Malla suburetral retropúbica (TVT): experiencia clínica y análisis de datos en el Hospital El Carmen de Maipú / Retropubic suburethral mesh (TVT): clinical experience and data analysis at the Hospital El Carmen de Maipú

La incontinencia urinaria de esfuerzo es la pérdida involuntaria de orina durante una maniobra de esfuerzo físico, ejercicio, estornudo o tos. Afecta aproximadamente al 15% de las mujeres de 30-60 años y su prevalencia es del 30-41%. Aunque existen terapias conservadoras para su manejo, muchas pacientes terminarán necesitando cirugía para su resolución. Las mallas suburetrales son alternativas para el manejo quirúrgico, existiendo dos vías de instalación, la transobturadora (TOT o TVT-O) y la retropúbica (del inglés tension-free vaginal tape o TVT), siendo esta última la que presenta mejores resultados y menos complicaciones posoperatorias. Objetivo: evaluar la tasa de efectividad y las complicaciones de la TVT en la Unidad de Piso Pélvico Femenino del Hospital El Carmen de Maipú entre los años 2015 y 2020. Materiales y Métodos: Se obtuvieron 715 registros de pacientes que fueron sometidas a TVT y se logró contactar telefónicamente con el 60,69% de ellas. Resultados: Los resultados muestran una tasa de efectividad del 94,8% y una tasa de complicaciones del 2,3%. Conclusión: Este estudio aporta evidencia local de los resultados posoperatorios en la IOE en pacientes que requirieron la instalación de una malla suburetal retropúbica, demostrando ser una cirugía altamente efectiva y segura.

Stress urinary incontinence is the involuntary loss of urine during physical exertion, exercise, sneezing, or coughing. It affects approximately 15% of women aged 30-60, with a prevalence of 30-41%. Although there are conservative therapies for its management, many patients will eventually require surgery for resolution. Suburethral sling are considered for surgical management, and there are two installation alternatives, transobturator (TOT or TVT-O) and retropubic (tension-free vaginal tape or TVT), with the latter presenting better results and fewer postoperative complications. Objetive: to evaluate effectiveness rate and complications of the TVT in the Female Pelvic Floor Unit of Hospital El Carmen de Maipú between 2015 and 2020. Materials and Methods: A total of 715 patient records were obtained for those who underwent TVT, and 60.69% of them were successfully contacted by telephone. Results: The results show an effectiveness rate of 94.8% and a complication rate of 2.3%. Conclusion: This study provides local evidence for the results of stress urinary incontinence that required the placement of a retropubic suburethral sling, proving to be a highly effective and safe surgery.

Reparación quirúrgica por vía vaginal de fístulas vesicovaginales: una experiencia exitosa / Vaginal surgical repair of vesico-vaginal fistulas: a successful experience

OBJETIVO: Se presenta una serie de casos de reparación por vía vaginal de fístula vesicovaginal (FVV) de nuestro centro. MATERIAL Y MÉTODOS: Estudio observacional descriptivo. Se evaluaron todas las pacientes con reparación quirúrgica de FVV en el Centro de Innovación de Piso Pélvico del Hospital Sótero del Río entre 2016 y 2022. RESULTADOS: Se reportaron 16 casos, de los cuales el 81,3% fueron secundarios a cirugía ginecológica. En todos se realizó la reparación por vía vaginal, con cierre por planos. En el 94% (15/16) se logró una reparación exitosa en un primer intento. El tiempo de seguimiento poscirugía fue de 10 meses (rango: 3-29). No hubo casos de recidiva en el seguimiento. Una paciente presentó fístula de novo, la cual se reparó de manera exitosa en un segundo intento por vía vaginal. Se reportaron satisfechas con la cirugía 15 pacientes, con mejoría significativa de su calidad de vida. Una paciente reportó sentirse igual (6,3%), pero sus síntomas se debían a síndrome de vejiga hiperactiva que la paciente no lograba diferenciar de los síntomas previos a la cirugía. CONCLUSIÓN: Las FVV en los países desarrollados son secundarias a cirugía ginecológica benigna. La cirugía por vía vaginal en nuestra serie demostró una alta tasa de éxito, con mejora significativa en la calidad de vida de las pacientes.

OBJETIVE: We present a case series of vesico-vaginal fistulas (VVF) vaginal repair in our center. MATERIAL AND METHODS: Descriptive observational study. All patients with surgical repair of VVF at the Centro de Innovación en Piso Pélvico of Hospital Sótero del Río were evaluated between September 2016 and September 2022. RESULTS: 16 cases were reported. 81.3% were secondary to gynecological surgery. In all cases, a vaginal repair was performed, with a layered closure. 94% (15/16) had no contrast extravasation at the time of examination, confirming fistula closure. The follow-up time was 10 months (range: 3-29). There were no cases of recurrence during follow-up. 1 patient presented de novo fistula which was successfully repaired in a second attempt vaginally. 15/16 patients reported being satisfied with the surgery, with significant improvement in quality of life. 1 patient reported feeling the same (6.3%), but her symptoms were due to overactive bladder syndrome that the patient could not differentiate from the symptoms prior to surgery. CONCLUSION: VFV in developed countries are mainly secondary to benign gynecological surgery. Vaginal surgery in our series achieved a significant improvement in the quality of life of patients.

Suspensión alta al ligamento uterosacro con suturas permanentes en el prolapso apical: seguimiento a 24 meses / High suspension to the uterosacral ligament with permanent sutures in the apical prolapse: 24-month follow-up

Introducción: El prolapso de órganos pélvico (POP) es una patología frecuente que afecta hasta el 60% de las mujeres. La fijación alta al ligamento uterosacro (FAUS) transvaginal es una alternativa para el tratamiento del prolapso apical con buenos resultados, tiempos operatorios y de recuperación acotados, además de bajas tasas de complicaciones. Objetivo: Evaluar la tasa de éxito anatómico y subjetivo en pacientes portadoras de un prolapso apical sometidas a FAUS en el Hospital de Quilpué a 24 meses de seguimiento. Materiales y método: Se realizó un estudio retrospectivo observacional descriptivo, seleccionando a todas las pacientes sintomáticas con un prolapso apical ≥ 2 de la clasificación de POP-Q, sometidas a una FAUS entre septiembre de 2014 y octubre de 2019. Los datos fueron obtenidos desde la base de datos de la unidad de uroginecología del Hospital de Quilpué, previa aprobación del comité de ética. El éxito objetivo se definió como un punto C a 1 centímetro sobre el himen y el éxito subjetivo con una escala de impresión de mejora global del paciente (PGI-I) mejor o mucho mejor y/o una escala visual analógica (EVA) mayor al 80%, a 24 meses de seguimiento. Resultados: Se incluyeron 46 pacientes. La tasa de éxito objetivo fue del 84% y de éxito subjetivo del 70%. Conclusiones: La FAUS transvaginal con suturas permanentes es una excelente alternativa para el tratamiento del prolapso apical con una tasa de éxito similar al gold standard a 24 meses de seguimiento.

Introduction: Pelvic organ prolapse (POP) is a frequent pathology that affects up to 60% of women. Transvaginal uterosacral ligament high fixation (USLs: utero-sacral ligaments) is an alternative for the treatment of apical prolapse with good results, limited operative and recovery times, as well as low rates of complications. Objective: To evaluate the anatomical and subjective success rate in patients with an apical prolapse undergoing STALUS at the Quilpué Hospital at 24 months of follow-up. Materials and method: A descriptive observational retrospective study was carried out, selecting all symptomatic patients with an apical prolapse ≥ 2 of the POP Q classification, submitted to a FAUS between September 2014 and October 2019. The data were obtained from the database of the Urogynecology Unit of the Quilpué Hospital, prior approval of the ethics committee. Objective success was defined as a C-point 1 centimeter above the hymen and subjective success with better or much better Patient Global Impression-Improvement (PGI-I) scale and/or a greater than 80% Visual Analogue Scale (VAS), at 24 months of follow-up. Results: 46 patients were included. The objective success rate was 84% and the subjective success rate was 70%. Conclusions: The transvaginal FAUS with permanent sutures is an excellent alternative for the treatment of apical prolapse with a success rate similar to the gold standard at 24 months of follow-up.

Resección intestinal por endometriosis severa, diagnóstico y tratamiento luego de la introducción de la Unidad de Endometriosis: revisión de 18 años en el Hospital Clínico de la Universidad de Chile / Bowel resection for severe endometriosis, diagnosis and treatment after the introduction of Endometriosis Unit: 18 years review, Clinical Hospital of the University of Chile

INTRODUCCIÓN: La endometriosis intestinal afecta en gran medida la calidad de vida de una mujer joven y habitualmente requiere un tratamiento quirúrgico con resección intestinal. Esta cirugía es técnicamente compleja por las adherencias firmes del intestino a la vagina, el útero y los ovarios. OBJETIVO: Describir y analizar los resultados quirúrgicos e histopatológicos de las resecciones intestinales por endometriosis grave durante los últimos 18 años en el Hospital Clínico de la Universidad de Chile, en relación con la introducción de la unidad multidisciplinaria de endometriosis, a partir del año 2011, y las experiencias publicadas en la literatura chilena y extranjera. MÉTODO: Trabajo retrospectivo realizado en un hospital terciario desde el año 2001 hasta el año 2019. Las pacientes se asignaron a dos grupos según el período de cirugía: grupo 2001-2010 y grupo 2011-2019, luego de la introducción de la unidad de endometriosis. Se recopilaron todas las pacientes a las que se realizó una resección intestinal (discoidal o segmentaria) por endometriosis, por laparotomía o laparoscopía. Los datos distribuidos normalmente se presentan como promedio ± DE y los datos no paramétricos como mediana (rango). Las comparaciones demográficas de variables continuas se hicieron con la prueba t de Student y las de las variables categóricas con las pruebas de ji al cuadrado o de Fisher. La significación estadística se estableció en p < 0,05. RESULTADOS: Se recopilaron 52 casos. El 94,2% de las cirugías fueron electivas. El 5,8% fueron de urgencia por obstrucción intestinal (todas entre 2001 y 2010). Un 75% de las cirugías fueron laparoscópicas. Se realizó resección segmentaria en el 67,3%, resección discoidal simple en el 28,8%, resección discoidal doble en el 1,9% y resección segmentaria y una discoidal en el 1,9%. La histopatología demostró compromiso de la lesión hasta la mucosa intestinal en un 7,7%. Hubo franca disminución del dolor en el seguimiento de las pacientes. El 24% de las pacientes con deseo de embarazo y endometriosis intestinal lograron un parto de término mediante fecundación in vitro o espontáneamente. Hubo cuatro complicaciones posoperatorias, tres de ellas de categoría II según la clasificación de Clavien-Dindo y una de categoría IV A con reintervención a las 72 horas. Al comparar ambos periodos, en 2001-2010 los exámenes diagnósticos utilizados fueron ecografía transvaginal (0%), enema baritado (60%), tomografía computarizada de abdomen y pelvis (45%) y resonancia magnética pelviana (20%), mientras que en 2011-2019 fueron ecografía transvaginal (100%), enema baritado (3%), tomografía computarizada (3%) y resonancia magnética pelviana (66%). En 2001-2010, las lesiones fueron más más infiltrativas (mayor compromiso mucoso y submucoso) (75 vs. 16% de las resecciones intestinales; p < 0,05), estenóticas (cirugías de urgencia por obstrucción), con mayor porcentaje de resecciones segmentarias (100 vs. 46,9%; p < 0,05) y más días de hospitalización (5,8 ± 2,3 vs. 4,1 ± 0,9 días) que en 2011-2019. CONCLUSIONES: A nuestro entender, esta es la serie más grande publicada en Chile de resecciones intestinales por endometriosis. Estos hallazgos demuestran cómo la introducción de la unidad multidisciplinaria de endometriosis permite un diagnóstico precoz y un tratamiento quirúrgico eficaz y oportuno, tal como se decribe en la literatura.

INTRODUCTION: Bowel endometriosis severely affects a young woman's quality of life and often requires surgical treatment with bowel resection. This surgery is technically complex due to the tight adhesions of the intestine to the vagina, uterus, and ovaries. The objective of this work is to describe and analyze the surgical and histopathological results of intestinal resections for severe endometriosis during the last 18 years at the Clinical Hospital University of Chile, in relation to the implementation of the multidisciplinary endometriosis unit, based on the year 2011 and the experiences published in Chilean and foreign literature. METHOD: Retrospective work carried out in a tertiary hospital from 2001 to 2019. The patients were assigned to two groups according to the surgery period: group 2001-2010 and group 2011-2019, after endometriosis unit formation. All patients who underwent bowel resection (discoidal or segmental) for endometriosis by laparotomy or laparoscopy were collected. Normally distributed data are presented as mean ± SD and nonparametric data as median (range). Demographic comparisons of continuous variables are compared using Student's t test and categorical variables using chi squared or Fisher's test. Statistical significance was established at p < 0.05. RESULTS: 52 cases were collected. 94.2% of the surgeries were elective. 5.8% were urgent due to intestinal obstruction (all between 2001 and 2010). 75% of the surgeries were laparoscopic. Segmental resection 67.3%, simple discoidal resection 28.8%, double discoidal resection 1.9% and segmental resection and a discoidal resection 1.9%. Histopathology showed involvement of the lesion up to the intestinal mucosa in 7.7%. A marked decrease in pain in the follow-up of the patients. 24% of the patients with a desire for pregnancy and intestinal endometriosis achieved a full-term delivery by IVF or spontaneously. There were four postoperative complications, three of them category II according to the Clavien-Dindo classification, and one category IV A complication with reoperation at 72 h. When comparing both periods, between 2001-2010 the diagnostic tests used were: transvaginal ultrasound (ECO TV) (0%), barium enema (BE) (60%), abdomen pelvis CT (45%) and pelvic resonance (MRI) (20%). Between 2011 and 2019 ECO TV (100%), EB (3%), TAC (3%) RM (66%). In the period 2001 to 2010, the lesions were more infiltrative (greater mucosal and submucosal involvement) (75% vs 16% of intestinal resections (P <0.05)), stenotic (urgent surgery for obstruction), with a higher percentage of resections segmental (100% vs 46.9% (P <0.05) and more days of hospitalization (5.8 ± 2.3 SD vs 4.1 ± 0.9 SD) than in the period from 2011 to 2019. CONCLUSIONS: To our knowledge, this is the largest series published in Chile of intestinal resections for endometriosis. These findings demonstrate how the introduction of the multidisciplinary endometriosis unit allows early diagnosis and effective and timely surgical treatment as described in the literature.

Histerectomía total vía abdominal: revisión de la literatura / Total abdominal hysterectomy: a literature review

Hysterectomy is the most common gynecological surgery in non-pregnant women. There are different surgical approaches for total hysterectomy, abdominal, vaginal, laparoscopic and robotic routes. The choice is determined by different factors such as uterine size, malformations, surgical risks, skill of the surgeon, expected postoperative quality of life, and monetary costs. The surgical technique is well described in the literature, however, there are certain anatomical and functional considerations that must be known before performing the hysterectomy to avoid complications. The most frequent complications are hemorrhage, infections, thromboembolism, urinary and gastrointestinal tract injuries. Majority can be avoided with an adequate procedure and management of pre-existing comorbidities. (AU)

Sistema de evacuación seguro de neumoperitoneo y humo quirúrgico en cirugía laparoscópica mediante trampa de agua en tiempos de COVID-19 / Safe evacuation system for pneumoperitoneum and surgical smoke in laparoscopic surgery using a water trap in times of COVID-19

INTRODUCCIÓN: La reciente pandemia por SARS-CoV-2 (COVID-19) ha hecho resurgir preocupación sobre la exposición inadvertida del equipo quirúrgico a agentes infecciosos transmisibles por vía aérea durante el acto quirúrgico. El objetivo de este trabajo es describir la confección de un sistema de filtrado simple y de bajo costo que permite reducir el riesgo de exposición al virus, particularmente en el proceso de aspiración, recambio y remoción del neumoperitoneo en cirugía laparoscópica. MATERIALES Y MÉTODO: Se diseñó e implementó un circuito cerrado de evacuación y de filtrado del neumoperitoneo en cirugías ginecológicas laparoscópicas en un centro de salud terciario. El circuito incluye un filtro HEPA (High Efficiency Particulate Air) y una trampa de vacío que contiene una solución de inactivación en base a amonio cuaternario o hipoclorito de sodio. RESULTADOS: Desde su implementación se han realizado 17 cirugías laparoscópicas ginecológicas por diversas patologías. Dos de ellas fueron en pacientes Covid-19 (+). A la fecha no se han reportado contagios en el equipo médico que participó en la cirugía. CONCLUSIONES: Es posible implementar un sistema de evacuación del neumoperitoneo en cirugía laparoscópica presumiblemente eficaz en minimizar el riesgo de exposición al virus SARS-COV-2 (Covid-19). Su bajo costo lo hace especialmente recomendable en países en vías de desarrollo.

INTRODUCTION: The recent SARS-CoV-2 (COVID-19) pandemics has raised concern on the incidental exposition of health team to air transmissible infectious agents during surgeries. The main goal of this work is to communicate a simple and low-cost filtering system allowing to reduce the risk of contagion related to the virus, associated with pneumoperitoneum removal during surgical laparoscopy. METHODS: A closed circuit of gas removal and filtering was developed and implemented in laparoscopic gynecologic procedures at a tertiary teaching hospital. The circuit included an HEPA (High Efficiency Particulate Air) filter and a vacuum trap containing an inactivating solution based on quaternary ammonium or sodium hypochlorite. RESULTS: Since its introduction, seventeen laparoscopic surgeries have been carried out for different gynecologic pathologies. Two of them in Covid (+) cases. To date, no contagion has been reported among health teammates participating in these surgeries. CONCLUSIONS: It is possible to implement a pneumoperitoneum evacuation system in laparoscopic surgery presumably effective in minimizing the risk of exposure to the SARS-COV-2 virus (Covid-19). Its low cost makes it especially recommended in developing countries.

Complicaciones quirúrgicas intraoperatorias en laparoscopía ginecológica en el Hospital Padre Hurtado / Intraoperative surgical complications in gynecological laparoscopy at Padre Hurtado Hospital

INTRODUCCIÓN: Actualmente la cirugía laparoscópica es el gold standard de la mayoría de las cirugías ginecológicas benignas. Se estima una tasa de complicaciones en cirugía ginecológica por laparoscopía de 3.2 por 1000 pacientes, donde alrededor del 50% ocurren al momento de la primera entrada. Existen numerosas clasificaciones de las complicaciones quirúrgicas, entre ellas, la clasificación Clavien-Dindo se centra en el tratamiento postquirúrgico y tiene como objetivo unificar criterios y hacerlas comparables entre distintos centros. OBJETIVO: Describir las complicaciones en cirugía laparoscópica ginecológica en el Hospital Padre Hurtado, destacando el subgrupo de primera entrada y su clasificación Clavien-Dindo. METODOLOGÍA: Cohorte retrospectiva que incluyó a todas las pacientes operadas por laparoscopía en el pabellón de ginecología del Hospital Padre Hurtado desde el año 2014 al 2017. Se utilizó el software SPSS statistics v25, con prueba X2 para el análisis de las variables no paramétricas y t de Student para las variables paramétrica, considerando una significación estadística con p<0,05. RESULTADOS: De las 513 cirugías laparoscópicas ginecológicas realizadas en el período evaluado, sólo el 4,3% del total de las pacientes tuvieron complicaciones. De éstas, un 9% fueron de primera entrada, y en todos los casos fueron complicaciones menores o Clavien-Dindo I y II. Hubo 2 complicaciones Clavien-Dindo >III B, lo que correspondió a un 0,39%. CONCLUSIÓN: En nuestro grupo hubo una baja incidencia de complicaciones quirúrgicas y de primera entrada lo que es comparable con otras series publicadas.

INTRODUCTION: Laparoscopic surgery is currently the gold standard of most benign gynecological surgeries. A complication rate in gynecological laparoscopy is 3.2 per 1000 patients, where around 50% occur at the time of the first entry. There are numerous classifications of surgical complications, among them, Clavien-Dindo classification focuses on post-surgical treatment and aims to unify criteria and lets compare between different centers. OBJECTIVE: To describe the complications in gynecological laparoscopic surgery at the Padre Hurtado Hospital, highlighting the first entry subgroup and Clavien-Dindo classification. METHODOLOGY: Retrospective cohort that included all gynecological laparoscopy patients in Padre Hurtado Hospital from 2014 to 2017. The SPSS statistics v25 software was used, with X2 test for the analysis of non-parametric variables and t Student for the parametric variables, considering a statistical significance with p <0.05. RESULTS: 513 gynecological laparoscopic surgeries was performed in the evaluated period, only 4.3% of the total patients had complications. Of these, 9% were first entry, and in all cases were minor complications or Clavien-Dindo I and II. There were 2 patients with Clavien-Dindo complications > III B, which corresponded to 0.39%. CONCLUSION: In our group there was a low incidence of surgical complications and first entry which is comparable with other published series.

Ergonomía en cirugía laparoscópica ginecológica / Ergonomics and gynecologic laparoscopic surgery

INTRODUCCIÓN Y OBJETIVOS: Están demostradas las ventajas de la cirugía laparoscópica para el paciente en términos de dolor, rápida recuperación y precisión quirúrgica, sin embargo, no existen estudios nacionales respecto al impacto en los cirujanos. El objetivo de este trabajo es realizar un estudio prospectivo de evaluación ergonómica de ginecólogos que operan cirugía laparoscópica. MÉTODOS: Se utilizaron métodos de evaluación específica por ergónomo experto y percepción de los participantes. Se evaluaron, carga global de trabajo (NASA-tlx), carga bio-mecánica (REBA) y la percepción de molestias músculo-esqueléticas (Escala de Discomfort Corporal). Se recogieron datos personales y de la cirugía, para explorar la existencia de dificultades técnicas. RESULTADOS: 86,7% de los ginecólogos evidenciaron altos niveles de carga global de trabajo, siendo las variables esfuerzo y rendimiento, las de mayor puntaje. El nivel de riesgo bio-mecánico, fue catalogado como medio en la totalidad de la población. 60% manifestó discomfort corporal durante la cirugía. En cuanto a las dificultades técnicas, el efecto fulcrum estuvo presente en el 46% de los cirujanos, el mismo porcentaje tuvo síntomas de ojo seco. El 68% alguna vez accionó el pedal equivocado y ha sentido parestesia del pulgar. CONCLUSIONES: La cirugía laparoscópica ginecológica, presenta una elevada carga global de trabajo. El ginecólogo percibe un importante discomfort corporal y algunas dificultades técnicas. Es necesario incorporar medidas ergonómicas, para minimizar y/o disminuir los factores de riesgo mental y físicos, y así prevenir el desgaste precoz y lesiones a futuro en los cirujanos.

INTRODUCTION AND OBJECTIVES: Laparoscopic surgery had demonstrated advantages such as less pain, rapid recovery and surgical precision. There are no national data regarding the impact on surgeon's health. This is a prospective study on ergonomic evaluation and laparoscopic surgery performed by gynecologists. METHODS: Specific evaluation methods were used such as Global workload (NASA-tlx), bio-mechanical load (REBA) and the perception of musculoskeletal discomfort (Body Part Discomfort Scale). Personal opinions and surgery data were collected to explore the existence of technical difficulties. RESULTS: 86.7% of gynecologists cataloged surgery as high level of global workload. Effort and performance variables were most important. Bio-mechanical risk level was classified as medium in the entire population. 60% showed body discomfort during surgery. Regarding technical difficulties, fulcrum effect was present in 46% of surgeons, the same percentage had dry eye symptoms. 68% have a pedal error activation during surgery and felt paresthesia of the thumb. CONCLUSIONS: Gynecological laparoscopic surgery has a high overall workload. The gynecologist perceives an important body discomfort and some technical difficulties. It is necessary to incorporate ergonomic measures, to minimize and / or reduce mental and physical risk factors, and thus prevent early wear and future injuries in surgeons.

Cirurgia robótica em ginecologia: atualidade e perspectivas / Robotic surgery in gynecology: current and perspectives

No ano de 2018, aproximadamente 549.000 cirurgias robóticas em ginecologia foram realizadas no mundo, ocupando o segundo lugar em volume de procedimentos. Estudos sugerem superioridade ou equivalência dessa tecnologia em relação à cirurgia laparoscópica, porém o custo, a disponibilidade e o treinamento limitam sua adoção. Nesta revisão narrativa, os principais benefícios e limitações dos procedimentos ginecológicos robóticos foram analisados. O uso de robôs na histerectomia para o tratamento de lesões benignas apresentou menor incidência de lesões iatrogênicas e de sangramentos em relação à laparoscopia convencional. Na miomectomia robótica, além de menor taxa de complicações, maior volume de miomas retirados foi observado. A cirurgia robótica tem sido bem-sucedida para cirurgias de estadiamento no câncer de endométrio em estágios precoces (I e II), devido à menor taxa de complicações em relação à cirurgia aberta e aos resultados satisfatórios obtidos em mulheres obesas. A histerectomia robótica realizada no tratamento de câncer de colo do útero apresentou menor perda sanguínea em parte dos estudos, porém um ensaio clínico recente demonstrou maior mortalidade no grupo dos procedimentos minimamente invasivos. Espera-se que, com a redução dos custos e a ampliação dos treinamentos, a cirurgia robótica seja uma ferramenta complementar às modalidades já existentes.(AU)

In 2018, 549,000 robotic gynecology surgeries were done in the world, ranking second in volume of procedures. Studies suggest the superiority or equivalence of this technology over laparoscopic surgery, but its cost, availability, and training limit its adoption. In this narrative review, the benefits and limitations of robotic gynecological procedures were investigated. Using robots in hysterectomy for the management of benign lesions showed a lower incidence of iatrogenic lesions and bleeding compared to conventional laparoscopy. In robotic myomectomy, besides a lower complication rate, a larger volume of removed fibroids was noted. Robotic surgery has been successful in the early stages (I and II) endometrial cancer staging surgeries, because of the lower complication rate compared to open surgery and the satisfactory results achieved in obese women. Robotic hysterectomy performed in the treatment of cervical cancer showed less blood loss in part of the studies, but a recent clinical trial showed higher mortality in the minimally invasive procedures group. It is desired that with the reduction of costs and the spread of training robotic surgery will be a complementary tool to existing modalities.(AU)

Comparison of pressure-controlled volume-guaranteed ventilation and volume-controlled ventilation in obese patients during gynecologic laparoscopic surgery in the Trendelenburg position / Comparação entre ventilação garantida por volume controlado por pressão e ventilação controlada por volume em pacientes obesos durante cirurgia laparoscópica ginecológica na posição de Trendelenburg

Abstract Background and objectives: The aim of this study was to investigate the efficacy of the pressure-controlled, volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) modes for maintaining adequate airway pressures, lung compliance and oxygenation in obese patients undergoing laparoscopic hysterectomy in the Trendelenburg position. Methods: Patients (104) who underwent laparoscopic gynecologic surgery with a body mass index between 30 and 40 kg.m-2 were randomized to receive either VCV or PCV-VG ventilation. The tidal volume was set at 8 mL.kg-1, with an inspired oxygen concentration of 0.4 with a Positive End-Expiratory Pressure (PEEP) of 5 mmHg. The peak inspiratory pressure, mean inspiratory pressure, plateau pressure, driving pressure, dynamic compliance, respiratory rate, exhaled tidal volume, etCO2, arterial blood gas analysis, heart rate and mean arterial pressure at 5 minutes after induction of anesthesia in the and at 5, 30 and 60 minutes, respectively, after pneumoperitoneum in the Trendelenburg position were recorded. Results: The PCV-VG group had significantly decreased peak inspiratory pressure, mean inspiratory pressur, plateau pressure, driving pressure and increased dynamic compliance compared to the VCV group. Mean PaO2 levels were significantly higher in the PCV-VG group than in the VCV group at every time point after pneumoperitoneum in the Trendelenburg position. Conclusions: The PCV-VG mode of ventilation limited the peak inspiratory pressure, decreased the driving pressure and increased the dynamic compliance compared to VCV in obese patients undergoing laparoscopic hysterectomy. PCV-VG may be a preferable modality to prevent barotrauma during laparoscopic surgeries in obese patients.

Resumo Justificativa e objetivos: O objetivo deste estudo foi investigar a eficácia dos modos de ventilação garantida por volume controlado por pressão (PCV-VG) e ventilação controlada por volume (VCV) para manter pressões adequadas nas vias aéreas, complacência pulmonar e oxigenação em pacientes obesos submetidos à histerectomia laparoscópica na posição de Trendelenburg. Métodos: Cento e quatro pacientes submetidos à cirurgia ginecológica laparoscópica, com índice de massa corporal entre 30 e 40 kg.m-2, foram randomizados para receber ventilação com VCV ou PCV-VG. O volume corrente foi fixado em 8 mL.kg-1, com uma concentração inspirada de oxigênio de 0,4 e pressão positiva expiratória final (PEEP) de 5 mmHg. Registramos os seguintes parâmetros: pressão de pico inspiratório, pressão inspiratória média, pressão de platô, driving pressure, complacência dinâmica, frequência respiratória, volume corrente expirado, etCO2, gasometria arterial, frequência cardíaca e pressão arterial média aos 5, 30 e 60 minutos, respectivamente, após o pneumoperitônio na posição de Trendelenburg. Resultados: O grupo PCV-VG apresentou uma redução significativa da pressão de pico inspiratório, pressão inspiratória média, pressão de platô, driving pressure e aumento da complacência dinâmica comparado ao grupo VCV. Os níveis médios de PaO2 foram significativamente maiores no grupo PCV-VG do que no grupo VCV em todos os momentos após o pneumoperitônio na posição de Trendelenburg. Conclusões: O modo de ventilação PCV-VG limitou a pressão de pico inspiratório, diminuiu a driving pressure e aumentou a complacência dinâmica, comparado ao VCV em pacientes obesas submetidas à histerectomia laparoscópica. O PCV-VG pode ser uma modalidade preferida para prevenir o barotrauma durante cirurgias laparoscópicas em pacientes obesos.

Removal of intramural trapped intrauterine device by cystoscopic incision of bladder wall

ABSTRACT A healthy 37 - year - old woman referred to our clinic with one - year history of recurrent urinary tract infection, dysuria and frequency. Her past medical history informed us that an IUD (Copper TCu380A) had been inserted 11 years ago. Eleven months after the IUD insertion she had become pregnant, unexpectedly. At that time, she had undergone gynecological examination and abdominal ultrasound study. However, the IUD had not been found, and the gynecologist had made the diagnosis of spontaneous fall out of the IUD. She had experienced normal pregnancy and caesarian section with no complications. On physical examination, pelvic examination was normal and no other abnormalities were noted. Urinalysis revealed microhematuria and pyuria. Urine culture was positive for Escherichia coli. Ultrasound study revealed a calculus of about 10 mm in the bladder with a hyperdense lesion. A plain abdominal radiograph was requested which showed a metallic foreign body in the pelvis. We failed to remove the IUD by cystoscopic forceps because it had strongly invaded into the uterine and bladder wall. Despite previous papers suggesting open or laparoscopic surgeries in this situation (1, 2), we performed a modified cystoscopic extraction technique. We made a superficial cut in the bladder mucosa and muscle with J - hook monopolar electrocautery and extracted it completely with gentle traction. This technique can decrease the indication of open or laparoscopic surgery for extraction of intravesical IUDs. In the other side of the coin, this technique may increase the risk of uterovesical fistula. Therefore, the depth of incision is important and the surgeon should cut the bladder wall superficially with caution. Although present study is a case report which is normally classified as with low level of evidence, it seems that our modified cystoscopic extraction technique is a safe and useful method for extraction of partially intravesical IUDs.

Comparative clinical study between preoperative oral administration of paracetamol, celecoxib and pregabalin on postoperative pain in gynecological laparoscope

Background: Since the introduction of laparoscopic surgeries, postoperative pain has been generally reduced. However, it can still peak, especially during the early postoperative period and becomes the main cause of overnight hospital stay and prolonged convalescence after this day-case surgical procedure. Thus, optimizing postoperative pain relief, not only to sub-serve reduction of its intensity but to also enhance the recovery and shorten length of stay became the broader target of multimodal pain control regimens nowadays. That is why; searching for a drug that would be effective in reducing pain, safe from major adverse effects and can meanwhile possess an opioid-sparing potentiality would be a merit so as to improve the success rate of ambulatory day-care surgeries. Objective: To study the analgesic effects of preemptive single oral dose of paracetamol, celecoxib and pregabalin in patients undergoing gynecological laparoscope. Method: Preoperative evaluation, preparation and premedication was assessment, and routine laboratory investigations was done. Postoperative pain, Level of Sedation was measured. Results: There was statistical significant difference between the three groups regarding VAS. There was statistical significant difference between the three groups regarding the total pethidine consumption. Regarding postoperative level of sedation, blood glucose there was no statistical significant difference between the three groups. Conclusion: Oral pregabalin in a dose of 150 mg 2 hour before surgery, is significantly attenuating pain intensity and total meperidine consumption during the first 6 hours postoperatively

Addressing the challenges of reoperative robotic-assisted sacrocolpopexy

ABSTRACT Sacrocolpopexy is the gold-standard repair for apical pelvic organ prolapse (POP). However, over half of women with POP who undergo the surgery experience recurrence, particularly those with higher preoperative stage, younger age, and greater body weight. We address the challenges of repairing recurrent POP in a patient with a prior transabdominal mesh sacrohysteropexy.

Perioperative complications and short-term outcomes of abdominal sacrocolpopexy, laparoscopic sacrocolpopexy, and laparoscopic pectopexy for apical prolapse

ABSTRACT Objective: To investigate differences in perioperative complications and short-term outcomes of patients who underwent abdominal sacrocolpopexy / sacrohysteropexy, laparoscopic sacrocolpopexy / sacrohysteropexy, or laparoscopic pectopexy due to apical prolapse. Materials and Methods: A retrospective cohort study was performed on 110 patients who underwent apical prolapse surgery between January 1, 2011, and July 31, 2017. Only symptomatic uterine or vaginal vault prolapse patients with stage 2-4, according to the pelvic organ prolapse quantification system, were included. Baseline and intraoperative variables of groups; perioperative complications, including hemorrhage, urinary, and wound complications, blood transfusion, ileus, and short-term outcomes were compared. Results: A total of 68 abdominal sacrocolpopexies (44 sacrocolpopexies and 24 sacrohysteropexies), 14 laparoscopic sacrocolpopexies (10 sacrocolpopexies and 4 sacrohysteropexies), and 28 laparoscopic pectopexies (16 pectopexies and 12 pectohysteropexies) were analyzed. Baseline characteristics and intraoperative variables were similar. However, the mean operating time was significantly shorter in the laparoscopic pectopexy group (74.9 min) when compared with that of the other groups (p < 0.01). During the six-month follow-up period, no prolapse recurrence and mesh erosion / exposure were observed in any group. De-novo stress urinary incontinence, urgency, and defecation problems, as well as perioperative complication rates, were not statistically significantly different between the groups. Conclusions: Although the complication rates and short-term outcomes were not significantly different between the groups, minimally invasive approaches were associated with reduced procedural-related morbidity. Laparoscopic pectopexy is a promising endoscopic prolapse surgery and can be an alternative technique to sacrocolpopexy.

Safety model for the introduction of robotic surgery in gynecology / Modelo de segurança para a introdução da cirurgia robótica em ginecologia

Abstract Objective To analyze the perioperative results and safety of performing gynecological surgeries using robot-assisted laparoscopy during implementation of the technique in a community hospital over a 6-year period. Methods This was a retrospective observational study in which the medical records of 274 patients who underwent robotic surgery from September 2008 to December 2014 were analyzed. We evaluated age, body mass index (BMI), diagnosis, procedures performed, American Society of Anesthesiologists (ASA) classification, the presence of a proctor (experienced surgeon with at least 20 robotic cases), operative time, transfusion rate, perioperative complications, conversion rate, length of stay, referral to the intensive care unit (ICU), and mortality. We compared transfusion rate, perioperative complications and conversion rate between procedures performed by experienced and beginner robotic surgeons assisted by an experienced proctor. Results During the observed period, 3 experienced robotic surgeons performed 187 surgeries,while 87 surgeries were performedby 20 less experienced teams, always with the assistance of a proctor. The median patient age was 38 years, and the median BMI was 23.3 kg/m2. The most frequent diagnosis was endometriosis (57%) and the great majority of the patients were classified as ASA I or ASA II (99.6%). The median operative time was 225 minutes, and the median length of stay was 2 days. We observed a 5.8% transfusion rate, 0.8% rate of perioperative complications, 1.1% conversion rate to laparoscopy or laparotomy, no patients referred to ICU, and no deaths. There were no differences in transfusion, complications and conversion rates between experienced robotic surgeons and beginner robotic surgeons assisted by an experienced proctor. Conclusion In our casuistic, robot-assisted laparoscopy demonstrated to be a safe technique for gynecological surgeries, and the presence of an experienced proctor was considered a highlight in the safety model adopted for the introduction of the robotic gynecological surgery in a high-volume hospital and, mainly, for its extension among several surgical teams, assuring patient safety.

Resumo Objetivo Analisar os resultados perioperatórios e a segurança da realização de cirurgias ginecológicas por laparoscopia robô-assistida durante a implementação da técnica num hospital comunitário ao longo de 6 anos. Métodos Este foi umestudo retrospectivo observacional, comanálise dos prontuários de 274 pacientes que se submeteramà cirurgia robótica de setembro de 2008 a dezembro de 2014. Avaliamos idade, índice de massa corpórea (IMC), diagnóstico, procedimentos realizados, classificação da Sociedade Americana de Anestesiologia (ASA), presença de um preceptor (cirurgião experiente, compelomenos 20casos robóticos), tempocirúrgico, taxa de transfusão, complicações perioperatórias, taxa de conversão, tempo de internação, encaminhamento para Unidade de Terapia Intensiva (UTI) e mortalidade. Comparamos taxa de transfusão, complicações perioperatórias e taxa de conversão entre procedimentos realizados por cirurgiões experientes com a técnica e cirurgiões iniciantes na robótica, sempre assistidos por um preceptor experiente. Resultados Durante o período observado, 3 cirurgiões experientes realizaram 187 cirurgias, enquanto que 87 cirurgias foram realizadas por 20 equipes menos experientes, sempre com a presença de um preceptor. A mediana da idade foi 38 anos, e a mediana do IMC foi 23,3 kg/m2. O diagnósticomais frequente foi endometriose (57%) e a grande maioria das pacientes foi classificada como ASA I ou ASA II (99,6%). O tempo de cirurgia teve uma mediana de 225 minutos, e o tempo de permanência hospitalar teve uma mediana de 2 dias. Observamos 5,8% de taxa de transfusão, 0,8% de taxa de complicações perioperatórias, 1,1% de taxa de conversão para laparoscopia ou laparotomia e não houve pacientes encaminhadas à UTI, nem óbitos. Não houve diferença nos índices de transfusão, complicações e conversão entre cirurgiões experientes e cirurgiões iniciantes na robótica, assistidos por umpreceptor experiente. Conclusão Em nossa casuística, a laparoscopia robô-assistida demonstrou ser uma técnica segura para cirurgias ginecológicas, e a presença de um preceptor experiente foi considerada um ponto de destaque no modelo de segurança adotado para a introdução da cirurgia robótica em ginecologia num hospital de grande volume e, principalmente, na sua expansão entre diversas equipes cirúrgicas, mantendo a segurança das pacientes.

Manejo de la fístula ano-recto-vaginal compleja mediante el procedimiento de Martius: reporte de cinco casos / Martius procedure in complex anorectal-vaginal fistula management: five-case report

La reparación de fístulas ano-recto-vaginales complejas representa un reto anatomoquirúrgico para el cirujano, debiendo seleccionarse el procedimiento quirúrgico adecuado para cada caso. El procedimiento de Martius consiste en la trasposición del músculo bulbocavernoso para reparar la fístula recto-vaginal. Se presentan cinco casos de fístulas ano-recto-vaginales reparadas por este procedimiento desde el 2010 hasta el 2014. La edad promedio fue de 38,2 años, tres fístulas (60%) fueron de etiología obstétrica, una inducida por radiación y otra de etiología desconocida. El seguimiento promedio fue de 25 meses, con una tasa de éxito de 100%. El procedimiento de Martius es una buena alternativa para la reparación quirúrgica de fístulas ano-recto-vaginales complejas.

The repair of complex anorectal-vaginal fistulas represents an anatomic-surgical challenge for the surgeon, and the appropriate surgical procedure must be selected for each case. The procedure of Martius is described as the transposition of the bulbocavernosus muscle to repair the recto-vaginal fistula. Five cases of anorectal-vaginal fistulae were repaired by this procedure from 2010 to 2014. The mean age was 38.2 years; three fistulas (60%) were of obstetric etiology, one induced by radiation and one of unknown etiology. The mean follow-up was 25 months, with a 100% success rate. The Martius procedure is a good alternative for the surgical repair of complex anorectal-vaginal fistulas.

Efficacy and safety of Elevate® system on apical and anterior compartment prolapse repair with personal technique modification

ABSTRACT Aim: To evaluate the effectiveness and safety of Anterior Elevate® mesh kit system (AES) in woman with symptomatic stage 3 or 4 anterior and/or apical pelvic organ prolapse (POP). Materials and Methods: This retrospective, monocentric, single surgeon study enrolled between May 2010 and January 2013 fifty-six woman experiencing symptomatic anterior vaginal prolapse with or without apical descent (POP-Q stage 3 or 4). All women received a AES and 7 (12.5%) received a concomitant transvaginal hysterectomy. Primary endpoint was anatomic correction of prolapse; success was defined as POP-Q stage ≤ 1 or asymptomatic stage 2. Secondary endpoints were quality-of-life (QOL) results and patients' safety outcomes, which were assessed by 3 validated self-reporting questionnaires at baseline and annually: ICIQ-UI short form, ICIQ-VS and P-QOL. All patients completed 2-years and 28 women 3-years of follow-up. Surgical approach was modified in women with uterus, moving the two-propylene strips anteriorly around the cervix itself crossing one another, so the left will take place in the right side and the right on the opposite. This modification was made in order to better support the uterus. Results: Vaginal mesh exposure was present in 3 (5,3%) patients. Very good anatomical outcomes were seen, with one (1,8%) failure at 6-months, 4 (7,1%) at 1-year, 6 at 2-years (10,7%). Statistically significant improvements were seen in the ICIQ-VS and P-QOL questionnaires throughout follow-up. Conclusion: Our data suggest that AES is a minimally-invasive transvaginal procedure to repair anterior and apical POP, with good evidence related to mid-term safety and efficacy.