Alex Taylor

Outpatient hysteroscopy: traditional versus the ‘no-touch’ technique

Objective  To assess whether outpatient hysteroscopy using the ‘no‐touch’ technique confers any advantages in terms of patient discomfort over the traditional technique.

Surgical and radiological management of uterine fibroids--a UK survey of current consultant practice.

Background.  The aim of this study was to determine the current surgical and radiological management of uterine fibroids by consultants working in the UK.

Endometriosis arising during estrogen and testosterone treatment 17 years after abdominal hysterectomy: a case report.

OBJECTIVE To report the possible association between the use of oestrogen replacement therapy and endometriosis in a postmenopausal woman. METHODS We present a case of a postmenopausal, previously hysterectomised, woman who received hormonal replacement therapy and developed a large broad ligament cyst. Two years prior to her presentation she had been complaining of pelvic pain and deep dyspareunia. RESULTS Pelvic ultrasound showed an adnexal cyst that was increasing in size. CA-125 was normal. Laparoscopy revealed multiple endometriotic deposits and a broad ligament cyst. Cystectomy and oophorectomy were done. Histology confirmed a diagnosis of endometriosis including the broad ligament cyst. CONCLUSIONS Hormonal replacement therapy can be associated with de novo endometriosis including at sites, which are unusual.

One stop fertility clinic

The objective of this study was to determine the feasibility and acceptability of out-patient based investigation of infertile couples using a prospective observational study based in a large undergraduate teaching hospital. We studied couples referred to secondary care for investigation of their infertility. Investigations involved pelvic ultrasound, diagnostic hysteroscopy and culdoscopy. The main outcome measures were feasability of investigations, findings, patient views, and a management plan. RESULTS 199 of 347 (57.3%) couples referred met our selection criteria, and 162 of this group have attended. Thirty-one (19.1%) were judged to be unsuitable for culdoscopy, and culdoscopy failed in a further 29 (17.9%). The average time for the three procedures was 41.2 (SD 17.2) minutes, and over 1/3 of patients were found to have pelvic pathology. The investigations were well tolerated and there was only one complication necessitating admission to hospital. Most patients appreciated the need for a single hospital visit and the availability of immediate results. CONCLUSIONS A One Stop approach to the investigation of infertility is attractive but not suitable for or desired by all infertile couples. Organisational issues were also identified.

Correspondence: Reducing blood loss at open myomectomy using triple tourniquet: a randomised controlled trial

Sir, We are grateful for the interest shown in our work by Banu and Manyonda. They, like us, serve a community with a high prevalence of fibroids and face similar challenges when performing myomectomy. We applaud their innovative use of an absorbable embolic agent preoperatively as an alternative to our intraoperative triple tourniquets, and we hope that they are evaluating the technique within the context of a randomised controlled trial (RCT). To date, they have only published a short communication on five women and did not report any data on postoperative ovarian function or uterine artery haemodynamics.1 With regard to the question of generalisability, readers can see from the trial profile in the original article, of the 171 women referred to the fibroid clinic, 70 elected to have surgical treatment and of these, 30 underwent open myomectomy. Twenty-eight (93%) were then enroled into the study. It should be remembered that surgery is not always necessary, that not all women want surgery and that if chosen, the surgical route may vary. However, when laparotomy was appropriate, tourniquets were applicable in almost all cases, making the technique in our opinion, ‘generalisable’. In our experience, the issue of cervical fibroids affecting access and the application of the uterine artery tourniquet is

Absorbable Cervical Tourniquet at Open Myomectomy: A Pilot Study

Objective: To assess the effects of vascular occlusion of the uterine arteries with an absorbable cervical tourniquet at open myomectomy. Methods: Twelve women with a large fibroid uterus underwent open myomectomy for surgical management of menorrhagia and pelvic pressure symptoms. All patients had a number-1 polyglactin (absorbable) suture tied around the cervix to occlude the uterine vessels and temporary tourniquets tied around the infundibulopelvic ligaments to occlude the ovarian vessels. Intraoperative blood loss was assessed by suction and swabs, and postoperative loss by surgical drains. Results: The mean age of patients was 40 years (standard deviation 2.4). The median uterine size was equivalent to 19 weeks gestation (range 16–28). An average of 17 fibroids were removed from each patient (range 2–84) weighing 608g (range 220–3030). The average intraoperative blood loss was 840 mL (range 400–1540). Postoperatively, the median loss in the drain at 24 hours was 350 mL (range 65–760). The median dro...

Myomectomy can be 'life saving'--a case of a 36-week fibroid uterus managed conservatively in a 40-year-old nulliparous woman

Discussion Empty pelvis syndrome can be defined as an empty space or cavity following pelvic exenteration which may result in the formation of an abscess, haematoma or lymphocoele, leading to persistent discharge and sinus formation with or without chronic infection. There may be some similarities between this and chronic osteomyelitis, which predisposes to chronic sinus formation and sarcomatous change in bone either spontaneously or as a result of radioor chemotherapy. Unfavourable consequences as described in the case report can be avoided or minimised by procedures for filling the empty pelvis with omental flaps, pedicle myocutaneous flaps from the rectus abdominis or the gracilis muscle or placement of absorbable mesh. These procedures may be effective in preventing small bowel loops from descending into the lower pelvis (Crowe et al., 1999). The possibility of perineal preservation with colo-anal continuity in selected cases may reduce postoperative morbidity following pelvic exenteration (Brodsky et al., 1993). The psychological consequences are considerable. Krouse et al. (1990) describe four stages in the woman’s experience. The first stage, i.e. recognition or exploration, centres on the recognition of symptoms and diagnosis. The crisis or the climate stage occurs when treatment is initiated. The adaptation or maladaptation stage occurs after treatment. The resolution or disorganisation stage occurs after treatment, which concerns the long-term sequele. Guilt, embarrassment, anxiety, isolation and fear or denial of the disease are the hallmarks of the first stage. Anxiety, depression, altered body image and concern about changing relationships characterise the second. The adaptation or maladaptation stage is centred on the patient’s functional status, self-perception changes, stabilisation of interpersonal relationships and employment. Isolation is a risk during that phase, which encompasses the first postoperative year. Resolution rests on an increased involvement in life. This involves an enhanced self-worth and a successful attempt to integrate the experience spiritually. Continuing follow-up of these patients is of great importance to evaluate results, provide reassurance and to give symptomatic relief to those in whom treatment has failed. Frequency of follow-up may vary slightly between centres. A typical recommendation may be 3-monthly follow-up to 2 years and annual visits thereafter.