higher in the setting of reported partial ET visibility (26.1%; 95% CI, 10.2%-48.4%) and pelvic pain (14.5%; 95% CI, 7.7%-23.9%).
CONCLUSION AND RELEVANCE
These findings suggest that the transvaginal ultrasonography triage strategy is not reliable among Black adults at risk for EC. In the presence of postmenopausal bleeding, tissue sampling is strongly recommended.
PubMed: 38935372
DOI: 10.1001/jamaoncol.2024.1891 -
Journal of Taibah University Medical... Jun 2022Sarcomas arising from the cervix are rare, and the reported prevalence is 0.20-0.55%. A 15-year-old Para 0 secondary school student presented to the emergency department...
Sarcomas arising from the cervix are rare, and the reported prevalence is 0.20-0.55%. A 15-year-old Para 0 secondary school student presented to the emergency department in shock with a 1-year history of painless vaginal protrusion, vaginal bleeding, foul-smelling vaginal discharge, occasional passage of blood clots, fatigue, fainting episodes, and weight loss. She was resuscitated with intravenous fluids and blood transfusions. General examination revealed a young girl with a 16-week sized abdominal mass. Vaginal examination revealed a large mobile fleshy mass 14 cm by 10 cm with an offensive discharge and odour. It was externally friable, bled actively on contact, had areas of tissue necrosis, and was oedematous. It was difficult to determine the adnexa structures because of tenderness. Examination under anaesthesia showed that the mass was continuous with the cervix and was not attached to the vagina or vulva. The histology report of the biopsied specimens showed features consistent with cervical leiomyosarcoma (LMS). Cervical LMS was confirmed by immunohistochemistry and a total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed as definitive treatment. Postoperative hormone replacement therapy was initiated. The patient's postoperative condition was stable and there was no tumour recurrence for >2 years on follow-up. Making a diagnosis and instituting surgical and adjuvant treatments for LMS in a low-resource setting are challenging. This is due to lack of access to universal healthcare coverage. A multidisciplinary approach with early diagnosis and complete surgical resection of the tumour provides the most favourable possibility of an improved survival and quality of life.
PubMed: 35722227
DOI: 10.1016/j.jtumed.2021.10.007 -
Cureus Jan 2023The present randomised controlled trial was conducted to compare haemostatic efficiency, operative time, and overall performance of the electrothermal bipolar vessel...
INTRODUCTION
The present randomised controlled trial was conducted to compare haemostatic efficiency, operative time, and overall performance of the electrothermal bipolar vessel sealing (EBVS) system with conventional suturing in abdominal hysterectomy.
MATERIALS AND METHODS
The trial was designed with standard parallel arms, i.e., vessel sealing and suture ligature arms. Sixty patients were block randomised into either arms with 30 patients in each. A hand-held vessel sealing instrument was used to perform a hysterectomy in the vessel sealing arm and the quality of the uterine artery seal achieved at the first attempt was graded on an ordinal scale of 1-3 to quantify haemostatic efficiency. Operative time, intra-operative blood loss, and peri-operative complications were compared between the two arms.
RESULTS
Significantly reduced mean operative time (26.97±8.92 vs 33.67±8.62 minutes; p=0.005) and intra-operative blood loss (111±53.31 mL vs 320±193.90 mL; p=0.001) was observed in the Vessel Sealing Arm compared to Suture Ligature Arm. Of total 60 uterine seals (from bilateral uterine artery transaction in 30 hysterectomies in the Vessel Sealing Arm), 83.34% were Level 1 with Complete Seal and no residual bleeding, 8.33% were Level 2 or Partial Seals with minimal bleeding, requiring the use of vessel sealers for a second time, while 8.33% had Seal Failure (Level 3) with significant bleeding requiring additional re-security of stumps with sutures. Modal pain scores on the first three postoperative days and duration of hospital stay were significantly less in the Vessel Sealer Arm, reflecting reduced postoperative morbidity. Outcomes were comparable across operators.
CONCLUSION
Vessel Sealing System gives superior surgical results with lesser operative time, minimal blood loss, and reduced morbidity.
PubMed: 36843794
DOI: 10.7759/cureus.34123 -
PloS One 2021Autonomic neurons innervating uterine horn is probably the only nerve cell population capable of periodical physiological degeneration and regeneration. One of the main...
Autonomic neurons innervating uterine horn is probably the only nerve cell population capable of periodical physiological degeneration and regeneration. One of the main sources of innervation of the uterus is paracervical ganglion (PCG). PCG is a unique structure of the autonomic nervous system. It contains components of both the sympathetic and parasympathetic nervous system. The present study examines the response of neurons of PCG innervating uterine horn to axotomy caused by partial hysterectomy in the domestic pig animal model. The study was performed using a neuronal retrograde tracing and double immunofluorescent staining for tyrosine hydroxylase (TH), dopamine beta-hydroxylase (DβH), choline acetyltransferase (ChAT), vesicular acetylcholine transporter (VAChT), neuronal nictric oxide synthase (nNOS), galanin, neuropeptide Y (NPY), vasoactive intestinal peptide (VIP), pituitary adenylate cyclase-activating peptide (PACAP), somatostatin and substance P (SP). Our study showed that virtually all neurons of the porcine PCG innervating uterine horn are adrenergic and we did not confirm that PCG is the source of cholinergic fibers innervating uterine horn of the pig. After axotomy there was a decrease in expression of catecholamine-synthesizing enzymes (TH, DβH) and a strong increase in the galanin expression. The increase of the number of NPY-IR neurons in the ganglia after axotomy was observed. There were no changes in the expression of other studied substances in the PCG neurons innervating the uterine horn, what was often found in rodents studies. This indicates that neurons can respond to damage in a species-specific way.
Topics: Animals; Choline O-Acetyltransferase; Dopamine beta-Hydroxylase; Female; Ganglia, Spinal; Hysterectomy; Neurons; Nitric Oxide Synthase; Pituitary Adenylate Cyclase-Activating Polypeptide; Somatostatin; Substance P; Swine; Tyrosine 3-Monooxygenase; Uterus; Vasoactive Intestinal Peptide; Vesicular Acetylcholine Transport Proteins
PubMed: 33497400
DOI: 10.1371/journal.pone.0245974 -
Contrast Media & Molecular Imaging 2021The study aimed to explore the application value of MRI images based on the optimized self-adaptive edge detection algorithm in the diagnosis of placenta previa and in...
The study aimed to explore the application value of MRI images based on the optimized self-adaptive edge detection algorithm in the diagnosis of placenta previa and in the prediction of postpartum hemorrhage. Specifically, a self-adaptive edge detection algorithm was constructed based on optimized edge operators, with the nearest scale parameters analyzed. It was then used to process the MRI images of 36 patients with placenta previa. MRI images of different types of placenta previa were analyzed. The results found that the placenta of the complete placenta previa was attached to the lower wall of the uterus and covered the internal cervix in shape, and the placenta adhered to the anterior and lower wall of the uterus, with widespread placenta accreta noted. With the results of cesarean section as the standard, it was observed that 2 cases of complete placenta previa were diagnosed as partial placenta previa. The diagnostic accuracy rate was 94.44%, which was not notably different from the results of cesarean section ( > 0.05). The postpartum hemorrhage rate and hysterectomy rate of complete placenta previa were higher than partial placenta previa and marginal placenta previa, and the difference was notable ( < 0.05), but no notable differences were noted in placenta adhesion, placenta accreta, neonatal death, and neonatal asphyxia between the three types of placenta previa ( > 0.05). The incidence of thinned myometrium, placenta penetrating the cervix, placenta accreta, and uneven placental signal in patients with postpartum hemorrhage was higher versus those without postpartum hemorrhage, and the difference was notable ( < 0.05). In a word, MRI images based on the self-adaptive edge detection algorithm can clearly show the status of placenta previa and exhibit better diagnosis effects and a higher accuracy rate. The thinned myometrium, the placenta penetrating the cervix, placenta accreta, and uneven placental signal may be the related risk factors for postpartum hemorrhage in patients with placenta previa.
Topics: Adult; Algorithms; Cesarean Section; Female; Humans; Magnetic Resonance Imaging; Middle Aged; Perinatal Death; Placenta; Placenta Accreta; Placenta Previa; Postpartum Hemorrhage; Pregnancy; Young Adult
PubMed: 34526873
DOI: 10.1155/2021/8343002 -
Journal of Adolescent and Young Adult... Dec 2021To determine how young patients with early-stage endometrial cancer are counseled regarding fertility preserving therapy and pregnancy options by gynecologic oncology...
Management and Recommendations for Future Pregnancy in Patients with Early-Stage Endometrial Cancer: A Survey of Gynecologic Oncologists and Reproductive Endocrinology and Infertility Specialists.
To determine how young patients with early-stage endometrial cancer are counseled regarding fertility preserving therapy and pregnancy options by gynecologic oncology and reproductive endocrinology and infertility (REI) providers. Anonymous online survey of Society of Gynecology Oncology (SGO) and the Society for Reproductive Endocrinology and Infertility (SREI) members; data were analyzed using chi-square and -tests. Twelve percent (169/1433) of SGO and 6.5% (60/927) of SREI members responded to the survey request. Most providers manage fewer than 10 fertility preservation patients annually. All gynecologic oncologists offer conservative management to patients with grade 1 endometrial cancer without evidence of invasion, and 40% would offer it to patients with grade 2 or <50% invasion. Magnetic resonance imaging was the most common method of assessing invasion, and the progesterone intrauterine device was the preferred first-line treatment. Two-thirds of providers would recommend hysterectomy if no endometrial response was noted by 12 months, two-thirds would continue conservative management for more than a year if a partial response was noted, and 70% would recommend hysterectomy after a patient completes childbearing. Comparatively, 60% of REI providers would recommend hysterectomy after childbearing. More gynecologic oncologists than REI providers recommend attempting spontaneous conception and for longer durations before initiating fertility treatments. Heterogeneous management styles exist among and between gynecologic oncology and REI providers for patients with early-stage endometrial cancer desiring future pregnancy. Improved guidelines are needed regarding treatment and monitoring surrounding trials of conception and pregnancy.
Topics: Endometrial Neoplasms; Female; Fertility Preservation; Humans; Hysterectomy; Infertility; Oncologists; Pregnancy
PubMed: 33960835
DOI: 10.1089/jayao.2020.0228 -
Annals of Transplantation Jun 2020BACKGROUND Minimally invasive surgery (MIS) has rapidly advanced, but its use in transplant patients has lagged. We share our experience of MIS for patients after kidney...
BACKGROUND Minimally invasive surgery (MIS) has rapidly advanced, but its use in transplant patients has lagged. We share our experience of MIS for patients after kidney and liver transplantation and compare our results with similar studies in the literature. MATERIAL AND METHODS This study included 14 MIS (12 laparoscopic, 2 transvaginal) procedures for 13 transplant cases (6 liver and 7 kidney) done from May 2006 to May 2018. Gastrointestinal surgery was performed in 6 cases: appendectomy performed 8 months after liver transplant and 16 months after kidney transplant in 2 cases, radical right hemi-colectomy performed 6 weeks after liver transplant in 1 case; exploration for chylous ascites 6 months after liver transplant in 1 case, sleeve gastrectomy performed 3 years after kidney transplant in 1 case, and partial hepatectomy performed 12 years after kidney transplant in 1 case. For urological problems, 2 patients received ipsilateral right-side nephroureterectomy performed 10 and 12 years after kidney transplant, and 1 patient received contralateral left-side nephroureterectomy performed 12 years after kidney transplant. The 2 liver transplant patients with huge incisional hernias received repair approximately 3 and 2 years after liver transplant. Three patients underwent gynecological surgery: 2 transvaginal for pelvic floor reconstruction in 1 patient with liver transplant and 1 hysterectomy in a kidney transplant patient, and 1 laparoscopic-assisted hysterectomy in a kidney transplant patient. We retrospectively analyzed the clinical presentation, operative findings, operation time, postoperative complications, and length of stay. RESULTS The postoperative course was uneventful, with early resumption of oral intake, including immunosuppressants administered the same as in the non-transplant patients. All surgical procedures in these transplant patients were achieved without conversion, showed stable kidney and liver function, had better surgical outcomes in comparison with traditional surgery, and most of them were discharged within 1 week. CONCLUSIONS Laparoscopic and non-laparoscopic MIS surgery are feasible and safe for abdominal organ transplant patients and are helpful for timely intervention in cases with acute abdomen. No adjustment of immunosuppressant is usually needed, as oral intake can be resumed very soon after surgery.
Topics: Adult; Female; Humans; Kidney Transplantation; Length of Stay; Liver Transplantation; Male; Middle Aged; Minimally Invasive Surgical Procedures; Postoperative Complications; Transplant Recipients; Treatment Outcome
PubMed: 32541640
DOI: 10.12659/AOT.922602 -
The Journal of Maternal-fetal &... Nov 2021Cesarean delivery (CD) is one of the most common operations worldwide. Vaginal birth after cesarean (VBAC) could be a solution to decrease increased CD rates. On the...
Cesarean delivery (CD) is one of the most common operations worldwide. Vaginal birth after cesarean (VBAC) could be a solution to decrease increased CD rates. On the other hand, risks of VBAC on maternal and neonatal outcomes drifts physicians and patients to a scheduled CD. Successive CDs, especially after the 3rd operation, increase complications for the fetus and the mother. Operation type (emergency or elective CD) could be a risk factor of increased morbidities, like placental implantation anomalies. Evaluation of these conditions related to complications and morbidities were investigated. Women who underwent the fourth and more repeat CD in Bursa Yuksek Ihtisas Training Research Hospital between March 2016 and December 2019 were retrospectively reviewed. Pre-operative characteristics, per-operative and post-operative complications were reviewed. Patients were separated into groups as operational type, repeat cesarean number, and major morbidities. A comparison between groups was evaluated. A total of 46.048 women gave birth, of which 17,721 underwent CDs with a rate of 38%. The rate of primary CD was 18%. The number of the fourth or more CD performed was 854. The number of patients who underwent fourth and fifth or more CD and of these operational data could be accessed was 599 and 145, respectively. The overall complications were detected as severe adhesions (: 220), preterm delivery (: 91), stillbirth (: 9), admission to NICU (: 98), bladder injury (: 10), uterine scar dehiscence (: 6), uterine rupture (: 6), uterine atony (: 26), blood transfusion requirement (: 68), preterm delivery (: 91), placenta previa totalis (: 24), morbidly adherent placenta (: 14), hysterectomy (: 12), partial uterine resection (: 2), uterus-conserving interventions (: 26). The number of patients with major morbidity was 105. Emergency cesarean performed in 339 of 744 patients. A comparison of the emergency cesarean group with elective repeat cesarean group revealed no significant difference in operative adverse outcomes. Comparing patients between 4th repeat CD with 5th and more CD revealed a significant difference in severe adhesion, morbidly adherent placenta and hysterectomy. Previa totalis were detected in 24 patients. All of them experienced major morbidity with 12 of them underwent hysterectomy. The rest of them performed Uterus-conserving treatments (B-Lynch Suture, Bacri Balloon, Hypogastric artery ligation ) and a total of 51 units of packed red blood cells and 32 units of Fresh Frozen Plasma were transfused to 9 (37%) of 24 patients. The major risk factor of the morbidity is placenta previa whose incidence has dramatically increased after 3rd cesarean. Emergency cesarean did not increase the complication rate in the present study. Fourth and more repeat CDs ought to be performed by experienced obstetricians in high-equipped tertiary hospitals.
Topics: Female; Humans; Placenta; Placenta Accreta; Placenta Previa; Pregnancy; Retrospective Studies; Vaginal Birth after Cesarean
PubMed: 32429719
DOI: 10.1080/14767058.2020.1765332