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Annals of Translational Medicine Apr 2024A core concept of the Integral Theory System is that "ligaments are for structure; vagina is for function". The vagina and uterus should be conserved. Because the vagina... (Review)
Review
A core concept of the Integral Theory System is that "ligaments are for structure; vagina is for function". The vagina and uterus should be conserved. Because the vagina is an organ, its collagen and elastin, which are so necessary for its function, cannot regenerate once they are removed. Removing the uterus involves severing the descending uterine artery, which is the principal blood supply of the proximal part of the uterosacral ligaments (USLs), and so may cause atrophy, which can cause future incontinence problems because of collagen loss after menopause. The diagnostic algorithm guides which of the five pelvic ligaments need repair. Native ligament plication can be adequate for prolapse/symptom cure, but only in premenopausal women. Postmenopausal women are usually collagen deficient and require collagen-creating tapes or wide-bore polyester sutures to restore structural collagen in the ligaments. Of extreme importance, vaginal tissue excision should be avoided, as consequent scarring may cause "tethered vagina syndrome" (TVS). TVS can cause massive uncontrolled urine loss because the scar tissue in the bladder neck area of the vagina can link the more powerful posterior muscles to the anterior, so the posterior urethra wall is forcibly pulled open, when given the signal to close. Instead of vaginal excision, a "concertina" suture technique re-assigns and shrinks excess vaginal tissue to normal anatomy by 6 weeks. In conclusion, the five key surgical principles of the Integral Theory System are: ligaments are for structure, vagina is for function; structure (prolapse) and function (symptoms) are related; repair the structure and you will restore the function; avoid vaginal excision and hysterectomy; create new collagen to reinforce the damaged ligaments.
PubMed: 38721467
DOI: 10.21037/atm-23-1769 -
Case Reports in Surgery 2024Hysterectomy is one of the most common gynecologic procedures performed worldwide. Vaginal cuff dehiscence with resultant bowel evisceration, while rare, is one of the...
Hysterectomy is one of the most common gynecologic procedures performed worldwide. Vaginal cuff dehiscence with resultant bowel evisceration, while rare, is one of the most serious complications of the procedure. We present the case of a 79-year-old female with vaginal cuff dehiscence several decades after hysterectomy. The patient had no significant antecedent symptoms until she experienced bowel evisceration during Valsalva. She underwent a successful reduction of bowel contents with limited resection and transvaginal cuff repair. This case highlights the risk of vaginal cuff dehiscence even decades following the procedure.
PubMed: 38716136
DOI: 10.1155/2024/2074381 -
Cureus Apr 2024Hysterectomy is one of the most frequently performed surgical procedures in the United States. Hysterectomy for benign gynecological reasons can be performed through...
Hysterectomy is one of the most frequently performed surgical procedures in the United States. Hysterectomy for benign gynecological reasons can be performed through several approaches: abdominal, laparoscopic, laparoscopically assisted vaginal, robotic-assisted, and vaginal natural orifice hysterectomy. The choice of approach is strongly influenced by factors such as previous procedures, safety, and recovery process. Currently, vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy (LAVH), assisted vaginal hysterectomy, and robotic-assisted vaginal hysterectomy are considered minimally invasive approaches with multiple benefits to the patient such as less trauma, shorter operative time, and shorter postoperative period. However, in patients with pelvic adhesions, adhesions within the abdominal cavity, especially omental adhesions to the abdominal wall, and adhesions between the uterus and the bladder caused by multiple cesarian sections or prior surgery on the cervix, these minimally invasive approaches are problematic. In this report, we describe in detail our approach to LAVH in a patient with severe abdominal adhesions and an absent cervix. We believe that our approach is safe and relatively fast compared to an open abdominal procedure and, therefore, it may help gynecologic surgeons-in-training nationwide.
PubMed: 38707153
DOI: 10.7759/cureus.57482 -
Journal of Gynecologic Surgery Apr 2024The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of...
BACKGROUND
The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines.
METHODS
This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field.
RESULTS
The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials.
CONCLUSIONS
vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).
PubMed: 38690154
DOI: 10.1089/gyn.2023.0098 -
Przeglad Menopauzalny = Menopause Review Mar 2024Hysterectomy is a common surgical procedure performed to remove the uterus. This is considered as a clean-contaminated surgical procedure. It is a safe procedure, but... (Review)
Review
Hysterectomy is a common surgical procedure performed to remove the uterus. This is considered as a clean-contaminated surgical procedure. It is a safe procedure, but major and minor complications can occur, including vault hematoma and vault cellulitis, which are specific to the surgical site. Vault hematoma is the accumulation of blood within the vaginal vault, while vault cellulitis is an infection of the vaginal vault or the surgical cuff following a hysterectomy. Vault hematoma may be caused by trauma during surgery, improper hemostasis or infection. Smaller hematomas may resolve with conservative management, but larger vault hematomas and infected hematomas may need surgical drainage and antibiotic coverage. Vault cellulitis typically occurs due to the introduction of bacteria into the surgical site which may occur due to inappropriate postoperative care and contaminated materials. The patient may present with pelvic pain and fever. Broad-spectrum antibiotics are typically prescribed to treat the infection. While both these complications are relatively rare and appear to be mild, healthcare providers should be vigilant in recognizing and managing them promptly to prevent adverse outcomes. Prophylactic antibiotics should be administered before the surgery to reduce the risk of infection. Care should be taken to minimize tissue trauma, ensure proper hemostasis, and maintain strict aseptic techniques during surgery.
PubMed: 38690067
DOI: 10.5114/pm.2024.136011 -
Research and Practice in Thrombosis and... Mar 2024Von Willebrand disease (VWD) type 3 is characterized by a complete deficiency of von Willebrand factor (VWF), resulting in a severe bleeding phenotype. Treatment often...
BACKGROUND
Von Willebrand disease (VWD) type 3 is characterized by a complete deficiency of von Willebrand factor (VWF), resulting in a severe bleeding phenotype. Treatment often requires administration of VWF concentrates/factor (F)VIII. However, the development of alloantibodies is a rare complication, resulting in ineffective recovery and allergic reactions. Emicizumab, a bispecific antibody mimicking FVIII function, has emerged as a potential alternative, with promising results reported in several case reports.
KEY CLINICAL QUESTION
Description of multiple approaches to control highly severe postpartum hemorrhage in type 3 VWD with alloantibodies, including off-label use of emicizumab.
CLINICAL APPROACH
Here we present a 28-year-old patient with type 3 VWD and alloantibodies, known to have arthropathy of the right elbow. Previous immune tolerance induction was unsuccessful. Despite receiving negative pregnancy advice during preconception counseling, the patient became pregnant. Delivery was induced at 38 4/7 weeks with prostaglandin, and recombinant FVIIa (rFVIIa) was administered every 2 hours. Despite administration of rFVIIa, bleeding persisted, requiring manual placental removal and insertion of a Bakri balloon. Since bleeding persisted, plasma-derived VWF was administered with an initial excellent recovery and successful embolization of the uterine artery. Twelve days postpartum, she developed endometritis and recurrent vaginal bleeding treated with antibiotics, rFVIIa every 2 hours, and multiple erythrocyte transfusions. Plasma-derived VWF was administered but was complicated by anaphylaxis and no recovery. Due to persistent vaginal bleeding, reembolization of uterine arteries was performed and off-label emicizumab was initiated. Twenty-nine days postpartum, she developed septic shock requiring an abdominal hysterectomy, again complicated by severe bleeding necessitating direct intraabdominal packing after rFVIIa. A computed tomography scan 9 days postsurgery revealed thrombosis in the left iliac vein and asymptomatic pulmonary embolisms. rFVIIa was stopped and prophylactic low-molecular-weight heparin was started. The patient was discharged 2 months after delivery on low-dose low-molecular-weight heparin, emicizumab, and antibiotics for an intra-abdominal abscess. During 2.5 years of emicizumab prophylaxis, she has had no rebleeding in her arthropathic right elbow.
CONCLUSION
The current case emphasizes the postpartum clinical challenges of patients with type 3 VWD and alloantibodies. It underscores the potential role of emicizumab in maintaining hemostatic control.
PubMed: 38689620
DOI: 10.1016/j.rpth.2024.102399 -
Cureus Mar 2024Uterine rupture is a rare but critical obstetric complication that demands a swift and decisive intervention to ensure the well-being of the mother and fetus. We present...
Uterine rupture is a rare but critical obstetric complication that demands a swift and decisive intervention to ensure the well-being of the mother and fetus. We present a case report detailing the surgical management of a bizarre uterine rupture in a multigravida female with two previous vaginal deliveries and a previously unscarred uterus. This case highlights the challenges of treating and diagnosing, particularly in the Indian setting, an antenatally unregistered patient with rare obstetrical complications. Emphasizing the clinical challenges faced and the multidisciplinary approach employed for optimal outcomes, this report underscores the importance of a high degree of suspicion, early diagnosis, timely intervention, and comprehensive intraoperative and postoperative care in addressing this rare obstetric catastrophic event. This article's main focus is multicentric, aiming to showcase the obstacles to maintaining low maternal mortality and morbidity, the presence of inadequate awareness in society, and the importance of multimodal treatment and planning.
PubMed: 38686227
DOI: 10.7759/cureus.57273 -
Archives of Gynecology and Obstetrics Jul 2024This study aimed to evaluate the clinical efficacy and safety of argon plasma coagulation (APC) therapy and interferon therapy in patients with grade I and II vaginal... (Comparative Study)
Comparative Study
PURPOSE
This study aimed to evaluate the clinical efficacy and safety of argon plasma coagulation (APC) therapy and interferon therapy in patients with grade I and II vaginal intraepithelial neoplasia (VaIN).
METHODS
A total of 112 patients with VaIN were diagnosed via colposcopy-induced biopsy and classified into the APC group (n = 77) and interferon group (n = 35). Clinical data including age, grade, symptoms, historical or concomitant neoplasia of the lower genital tract, indications for hysterectomy, pregnancy history, cytology, human papillomavirus (HPV) subtype, treatment modalities, and clinical outcomes were analyzed, retrospectively. Complications and clinical outcomes were assessed at 6- and 12-month follow-ups.
RESULTS
There was no significant difference in the HPV clearance rate between the APC (53.42%) and interferon (33.33%) groups at 6 months after treatment. However, the 12-month follow-up of the APC group showed a significantly higher HPV clearance rate as compared to the interferon group (87.67% vs. 51.52%, P < 0.05). The APC group exhibited a significantly higher cure rate (79.22% vs. 40.0%) and lower persistence rate (12.99% vs. 37.14%) than the interferon group (P < 0.05). Adverse reaction analysis revealed that the primary reaction in the APC group was vaginal drainage, in contrast to the increased vaginal discharge in the interferon group; though the difference was significant (68.83% vs. 28.57%, P < 0.05), no serious complications were observed.
CONCLUSIONS
Treatment with APC is a safe and more effective procedure against VaIN I and II, compared to interferon. APC may serve as a viable alternative to other physiotherapies.
Topics: Humans; Female; Retrospective Studies; Vaginal Neoplasms; Adult; Middle Aged; Argon Plasma Coagulation; Carcinoma in Situ; Papillomavirus Infections; Treatment Outcome; Interferons; Colposcopy; Combined Modality Therapy
PubMed: 38683394
DOI: 10.1007/s00404-024-07477-3 -
Asian Pacific Journal of Cancer... Apr 2024To investigate the prevalence of high-risk (HR) human papillomavirus (HPV) detection and HPV vaccination among women undergoing cervical cancer screening during the HPV...
Prevalence of High-Risk HPV Detection and HPV Vaccination in Cervical Cancer Screening During the HPV Vaccination Era at Siriraj Hospital - Thailand's Largest National Tertiary Referral Center.
OBJECTIVE
To investigate the prevalence of high-risk (HR) human papillomavirus (HPV) detection and HPV vaccination among women undergoing cervical cancer screening during the HPV vaccination era at Siriraj Hospital - Thailand's largest national tertiary referral center.
METHODS
This prospective cross-sectional study was conducted at our center's outpatient gynecology clinic during September-December 2021. Women aged ≥18 years with no previous hysterectomy, no history of preinvasive or invasive cervical cancer, and no current pregnancy who visited for cervical cancer screening were eligible for enrollment. Women with abnormal vaginal discharge/bleeding, and specimens with inadequate cellularity were excluded. We collected sociodemographic data, history of HPV vaccination, cervical cytology results, and high-risk HPV testing results. Reverse transcription polymerase chain reaction was used to determine HPV genotype.
RESULTS
A total of 216 women (mean age: 41.7 years (range: 25-65), 75.9% premenopausal) were enrolled. Twenty of 216 (9.3%) women tested positive for HR-HPV, and 15 of 216 (6.9%) women had been previously vaccinated for HPV. The most common HPV genotypes detected were Group B infection (HPV 35/39/51/56/59/66/68) (38.9%), followed by HPV16 (27.78%), Group A infection (HPV 31/33/52/58) (27.8%), and HPV18 (5.56%). No HPV45 infection was detected. The detection rate of cytologic abnormalities was 4.16%. Three-quarters (77.8%) of patients with cytologic abnormalities were HR-HPV positive.
CONCLUSION
Among the 216 women who underwent cervical cancer screening in this study, there was a 9.3% prevalence of HR-HPV infection, and a 6.9% prevalence of HPV vaccination. Among the 15 vaccinated women, 2 tested positive for HPV16 (1 normal cytology, 1 abnormal cytology).
Topics: Humans; Female; Uterine Cervical Neoplasms; Papillomavirus Infections; Thailand; Adult; Papillomavirus Vaccines; Cross-Sectional Studies; Middle Aged; Prospective Studies; Tertiary Care Centers; Prevalence; Early Detection of Cancer; Aged; Papillomaviridae; Vaccination; Follow-Up Studies; Prognosis; Uterine Cervical Dysplasia
PubMed: 38679983
DOI: 10.31557/APJCP.2024.25.4.1241 -
International Journal of Surgery Case... Jun 2024Uterine artery pseudoaneurysm is an extraluminal collection of blood caused by damage to the arterial wall which can result from cesarean section, myomectomy,...
INTRODUCTION AND IMPORTANCE
Uterine artery pseudoaneurysm is an extraluminal collection of blood caused by damage to the arterial wall which can result from cesarean section, myomectomy, hysterectomy, laparoscopic excision of deep endometriotic lesions, dilation and curettage and uterine cervical conization. Uterine artery pseudoaneurysm may go unnoticed as a possible cause of post-partum hemorrhage.
CASE PRESENTATION
We report a case of 25 years female who presented with 3 episodes of per vaginal bleeding on the 34th postoperative day of cesarean section. Computed tomography angiogram confirmed the aneurysm of the left uterine artery and the artery was embolized for the management of aneurysm. Follow-up scan showed normal blood flow and her symptoms were relieved after the procedure.
DISCUSSION
Uterine artery pseudoaneurysm can be diagnosed by Doppler ultrasound which shows intrauterine mass with swirling blood flow. The gold standard investigation is computed tomography angiography. Uterine artery embolization is the recent treatment approach which is both safe and effective.
CONCLUSION
Women who present with postpartum vaginal bleeding should be promptly evaluated for uterine artery pseudoaneurysm. Uterine artery pseudoaneurysm can then be effectively managed through embolization, ensuring timely intervention and improved maternal health outcomes.
PubMed: 38678997
DOI: 10.1016/j.ijscr.2024.109697