Fertility Outcome after Cornual Resection for Interstitial Pregnancies.

STUDY OBJECTIVE: To evaluate future pregnancy rates beyond gestational week 24 after cornual resections for interstitial pregnancies, subsequent modes of delivery, and the rate of later uterine ruptures. DESIGN: A single-center historic cohort with follow-up registry data (Canadian Task Force classification II-2). SETTING: Department of Gynecology, Oslo University Hospital, Oslo, Norway. PATIENTS: Forty consecutive women with interstitial ectopic pregnancies were treated in the study period from 2005 to 2016, 33 of whom were treated with laparoscopic cornual resection (3 converted to laparotomy). Twenty-six of the 33 women were presumed still fertile after treatment (cases) and thereby age and parity matched with a reference group of 52 women with an equal follow-up time having undergone salpingectomy for tubal (noninterstitial) ectopic pregnancies (controls) (ratio 1:2). Subsequent fertility data for both groups were retrieved from medical records and the national Medical Birth Registry of Norway. INTERVENTIONS: None, data extracted from the patients' medical records and the Medical Birth Registry of Norway. MEASUREMENTS AND MAIN RESULTS: The incidence of interstitial pregnancies among the ectopic pregnancies was 3%. The median time to follow-up for cases and controls was 76 and 71 months, respectively. Subsequent pregnancy rates beyond gestational week 24 were equal in both groups (46% [cases] and 54% [controls]). Cesarean delivery in subsequent pregnancies was more common among women having undergone cornual resections (60% vs 18%, p = .006). Only 2 subsequent uterine ruptures were encountered. CONCLUSION: Cornual resection as treatment for interstitial pregnancies seems to have no added detrimental effect on subsequent pregnancy rates compared with salpingectomy for noninterstitial tubal ectopic pregnancies. However, they more often lead to elective cesarean deliveries in subsequent pregnancies.

Complications in operative hysteroscopy - is prevention possible?

Operative hysteroscopy in a hospital setting has revolutionized surgical treatment of benign uterine disorders. It is minimally invasive, cost- and time-effective, and may spare patients major surgical interventions. Operative hysteroscopy in a day-case hospital setting is regarded as a safe and well-tolerated procedure with low complication rates. However, prevention of adverse events is crucial in daily practice to optimize patient care. Complications in operative hysteroscopy can be divided into early complications, including bleeding, uterine perforation, infection and fluid overload, or late complications and suboptimal outcomes, such as incomplete resection and intrauterine adhesions. Awareness and knowledge of management of adverse events as well as the use of possible preventative measures will increase the quality and safety of hysteroscopic surgery. The present commentary focuses on these issues as an up-to-date basis for everyday clinical practice.

Autotransplantation of cryopreserved ovarian tissue after treatment for malignant disease - the first Norwegian results.

INTRODUCTION: With increasing survival rates after treatment for cancer in prepubertal girls and women of reproductive age, an increasing focus on quality of life has emerged. Both irradiation and cytotoxic drugs can be detrimental to future fertility, consequently several treatment alternatives have been developed to spare or restore fertility in young females diagnosed with cancer. One of these options is cryopreservation of ovarian tissue before treatment and autotransplantation at a later time. MATERIAL AND METHODS: We present the Norwegian experience after 11 years of practice with ovarian tissue cryopreservation. A total of 164 patients have had ovarian tissue cryopreserved during the period 2004-2014. Fifteen patients died during the observation period. Six patients requested autotransplantation, which was performed in two women. RESULTS: Both patients conceived, one spontaneously and one after assisted reproduction due to a concomitant male factor. The pregnancies were uneventful and they each gave birth to a healthy child. CONCLUSIONS: Cryopreservation with later autotransplantation of ovarian tissue should be offered to a selected group of young women with cancer.

Laparoscopic supracervical hysterectomy performed with and without excision of the endocervix: a randomized controlled trial.

STUDY OBJECTIVE: To compare the occurrence of vaginal bleeding and patient satisfaction 12 months after laparoscopic supracervical hysterectomy performed with and without excision of the endocervix. DESIGN: A prospective, randomized, controlled trial. DESIGN CLASSIFICATION: Canadian Task Force Classification I. SETTING: Norwegian university teaching hospital. PATIENTS: One hundred forty consecutive premenopausal women referred for hysterectomy on the basis of a benign condition. INTERVENTIONS: The study participants were randomized to standard laparoscopic supracervical hysterectomy (n = 70) or laparoscopic supracervical hysterectomy with excision of the endocervix in a reverse cone pattern (n = 70). MEASUREMENTS AND MAIN RESULTS: The main outcome measures were the occurrence of vaginal bleeding and patient satisfaction 12 months after the procedure. One hundred thirty women (92.3%) were followed up according to the study protocol. In total, 43 women (33.1%) reported bleeding episodes during the first 12 months after the laparoscopic supracervical hysterectomy; 22 (16.9 %) of these women had cyclic bleeding. All reported bleeding episodes were minimal. Patient satisfaction after the hysterectomy was very high with a mean visual analog score (on a scale of 0-10) of 9.3 (standard deviation = 1.4). There were no significant differences between the 2 treatment groups regarding the main outcomes 12 months after the procedure. CONCLUSION: The patient satisfaction after laparoscopic supracervical hysterectomy is very high. Episodes of minimal vaginal bleeding after the procedure are relatively common, but such bleeding does not affect patient satisfaction. Removal of the endocervix by reverse conization during laparoscopic supracervical hysterectomy appears to have no effect in terms of reduced bleeding or improved patient satisfaction.

Endometriosis of the pancreas.

Endometrial cyst of the pancreas was first described in 1984. The condition is extremely rare, and only a few case reports have been described. Herein we present a case report of a peripancreatic endometriosis cyst in a perimenopausal woman. Computed tomography, magnetic resonance imaging, and regression of the cyst during an observation period of a few months made the diagnosis most likely before laparoscopic surgery. Awareness of the condition, optimal preoperative imaging, and clinical features are discussed.

Parasitic leiomyomas after laparoscopic surgery with morcellation.

Parasitic leiomyomas after laparoscopic surgery with morcellation are a rare entity, and only a few small series and single case reports have been published in recent years. This was first known as a spontaneously occuring condition, but in recent years it has been observed more frequently as an iatrogenic condition after morcellation, and may occur several years after primary surgery. We present three patients diagnosed in an eight year period, representing an incidence of 0.12% after morcellation procedures in our department. The mechanisms leading to parasitic leiomyomas are discussed, as well as how we should minimize the risk of development of this rare condition.

Catamenial pneumothorax, clinical manifestations--a multidisciplinary challenge.

INTRODUCTION: Pleural endometriosis is a rare condition. Spontaneous, recurring pneumothorax occurring during menstruation, referred to as catamenial pneumothorax, is associated with pleural endometriosis. A multidisciplinary approach is needed for a successful result. MATERIAL AND METHODS: During the last five years (2005-2010), we have treated six patients with menstruation related pneumothorax at Oslo University Hospital. The surgical treatment was performed by the thoracic surgery department but the medical follow-up was carried out by the gynecological and pulmonary medicine departments. RESULTS: We report three of the patients treated. All three patients were premenopausal, aged 19-36, and had recurring, menstruation related, spontaneous pneumothorax, predominantly on the right side. The condition was treated by various surgical approaches, including chest tube drainage, video assisted thoracic surgery, chemical pleurodeses and thoracotomy. CONCLUSION: Spontaneous, recurring pneumothorax in women with no previous history of endometriosis can be the first manifestation of pleural endometriosis. The disorder requires surgical intervention, but early diagnosis and postoperative hormonal therapy are just as important for a successful outcome.

Ureteral endometriosis and loss of renal function: mechanisms and interpretations.

Ureteral endometriosis is associated with deep endometriosis and is relatively uncommon. In some patients, progressive obstruction of the lower part of the ureter may occur, with silent loss of renal function as a consequence. We report on three patients with loss of renal function, in whom different pathogenic mechanisms probably were the decisive cause. Failure to diagnose deep endometriosis with ureteral involvement, misinterpretation of hydroureter at magnetic resonance imaging and lack of typical symptoms may all be reasons for development of loss of renal function. With only one functional kidney, these patients should be followed closely with renal function tests and ultrasound, and in certain cases also by magnetic resonance imaging or renal scintigraphy.

Should we recommend hysterectomy more often to premenopausal and climacteric women?

In developed countries, women live on average over 30 years as postmenopausal. In the premenopausal and climacteric period, abnormal uterine bleeding and other symptoms may occur. In addition, endometrial cancer is the most common gynecological malignancy, and possible hormone replacement therapy is much more beneficial among women with prior hysterectomy. With this background and the recommended use of minimally invasive surgical techniques, we argue in favor of more liberal hysterectomy practice before and around the menopause. Many will disagree, because for many years we have argued to save the uterus, but considering pros and cons with the patient in focus, we discuss the topic and advertise for studies to support our view.

Imaging of endometriosis with computerized tomography colonography.

We demonstrate the use of computerized tomography colonography for the imaging of intestinal endometriosis to facilitate preoperative management in our hospital setting.

Total laparoscopic hysterectomy with single-port access without vaginal surgery.

There has been increasing attention to decreasing incisional morbidity and improving cosmetic outcomes in laparoscopic surgery by using fewer and smaller ports. Hysterectomy through single-port access has been reported in which the cuff was closed transvaginally. We report total laparoscopic hysterectomy through a single-port without vaginal surgery. Using improved instruments and bidirectional self-retaining sutures, the laparoscopic technique is almost as easy to perform as with the traditional 4-port access. This case illustrates the advantages and limitations of single-access laparoscopy.

A randomized trial comparing monopolar electrodes using glycine 1.5% with two different types of bipolar electrodes (TCRis, Versapoint) using saline, in hysteroscopic surgery.

OBJECTIVE: To compare three types of equipment during hysteroscopic resection. DESIGN: A randomized study. SETTING: Women's clinic at Ullevaal University Hospital, Oslo, Norway. PATIENT(S): Two hundred premenopausal women with menorrhagia caused by dysfunctional bleedings, fibroids, or polyps. INTERVENTION(S): Hysteroscopic resection was performed either with monopolar electrodes using glycine 1.5% as irrigant or with two different types of bipolar electrodes (TCRis; Olympus, Hamburg, Germany and Versapoint; Gynecare, Menlo Park, CA) using saline as irrigant. MAIN OUTCOME MEASURE(S): Change in serum sodium as a result of irrigant consumption, operating time, and amount of tissue removed. RESULT(S): A statistically significant reduction in mean serum sodium from 138.7 mmol/L to 133.8 mmol/L was seen in the monopolar group, compared with the case of the saline groups with no reduction. The amount of resected tissue in the monopolar and TCRis group was approximately 1.00 g/min, compared with 0.65 g/min in the Versapoint group. Loss of fluid during the procedure was significantly higher in the two bipolar groups. CONCLUSION(S): Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium. Irrigant consumption was significantly higher in the two bipolar groups, without any side effects during or after the procedure. Furthermore, the TCRis loop appears to be superior to the Versapoint loop, as regards operating time and amount of tissue removed.

Endometriosis entrapment of the obturator nerve after previous cervical cancer surgery.

A 26-year-old patient underwent pelvic lymphadenectomy and trachelectomy because of cervical cancer stage IB. Later she developed symptoms from obturator nerve entrapment. Examinations could not reveal metastatic cancer disease, but endometriosis surrounding the obturator nerve was discovered. Laparoscopic removal of the endometriotic tissue surrounding the nerve was performed and the patient's symptoms then disappeared.

First experience of a modified device for excision of the endocervix in a reverse cone during laparoscopic supracervical hysterectomy.

The objective of this study was to evaluate the performance and safety of a modified unipolar electrode developed for excision of the endocervix in a reverse cone pattern during laparoscopic supracervical hysterectomy (LSH) to reduce the occurrence of persistent vaginal bleeding after the procedure. The study is a prospective pilot trial performed at a Norwegian university teaching hospital. Excision of the endocervix was performed with the unipolar electrode immediately after the amputation of the cervix during LSH in 23 consecutive women referred to the department for hysterectomy on the basis of a benign condition. The mean duration of the inverse conization was 61.9 seconds (SD 24.7). The excision of the endocervix in a reverse cone pattern was reported to be without technical problems in 22 procedures (96%). The results of this pilot study indicate that the modified device is safe, technically easy to use, and prolongs the duration of the LSH procedure insignificantly. Long-term effects of the device will be evaluated in a prospective randomized trial.

[Surgical treatment of endometriosis]. / Kirurgisk behandling av endometriose.

BACKGROUND: Endometriosis is defined as a condition with ectopic endometrial tissue outside the uterine cavity, with pain and infertility as the dominating symptoms. The disease affects about 10% of fertile women. We have described the most common manifestations of endometriosis (peritoneal, ovarian and deep endometriosis) with an emphasis on surgical treatment. MATERIAL AND METHODS: This paper is based on literature retrieved from non-systematic searches of Medline and other databases, with an emphasis on randomised and large studies, as well as our own clinical experience and international collaboration. RESULTS AND INTERPRETATION: All gynecological departments should treat peritoneal endometriosis surgically in conjunction with diagnostic laparoscopy. Medical treatment, with amenorrhoea as a goal, relieves pelvic pain, but has no beneficial effect on fertility. ovarian endometriosis should be treated surgically. Upon surgery, the pseudocapsule should be removed, possibly with ablation close to the ovarian hilus to conserve as much functional ovarian tissue as possible. Larger endometriomas- especially kissing ovaries- are often combined with deep endometriosis, and treatment in specialized hospitals should be considered. deep endometriosis must usually be treated surgically. When endometriosis affects the vagina, bowel and/or bladder, surgery is challenging, time-consuming and often involves collaboration with gastrosurgeons and/or urologists. Treatment of these difficult cases should be centralized.

[Interstitial pregnancies--a clinical challenge]. / Interstitielle graviditeter--diagnostikk og behandling.

BACKGROUND: Interstitial pregnancy is a rare type of ectopic pregnancy, with a substantially increased morbidity and mortality. A pregnancy implanted in the interstitial part of the fallopian tube is often more difficult to diagnose and has multiple treatment modalities. The incidence seems to be increasing, but few gynaecological departments have guidelines regarding diagnosis and treatment. Our experience in managing this condition is presented. MATERIAL: Six cases diagnosed from August 2005 to September 2006 are presented. RESULTS AND INTERPRETATION: There are numerous treatment regimens reported for this condition, both surgical and medical. Four different treatments were chosen for the six patients presented. Two patients received methotrexate and four received surgical treatment initially. Methotrexate is an option in haemodynamically stable patients where there is no sign of rupture at the implantation site, but the optimal dosing and mode of administration is unknown. Medical treatment of these patients requires a closer follow-up than that for other ectopic pregnancies. Surgery is indicated in patients who are haemodynamically unstable and in those with a possible rupture. Surgery should also be considered as initial treatment in advanced gestations and in women who are not interested in future childbearing.

Surgery of borderline tumors of the ovary: retrospective comparison of short-term outcome after laparoscopy or laparotomy.

BACKGROUND: Laparoscopic management of borderline ovarian tumors is controversial. OBJECTIVE: To retrospectively compare outcome after surgery by laparoscopy or laparotomy for borderline tumors. METHODS: Ovarian tumors from all women operated at Ullevål University Hospital during a five-year period were re-evaluated histologically. Patients with borderline FIGO (International Federation of Gynaecology and Obstetrics) stage I tumors were retrospectively compared regarding surgery outcome following laparoscopy or laparotomy. RESULTS: Histological re-evaluation revealed only 3 misclassifications in 608 patients. Borderline tumors represented 36% of epithelial ovarian malignancies. The 107 borderline stage I included 52 serous, 53 mucinous, and 2 endometrioid tumors. Thirty-eight patients were operated on primarily by laparoscopy and 69 by laparotomy (including 14 women starting with laparoscopy). In the laparoscopy group, more women were premenopausal (63% versus 35%, p=0.01) and median tumor diameter was smaller (8.6 versus 16.4 cm, p<0.001) as compared to the laparotomy group. When tumor diameter exceeded 10 cm, intraoperative tumor rupture was significantly more frequent during laparoscopy than during laparotomy (p=0.01). Less postoperative complications were seen after laparoscopic operations (p=0.034), but laparoscopic surgeries were less extensive, without hysterectomy, as compared to laparotomy. During the 14-78 months follow-up time, no relapse occurred in either group. After fertility-sparing surgery, there was no statistical significant difference regarding successful pregnancies between the two groups. CONCLUSIONS: Laparoscopic treatment of borderline ovarian tumors is feasible if tumor is of moderate size (diameter below 10 cm), gives fewer complications, and shorter hospital stay. Long-term follow-up of larger materials is needed to determine the ultimate recurrence risk as well as fertility rates.