Multicentric data analysis of the learning curve for laparoscopic Shull's repair of pelvic floor defects.

Introduction: Pelvic organs prolapse remains a significant health concern affecting millions of women worldwide. The use of native tissues to suspend the apex has acquired relevance in urogynecologic surgery. One of the most commonly used procedures performed without mesh is the technique described by Shull, consisting of suturing the vaginal apex to the uterosacral ligaments. The objective of the study is to evaluate the learning curve of laparoscopic Shull's repair for the correction of pelvic floor defects, including the surgery time and surgical outcomes. Materials and methods: This is a retrospective study conducted at the Policlinico G. Martino, University of Messina, Messina, Italy, and Policlinico Vanvitelli, Vanvitelli University, Naples, Italy. All patients affected by grade I-IV POP, consisting of apical prolapse with or without cystocele, and who underwent laparoscopic Shull's technique for prolapse correction were enrolled. The endpoints to estimate the learning curve for the procedure were the percentage of laparoscopic procedures completed, operative time, and the early complication rate. Results: A total of 31 laparoscopic Shull repairs were collected for the study. To evaluate the learning curve of the technique, we divided the 31 cases into three different groups: Procedures 0-10; 11-20; 21-31. The parameter for evaluating technique learning was the operative time. Group 21-31 demonstrated an operative time of 97 min (SD 20), compared with 121 min (SD 23) in group 0-10 and 120 min (SD 13) in group 11-20. A comparison of these means through ANOVA showed a p-value of 0.01 for the entire system, and 0.95 for the comparison between 0 and 10 and 11-20, 0.04 for 0-10 vs. 21-31, and 0.02 between 11 and 20 and 21-31. Conclusions: The rate of surgical improvement in terms of time became effective after an average of 20 procedures. However, the improvement seems to be effective case by case for surgeons skilled in basic endoscopy.

Fetal aortic isthmus Doppler assessment to predict the adverse perinatal outcomes associated with fetal growth restriction: systematic review and meta-analysis.

PURPOSE: Fetal growth restriction (FGR) management and delivery planning is based on a multimodal approach. This meta-analysis aimed to evaluate the prognostic accuracies of the aortic isthmus Doppler to predict adverse perinatal outcomes in singleton pregnancies with FGR. METHODS: PubMed, EMBASE, the Cochrane Library, ClinicalTrials.gov and Google scholar were searched from inception to May 2021, for studies on the prognostic accuracy of anterograde aortic isthmus flow compared with retrograde aortic isthmus flow in singleton pregnancy with FGR. The meta-analysis was registered on PROSPERO and was assessed according to PRISMA and Newcastle-Ottawa Scale. DerSimonian and Laird's random-effect model was used for relative risks, Freeman-Tukey Double Arcsine for pooled estimates and exact method to stabilize variances and CIs. Heterogeneity was quantified using I2 statistics. RESULTS: A total of 2933 articles were identified through the electronic search, of which 6 studies (involving 240 women) were included. The quality evaluation of studies revealed an overall acceptable score for study group selection and comparability and substantial heterogeneity. The risk of perinatal death was significantly greater in fetuses with retrograde Aortic Isthmus blood flow, with a RR of 5.17 (p value 0.00001). Similarly, the stillbirth rate was found to have a RR of 5.39 (p value 0.00001). Respiratory distress syndrome had a RR of 2.64 (p value = 0.03) in the group of fetuses with retrograde Aortic Isthmus blood flow. CONCLUSION: Aortic Isthmus Doppler study may add information for FGR management. However, additional clinical trial are required to assess its applicability in clinical practice.

Hysteroscopic laser ablation of symptomatic uterine fibroids: insights from a prospective study.

OBJECTIVE: This study aimed to evaluate the feasibility and efficacy of in-office hysteroscopic ablation of submucous uterine fibroids using a diode laser. METHOD: A pilot study was conducted between January 2018 and January 2019 in a tertiary care university hospital. Patients with at least one symptomatic, class 0-2 FIGO classification, uterine fibroid ≤7 cm in size were eligible for inclusion. Evaluation of the changes in fibroid size and vascularity was performed using three-dimensional Doppler ultrasonography. Vaporization of the fibroid core was conducted using a 980-1470 nm wavelength diode laser inserted through the hysteroscope's working channel. The primary outcome was evaluation of the fibroid volume before and at 2 months after the procedure. RESULTS: Twenty women were enrolled in the study. At 2-month follow-up, the volume of the fibroids was significantly reduced (51.6 ± 22.5 vs. 33.4 ± 17.1 mm3; p < 0.001). A major reduction of three-dimensional sonographic color Doppler vascularity (observed by the same operator and confirmed by four blind reviewers) was also achieved in 12/20 patients (60%; p = 0.03) while a reported symptom of heavy menstrual bleeding decreased from 18/20 (90%) to 2/18 (10%; p < 0.01). CONCLUSION: Hysteroscopic laser ablation represents a feasible and effective alternative for treating women with symptomatic submucous fibroids in the office setting. Further studies with larger sample size and longer follow-up periods are needed to validate this promising technique.Key messageThis pilot study shows that in-office hysteroscopic laser ablation (HLA) could be a feasible alternative to treat symptomatic submucous uterine fibroids by coagulating their core, reducing their size and vascularization.

Influence of uterine manipulator on oncological outcome in minimally invasive surgery of endometrial cancer: A systematic review and meta-analysis.

AIM: The endoscopic approach for early-stage endometrial cancer (EC) treatment is considered gold standard. Some authors expressed their concern regarding uterine manipulator (UM) as a risk factor for tumor spillage and dissemination allowing peritoneal or lympho-vascular spaces invasion (LVSI). This meta-analysis aimed to evaluate the effect of UM on the presence of LVSI, recurrence rate and presence of atypical or malignant peritoneal cytology in patients with endometrial cancer. METHODS: We searched electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO, Google Scholar, and ClinicalTrials.gov. The pooled results were used to evaluate the association between the use of UM and oncological outcomes. This systematic review was reported according to PRISMA statement 2020. Statistical meta-analysis was performed using Review Manager software. RESULTS: This systematic review included 18 studies (3 prospective studies, 13 retrospective studies, and 2 RCT). The pooled results showed no significant difference (RR: 0.86, 95% CI, 0.69 to 1.08) in the incidence of LVSI between manipulated hysterectomy and total abdominal hysterectomy (TAH) and between UM group and non-UM group in minimally invasive surgery (RR: 1.18, 95% CI, 0.76 to 1.85), no significant difference in the rate of recurrence (RR: 1.11, 95% CI, 0.71 to 1.74), in the incidence of positive peritoneal cytology between manipulated and non-manipulated hysterectomies in minimally invasive surgery (RR: 1.89, 95% CI, 0.74 to 4.83) and before and after the use of uterine manipulator (RR: 1.21, 95% CI, 0.68 to 2.16). We found a positive association between malignant cytology and hysterectomies in which a uterine manipulator had been used in a sub-group analysis where LH/LAVH were compared to TAH. (RR = 2.26, 95% CI, 1.08-4.71. P = 0.03). CONCLUSIONS: This meta-analysis supports that the use of uterine manipulator for minimally invasive treatment of endometrial cancer does not increase the rate of recurrence and LVSI. Therefore, the opportunity of any other studies on its use in endometrial cancer women should be questioned.

Hysteroscopic treatment of submucosal fibroids in perimenopausal women: when, why, and how?

Uterine fibroids are a common finding in premenopausal women. They considerably reduce the quality of life by provoking abnormal uterine bleeding and consequent anemia and pelvic pain. Over the past 20 years, radical surgery (hysterectomy) for symptomatic fibroids has been partially replaced with minimally invasive surgical procedures that spare the uterus, with lower costs and reduced morbidity. Outpatient and inpatient operative hysteroscopy have been validated as safe and effective minimally invasive treatment options for both submucosal and intramural fibroids. In such a scenario, several technological innovations and the possibility of pharmacological pretreatment have enhanced the hysteroscopic approach. However, the counseling and treatment of perimenopausal women remain a challenge for the gynecologist. The main purpose of this review is to provide an updated guide to the management of submucosal fibroids in perimenopausal women, depicting how, when, and why hysteroscopic treatment is a valuable choice to eliminate symptoms and satisfy the patient's wish to improve their overall quality of life.

Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review.

In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.