C.E. Miller

Adnexal Torsion: Review of the Literature

Adnexal torsion is one of a few gynecologic surgical emergencies. Misdiagnosis or delay in treatment can have permanent sequelae including loss of an ovary with effect on future fertility, peritonitis, and even death. A PubMed search was performed between 1985 and 2012 for reviews, comparative studies, and case reports to provide a review of the epidemiology, risk factors, clinical presentation, common laboratory and imaging findings, and treatments of adnexal torsion. Common symptoms of torsion include pain, nausea, and vomiting, with associated abdominal or pelvic tenderness, and may differ in premenarchal and pregnant patients. Laboratory and imaging findings including ultrasound with Doppler analysis, computed tomography, and magnetic resonance imaging can assist in making the diagnosis but should not trump clinical judgment; normal Doppler flow can be observed in up to 60% of adnexal torsion cases. Treatment depends on the individual patient but commonly includes detorsion, even if the adnexae initially seem necrotic, with removal of any associated cysts or salpingo-oophorectomy, because recurrence rates are higher with detorsion alone or detorsion with only cyst aspiration.

Persistent bleeding after laparoscopic supracervical hysterectomy.

Background and Objectives: In our clinical experience, there seemed to be a correlation between cervical stump bleeding and adenomyosis. Therefore, we wanted to conduct a study to determine whether there was an actual correlation and to identify other risk factors for persistent bleeding after a laparoscopic supracervical hysterectomy. Methods: The study included women who underwent laparoscopic supracervical hysterectomy from January 1, 2003, through December 31, 2012. Data were collected on age, postmenopausal status, body mass index (BMI), uterine weight, indication for hysterectomy, concomitant bilateral salpingo-oophorectomy (BSO), presence of endometriosis, surgical ablation of the endocervix, adenomyosis, presence of endocervix in the specimen, and postoperative bleeding. Results: The study included 256 patients, of whom 187 had no postoperative bleeding after the operation, 40 had bleeding within 12 weeks, and 29 had bleeding after 12 weeks. The 3 groups were comparable in BMI, postmenopausal status, uterine weight, indication for hysterectomy, BSO, surgical ablation of the endocervix, adenomyosis, and the presence of endocervix. However, patients who had postoperative bleeding at more than 12 weeks were significantly younger (P = .002) and had a higher rate of endometriosis (P < .001). Conclusions: Risks factors for postoperative bleeding from the cervical stump include a younger age at the time of hysterectomy and the presence of endometriosis. Therefore, younger patients and those with endometriosis who desire to have no further vaginal bleeding may benefit from total hysterectomy over supracervical hysterectomy. All patients who are undergoing supracervical hysterectomy should be counseled about the possible alternatives, benefits, and risks, including continued vaginal bleeding from the cervical stump and the possibility of requiring future treatment and procedures.

The minimally invasive approach to the symptomatic isthmocele – what does the literature say? A step-by-step primer on laparoscopic isthmocele – excision and repair

Purpose of review The purpose of this review is to understand the minimally invasive approach to the excision and repair of an isthmocele. Recent findings Previous small trials and case reports have shown that the minimally invasive approach by hysteroscopy and/or laparoscopy can cure symptoms of a uterine isthmocele, including abnormal bleeding, pelvic pain and secondary infertility. A recent larger prospective study has been published that evaluates outcomes of minimally invasive isthmocele repair. Smaller studies and individual case reports echo the positive results of this larger trial. Summary The cesarean section scar defect, also known as an isthmocele, has become an important diagnosis for women who present with abnormal uterine bleeding, pelvic pain and secondary infertility. It is important for providers to be aware of the effective surgical treatment options for the symptomatic isthmocele. A minimally invasive approach, whether it be laparoscopic or hysteroscopic, has proven to be a safe and effective option in reducing symptoms and improving fertility. Video abstract http://links.lww.com/COOG/A37.