Nash S. Moawad

Diagnosis, management, and long-term outcomes of rectovaginal endometriosis

Rectovaginal endometriosis is the most severe form of endometriosis. Clinically, it presents with a number of symptoms including chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia, and rectal bleeding. The gold standard for diagnosis is laparoscopy with histological confirmation; however, there are a number of options for presurgical diagnosis, including clinical examination, transvaginal/transrectal ultrasound, magnetic resonance imagining, colonoscopy, and computed tomography colonography. Treatment can be medical or surgical. Medical therapies include birth control pills, oral progestins, gonadotropin-releasing hormone agonists, danazol, and injectable progestins. Analgesics are often used as well. Surgery improves up to 70% of symptoms. Surgery is either ablative or excisional, and is conducted via transvaginal, laparoscopic, laparotomy, or combined approaches. Common surgical techniques involve shaving of the superficial rectal lesion, laparoscopic anterior discoid resection, and low anterior bowel resection and reanastomosis. Outcomes are generally favorable, but postoperative complications may include intra-abdominal bleeding, anastomotic leaks, rectovaginal fistulas, strictures, chronic constipation, and the need for reoperation. Recurrence of rectal endometriosis is a possibility as well. Other outcomes are improved pain-related symptoms and fertility. Long-term outcomes vary according to the management strategy used. This review will provide the most recent approaches and techniques for the diagnosis and treatment of rectovaginal endometriosis.

Cost-effectiveness of office hysteroscopy for abnormal uterine bleeding.

Background and Objectives: Office diagnostic hysteroscopy allows physicians to directly view the endometrial cavity, tubal ostia, and endocervical canal without taking the patient to the operating room (OR). We sought to determine whether office hysteroscopy performed to evaluate abnormal uterine bleeding decreases the need for hysteroscopy performed in the OR and the associated financial and risk implications. Methods: One hundred thirty patients who underwent office diagnostic hysteroscopy between January 2009 and March 2012 at 2 outpatient clinics in an academic university setting were identified. Records were reviewed from paper charts and electronic medical records. Hospital charts for patients who required hysteroscopy in the OR were reviewed as well. Charge estimates were obtained from our billing department. These results were analyzed for review of the data. Results: Seventy-five of the 130 women who underwent diagnostic office hysteroscopy for abnormal bleeding did not need to undergo hysteroscopy in the OR. This represents estimated savings of

Laparoscopic Ovarian Transposition Before Pelvic Cancer Treatment: Ovarian Function and Fertility Preservation

1498 per patient (95% confidence interval,

The UF Family of hybrid phantoms of the pregnant female for computational radiation dosimetry

1051–

Hysteroscopy in Complex Müllerian Anomalies

1923) in procedure charges. Among the 55 women who underwent OR hysteroscopy, there was 71% agreement between findings on hysteroscopy in the office and in the OR. Conclusion: Office hysteroscopy is a useful diagnostic tool that can help decrease the rate of diagnostic hysteroscopy in the OR under anesthesia when used in a select patient population.

The Prolapsed Myoma

Survivors of pelvic cancer treatment live with the ramifications of pelvic radiation for many years after their cure. Several options are available to preserve ovarian function and fertility in reproductive age women undergoing pelvic radiation. Laparoscopic ovarian transposition is an under-utilized, yet fairly simple surgical procedure to relocate the ovaries away from the radiation field. Although randomized-controlled trials on the outcomes of ovarian transposition are scarce, there is a growing body of evidence on the risks and benefits of this procedure, in terms of prevention of premature ovarian failure, and potentially preserving fertility. In this review, we summarize the available data on the indications, patient selection and outcomes of ovarian transposition, as well as illustrate the technique of the procedure.

An 8 cm Subserosal Fibroid in a Patient with Unexplained Infertility and Pain

Efforts to assess in utero radiation doses and related quantities to the developing fetus should account for the presence of the surrounding maternal tissues. Maternal tissues can provide varying levels of protection to the fetus by shielding externally-emitted radiation or, alternatively, can become sources of internally-emitted radiation following the biokinetic uptake of medically-administered radiopharmaceuticals or radionuclides located in the surrounding environment--as in the case of the European Unions SOLO project (Epidemiological Studies of Exposed Southern Urals Populations). The University of Florida had previously addressed limitations in available computational phantom representation of the developing fetus by constructing a series of hybrid computational fetal phantoms at eight different ages and three weight percentiles. Using CT image sets of pregnant patients contoured using 3D-DOCTOR(TM), the eight 50th percentile fetal phantoms from that study were systematically combined in Rhinoceros(TM) with the UF adult non-pregnant female to yield a series of reference pregnant female phantoms at fetal ages 8, 10, 15, 20, 25, 30, 35 and 38 weeks post-conception. Deformable, non-uniform rational B-spline surfaces were utilized to alter contoured maternal anatomy in order to (1) accurately position and orient each fetus and surrounding maternal tissues and (2) match target masses of maternal soft tissue organs to reference data reported in the literature.

A Minimally Invasive Approach to an Iatrogenic Pelvic Mass

Mullerian anomalies include embryologic abnormalities of the uterus, cervix, and vagina, and are believed to occur secondary to the in utero disruption of the embryological development of the paramesonephric (Mullerian) ducts. The incidence of Mullerian anomalies is difficult to estimate because many patients are asymptomatic; uterine septum is the most common anomaly. A number of classification systems exist to facilitate diagnosis and treatment options. The most recently developed European Society of Human Reproduction and Embryology (ESHRE) and the European Society of Gynecologic Endoscopy (ESGE) system takes into account anomalies of the uterus as well as those of the cervix and vagina. Using classification systems aids in the diagnosis of anomalies through multiple imaging modalities, including magnetic resonance imaging, 3D ultrasound, and hysteroscopy. Hysteroscopy is an extremely valuable tool in assessing female reproductive organs, and its minimally invasive approach has made it a vital therapeutic tool in the outpatient setting for women. Major advances in hysteroscopic surgery and instrumentation have led to hysteroscopic septoplasty virtually replacing open surgery in recent years. Hysteroscopy is cost-effective, and patients benefit from a quick recovery, minimal complications, and good reproductive outcomes.

Retained products of conception through a perforated uterine wall following elective abortion: a unique case report.

A 37-year-old patient presented to the emergency department with heavy bleeding, cramping, lightheadedness, and dizziness. She appeared pale and fatigued, with tachycardia to a heart rate of 119 bpm and normal blood pressure and temperature. Upon speculum examination, she was noted to be actively bleeding with moderate amount of blood in the vagina. She was noted to have a large fungating mass protruding from the cervical os, which was quite dilated to about 4–5 cm. The cervical rim itself appeared normal without focal lesions. On bimanual examination, the uterus was enlarged to approximately10 weeks in size, difficult to assess due to the likely prolapsed mass. No Pap or endometrial biopsy was obtainable in the presence of the mass.

Attributes and Barriers to Care of Pelvic Pain in University Women

A 37-year-old nulligravid woman presents with a chief complaint of a 1-year history of infertility. Prior to this, she used oral contraceptives for 18 years, and she does not currently take any medications. Her menses occur every 28–30 days, are of moderate flow, and last 3–4 days. There have been no recent changes in her menstrual flow volume or duration. She also complains of >6 months of gradually increasing abdominal discomfort that she describes as a feeling of abdominal fullness with weekly episodes of severe cramping pain. Her pain is unrelated to activity or menses. She also complains of urinary frequency, but denies any other urinary symptoms or changes in bowel habits or dyspareunia. Her past medical, surgical, and social histories are unremarkable.