Jerome L. Yaklic

Contained morcellation using the GelPOINT advance access platforms and 3M Steri-Drape endobag

OBJECTIVE To report a technique that safely allows power and hand morcellation for laparoscopic hysterectomy and myomectomy specimens in a contained fashion in the event of unsuspected uterine sarcoma or leiomyosarcoma. DESIGN Video article introducing a method for enclosed tissue morcellation for laparoscopic specimens. SETTING Hospital of an academic-based practice. PATIENT(S) Two patients underwent laparoscopic hysterectomy: a 57-year-old G7 P5025 female for leiomyoma, anemia, and a history of CIN-3; and a 38-year-old G0P0 female with a 10-year history of pelvic pain and severe dysmenorrhea who failed medical therapy. INTERVENTION(S) A technique using the GelPOINT Platform incision extender system and GelSeal Cap (GSP) Advanced Access Platform and a 50 cm × 50 cm 3M Steri-Drape endobag for enclosed intracorporeal and extracorporeal tissue morcellation of laparoscopic specimens. MAIN OUTCOME MEASURE(S) For training purposes, we used a pelvic simulator and cadaver to describe the step-by-step process and troubleshoot issues to optimize intra- and extracorporeal morcellation. This allowed for easier implementation on the live patient. RESULT(S) Simulation training and the cadaver model provided a learning platform for contained internal power and external hand morcellation, accelerating the learning curve in its application to the live patient. CONCLUSION(S) The GSP and 3M Steri-Drape endobag is an alternative for laparoscopic power or hand morcellation. Using simulation training helped transition this technique to the live patient, allowing for easy and safe removal of tissue specimens and minimizing the potential for tissue seeding and dissemination.

Metroplasty to treat chronic pelvic pain resulting from outflow tract müllerian anomalies

Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities.

Challenges and considerations in optimizing ovarian stimulation protocols in oncofertility patients

The scope of cancer treatment in women of childbearing age has changed in the last decade. Fertility preservation is no longer an afterthought but central to multi-disciplinary cancer treatment planning and should be addressed due to the cytotoxic effects of cancer therapy. However, oncology patients present as a unique treatment challenge as the physician must balance the urgency of fertility preservation with the risks of delaying cancer therapy. Controlled ovarian stimulation (COS) is routinely applied in assisted reproductive technology but can be contraindicated in women with estrogen-receptor-positive tumors. This paper reviews some of the challenges to consider when using COS and newer stimulation protocols to minimize risks and optimize outcomes in oncofertility patients.

Hysteroscopic morcellator to overcome cervical stenosis

OBJECTIVE To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. DESIGN Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. SETTING Academic-based practice. PATIENT(S) A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. INTERVENTION(S) A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. MAIN OUTCOME MEASURE(S) Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. RESULT(S) The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. CONCLUSION(S) Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications.

Vulvodynia: What We Know and Where We Should Be Going

Objective The aim of the study was to review the current nomenclature and literature examining microbiome cytokine, genomic, proteomic, and glycomic molecular biomarkers in identifying markers related to the understanding of the pathophysiology and diagnosis of vulvodynia (VVD). Materials and Methods Computerized searches of MEDLINE and PubMed were conducted focused on terminology, classification, and “omics” variations of VVD. Specific MESH terms used were VVD, vestibulodynia, metagenomics, vaginal fungi, cytokines, gene, protein, inflammation, glycomic, proteomic, secretomic, and genomic from 2001 to 2016. Using combined VVD and vestibulodynia MESH terms, 7 references were identified related to vaginal fungi, 15 to cytokines, 18 to gene, 43 to protein, 38 to inflammation, and 2 to genomic. References from identified publications were manually searched and cross-referenced to identify additional relevant articles. A narrative synthesis of the articles was conducted; however, meta-analysis was not conducted because of substantial heterogeneity in the studies and limited numbers of control-matched studies. Results Varying definitions of VVD complicate a meta-analysis, and standard definitions will better allow for comparisons of studies and enhance the applicability of evidence to patient populations. Although data are still limited, genomic and molecular diagnostic testings continue to be investigated as potential tools for the diagnosis of VVD. Conclusions Standardized nomenclature will allow for comparability of studies and progress in research related to the pathophysiology of VVD and to facilitate clinical decision making and treatment choices. Although the current understanding of the pathogenesis of VVD is limited, there are new opportunities to explore potential diagnostic markers differences in women with VVD, which may lead to targeted therapy.

A Multi-State Analysis of Early-Term Delivery Trends and the Association With Term Stillbirth Trends in Stillbirth by Gestational Age in the United States, 2006-2012 Stillbirth and the 39-Week Rule: Can We Be Reassured?

2015. That this is seen across populations and decades demonstrates this risk of stillbirth as the inherent biology of pregnancy and independent of arbitrary definitions of “term” or of some point in gestational age, whether 39 weeks or 38 or 40 weeks. This continued failure to recognize that, at term, remaining undelivered results in an ever-increasing risk of stillbirth does not serve our patients well. Biology rarely pays much heed to arbitrary rules and definitions, as this latest report documents. The challenge we face becomes not only to understand and recognize the underlying phenomena of term stillbirth, but to develop a reasonable and coherent approach to patient management as it relates to gestational age, incorporating the known data of fetal, maternal, and neonatal outcomes. It is unlikely any one-sizefits-all recommendation regarding management at term will be best. Individualized determinations based on patientspecific factors likely will be the preferred approach. It is essential that this discussion takes place.

Vaginal Urinary Calculi Formation Secondary to Vaginal Mesh Exposure with Urinary Incontinence

Background Vaginal stones may form in the setting of mesh exposure with urinary incontinence. This report serves to help understand the presentation, evaluation, and management of vaginal urinary stones. Case A 68-year-old female presented with a vaginal calculus. She had a history of anterior and posterior polypropylene mesh placement for prolapse 7 years earlier and urinary incontinence. The stone was identified on a portion of exposed mesh and removed in office. Pathology confirmed urinary etiology. The exposed mesh resolved with topical estrogen. Cystourethroscopy excluded urinary fistula and bladder mesh erosion. Conclusions When identified, a vaginal calculus should be removed and evaluated for composition. Cystourethroscopy should be performed to assess potential urinary tract fistulas and mesh erosion. Additional imaging should be considered.

Medical professionalism and enculturation of the millennial physician: meeting of the minds

The conceptualization of medicine as a profession that is held to ethical and practical standards wasfirst formalized through the writings of 18th-century British physician-ethicists Gregory and Percival (1). This was in response to the lack of standardization in both training and practice that existed within medicine at the time. Percivals Medical Ethics subsequently served as a reference for the first Code of Medical Ethics issued by the American Medical Association in 1847 (2). Today, it is universally accepted that an important aspect of becoming a physician is the learning and implementing of high standards of medical professionalism into practice. Professionalism as identified by the Accreditation Council for Graduate Medical Education (ACGME) is a core competency for residents and includes compassion, responsiveness to patient needs that supersedes self-interest, respect for patient privacy, and sensitivity to diverse patient populations (3). Professionalism is viewed not only as the competence or skill expected of a professional; it also requires one to act appropriately at all times using essential behaviors including being approachable, polite, courteous, and respectful of confidentiality and dignity. Moreover, it also necessitates us to challenge poor practice and unacceptable behaviors and attitudes. Professional standards within medicine are perceived differently among the different generations that compose its body of practitioners, with each possessing their own defining character traits that impact their professional interactions and attitudes. The Millennials, also known as Generation Y, are those practitioners born between 1980 and 2005 who are currently being educated and mentored. In contrast, the Baby Boomers, born between 1946 and 1964, and the Generation Xers, born between 1965 and 1980, are the educators and mentors for the Millennials. Millennials, whose formative years have coincided with the fast-paced changes in technologies used within the home and the workplace, have been characterized as entitled, indulged, and sheltered and see their physician role as a job and not their identity. In contrast, Baby Boomers are often characterized, at least within medicine, as competitive workaholics, while the GenXers are considered cynical, skeptical, and pessimistic. The literature reveals that these generational groupings are at discord on the definition of professionalism to the degree that the older generation of physicians perceives their younger counterparts as negatively affecting medical professionalism to the point of impacting patient care. In a recent study, unprofessional conduct related to responsibility (56%) was the most common type of infraction among medical students, including missed deadlines, unexcused absences, and tardiness (4). Other professional violations included inappropriate posting on social media outlets of off-duty lifestyle and patient images and voicing of opinions that may call ethics or integrity into question. Other behaviors

PCOS from Conception to Menopause: A Review of Our Current Understanding

PCOS from Conception to Menopause: A Review of Our Current Understanding Polycystic ovary syndrome (PCOS) appears to be a part of a lifelong continuum starting in utero, with progressive signs in the adolescent female. It is recognized as the most common endocrinopathy in reproductive age women, and may have sequelae in the menopausal PCOS woman. PCOS is a disorder characterized by hyperandrogenism and chronic anovulation affecting at least 1 in 15 women or approximately 6-7% of reproductive age women. Metabolic and health complications associated with PCOS include obesity, insulin resistance, dyslipidemia, pancreatic beta-cell dysfunction, type 2 diabetes, cardiovascular disease, endometrial cancer, sleep apnea, inflammation, and infertility.