S. Misirlioglu

Utilization of the Bologna criteria: a promise unfulfilled? A review of published and unpublished/ongoing trials

OBJECTIVE To study the use of the Bologna criteria (BC) for the definition of poor ovarian responders (POR) in clinical practice and research. DESIGN Systematic review of published and unpublished/ongoing trials between January 2012 and August 2017 on POR. SETTING Not applicable. PATIENT(S) Not applicable. INTERVENTION(S) The databases were searched using the relevant medical subject headings including all subheadings. The search was limited to humans and English language. The references of the included studies were cross-searched for possibly missed articles. Only clinical trials providing an evidence level ≥ III were included. Case reports, review, letters, and hypothetical articles were excluded. MAIN OUTCOME MEASURE(S) Extracted studies were divided into two groups: studies in which the BC were used or not. RESULT(S) One hundred nine published clinical studies analyzing a total of 30,540 women and 112 unpublished/ongoing trials were identified. The BC were used to define POR in 56 (51%) of the published and 44 (39%) of the unpublished trials. The use of the BC gradually increased from 29% to 53% from 2012 to 2017. Asian researchers were more likely to use the BC compared with European and North American researchers (65%, 49%, and 23%, respectively). Neither the design of the study nor the impact factor of the publishing journal was correlated with the use of the BC. CONCLUSION(S) There is still reluctance to use the BC for the definition of POR, which makes it difficult to combine data from small studies and reach a meaningful conclusion.

Leiomyomatosis Peritonealis Disseminata That Caused Hydroureter in Association With Deep Infiltrating Endometriosis

Objective: To show and describe the laparoscopic technique in the excision of posterior vaginal wall mesh. Clinical Information: A 60 year-old female with posterior vaginal compartment prolene mesh placed for stage-3 rectocele presented with a 4-year history of persistent vaginal pain, dyspareunia, urinary frequency and urgency. She had a history of total laparoscopic hysterectomy with bilateral salpingo-oophorectomy in 2008 followed by placement of a posterior vaginal wall prolene mesh kit in 2010 for stage 3 rectocele. An attempt at vaginal identification and excision of the mesh was not possible thus mandating a laparoscopic approach. Interventions: Laparoscopic approach for the excision of posterior vaginal wall mesh. Results: Successful mesh excision from the posterior vaginal wall connective tissue and resolution of vaginal pain and dyspareunia on the patient’s 6-week follow-up.

Contained Power Morcellation Versus Transvaginal Extraction for Retrieval of Laparoscopically Removed Myomas: A Comparison of Perioperative Outcomes

Objective. To evaluate clinical and operative outcomes of transvaginal extraction (TVE) and contained power morcellation (CPM) for myoma retrieval after laparoscopic myomectomy. Materials and Methods. Prospective data from 35 consecutive cases using CPM were compared with retrospective data of all cases using TVE from December 2014 to January 2017. Patients were matched 1:1 based on myoma diameter. A total of 62 women were included in the final analysis. Specimen retrieval was performed using the TVE or CPM within an insufflated isolation bag. Results. Age, body mass index, mode of prior obstetric delivery, history of previous abdominal surgery, indication for myomectomy, and the myoma(s) characteristics were similar between groups. Retrieval time was significantly shorter in the TVE group compared with the CPM group: 10 minutes (3-15 minutes) versus 17 minutes (14-42 minutes); P < .001. Time required for placement of the instruments was 9.7 minutes for the isolation bag and 0.5 minutes for the vaginal extractor. Additional analgesic administration for pain relief was necessary in 13 patients (42%) in the TVE group and 23 patients (72%) in the CPM group (P = .01). Total cost of the hospital stay was significantly higher in the CPM group compared with the TVE group (P < .001). Estimated blood loss and duration of hospital stay were similar between groups. Conclusion. Both CPM and TVE can be used for safe retrieval of large myomas that are removed laparoscopically. Compared with CPM, TVE was associated with a shorter retrieval time, less postoperative pain, and less hospital costs.

Clermont-Ferrand versus Vectec uterine manipulator for total laparoscopic hysterectomy

Abstract Objective: To compare the operation time and performance of two uterine manipulators used for total laparoscopic hysterectomy (TLH). Material and methods: Design: Retrospective cohort analysis. Design classification: Canadian Task Force Classification II-2. Setting: Tertiary-care university-based teaching hospital and academic affiliated private hospital. Patients: All consecutive patients who underwent for TLH between January 2014 and June 2017. All operations were performed by two expert endoscopic surgeons using one of the following uterine manipulators depending on surgeon preferences: Clermont-Ferrand (CF) or Vectec (VT) MAUT60. Patients were excluded if additional surgeries such as urogynecological procedures were performed, TLH was converted to laparotomy prior to colpotomy, and when their operation records could not be obtained. A total of 169 patients were added to final analysis. Operation time, colpotomy time and the subjective performance of manipulators such as movement of the uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were evaluated by watching un-edited operation videos. Results: A total of 169 patients (83 patients in CF group; 86 patients in VT group) were included in the final analysis. Patients’ baseline characteristics were comparable between groups. Operation time and time required for colpotomy were significantly shorter in the VT group. Lateral movements of the manipulators and elevation of the uterus were better with VT compared to CF (p = .001 for both). Compared to the CF, VT was superior for visualization of the vaginal fornices (p = .004) and maintenance of pneumoperitoneum (p < .001). Both surgeons had perfect agreement on the performance grading of manipulators (p < .001, Kappa values were between 0.86–0.92). There was no difference between groups in estimated blood loss and duration of hospital stay. Reinsertion or the need to change the manipulator was not required in either group. No pelvic or vaginal abscess, cuff cellulitis, dehiscence, or hematoma formations were noted. Conclusion: Laparoscopic hysterectomy assisted with the VT uterine manipulator is associated with shorter operation and colpotomy time. Furthermore, the movements of uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were significantly better with VT compared to the CF manipulator.

Surgical correction of T-shaped uteri in women with reproductive failure: long term anatomical and reproductive outcomes

OBJECTIVE To evaluate the long term anatomical and reproductive outcomes of hysteroscopic treatment for T shaped uterus in patients presenting with reproductive failure. METHODS This prospective cohort study included 56 patients with a history of long-standing unexplained infertility, recurrent implantation failure (RIF), and/or recurrent pregnancy loss (RPL) who were eligible for metroplasty by office hysteroscopy. Office hysteroscopy under conscious sedation was performed. Anatomical outcomes were assessed with pre- and postoperative measurements of the transostial, isthmic and myometrial diameters and the uterine volume using three-dimensional transvaginal sonography (3D-TVS). Reproductive outcome was assessed after spontaneous or assisted conception. RESULTS Hysteroscopic treatment significantly increased the volume of the uterus from a mean of 2.5+1mL before surgery to 3.2±1mL by the end of 1 year as measured by 3D-TVS. According to the main indication to perform metroplasty, 20 of 32 (62.5%) patients with long standing unexplained infertility, 9 of 14 (64%) patients with RIF, and 8 of 10 (80%) patients with RPL conceived either spontaneously or with assisted reproduction. CONCLUSIONS Office hysteroscopic metroplasty results in a significant long-term expansion of the uterine cavity and improved reproductive outcomes in women presenting with a T shaped uterus and poor reproductive history.

Use of a gelatin-thrombin hemostatic matrix in obstetrics and gynecological surgery

Gelatin-thrombin matrix (GTM) is a hemostatic sealant consisting of bovine-derived gelatin matrix and human-derived thrombin, combining both mechanical and active mechanisms to achieve hemostasis. It was approved by the Food and Drug Administration in 1999. GTM has been used by several surgical specialties; however, it is a possibly an under-used tool in obstetrics and gynecology. A limited number of studies have been performed on its use during laparoscopic endometrioma excision and myomectomy. It may prove useful in endometrioma excision in reproductive aged women because it is likely to harm ovarian reserve less than electrocautery; however, this conclusion needs to be validated. The only study on GTM use in myomectomy included 50 women randomized into GTM and control groups, and showed decreased blood loss and shorter hospital stays in the GTM group. In gynecologic oncology, it was successfully used to reduce lymphocele cases in a cohort study. GTM has been used successfully in obstetrics in a handful of cases of uncontrolled bleeding from caesarean scar, placental site, ectopic pregnancy, rectovaginal hematoma, and venous plexus over the vaginal vault after emergency postpartum hysterectomy. Risk of viral transmission is a major concern about GTM, yet there are no reports on disease transmission with GTM use to date. Rare but serious adverse effects and complications have been reported such as fatal or near-fatal thromboembolism and small bowel obstruction. Although GTM is mostly a safe product, it is still not free of complications and risks. In conclusion, although routine use of GTM cannot be recommended due to concerns about its safety, cost, and availability, it may prove useful when conventional hemostatic methods such as suturing and electrocauterization fail or are not appropriate.

Unidirectional barbed suture for vaginal cuff closure without backward stitch in total laparoscopic hysterectomy

To evaluate the safety and efficacy of unidirectional barbed suture technique for vaginal cuff closure in total laparoscopic hysterectomy (TLH).

Laparoscopic Removal of Bladder From the Uterine Niche With Retrograde Dissection

Videolaparoscopy citorreduction with debulking limphadenectomy in a Fallopian tube cancer patient. We present the case of a fifity-seven years old woman who underwent to non-oncologic hysterectomy with bilateral salpingoophoretomy, in another medical service, with the diagnosis of Fallopian tube serous adenocarcinoma. Postoperative TC showed a conglomerate retroperitoneal lymph node mass of 4.3 by 3.6 cm. So, we performed a videolaparoscopy cytorreduction wich included omentectomy and debulking limphadenectomy. The video shows the debulking time which was laboured and demanded extremely delicate movements. We change the laparoscopic instruments and energy several times to achieve the best way to overcome challenges safety. The total procedure time was 7 hours and blood loss was 200cc. About the patological report, 6 of 31 retroperitoneal nodes was positive for adenocarcinoma. At he present time, patient is on chemotherapy, on the third cycle of carboplatin and paclitaxel.