Hussein Warda

Interstitial ectopic pregnancy: conservative surgical management.

Introduction: Interstitial pregnancy is a rare and life-threatening condition. Diagnosis and appropriate management are critical in preventing morbidity and death. Case Description: Four cases of interstitial pregnancy are presented. Diagnostic laparoscopy followed by laparotomy and cornuostomy with removal of products of conception was performed in 1 case. Laparoscopic cornuostomy and removal of products of conception were performed in the subsequent 3 cases with some modifications of the technique. Subsequent successful reproductive outcomes are also presented. Discussion: Progressively conservative surgical measures are being used to treat interstitial pregnancy successfully, with no negative impact on subsequent pregnancies.

Risk Factors for Surgical Site Infection in Patients Undergoing Sacral Nerve Modulation Therapy.

Objectives The aim of this study was to identify risk factors for surgical site infection in patients undergoing sacral nerve modulation (SNM) surgery. Methods We conducted a retrospective cohort analysis of 290 patients undergoing a total of 669 SNM procedures between 2002 and 2012 by 2 fellowship-trained female pelvic medicine and reconstructive surgery attending physicians at the University of California–Irvine Medical Center. Infection was defined as a charted abnormal examination finding at the implantation site (erythema, induration, purulent discharge) resulting in prescription of antibiotics, hospitalization, or explantation. We extracted information from the medical record regarding possible risk factors for infection including age, body mass index, immunosuppression (diabetes mellitus, chronic steroid use, smoker, chemotherapy), number of procedures per patient, and number of days between stages 1 and 2. In addition, we compared infection rates before and after 2008 when a clinical practice change was made with the implementation of home chlorhexidine washing (CHW) prior to SNM surgery. Results Thirty infections occurred, 25 of which were managed with oral antibiotics. Nine required intravenous antibiotics, and 11 required removal of the implanted device. Three patients experienced infection on 2 separate occasions. Seventeen infections had culture data available. Nine of the patients who underwent explantation had wound cultures positive for methicillin-resistant Staphylococcus aureus. Thirteen of the 26 patients who developed infection had medical histories significant for immunosuppression. Three patients developed late-onset abscess formation at 234, 257, and 687 days after stage 2, respectively. The median time between the most recent SNM procedure and development of infection was 14 days (range, 6–88 days). Body mass index and immunosuppression were significant predictors of infection, whereas age, parity, indication for procedure, and number of days between stages 1 and 2 were not found to be independent predictors. Three hundred twenty-three procedures were performed prior to and 346 procedures were performed after institution of home CHW. Twenty-four (80%) of the 30 reported infections were prior to CHW, whereas only 6 infections (20%) occurred after this change in practice. Prior to institution of CHW, the infection rate was 7.4%, and after institution of CHW, it was 1.7% (P = 0.002). Of the 83 patients with compliance data available for CHW use, 71 reported using CHW, whereas 12 reported not using CHW. Conclusions Surgical site infection is a significant risk of SNM surgery, although our infection rate is lower than previously reported. Chlorhexidine washing appears to reduce the risk of infection in this population. Because the majority of infections requiring explantation were methicillin-resistant S. aureus positive, prophylactic treatment for this organism should be considered as an additional strategy to reduce infection. Body mass index and immunosuppression appear to be independent risk factors for infection.

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.

A trial placement of a prophylactic ureteral catheter during the excision of a huge pelvic mass with incidental cystotomy.

Ureteral injuries are one of the major complications following gynecologic surgeries. They are serious, troublesome, often associated with significant morbidity, and are one of the most common causes for legal action against gynecologic surgeons. The reported rates of injury depend on the vigilance of diagnosis, type of surgery and other risk factors. We present a case of a 48 year old obese Caucasian female with no significant past medical history who came in with back pain and progressive abdominal swelling for the past three months and was found to have a very large pelvic mass. After preoperative evaluation, including: medical history, physical exam, and imaging studies showing a heterogenous mass 24.6 x 33.0 x 43.1, we predicted that the risk of urinary tract injuries was very high. We used preoperative prophylactic bilateral ureteral catheters to prevent injury. A surgical oncologist was consulted and an exploratory laparotomy was performed with removal of the large multi–lobulated pelvic mass + total abdominal hysterectomy, bilateral salpingo–oophorectomy, and appendectomy all performed at the same time. Patient had an incidental cystotomy during the procedure, which was repaired intra–operatively. The ureters remained intact with no injuries. The importance of thorough preoperative identification, evaluation and anticipation of ureteral injuries will be discussed in detail.