Moty Pansky

Conservative management of adnexal torsion in premenarchal girls

STUDY OBJECTIVE To evaluate treatment of premenarchal girls with torsion of the adnexa. DESIGN Retrospective review of medical records (Canadian Task Force classification II-2). SETTING Tertiary care, university-affiliated hospital. PATIENTS Eight premenarchal girls (age range 3-12 yrs) with twisted adnexa. INTERVENTION Laparoscopic detorsion and follow-up with B scan and Doppler ultrasound imaging. MEASUREMENTS AND MAIN RESULTS Duration of complaints ranged from 8 to 72 hours (mean 34.6 hrs) and the interval from admission to surgery ranged from 6 to 24 hours (mean 18.7 hrs). Four patients had torsion of normal-appearing adnexa. The other four had ovarian neoplasms. Two had cystic mature teratomas (dermoid cysts) and one a serous cystadenoma that required additional operation. The fourth girl had a simple ovarian cyst that was aspirated laparoscopically. Seven girls (87%) had normal-appearing ovaries on follow-up ultrasound. In one patient, a small ovary was seen, with no intraovarian blood flow on color Doppler. CONCLUSION Although the diagnosis of torsion of the adnexa in premenarchal girls is difficult and usually delayed, laparoscopic detorsion seems to be an effective adnexa-sparing approach. We suggest that laparoscopy should be the treatment of choice and that detorsion, rather than adnexectomy, be performed more often in these patients.

The Major Histopathologic Characteristics in the Vulvar Vestibulitis Syndrome

Objective: In order to better understand the etiology of the vulvar vestibulitis syndrome, we examined the histopathologic parameters in vestibular mucosa, and compared the findings in specimens obtained from women with vulvar vestibulitis with those obtained from the control group. Study Design: Specimens of vestibulitis were obtained from 24 patients, undergoing circumferential vestibulectomy under general anesthesia due to the symptoms and signs consistent with vulvar vestibulitis. Control specimens were obtained from 16 women, without symptoms or signs of vulvar vestibulitis, undergoing reconstructive introital surgery due to roomy vagina, rectocele or painful episiotomy. All vestibular tissue specimens were examined for intensity of inflammation, extension of inflammatory cells into the epithelium, vascular proliferation, the presence of mast cells and proliferation of peripheral nerve bundles. Results: No significant difference was found regarding the degree of inflammation, the extension of inflammatory cells into the epithelium, the vascular proliferation and the presence of mast cells while comparing the study and the control groups. The only histopathologic feature, differentiating the patients with vulvar vestibulitis from the control group, was the proliferation of peripheral nerve bundles found in 19 out of 24 (79.1%) specimens expressing vestibulitis and in none of 16 control specimens (p < 0.0001). Conclusion: Our results, therefore, support the existence of peripheral nerve hyperplasia in vestibular tissue obtained from patients with vulvar vestibulitis, and exclude the role of active inflammation or mast cells as probable etiologies for the vulvar vestibulitis syndrome.

NONSURGICAL MANAGEMENT OF TUBAL PREGNANCY : NECESSITY IN VIEW OF THE CHANGING CLINICAL APPEARANCE

The incidence of ectopic pregnancy is definitely increasing. Ectopic pregnancies are diagnosed earlier these days because of the improvement in diagnostic means and the increasing awareness of the condition. It seems that there is a dramatic change in the clinical presentation of this disease; it used to be a grave and life-threatening condition, and now it is a more benign presentation. The vast majority of the diagnosed ectopic pregnancies are unruptured. This has stimulated various investigators to attempt nonsurgical methods of treatment such as systemic administration of methotrexate or RU 486 (mifepristone) or local injection of methotrexate, potassium chloride, or prostaglandins under laparoscopic or ultrasonographic guidance. Most of these conservative, nonsurgical measures proved efficient in 80% to 90% of cases. Expectant management, which was practiced in some cases, proved to be equally successful. We believe that the ideal mode of treatment in early unruptured ectopic pregnancy is still to be determined. The answer probably lies in proper selection.

Can we rely on blind endometrial biopsy for detection of focal intrauterine pathology

OBJECTIVE To compare the diagnostic power of random endometrial biopsy with hysteroscopy for intrauterine lesions. STUDY DESIGN A retrospective cohort study of 639 women evaluated by diagnostic office hysteroscopy and endometrial biopsy (Novak curette) was carried out between 10/1997-6/2000. Reasons for evaluation were postmenopausal bleeding, abnormal uterine bleeding, ultrasound or hystero-salpingography findings, intrauterine device removal, suspected retained products of conception, infertility, late abortions and recurrent abortions. RESULTS The womens mean age was 43.4+/-13.3 years (range, 18-88). The most prevalent indication for investigation was abnormal uterine bleeding (n=218, 34.1%), followed by sonographic or hystero-salpingographic findings (n=167, 26.1%). Hysteroscopy revealed a normal uterine cavity in 367 (57.4%) women. Endometrial polyps and submucosal fibroids were the most common hysteroscopic findings (in 151 [23.6%] and 72 [11.3%], respectively). The hysteroscopic findings were compared with the pathology results in 558 cases. The sensitivity of the Novak curette for detection of endometrial polyps and submucosal fibroids was only 8.4% and 1.4%, respectively. The positive predictive value (30.9%) and the negative predictive value (57.9%) for both lesions were likewise low. On the other hand, hysteroscopy was not effective in diagnosing the 27 cases of hyperplasia (26 simple and one complex) all without atypia. CONCLUSION Random endometrial sampling alone is not effective for diagnosing focal lesions of the uterine cavity and should be combined with other modalities, preferably diagnostic hysteroscopy.

Torsion of normal adnexa in postmenarchal women and risk of recurrence.

OBJECTIVE: To compare the incidence of recurrent torsion of normal adnexa to recurrent torsion of abnormal adnexa in postmenarchal women. METHODS: All cases of surgically confirmed adnexal torsion operated on in our department from January 2002 to April 2006 were retrospectively analyzed. Classification as torsion of pathologic adnexa versus torsion of normal adnexa was based on pre- and postoperative pelvic sonograms, operative findings, and pathologic diagnoses (when available). The torsion recurrence rates were evaluated by a telephone questionnaire, with 90.5% compliance. RESULTS: Twelve women had twisted normal adnexa and 50 women had twisted abnormal adnexa. The women with twisted normal adnexa were younger (25.5±7.9 years versus 31.4±11.4 years, P=.10) and had a lower median parity (0 versus 1, P=.06). Both groups had similar clinical presentations and a similar mean time from admission to surgery. The torsion recurrence rates were 63.6% (95% confidence interval [CI] 0.3–0.9) in the twisted normal adnexa group and 8.7% (95% CI 0.02–0.2) in the twisted abnormal adnexa group (P<.001). The retorsion risk of the pathologic adnexa was especially low after cystectomy (5.3%, 95% CI 0.001–0.3) or salpingo-oophorectomy (0%). The Kaplan-Meier life table analysis also showed a higher retorsion risk for normal adnexa (P=.008). CONCLUSION: The current adnexa-sparing laparoscopic management of adnexal torsion by simply untwisting may predispose to recurrent torsion of normal adnexa. The role of ovariopexy procedures in the prevention of recurrent torsion events remains uncertain. LEVEL OF EVIDENCE: III

Oophoropexy to Prevent Adnexal Torsion: How, When, and for Whom?

STUDY OBJECTIVE To assess the efficacy of oophoropexy in obviating recurrent torsion and its possible long-term effects. DESIGN Case series and review of the literature (Canadian Task Force classification III). SETTING University hospital. PATIENTS Women who underwent oophoropexy for recurrent torsion of normal adnexa between 2003 and 2008. MEASUREMENTS AND MAIN RESULTS Retrieved information included the indication for oophoropexy, surgical methods, recurrence, and follow-up. Seven women underwent oophoropexy during the study period because of recurrent torsion of normal adnexa. One additional patient had experienced 3 torsion events of cystic adnexa. Surgical methods included suturing of the ovary to the pelvic sidewall or to the round ligament and plication of the utero-ovarian ligaments. Recurrence occurred in 1 of 6 patients for whom follow-up was available. All 6 patients reported spontaneous menstruation, and 2 conceived spontaneously and gave birth. Ultrasound at long-term follow-up (9-58 months) demonstrated normal ovaries. CONCLUSION Oophoropexy seems to be efficacious in preventing recurrent torsion. It is our impression that plication of the utero-ovarian ligaments has advantages over other approaches insofar as surgical feasibility and anatomical conservation.

Does intraoperative spillage of benign ovarian mucinous cystadenoma increase its recurrence rate

OBJECTIVE To report a higher than estimated recurrence rate of benign mucinous cystadenomas after complete resection of the first one, and to assess potential risk factors for recurrence after complete surgical excision. STUDY DESIGN We retrospectively reviewed all cases of women who underwent either laparoscopic or laparotomic removal of benign mucinous adnexal cysts by either adnexectomy or cystectomy in our institution between 1996 and 2006. RESULTS Included were the data of 42 women who fulfilled study entry criteria. Three of them (7.1%) underwent a second operation because of a recurrence of the lesion. A significantly higher rate of women who had cyst recurrence had undergone cystectomy as opposed to adnexectomy (P < .05). Intraoperative rupture of cysts during cystectomy was also significantly associated with cyst recurrence (P < .03). CONCLUSION Mucinous cystadenoma recurrence is apparently not as rare as reported in the literature. Intraoperative cyst rupture and cystectomy instead of adnexectomy emerged as being two risk factors for recurrence.

Torsion of normal adnexa in postmenarcheal women: can ultrasound indicate an ischemic process?

Torsion of normal adnexa is a rare event involving steadily increasing congestion and ischemia of the ovary. We investigated whether this process can be characterized by sonographic features.

Conservative management of interstitial pregnancy using operative laparoscopy

Interstitial pregnancy has been treated so far mainly by either resection of the cornu or hysterectomy. In this article, two patients with cornual pregnancy were operated upon laparoscopically with an uneventful postoperative recovery. This laparoscopic treatment is simple, does not require extensive operative laparoscopic expertise, and is relatively short and less expensive than laparotomy.We suggest that laparoscopic conservative repair be used to replace cornual resection by laparotomy or hysterectomy in cases of early diagnosed interstitial pregnancy.

Hysteroscopic management of retained products of conception: meta-analysis and literature review

OBJECTIVE Hysteroscopic removal of retained products of conception (RPOC) may allow complete removal of RPOC and decreased rates of intrauterine adhesions (IUA) when compared to the traditional blind curettage. The aim of this meta-analysis is to examine the current evidence regarding the use of hysteroscopy for treatment of RPOC. STUDY DESIGN A literature search was conducted in December 2012 using MEDLINE and ClinicalTrials. The study selection criteria were use of the standard hysteroscopic technique for removal of RPOC in 5 or more cases, in any study design. We reviewed 11 studies, of which 5 retrospective studies met the selection criteria (comprising 326 cases). The rates of incomplete RPOC removal, surgical complications, post-operative IUA and subsequent pregnancies were abstracted and weighted events rates using a fixed meta-analysis model were calculated. RESULTS Only one study compared the rates of IUA following hysteroscopy and curettage, precluding a meta-analysis comparison of the two techniques. There were no cases of incomplete RPOC removal. Three perioperative complications occurred (uterine perforation, infection, and vaginal bleeding). IUA on follow-up hysteroscopy were found in 4/96 women (weighted rate of 5.7%, 95% CI 2.4%, 13.0%). Of the 120 women desiring a subsequent pregnancy 91 conceived (weighted rate of 75.3%, 95% CI 66.7%, 82.3%). CONCLUSIONS The lack of traditional curettage comparison groups in most studies precludes the conclusion that hysteroscopy is superior to traditional curettage, but this procedure does appear to have low complication rates, low rates of IUA, and high rates of subsequent pregnancies.