Malformaciones müllerianas: actualización y revisión a propósito de casos clínicos, 2022 / Müllerian malformations: update and review of clinical cases, 2022

Las malformaciones müllerianas (MM) son un grupo de anomalías estructurales originadas por fallas de desarrollo de los conductos paramesonéfricos o de Müller durante las primeras 16 semanas de gestación. Un oportuno diagnóstico y una correcta clasificación permiten ofrecer el mejor manejo y diferenciar aquellas pacientes que requieren tratamiento quirúrgico. Se realizó una revisión de la literatura sobre MM en las bases de datos Epistemonikos, SciELO, Cochrane y PubMed. Se rescataron todas las pacientes ingresadas con diagnóstico de MM. En el año 2021, la American Society of Reproductive Medicine publicó un consenso en el que se estandarizó la nomenclatura, se amplió el espectro y se simplificó la clasificación. La clínica es variada, e incluye pacientes asintomáticas cuyo diagnóstico es un hallazgo por imágenes. Los mejores estudios imagenológicos son la resonancia magnética (RM) y la ultrasonografía 3D, dejando la histeroscopia y la laparoscopia (método de referencia) como procedimiento diagnóstico-terapéutico. Se presentan casos clínicos desarrollados durante el primer trimestre de 2022. Recomendamos la utilización sistemática de la RM para el diagnóstico de anomalías complejas u obstructivas del aparato genital. El tratamiento de estas patologías debe ser realizado por ginecólogos endoscopistas expertos, e incluye tratamiento médico y quirúrgico, el cual debe ser enfocado en cada paciente dependiendo del tipo de MM y de los deseos de fertilidad.

Müllerian malformations (MM) are a group of structural anomalies caused by developmental failure of the paramesonephric or Müllerian ducts during the first 16 weeks of gestation. Timely diagnosis and classification allow us to offer the best management and to differentiate those patients who require surgical treatment. Literature review on MM in Epistemonikos, SciELO, Cochrane and PubMed databases. All patients admitted with a diagnosis of MM were rescued. In 2021, the American Society of Reproductive Medicine publishes a consensus where it standardizes the nomenclature, broadens the spectrum, and simplifies the classification. The clinical picture is varied and includes asymptomatic patients whose diagnosis is an imaging finding. The best imaging studies are magnetic resonance imaging (MRI) and 3D ultrasonography, leaving hysteroscopy and laparoscopy (gold standard) as diagnostic therapeutic. Clinical cases developed during the first trimester 2022 are presented. We recommend the routine use of MRI for the diagnosis of complex and/or obstructive anomalies of the genital tract. The treatment of these pathologies should be performed by expert endoscopic gynecologists and include medical and surgical treatment, which should be focused on each patient, depending on the type of MM and fertility desires.

Fístula utero-yeyunal secundaria a migración de dispositivo intrauterino: reporte de un caso / Utero-jejunal fistula secondary to intrauterine device migration: a case report

RESUMEN El dispositivo intrauterino (DIU) es un método anticonceptivo muy popular, eficaz y seguro. Aunque posee complicaciones bien descritas como es la migración, la que puede ser a otros órganos dentro de la cavidad peritoneal. La fístula uteroyeyunal es un evento clínico poco frecuente, pero de gran repercusión si no es diagnosticada y tratada. Se presenta el caso de una paciente usuaria de DIU, el que migra a cavidad abdominal, con posterior formación de fístula uteroyeyunal.

ABSTRACT The intrauterine device is a popular, efficient and safe contraceptive. Although it has some well described complications, such as migration, which may be to the different organs inside of the peritoneal cavity. The uterus-jejunal fistula is a rare clinical event, but with great repercussion if it is not well assessed and treated properly. We present the clinical case of a patient with a migrated intrauterine device and a fistula uterus-jejunal formation.

A randomized controlled study on an integrated approach to prevent and treat re-adhesion after transcervical resection of moderate-to-severe intrauterine adhesions

OBJECTIVES: This study aims to compare the clinical efficacy of an integrated approach to prevent and treat the recurrence of moderate-to-severe intrauterine adhesions (IUA) after hysteroscopic transcervical resection of adhesion (TCRA). METHODS: The study included a total of 70 patients with moderate-to-severe IUAs who underwent TCRA. Patients were randomly divided into two groups: treatment group (n=35) and control group n=35). In the treatment group, patients underwent balloon uterine stent placement and artificial cycle as well as received intrauterine perfusion of Danshen injection and oral Chinese medicine. In the control group, patients underwent balloon uterine stent placement and artificial cycle as well as received hyaluronic acid sodium and intrauterine device (IUD). Follow-up was performed after treatment of uterine cavity, menstruation and pregnancy. RESULTS: After 3 months of treatment, we observed a significantly lower rate of intrauterine re-adhesion (45.71% versus 77.14%, p=0.044) and significantly higher clinical efficiency (82.86% versus 77.14%, p=0.025) in the treatment group than those in the control group. After 6 months of treatment, we observed a significantly higher clinical efficiency in the treatment group than that in the control group (88.57% versus 68.57%, p=0.039). During the follow-up period, the pregnancy rate was 45.71% and 37.14% in the treatment group and control group, respectively, although the difference was not statistically significant (p=0.628). CONCLUSIONS: After surgical management of IUA, the integrated treatment combining a uterus stent placement and artificial cycle with Danshen injection and oral Chinese medicine can improve the condition of menstruation, and prevent and treat recurrence of IUA.

Prevalence and intensity of pain during diagnostic hysteroscopy in women attending an infertility clinic: analysis of 489 cases / Prevalência e intensidade da dor na histeroscopia diagnóstica em mulheres atendidas em uma clínica de infertilidade: análise de 489 casos

ABSTRACT Objective To investigate the prevalence and intensity of pain perception during diagnostic hysteroscopy in women and potential related factors. Methods A total of 489 women were investigated at an infertility clinic. Fluid diagnostic hysteroscopy was performed without analgesia or anesthesia by gynecologists with different levels of experience in operative hysteroscopy, using a 2.9mm rigid scope. The Visual Analog Scale was used to score pain intensity after vaginal speculum insertion and after hysteroscopy. Data collected included age, ethnicity, body mass index, history of infertility and endometrial surgery (curettage and/or hysteroscopy), smoking habits, and hysteroscopy diagnosis. Only the state of anxiety was assessed by the State-Trait Anxiety Inventory given to each patient before the procedure. Results Hysteroscopy median (25th to 75th) Visual Analog Scale scored 3.3 (3 to 5), and 41.7% of the women referred Visual Analog Scale score ≥4. Median (25th to 75th) State-Trait Anxiety Inventory score was 42 (38 to 45), and 58.3% of the women referred State-Trait Anxiety Inventory score >40. Hysteroscopy Visual Analog Scale score was significantly correlated to surgeon experience and to vaginal speculum insertion but not to State-Trait Anxiety Inventory score, ethnicity or abnormal hysteroscopic findings. Conclusion Diagnostic hysteroscopy was mostly perceived as a mild discomfort procedure by most women. Nevertheless, in a considerable number of cases, women perceived hysteroscopy as painful. Pain perception was linked to individual pain threshold and surgeon experience, but not to pre-procedural anxiety state levels, ethnicity or abnormal hysteroscopic findings.

RESUMO Objetivo Investigar a prevalência e a intensidade da percepção da dor durante a histeroscopia diagnóstica, bem como os possíveis fatores relacionados. Métodos Foram incluídas 489 mulheres submetidas à propedêutica de infertilidade. A histeroscopia diagnóstica foi realizada sem analgesia ou anestesia, por ginecologistas com níveis de experiência diferentes em histeroscopia, usando histeroscópio rígido de 2,9mm. A Escala Visual Analógica foi utilizada para avaliar a intensidade da dor após a inserção do espéculo vaginal e após a histeroscopia. Os dados coletados incluíram idade, etnia, índice de massa corporal, história de infertilidade e cirurgia endometrial (curetagem e/ou histeroscopia), tabagismo e histeroscopia diagnóstica. Avaliou-se apenas o estado de ansiedade pelo Inventário de Ansiedade Traço-Estado de cada paciente antes do procedimento. Resultados A mediana (25ºa 75º) de histeroscopia pela Escala Visual Analógica foi 3,3 (3 a 5), e 41,7% das mulheres obtiveram pontuação ≥4. A mediana (25ºa 75º) do Inventário de Ansiedade Traço-Estado foi 42 (38 a 45), e 58,3% das mulheres referiram pontuação >40. A pontuação da Escala Visual Analógica da histeroscopia apresentou correlação estatisticamente significante com a experiência do cirurgião e a inserção do espéculo vaginal, mas não a pontuação do Inventário de Ansiedade Traço-Estado, etnia ou achados histeroscópicos anormais. Conclusão A histeroscopia diagnóstica foi percebida pela maioria das mulheres como desconforto leve, mas um número considerável de pacientes classificou o procedimento como doloroso. A percepção da dor esteve ligada ao limiar individual e à experiência do cirurgião, mas não aos níveis de ansiedade pré-procedimento, à etnia e nem aos achados histeroscópicos anormais.

Sexual function after total laparoscopic hysterectomy or transabdominal hysterectomy for benign uterine disorders: a retrospective cohort

The objective of this study was to evaluate changes in sexual function after total laparoscopic hysterectomy (TLH) or transabdominal hysterectomy (TAH). This retrospective cohort study included patients with benign uterine tumors that were divided into TLH group and TAH group based on the hysterectomy technique used. Baseline, intraoperative, and postoperative characteristics were compared between groups. Postoperative sexual function was assessed using the Brief Index of Sexual Functioning for Women. The TLH and TAH groups contained 119 patients (age, 51.5±6.1 years) and 126 patients (age, 50.0±4.7 years), respectively. Baseline characteristics were comparable between groups, although uterine size was larger in the TAH group (P<0.001). Compared with the TAH group, the TLH group had a longer operative time (130.0±36.2 vs 107.3±28.5 min, P<0.001), lower pain index at 24 h (2.0±1.6 vs 4.0±2.6, P<0.001), and shorter hospitalization time (5.7±1.1 vs 8.1±1.2 days, P<0.001). Many patients in the TLH and TAH groups reported decreased satisfaction with their sexual life (67.5 and 56.0%, respectively), reduced frequency of sexual activity (70.1 and 56.0%, respectively), decreased libido (67.5 and 56.0%, respectively), orgasm dysfunction (42.9 and 42.9%, respectively), and increased dyspareunia (77.9 and 85.7%, respectively). However, there was no significant difference between groups in any of the indexes of postoperative sexual function (P>0.05). Both TLH and TAH had comparable negative effects on sexual function in women treated for benign uterine tumors in China, with a decreased frequency of sexual activity, reduced libido, orgasm dysfunction, and increased dyspareunia.

Live fetus inside the urinary bladder: a case report / Feto vivo dentro da bexiga urinária: relato de caso

ABSTRACT Vesicouterine fistula is a rare condition. Its incidence, however, has been increasing due to the higher incidence of cesarean sections. The presence of a live fetus inside the bladder who passed through a vesicouterine fistula is an extremely rare situation. We report a case of woman who underwent two previous cesarean sections, was referred to a hospital due to mild pelvic pain and genital bleeding. At the moment, physical examination was normal. Ultrasound scan revealed a gestational sac inserted into the anterior wall of the uterus, with a living fetus of approximately 13 weeks, with active body movement and normal heart rate inside it. The fetal abdomen, around the waist, was stuck at the opening of a vesicouterine fistula, so that the fetal head and trunk were entirely into the bladder cavity, while lower limbs remained at the uterine cavity. Laparotomy was performed, the fistulous tract was excised, the fetus (without heart beating) was removed on opening the bladder, and the uterine cavity was emptied. The defects in the bladder and uterus were repaired. The postoperative period was uneventful. A live fetus inside the urinary bladder is a rare condition the continuation of pregnancy is unlikely and the vesicouterine correction can be made by the time of surgical intervention.

RESUMO A fístula vesicouterina é uma condição rara. Sua incidência, no entanto, vem aumentando, devido à maior incidência de cesáreas. A presença de feto vivo dentro da bexiga por meio de uma fístula vesicouterina constutui situação extremamente rara. Relatamos o caso de uma mulher com duas cesarianas anteriores encaminhada para o hospital devido à dor pélvica leve e sangramento genital. Na hospitalização, o exame físico estava normal. A ultrassonografia revelou saco gestacional inserido na parede anterior do útero com feto vivo de aproximadamente 13 semanas, com movimento corporal ativo e frequência cardíaca normal. O abdômen fetal, ao redor da cintura, estava preso na abertura de uma fístula vesicouterina de modo que a cabeça e o tronco fetais estavam totalmente dentro da cavidade da bexiga, enquanto os membros inferiores permaneciam na cavidade uterina. A laparotomia foi realizada, o trajeto fistuloso foi excisado, o feto (que estava sem batimento cardíaco) foi removido ao abrir a bexiga, sendo a cavidade uterina esvaziada. Além disso, foram reparados os defeitos na bexiga e no útero. O pós-operatório transcorreu sem intercorrências. Feto vivo dentro da bexiga é uma condição rara, e a continuidade da gravidez é improvável, sendo que a correção vesicouterina pode ser feita no momento da intervenção cirúrgica.

Urinary incontinence following subtotal and total hysterectomy: a systematic review / Incontinência urinária após histerectomia subtotal e total: revisão sistemática

ABSTRACT Objective: To evaluate the best surgical approach for the female urinary incontinence. Methods: Systematic review conducted in MEDLINE® Cochrane, EMBASE and LILACS database up to September 1st, 2017. Articles were selected according to study type, type of intervention and outcomes. Articles were selected by more than one researcher based on title, abstract and full text. The SIGN checklist was used for bias assessment. Results: A total of 165 articles were retrieved from MEDLINE® . Twenty-five studies were elected for full text reading, and 11 of them were selected for the final text analysis. The heterogeneity between questionnaires used in different studies precluded a meta-analysis of results. Conclusion: This study yielded evidences supporting the hypothesis that total and subtotal hysterectomy have different impacts on urinary function of patients with benign uterine diseases. Articles revealed higher frequency of urinary incontinence following subtotal compared to total hysterectomy.

RESUMO Objetivo: Avaliar qual a melhor conduta cirúrgica na incontinência urinária feminina. Métodos: Revisão sistemática conduzida no MEDLINE®, Cochrane, EMBASE e LILACS até 1º de setembro de 2017. Os artigos foram escolhidos de acordo com o tipo de estudo e de intervenção, e seus resultados. Os artigos foram selecionados por mais de um pesquisador, com base no título, no resumo e no texto completo. O checklist SIGN foi usado para avaliar vieses. Resultados: No MEDLINE®, foram recuperados 165 artigos. Foram escolhidos 25 estudos para leitura do texto completo, e somente 11 foram escolhidos para análise do texto final. Não foi realizada metanálise dos resultados devido à heterogeneidade dos questionários usados em cada estudo. Conclusão: Encontrou-se evidência que suporta a hipótese de que as histerectomias total e subtotal causam impactos diferentes na função urinária de pacientes com doença uterina benigna. Os artigos mostraram maior frequência de incontinência urinária após histerectomia subtotal quando comparada à total.

Vesicouterine fistula (Youssef syndrome): case report and literature review / Fístula vesico-uterina (síndrome de Youssef): descrição de caso e revisão da literatura

Abstract Objective To describe a case of vesicouterine fistula and to review the literature related to this condition. Methods For the review, we accessed the MEDLINE, BIREME and LILACS databases; the references of the searched articles were also reviewed. Results A 38-year-old woman, in the 1st day after her 3rd cesarean, presented heavy hematuria, which was considered secondary to a difficult dissection of the bladder. A total of 6 months after delivery, she failed to resume her regular menstrual cycles and presented cyclic menouria and amenorrhea. At this time, she had two episodes of urethral obstruction by blood clots. She remained without a correct diagnosis until about two years postdelivery, when a vesicouterine fistula was confirmed through cystoscopy. A surgical correction through open abdominal route, coupled with hysterectomy, was performed. After the surgery, the symptoms disappeared. The review showed a tendency of change in the relative frequency of the different types of genitourinary fistulae. Vesicovaginal fistulae, usually caused by inadequate care during labor, are becoming less frequent than those secondary tomedical procedures, such as vesicouterine fistulae. The most common cause of this latter kind of fistula is cesarean section, especially repeated cesarean sections. The diagnosis is confirmed through one or more imaging exams, or through cystoscopy. The most common treatment is surgical, and the routes are: open abdominal, laparoscopic, vaginal or robotic. There are some reports of success with the conservative treatment. Conclusion Vesicouterine fistulae are becoming more common because of the increase in the performance of cesarean sections, and the condition must be considered a possible complication thereof.

Resumo Objetivo Apresentar um caso de fístula vesico-uterina e realizar revisão da literatura sobre esta condição. Métodos Revisão realizada consultando-se as bases MEDLINE, BIREME e LILACS, além das referências dos artigos consultados. Resultados Uma mulher de 38 anos, após sua terceira cesárea, no puerpério imediato, apresentou hematúria importante, que foi atribuída a uma dificuldade na dissecção da bexiga durante o procedimento. Seis meses pós-parto, emvez de retomar os ciclos menstruais regulares, apresentou menúria cíclica e amenorreia (síndrome de Youssef). A paciente chegou a apresentar obstrução uretral por coágulos, e permaneceu sem diagnóstico correto até cerca de anos pós-parto, quando este foi feito por cistoscopia. Ela foi então submetida a correção cirúrgica por via abdominal, associada a uma histerectomia, com desaparecimento dos sintomas. A revisão mostrou que tem havido mudança na frequência dos vários tipos de fístulas urogenitais. As fístulas vesicovaginais, normalmente secundárias à má assistência durante o parto, têm sido mais raras, enquanto aquelas secundárias a procedimentos médicos, como as vesicouterinas, têm sido mais frequentes. A causa mais comum deste tipo de fístula é a cesárea, especialmente a de repetição. A apresentação pode ser de amenorreia e menúria e/ou perda urinária. O diagnóstico é feito por um ou maismétodos de imagem ou cistoscopia. O tratamento mais comum é cirúrgico, por via abdominal aberta, laparoscópica, transvaginal ou robótica. Existem relatos de cura com tratamento conservador. Conclusão As fístulas vesicouterinas têm sido mais comuns devido ao aumento da proporção de cesáreas. Deve-se ter em mente a possibilidade deste diagnóstico e considerá-las uma das possíveis complicações da cesárea.

Initial experience with single-port robotic hysterectomy / Experiência inicial com histerectomia robótica por portal único

ABSTRACT Objective: This article presents the first series of robotic single-port hysterectomy cases performed at a hospital in Brazil. Methods: From November 2014 to October 2016, 11 patients were indicated to undergo, and nine of them were submitted to single-port hysterectomy using da Vinci Single-Site® platform. However, in two patients, due to multiple previous abdominal surgeries, large uterine volume, and/or a uterus with no mobility, a pneumoperitoneum was performed with a Verres needle, and the pelvic cavity was assessed using a 5mm optics endoscope. In these cases, single-port surgery was not recommended; therefore, multiportal robotic access was chosen, and no intercurrent events were reported. Nine single-port cases were operated on by the same surgeon at Hospital Israelita Albert Einstein. Patient data analyzed included age, body mass index, previous surgeries, and clinical diagnosis. Surgical data included operative time, skin incision, report of intraoperative complications, need for conversion to laparotomy, need for transfer to intensive care unit, need for blood transfusion, inadvertent injury to other organs, length of hospital stay, and death. Results: All cases were completed with da Vinci Single-Site® system, with no intercurrent events. Four patients presented with adenomyosis as the surgical indication, two had uterine myoma, one endometrial cancer, one endometrial polyp, and one desquamative inflammatory vaginitis. The mean age of patients was 44 years (range, 40 to 54 years), and body mass index varied between 23.4 and 33.2kg/m2 (mean 26.4). No complications occurred in any of the cases, such as intestinal or bladder injury, bleeding, or the need for a second surgery. All nine procedures were completed with the robotic single-port access, and no patient required a blood transfusion. Conclusion: Although this study merely presented an initial series of patients submitted to robotic single-port surgery, it demonstrated that the method is feasible and safe, suggesting the possible use of this technique in elective hysterectomy and other gynecological procedures in the future, as described in large reference centers of advanced surgery worldwide. Specifically, in gynecological practice, existing evidence on the use of robot-assisted, single-port surgery seems promising, and although it is not indicated in all cases, it should be considered as a surgical option. Nonetheless, further randomized and controlled clinical studies are necessary to establish the preeminence of robot-assisted, single-port surgery versus single-incision and conventional laparoscopy.

RESUMO Objetivo: Apresentar a primeira série de casos de histerectomia usando sistema robótico de portal único (single-port) em hospital no Brasil. Métodos: No período de novembro de 2014 a outubro 2016, de modo inédito no Brasil, 11 pacientes tiveram indicação inicial e 9 delas foram submetidas à histerectomia por portal único, com a plataforma da Vinci Single-Site®. Em duas pacientes, devido a múltiplas cirurgias abdominais prévias, grande volume uterino e/ou útero sem mobilidade, optou-se pela instalação de pneumoperitônio com agulha de Verres e inspeção da cavidade pélvica com ótica de 5mm, constatando-se, nestes casos, não ser viável a cirurgia por single-port, levando-se, assim, à opção pela técnica robótica multiportal, sem intercorrências. Os nove casos single-port foram operados por um mesmo cirurgião, no Hospital Israelita Albert Einstein. Os dados analisados das pacientes foram idade, índice de massa corporal, cirurgias anteriores e diagnóstico clínico. Os dados relacionados à cirurgia foram tempo operatório, incisão da pele, registro de complicações intraoperatórias, necessidade de conversão para laparotomia, necessidade de transferência para unidade de terapia intensiva, necessidade de transfusão sanguínea, lesão inadivertida de outros órgãos, tempo de internação e óbito. Resultados: Todos os casos foram concluídos sem intercorrências com a plataforma da Vinci Single-Site®. Quatro pacientes apresentavam adenomiose como indicação cirúrgica, duas apresentavam mioma uterino, uma câncer de endométrio, um pólipo endometrial e uma hidrorreia. A média de idade das pacientes foi 44 anos (variando de 40 a 54 anos) e o índice de massa corporal variou entre 23,4 a 33,2kg/m2 (média de 26,4). Nenhum caso teve qualquer tipo de complicação, como lesão intestinal ou vesical, sangramento ou necessidade de reabordagem cirúrgica. Todos os nove procedimentos foram concluídos com o portal único robótico, e nenhuma paciente necessitou de transfusão sanguínea. Conclusão: Apesar deste trabalho apresentar apenas uma série inicial de pacientes operadas por portal único robótico, ele demonstra a factibilidade do método e indica a possibilidade futura de adotar esta técnica em histerectomias eletivas e em outros procedimentos ginecológicos, assim como descrito em grandes centros de referência em cirurgia avançada no mundo. Especificamente na prática ginecológica, a evidência existente sobre o uso de portal único robô-assistido parece ser promissora e, ainda que nem todos os casos tenham indicação, é necessário que exista esta opção no arsenal cirúrgico. No entanto, estudos clínicos aleatorizados e controlados são necessários, a fim de se estabelecer a superioridade da cirurgia robótica por portal único diante da cirurgia laparoscópica com incisão única e da cirurgia laparoscópica convencional.

Síndrome de McKittrick-Wheelock: una causa infrecuente de hipokalemia e injuria renal aguda. Caso clínico / McKrittick-Wheelock syndrome: report of one case

McKittrick-Wheelock syndrome is caused by chronic water and electrolyte hypersecretion from an intestinal tumor, usually a villous adenoma, located in the rectum or sigmoid. Patients often have dehydration, hypovolemic shock and kidney failure associated with hypokalemia, hyponatremia, hypochloremia and metabolic acidosis. We report a 62-year-old male, suffering chronic diarrhea for eight years who was admitted after a syncope. He had severe hypokalemia, hyponatremia, metabolic acidosis, hypovolemia and acute renal failure. After his metabolic disorders were corrected, a colonoscopy showed a large rectosigmoid tumor with the characteristics of a villous adenoma. During the follow up after the complete tumor resection, the patient has remained asymptomatic.

Prevalencia de istmocele en el Hospital de San José de Bogotá, Colombia / Prevalence of isthmocele at the San José Hospital in Bogotá, Colombia

Objetivo: Describir la prevalencia de istmocele como hallazgo incidental en pacientes con antecedente de cesárea y síntomas clínicos asociados. Métodos: Estudio descriptivo de corte transversal, mediante muestreo no probabilístico por conveniencia, en pacientes con antecedente de cesárea, programadas para histeroscopia entre noviembre de 2014 y marzo de 2015, en el servicio de cirugía endoscópica ginecológica del Hospital San José de Bogotá, Colombia. Resultados: 42 pacientes fueron elegibles para el estudio por su antecedente de cesárea y todas fueron incluidas. La frecuencia de istmocele fue 83,3% en la histeroscopia, con similar localización en istmo y cérvix. La principal característica clínica presentada por las pacientes fue hemorragia uterina anormal (85,7%), mientras que la menos frecuente fue infertilidad (7,1%). En las pacientes con presencia de istmocele se observó una mayor prevalencia de dismenorrea (65,7% vs. 42,9%), antecedente de 2 o más cesáreas (60% vs. 42,9%) y cesárea de urgencia (54,3% vs. 28,6%) comparadas con el grupo de pacientes sin istmocele, en este último grupo se advirtió que el 100% de las pacientes no tenían antecedente de trabajo de parto previo. En mujeres con antecedente de cesárea y presencia de síntomas como sangrado uterino anormal, dismenorrea, dolor pélvico, infertilidad y dispareunia, la frecuencia de istmocele diagnosticado por histeroscopia fue mayor del 80%. Conclusión: El istmocele se debe a la cicatrización anómala uterina posterior a una cesárea, se requieren otros estudios para determinar no solo la prevalencia sino los factores protectores que reduzcan su incidencia para tener un impacto positivo en este tipo de pacientes.

Objective: To describe the prevalence of isthmocele as an incidental finding in patients with a history of cesarean section and associated clinical symptoms. Methods: Descriptive cross-sectional study using nonprobabilistic sampling for convenience in patients with a history of cesarean section, scheduled for hysteroscopy between November 2014 and March 2015, in the gynecological endoscopic surgery service of the Hospital San José de Bogotá, Colombia. Results: 42 patients were eligible for the study because of their previous cesarean section and all were included. The frequency of isthmocele was 83.3% in hysteroscopy, with similar localization in the isthmus and cervix. The main clinical characteristic presented by the patients was abnormal uterine bleeding (85.7%), while the less common was infertility (7.1%). A higher prevalence of dysmenorrhea (65.7% vs. 42.9%) was observed in patients with isthmocele, a history of 2 or more cesareans (60% vs. 42.9%) and an emergency cesarean section (54, 3% vs. 28.6%) compared to the group of patients without isthmocele, in the latter group it was noted that 100% of the patients had no previous history of labor. In women with a history of cesarean section and presence of symptoms such as abnormal uterine bleeding, dysmenorrhea, pelvic pain, infertility and dyspareunia, the frequency of isthmocele diagnosed by hysteroscopy was greater than 80%. Conclusion: Isthmocele is due to abnormal uterine cicatrization after cesarean section, other studies are required to determine not only the prevalence but also the protective factors that reduce its incidence to have a positive impact on this kind of patients.

Accuracy of Transvaginal Ultrasonography, Hysteroscopy and Uterine Curettage in Evaluating Endometrial Pathologies / Acurácia da ultrassonografia transvaginal, histeroscopia e curetagem uterina na avaliação de patologias endometriais

Abstract Objective To evaluate the accuracy of transvaginal ultrasonography, hysteroscopy and uterine curettage in the diagnosis of endometrial polyp, submucous myoma and endometrial hyperplasia, using as gold standard the histopathological analysis of biopsy samples obtained during hysteroscopy or uterine curettage. Methods Cross-sectional study performed at the Hospital Universitário de Brasília (HUB). Data were obtained from the charts of patients submitted to hysteroscopy or uterine curettage in the period from July 2007 to July 2012. Results One-hundred and ninety-one patients were evaluated, 134 of whom underwent hysteroscopy, and 57, uterine curettage. Hysteroscopy revealed a diagnostic accuracy higher than 90% for all the diseases evaluated, while transvaginal ultrasonography showed an accuracy of 65.9% for polyps, 78.1% for myoma and 63.2% for endometrial hyperplasia. Within the 57 patients submitted to uterine curettage, there was an accuracy of 56% for polyps and 54.6% for endometrial hyperplasia. Conclusion Ideally, after initial investigation with transvaginal ultrasonography, guided biopsy of the lesion should be performed by hysteroscopy, whenever necessary, in order to improve the diagnostic accuracy and subsequent clinical management.

Resumo Objetivo avaliar a acurácia da ultrassonografia transvaginal, da histeroscopia e da curetagem uterina no diagnóstico de pólipo endometrial, mioma submucoso e hiperplasia de endométrio, utilizando como padrão-ouro a análise histopatológica de amostras obtidas por biópsia realizada durante a histeroscopia ou a curetagem. Métodos estudo transversal realizado no Hospital Universitário de Brasília (HUB), cujas informações foram obtidas nos prontuários das pacientes que foram submetidas à histeroscopia ou curetagem uterina no período de julho de 2007 a julho de 2012. Resultados Foram avaliadas 191 pacientes, sendo que 134 foram submetidas à histeroscopia e 57 à curetagem uterina. Observou-se acurácia diagnóstica maior que 90% para todas as patologias avaliadas por histeroscopia, enquanto que por ultrassonografia transvaginal observou-se acurácia de 65,9% para pólipo, 78,1% para mioma e 63,2% para hiperplasia endometrial. Nas 57 pacientes submetidas a curetagem uterina, observou-se acurácia de 56% para pólipo e de 54,6% para hiperplasia endometrial. Conclusão Idealmente, após a investigação inicial com ultrassonografia transvaginal, deveria, sempre que necessário, ser realizada histeroscopia com biópsia guiada da lesão, o que melhoraria a acurácia diagnóstica e posterior conduta clínica.

Early Experience of Robotic Hysterectomy for Treatment of Benign Uterine Disease / Experiência inicial da histerectomia robótica no tratamento da patologia uterina benigna

Abstract Objectives To demonstrate the initial experience of robotic hysterectomy to treat benign uterine disease at a university hospital in Brazil. Methods A cross-sectional study was conducted to review data from the first twenty patients undergoing robotic hysterectomy at our hospital. The surgeries were performed from November 2013 to August 2014, all of them by the same surgeon. The patients were reviewed for preoperative characteristics, including age, body mass index (BMI), indications for the hysterectomy and previous surgeries. Data of operative times, complications, postoperative pain and length of hospital stay were also collected. Results The total operating room time was 252.9 minutes, while the operative time was 180.7 minutes and the console time was 136.6 minutes. Docking time was 4.2 minutes, and the average undocking time was 1.9 minutes. There was a strong correlation between the operative time and the patient's BMI (r = 0.670 ; p = 0.001). The console time had significant correlation with the uterine weight and the patient's BMI (r = 0.468; p = 0.037). A learning curve was observed during docking and undocking times. Conclusion Despite its high cost, the robotic surgery is gaining more space in gynecological surgery. By the results obtained in our hospital, this surgical proposal proved to be feasible and safe. Our initial experience demonstrated a learning curve in some ways.

Resumo Objetivos O presente projeto visa à documentação da experiência inicial do Hospital de Clínicas de Porto Alegre na realização da histerectomia robótica. Métodos Um estudo transversal foi realizado a fim de revisar dados das primeiras vinte pacientes submetidas à histerectomia robótica em nosso hospital. As cirurgias foram realizadas no período de novembro de 2013 a agosto de 2014, e todas tiveram o mesmo cirurgião. Foram analisadas características pré-operatórias, incluindo idade, índice de massa corporal, cirurgias prévias abdominais, paridade, indicação da histerectomia. Dados referentes aos tempos operatórios, complicações, dor pósoperatória e tempo de internação pós-operatória também foram coletados. Resultados O tempo de sala total foi de 252,9 minutos, enquanto o tempo cirúrgico total foi 180,7 minutos, e o tempo de console foi 136,6 minutos. O tempo médio de docking foi 4,2 minutos; e o tempo médio de undocking foi 1,9 minutos. Foi observada forte correlação entre o tempo cirúrgico total e o índice de massa corporal da paciente (r = 0,670; p = 0,001). O tempo de console teve correlação significativa com o peso uterino e com o índice de massa corporal das pacientes (r = 0,468; p = 0,037). Foi observada curva de aprendizado nos tempos de docking e undocking. Conclusão Apesar do alto custo, a robótica vem ganhando espaço na cirurgia ginecológica. Pelos resultados obtidos no nosso hospital, a proposta provou ser factível e segura. Nossa experiência inicial demonstrou curva de aprendizado em alguns aspectos.

La histerectomía laparoscópica y sus aspectos fundamentales / Laparoscopic hysterectomy and its fundamental aspects

La histerectomía es una de las técnicas quirúrgicas empleada con mayor frecuencia para tratar las enfermedades uterinas benignas, en nuestro país el abordaje por mínimo acceso para su tratamiento gana terreno en el campo de la cirugía ginecológica. Se realizó una revisión bibliográfica para resumir información sobre la histerectomía laparoscópica. Se expuso los aspectos fundamentales sobre su evolución, la técnica quirúrgica, sus indicaciones, contraindicaciones y complicaciones, así como ventajas y desventajas respecto a otras vías de abordaje para la histerectomía. Todo esto con el fin de crear un material de apoyo actualizado sobre este tema para residentes de especialidades quirúrgicas que practiquen esta intervención. Se concluyó que la histerectomía laparoscópica es una alternativa eficaz y segura para pacientes que cumplan los criterios para esta vía de abordaje(AU)

Hysterectomy is one of the most frequent surgical techniques used to treat benign uterine diseases. In our country, the minimum access approach gains support to perform it in the field of gynecological surgery. A literature review was made to summarize information about laparoscopic hysterectomy. The main aspects on its development, the surgical technique as such, its indications, counter- indications and complications, advantages and disadvantages in comparison to other approaches for hysterectomy were also discussed. The objective was to collect updated supporting materials on this topic for residents of different surgical specialties who practice this operation. It was concluded that laparoscopic hysterectomy is an effective safe alternative for patients who meet the criteria for this kind of surgical approach(AU)

Histopathological findings of abdominal hysterectomies in patients presenting with heavy menstrual bleeding [HMB]

To determine the frequency of different histopathological findings in hysterectomy specimens in patients with heavy menstrual bleeding. Cross-sectional study This study was carried out in Gynae Unit III [Sandemen Provincial Teaching Hospital Quetta] from January 2009- December 2009. Two hundred abdominal Hysterectomy cases done for the treatment of heavy menstrual bleeding [HMB] were included in this study. An exclusion criteria was vaginal hysterectomies, abdominal hysterectomies done for complaints other than manorrhagia and malignancies. After hysterectomy specimen of uterus sent for histopathology. The age ranged from 30-55 years with maximum number [62.5%] of cases in 41-50 years of age group. The main presenting complaint of patients was heavy cyclical menstrual flow. Total abdominal Hysterectomies with bilateral salpingoophoroctomy done in 120patients, in 80 patients both ovaries conserved. There was no intra-operative complication. Mild post operative complications occurred in 15% of cases. There was no death. On histopathology leiomyoma was most common pathlogy found in 55% cases. No malignancy was detected on histopathology of the uterus. The study confirmed that benign diseases were more common in hysterectomy specimen performed for HMB. Uterine fibroids and adenomyosis are the most common benign conditions found in hysterectomy specimens on histopathological examination

Total laparoscopic hysterectomy versus vaginal hysterectomy at the University Hospital of the West Indies: a 5-year retrospective study

OBJECTIVE: To compare the outcomes of total laparoscopic hysterectomy (TLH), a relatively new procedure, with vaginal hysterectomy (VH), a wellestablished procedure, in a university teaching hospital. SUBJECTS AND METHODS: A retrospective chart review of all patients who underwent TLH at the University Hospital of the West Indies between January 2007 and December 2011 was conducted. Chart review was also conducted of a group of patients who underwent VH during this time period. The groups were compared with respect to demographic data and intraoperative and postoperative outcomes. Statistical analysis was undertaken using the SPSS software, version 12.0 (SPSS, Chicago, IL). The Student unpaired ttest was used to analyse continuous variables, and the Chi-square test and Fisher exact test for categorical variables, when appropriate. A p-value of < 0.05 was considered statistically significant. RESULTS: Ten patients underwent TLH, and were compared with 22 women who underwent VH. There was no statistically significant difference between groups in uterine weight, estimated blood loss, postoperative analgesic requirement, or length of hospitalization. Total laparoscopic hysterectomy took significantly longer to perform (209.9 vs 145.6 minutes, p = 0.004). One patient in the TLH group had to be brought back to the operating theatre after three months because of bowel prolapse secondary to vault dehiscence. With the exception of one case of bladder injury in the VH group, there were no significant differences between the groups in terms of intraoperative and postoperative complications. CONCLUSION: Total laparoscopic hysterectomy, notwithstanding its learning curve, is as safe as VH. However, TLH was associated with a significantly longer operative time.

Vaginal hysterectomy in non-prolapsed uteruses: 6-year experience / Histerectomia vaginal em útero sem prolapso: experiência de 6 anos

OBJECTIVE: To evaluate the applicability of the technique of vaginal hysterectomy in non-prolapsed uterus. METHODS: A retrospective cohort study with 220 patients submitted to vaginal hysterectomy from January 2004 to July 2010 by the Vaginal Surgery and Pelvic Floor Team. Patients mean age was 44.4 years and they had on average three births (0-10 deliveries). The surgery was performed even in cases of previous abdominal surgery, and cesarean section was prevalent in 54.6% of patients. RESULTS: The mean uterus weight was 278.9g. The mean operative time was 93 minutes, and length of hospital stay was 24 hours after surgery in 65% of cases. There were no cases of visceral injury. The mean postoperative complication was cellulitis of the vaginal vault that occurred in 11 cases (5%) that received antibiotics. Mean blood loss corresponded to 1.4g/dL hemoglobin. From the analyzed sample, vaginal hysterectomy by vaginal route was feasible in 96.8% of patients, and abdominal conversion was necessary in 3.2%. CONCLUSION: Vaginal hysterectomy is a minimally invasive surgery, with fewer complications, and low morbidity. We believe that this procedure should be indicated to treat gynecological benign diseases.

OBJETIVO: Avaliar a aplicabilidade da técnica de histerectomia vaginal em úteros sem prolapso. MÉTODOS: Estudo de coorte retrospectivo de 220 pacientes submetidas à histerectomia vaginal no período de janeiro de 2004 a julho de 2010, pela Equipe de Cirurgia Vaginal e do Assoalho Pélvico. A média de idade dos pacientes foi de 44,4 anos e tiveram, em média, 3 partos (0-10 partos). A cirurgia foi realizada mesmo em casos de cirurgias abdominais prévias; a cesárea foi prevalente em 54,6% da amostra. RESULTADOS: O peso médio do útero foi de 278,9g. O tempo cirúrgico médio foi de 93 minutos, e o tempo de internação foi de 24 horas pós-operatórias em 65% dos casos. Não houve nenhum caso de lesão visceral. A complicação pós-operatória mais frequente foi celulite de cúpula, que ocorreu em 11 casos (5%), sendo tratadas com antibioticoterapia. A perda sanguínea foi, em média, de 1,4g/dL de hemoglobina. Foi possível a realização da histerectomia pela via vaginal em 96,8% das pacientes da amostra estudada e em 3,2% foi necessária a conversão para via abdominal. CONCLUSÃO: A histerectomia vaginal é uma cirurgia por orifício natural, minimamente invasiva, com baixas frequência de complicações e morbidade, sendo factível e segura para o tratamento de afecções uterinas benignas.

Huge uterine-cervical diverticulum mimicking as a cyst.

Here we report an incidental huge uterine-cervical diverticulum from a total abdominal hysterectomy specimen in a perimenopausal woman who presented with acute abdominal pain. The diverticulum was mimicking with various cysts present in the lateral side of the female genital tract. Histopathological examination confirmed this to be a cervical diverticulum with communication to uterine cavity through two different openings. They can attain huge size if left ignored for long duration and present a diagnostic challenge to clinicians, radiologists, as well as pathologists because of its extreme rarity. Therefore, diverticula should also be included as a differential diagnosis. Its histopathological confirmation also highlights that diverticula can present as an acute abdomen, requiring early diagnosis with appropriate timely intervention. Immunohistochemistry CD 10 has also been used to differentiate it from a mesonephric cyst.