A.J. DiSciullo

Papillary cystadenoma of the broad ligament in von Hippel-Lindau disease

Abstract We present radiologic-pathologic correlation in a case of von Hippel-Lindau disease diagnosed on the basis of the discovery of papillary cystadenoma of wolffian duct origin, a rare calcified tumor of the broad ligament that was visible on the abdominal radiograph.

TVT-Secur (Hammock) versus TVT-Obturator: a randomized trial of suburethral sling operative procedures.

Objectives This study aimed to compare TVT-Secur (TVT-S) and TVT-Obturator (TVT-O) suburethral slings for treatment of stress urinary incontinence (SUI). Methods This was a single-center, nonblinded, randomized trial of women with SUI who were randomized to TVT-S or TVT-O from May 2007 to April 2009. The primary outcome, SUI on cough stress test (CST), and quality-of-life and symptom questionnaires (Pelvic Floor Distress Inventory [PFDI-20] and Pelvic Floor Impact Questionnaire [PFIQ-7]) were assessed at 12 weeks and 1 year. Results Forty-three women were randomized to TVT-S and 44 to TVT-O. There were no differences in median baseline PFDI-20 and PFIQ-7. Twenty-two (52.4%) of 42 participants randomized to TVT-S had a positive CST result at evaluation after 12 weeks or 1 year, whereas 4 (9.1%) of the 44 in the TVT-O group had a positive CST result. The intent-to-treat analysis showed that the risk of a positive CST result was 6 times higher after TVT-S than TVT-O (risk ratio, 6.0; 95% confidence interval [CI], 2.3–16.0). Among women not lost to follow-up, the risk ratio for a positive CST result after TVT-S compared with TVT-O was 17.9 (95% CI, 2.5–128.0) at 12 weeks and 3.5 (95% CI, 1.1–11.0) at 1 year. Both TVT-S and TVT-O resulted in improved quality of life and symptoms at 12 weeks. There was no difference between the groups for PFDI-20 (P = 0.40) or PFIQ-7 (P = 0.43). A similar pattern was seen at 1 year (P = 0.85 and P = 0.36). Conclusions The TVT-S seems to have a higher risk of positive postoperative CST result; however, the procedures result in similar improvements in quality of life and symptoms.

Laparoscopic Supracervical Hysterectomy with Transcervical Morcellation: Initial Experience

STUDY OBJECTIVE To describe a novel method for morcellation at laparoscopic supracervical hysterectomy and to define its potential benefits. DESIGN Retrospective observational study (Canadian Task Force classification III). SETTING Hospital-based urogynecology and general gynecology practice and a single community teaching hospital of a university medical school. PATIENTS The first 51 women to undergo laparoscopic supracervical hysterectomy with transcervical morcellation at a single institution. INTERVENTION A novel surgical technique that uses a transcervical approach for morcellation of the uterine fundus after amputation from, and coring of, the cervix. MEASUREMENTS AND MAIN RESULTS Laparoscopic supracervical hysterectomy with transcervical morcellation was completed successfully in all 51 patients. Mean (SD) operating time for laparoscopic supracervical hysterectomy with transcervical morcellation alone was 64.3 (28.4) minutes, and median hospital stay was 1 day. There were no intraoperative or postoperative complications related to transcervical morcellation at a median (range) follow-up of 4.4 (1.6-11.7) months. CONCLUSION Laparoscopic supracervical hysterectomy with transcervical morcellation is a feasible procedure that removes the cervical core and does not require enlarging an abdominal port site for introduction of the uterine morcellator.

Laparoscopic Supracervical Hysterectomy With Transcervical Morcellation and Sacrocervicopexy: Initial Experience With a Novel Surgical Approach to Uterovaginal Prolapse

The objective of this retrospective study was to evaluate the feasibility, safety, and efficacy of a new laparoscopic technique for the treatment of uterovaginal prolapse using a transcervical access port to minimize the laparoscopic incision. From February 2008 through August 2010, symptomatic pelvic organ prolapse in 43 patients was evaluated and surgically treated using this novel procedure. Preoperative assessment included pelvic examination, the pelvic organ prolapse quantification scoring system (POP-Q), and complex urodynamic testing with prolapse reduction to evaluate for symptomatic or occult stress urinary incontinence. The surgical procedure consisted of laparoscopic supracervical hysterectomy with transcervical morcellation and laparoscopic sacrocervicopexy with anterior and posterior mesh extension. Concomitant procedures were performed as indicated. All procedures were completed laparoscopically using only 5-mm abdominal port sites, with no intraoperative complications. Patients were followed up postoperatively for pelvic examination and POP-Q at 6 weeks, 6 months, and 12 months. The median (interquartile range) preoperative POP-Q values for point Aa was 0 (-1.0 to 1.0), and for point C was -1.0 (-3.0 to 2.0). Postoperatively, median points Aa and C were significantly improved at 6 weeks, 6 months, and 12 months (all p < .001). One patient was found to have a mesh/suture exposure from the sacrocervicopexy, which was managed conservatively without surgery. We conclude that laparoscopic supracervical hysterectomy with transcervical morcellation and laparoscopic sacrocervicopexy is a safe and feasible surgical approach to treatment of uterovaginal prolapse, with excellent anatomic results at 6 weeks, 6 months, and 12 months. Potential advantages of the procedure include minimizing laparoscopic port site size, decreasing the rate of mesh exposure compared with other published data, and reducing the rate of postoperative cyclic bleeding in premenopausal women by removing the cervical core. Longer follow-up is needed to determine the durability and potential long-term sequelae of the procedure.

Atypical Presentation of a Vaginal Epithelial Inclusion Cyst

Vaginal masses can have numerous different presentations and causes. Physicians can often make an empiric diagnosis of these masses on the basis of their clinical presentation and location. Most of these diagnoses are correct, with the rare exception of the occasional urethral diverticulum or hydrocele. In this case report, we discuss the initial diagnosis of a suspected infected Bartholin gland duct cyst that was in fact a 10 × 8 × 7.5-cm epithelial inclusion cyst that extended through the ischiorectal fossa and down to the gluteal region, requiring extensive dissection. Also presented is a detailed description of the anatomical landmarks encountered at dissection through the vaginal sidewall and ischiorectal fossa.

The Use of Mechanical Bowel Preparation in Pelvic Reconstructive Surgery: A Randomized Controlled Trial

Objective To compare mechanical bowel preparation (MBP) using oral magnesium citrate with sodium phosphate enema to sodium phosphate (NaP) enema alone during minimally invasive pelvic reconstructive surgery. Methods We conducted a single-blind, randomized controlled trial of MBP versus NaP in women undergoing minimally invasive pelvic reconstructive surgery. The primary outcome was intraoperative quality of the surgical field. Secondary outcomes included surgeon assessment of bowel handling and patient-reported tolerability symptoms. Results One hundred fifty-three participants were enrolled; 148 completed the study (71 MBP and 77 NaP). Patient demographics, clinical and intraoperative characteristics were similar. Completion of assigned bowel preparation was similar between MBP (97.2%) and NaP (97.4%). The MBP group found the preparation more difficult (P<0.01) and reported more overall discomfort and negative preoperative side effects (all P⩽0.01). Quality of surgical field at initial port placement was excellent/good in 80.0% of the MBP group compared with 62.3% in the NaP group (P=0.02). This difference was not maintained by the conclusion of surgery (P=0.18). Similar results were seen in the intent-to-treat population. Surgeons accurately guessed preparation 65.7% of the time for MBP versus 41.6% for NaP (P=0.36). At 2 weeks postoperatively, both reported a median time for return of bowel function of 3.0 (2.0–4.0) days. Conclusions Mechanical bowel preparation with oral magnesium citrate before minimally invasive pelvic reconstructive surgery offered initial improvement in the quality of surgical field, but this benefit was not sustained. It was associated with an increase in patient discomfort preoperatively, but did not seem to impact postoperative return of bowel function. LEVEL OF EVIDENCE I

Improved adequacy of endometrial tissue sampled from postmenopausal women using the MyoSure Lite hysteroscopic tissue removal system versus conventional curettage

Objective To compare the diagnostic suitability of endometrial tissues obtained from postmenopausal women using the MyoSure Lite tissue removal system versus conventional curettage. Materials and methods Endometrial tissue was sampled in hysteroscopically normal extirpated uteri from seven postmenopausal women (65.9±6.6 years old) using both hysteroscopicguided morcellation and curettage (two quadrants/uterus with each method). Endometrial sampling was performed immediately after hysterectomy for benign reasons unrelated to uterine pathology. Retrieved endometrial tissue samples were evaluated for volume and diagnostic suitability by a pathologist who was masked to the sampling technique used. Results Endometrial tissue sampling times were similar for morcellation (44±23 s) and curettage (47±38 s). Mean tissue volume retrieved with MyoSure (1,411±775 mm3) was significantly greater than with curettage (1±2 mm3; p=0.0004, two-tailed t-test), with larger intact tissue fragments retrieved with morcellation. Both specimen volume and quality obtained by MyoSure Lite were deemed to be significantly better for histologic assessment than the tissues obtained with curettage (p=0.0006 by Fisher’s exact test and p=0.0137 by chi-square test, respectively). With dilation and curettage, samples were frequently too scanty for evaluation. Diagnostic concurrence between MyoSure Lite/dilation and curettage samples and histopathology of full-thickness samples taken afterward was also significantly better with MyoSure Lite than with curettage (p=0.0210). Conclusion Endometrial tissue sampling using the minimally invasive MyoSure Lite hysteroscopic tissue removal system may provide larger volumes of higher-quality endometrial tissue specimens for pathology assessment compared to specimens obtained using conventional curettage, in postmenopausal women.

Assessing Adequacy of Cervical Core Specimens From Extirpated Uteri: Implications for Laparoscopic Supracervical Hysterectomy With Transcervical Coring

STUDY OBJECTIVE To describe the histopathologic adequacy of cervical specimens after ex vivo excision of the cervical canal with cervical coring. DESIGN Descriptive study (Canadian Task Force classification III). SETTING Community medical center with university affiliation. INTERVENTION Endocervical coring. MEASUREMENTS AND MAIN RESULTS Eleven cervical core samples from hysterectomy specimens were evaluated. Cervical coring was performed using classic intrafascial supracervical hysterectomy instruments: 15 mm for 6 specimens and 20 mm for 5 specimens. Mean patient age was 49 years, and median (range) parity was 2 (0-3). Three patients (27.3%) were postmenopausal. In most patients (72.7%) leiomyomas and abnormal uterine bleeding was the indication for hysterectomy, and 3 patients (23.3%) had uterovaginal prolapse. The most common cervical pathologic diagnosis was chronic cystic cervicitis (72.7%). Histopathologic presence of the entire cervical transformation zone was present in all 11 cervical core samples. Endocervical glands were absent in the radial margins of all samples. Endometrial glands were absent in the radial margins in 7 samples (63.6%). There was no statistically significant difference in age, parity, cervical remnant, and cervical core dimensions between both core sizes (p > .05). CONCLUSION Cervical coring to remove the endocervical canal during hysterectomy resulted in adequate removal of endocervical glands and endometrial glands in most cases, using either the 15-mm or 20-mm classic intrafascial supracervical hysterectomy instrument.