The Evolution of Transvaginal Robot-Assisted Surgery in Gynecology.

Laparoscopy has advanced over the last three decades with residency training programs focusing on trans-abdominal laparoscopic techniques whether conventional or robotic. Despite attempts over many years to adopt vaginal surgery as the preferred method of hysterectomy, traditional vaginal surgery has largely fallen out of favor. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has gained popularity with patients and promises to provide an attractive option, but the surgical skills of many gynecologists have limited its widespread adoption. We explore the use of robot-assisted vNOTES (RA-vNOTES), which offers improved ergonomics, visualization, and wristed instruments for more precise surgery. Robotic vNOTES, was originally performed in Taiwan by Dr. Chyi-Long Lee in 2014.1 Our center has used the robotic vaginal approach for hysterectomy, myomectomy, sacrocolpopexy, adnexal surgery, endometriosis excision, and more. We have also shown feasibility in performing surgery on patients with a completely obliterated posterior cul-de-sac, long been thought to be a contraindication for the transvaginal approach. Enhancements have been made to improve safety and efficiency, such as the use of indocyanine green to visualize the ureters. There are some limitations on instrument maneuverability and reach with the current da Vinci® Xi (Intuitive Surgical, Sunnyvale, California) platform. However, with over 300 cases logged in our center, these limitations may be overcome with the new da Vinci® SP (Intuitive Surgical, Sunnyvale, California). We are eager to share our experience and hope that more gynecologic surgeons will choose this innovative approach for the benefit of our patients.

Robotic Single-Site Sacrocolpopexy with Retroperitoneal Tunneling.

INTRODUCTION: This series of cases was an investigation of the safety and feasibility of robotic laparoendoscopic single-site surgery (R-LESS) as a method of performing sacrocolpopexy. CASE PRESENTATION: This is a retrospective series of 15 cases of R-LESS sacrocolpopexy with the V-Loc (Medtronic, Minneapolis, Minnesota, USA) suture and a retroperitoneal tunneling technique performed by a single surgeon, combined with a literature review. Patient demographic information and perioperative data were analyzed. The standard robotic sacrocolpopexy steps were followed, but the surgeon used a combined technique of V-Loc suture and retroperitoneal tunneling to simplify the procedure. No additional ports were necessary in any of the patients. MANAGEMENT AND OUTCOME: Using the pelvic organ prolapse quantification (POP-Q) scoring method, the mean preoperative C-point of the 15 patients was +1.16 compared to the mean immediate postoperative C-point, which was -5.5. The mean total sacrocolpopexy time was 74.7 (range, 50-99) minutes and mean mesh anchoring time was 22.60 ± 3.85 minutes. The mean sacral promontory fixation and tunneling and mesh position times were 11.87 ± 3.02 and 5.80 ± 2.14 minutes, respectively. All 15 cases were performed without perioperative or long-term complications. DISCUSSION: R-LESS in combination with the V-Loc suture and the retroperitoneal tunneling technique can be safely and feasibly performed, especially in sacrocolpopexy and, potentially, in other POP surgeries. With adequate and systematic training, surgeons can acquire the necessary skills to perform this complex surgical procedure.

Development and history of morcellators.

PURPOSE OF REVIEW: Controversy exists surrounding extraction of tissue in gynecologic surgery using morcellators following cases of disseminated uterine cancers discovered after the use of electromechanical morcellators. This chapter traces the history of tissue extraction in gynecology and reviews the evolving scientific data and opinions regarding the future of morcellation. RECENT FINDINGS: Since the initial Food and Drug Administration warning about morcellation in 2014, subsequent studies do not support the Food and Drug Administration's high incidence of occult uterine cancer. Current research continues, focusing on methods of contained tissue morcellation, both laparoscopically and vaginally. SUMMARY: Minimally invasive surgical techniques have revolutionized gynecology, drastically reducing the need for open procedures. To maximize patient safety while preserving the rapid recovery and low morbidity of laparoscopic and vaginal approaches, optimal methods of tissue extraction need to be developed and promulgated.

Assessing the risk of laparoscopic morcellation of occult uterine sarcomas during hysterectomy and myomectomy: Literature review and the ISGE recommendations.

OBJECTIVE: This project of the International Society for Gynecologic Endoscopy (ISGE) had the objective to review the literature and provide recommendations on the occult sarcoma risk assessment in patients who are candidates for minimally invasive gynecological surgery involving intra-abdominal electromechanical tissue morcellation. STUDY DESIGN: The ISGE Task Force for Estimation of the Risk in Endoscopic Morcellation initially defined key topics and clinical questions which may guide a comprehensive preoperative patient assessment. A literature search within the Medline/PubMed and Cochrane Database was carried out using keywords "morcellation", "uterine fibroids", "uterine sarcoma", "myomectomy" and "hysterectomy". Relevant publications (original studies, meta-analyses and previous reviews), written in English and published until May 30th, 2017, were selected and analyzed. Previously emitted statements of 12 recognized professional societies or government institutions and their supporting literature were also studied. For each topic/clinical question, the available information was graded by the level of evidence. The ISGE recommendations were established in accordance with the evidence quality. RESULTS: In the light of available information, 9 recommendations on preoperative clinical, laboratorial and imaging evaluation of the candidates for intracorporeal uterus/leiomyoma morcellation were formulated, mainly based on consensus and expert opinions. There is a lack of high-quality evidence, which does not allow the establishment of strong recommendations. CONCLUSION: Electromechanical tissue morcellation may be used in gynecological patients who are considered "low risk" upon appropriate preoperative evaluation; however, further studies and prospective data collection are greatly needed to improve sarcoma risk assessment in women with presumed uterine leiomyomas.

Hand-Assisted Laparoscopic Hysterectomy for Large Uteri.

STUDY OBJECTIVE: To determine whether laparoscopic hand-assisted hysterectomy for a large uterus had different surgical outcomes compared with traditional open hysterectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Academic tertiary care hospital. PATIENTS: Women who had undergone laparoscopic hand-assisted hysterectomy for a large uterus were included as the hand-assist group. The control group comprised patients with similar final specimen weight (>1 kg), characteristics (body mass index, age), and surgical history, who underwent open hysterectomy for a large uterus. INTERVENTION: Laparoscopic hysterectomy using a hand-assist port for laparoscopic portion of the case. RESULTS: The 2 groups were similar in terms of specimen weight (median, 1765.5 g for hand-assist vs 1215.50 g for controls; p = .29). In univariate analysis, the median operating time was longer in the hand-assist group compared with controls (241.5 minutes vs 185.0 minutes; p = .002), whereas median length of stay was shorter in the hand-assist group (1.0 day vs 3.0 days; p < .0001). These differences remained significant after adjustment for potential confounders in multivariable analysis (p < .05). There was no difference in estimated blood loss (p > .05) between the 2 groups, although the change in hemoglobin was less in the hand-assist group compared with controls in multivariable analysis (adjusted mean.74 vs. 1.8; p = .04). Complications were divided into intraoperative complications (transfusion, consultation, bowel injury, bladder injury, ureter injury, and other), hospital postoperative complications (reoperation, transfusion, slow return of bowel function, ileus, poor pain control, fever of unknown origin, venous thromboembolism, pneumonia, and neuropathy), and complications after discharge (readmission, wound infection). The 2 groups had a similar low rate of complications (p > .05). CONCLUSION: Laparoscopic hand-assist hysterectomy is a feasible alternative to open hysterectomy in patients with a large uterus.

Compensation among graduated fellowship in minimally invasive gynecologic surgery fellows.

STUDY OBJECTIVE: The Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) is a postresidency fellowship developed with the mission to train the next generation of minimally invasive gynecologic surgeons. The need for surgeons trained in this field has increased, yet there remains a paucity of information regarding the compensation of these specialized surgeons. DESIGN: A survey was sent via e-mail to FMIGS graduates (N = 221) using an online survey tool; it was sent twice more to increase the response rate between July and December 2013. The survey collected information on current and starting salaries and benefits as well as academic rank, location, practice type, and practice breadth. Comparisons were analyzed using multivariable linear regression models (Canadian Task Force Classification II-2). SETTING: E-mail-based survey. PATIENTS: Graduates of the FMIGS. INTERVENTIONS: A single survey sent 3 times. MEASUREMENTS AND MAIN RESULTS: Of 221 graduates surveyed, 164 responded (response rate = 74%). Sixty-one percent of respondents (n = 100) were from academic institutions, and the remainder were from private practice (n = 64). Of all respondents, 27 (16.5%) reported less than 1 year of postfellowship experience and had a median starting salary of $216 399 (range, $106 834-$542 930). Survey respondents were on average 3.3 years (range, 0-14) out of fellowship with a median salary of $238 198 (range, $108 200-$993 765). Academic surgeons (average experience = 3.4 years) earned $208 743 (range, $106 834-$542 930) compared with private practice surgeons (average experience = 3.2 years) who earned $233 020 (range, $115 000-$454 448). CONCLUSION: Salaries and compensation benefits of graduates of the FMIGS are varied. This information is very relevant to those attempting to hire or become employed as gynecologic surgical specialists.

Trends in reported resident surgical experience in hysterectomy.

STUDY OBJECTIVE: To compare differences in trends in reported surgical experience of residents in obstetrics and gynecology in the United States insofar as abdominal, vaginal, and laparoscopic hysterectomy. DESIGN: Retrospective analysis of the national case log reports from the Accreditation Council for Graduate Medical Education (ACGME) for obstetrics and gynecology cases logged as "surgeon" from 2002 to 2012 (Canadian Task Force classification III). SETTING: AGCME-accredited residency programs in obstetrics and gynecology. PARTICIPANTS: Eleven thousand five hundred and eight graduating residents in obstetrics and gynecology (n = 11 508). MEASUREMENTS AND MAIN RESULTS: Since 2008, when the ACGME began reporting the 4-year cumulative hysterectomy case load statistics for graduating residents in obstetrics and gynecology, there has been no significant change in the mean (SD) number of hysterectomies performed by residents from 118.1 (38.0) cases in 2008-2009 to 116.1 (31.0) cases in 2011-2012 (p = .16; 95% confidence interval [CI], -0.78 to 4.78). During the past decade, however, the total number of reported abdominal hysterectomies consistently decreased from 89.1 (34.2) cases in 2002-2003 to 59.1 (21.0) cases in 2011-2012 (28% decrease; p <.001; 95% CI, 27.7-32.3). The number of vaginal hysterectomies also trended down from 34.9 (19.2) cases to 19.4 (9.0) cases (40% decrease; p <.001; 95% CI, 14.3-16.7). The ACGME did not report the number of laparoscopic hysterectomies performed by residents until 2008-2009, when residents reported performing 23.4 (17.0) cases. From 2008 to 2012, this number increased to 38.5 (20.0) cases (72% increase; p <.001; 95% CI, 13.6-16.6). The proportion of reported laparoscopic hysterectomies performed with robotic assistance was not separately reported. CONCLUSIONS: Although the overall number of hysterectomies reported by residents has remained stable since 2008, the predominant modes of hysterectomy during the past decade have changed substantially, with laparoscopic hysterectomy comprising an increasingly large proportion of resident experience. As laparoscopic hysterectomy has become more common, reported cases of abdominal and vaginal hysterectomies have decreased. Additional statistics on the percentage of laparoscopic hysterectomies performed using robotic assistance would be valuable to additionally analyze the effect of this new technology on resident training.

Magnetic resonance imaging-guided volumetric ablation of symptomatic leiomyomata: correlation of imaging with histology.

PURPOSE: To describe the preliminary safety and accuracy of a magnetic resonance (MR) imaging-guided high-intensity-focused ultrasound (HIFU) system employing new technical developments, including ablation control via volumetric thermal feedback, for the treatment of uterine leiomyomata with histopathologic correlation. MATERIALS AND METHODS: In this phase I clinical trial, 11 women underwent MR-guided HIFU ablation (Sonalleve 1.5T; Philips Medical Systems, Vantaa, Finland), followed by hysterectomy within 30 days. Adverse events, imaging findings, and pathologic confirmation of ablation were assessed. The relationship between MR imaging findings, thermal dose estimates, and pathology and HIFU spatial accuracy were assessed using Bland-Altman analyses and intraclass correlations. RESULTS: There were 12 leiomyomata treated. No serious adverse events were observed. Two subjects decided against having hysterectomy and withdrew from the study before surgery. Of 11 women, 9 underwent hysterectomy; all leiomyomata demonstrated treatment in the expected location. A mean ablation volume of 6.92 cm(3) ± 10.7 was observed at histopathologic examination. No significant differences between MR imaging nonperfused volumes, thermal dose estimates, and histopathology ablation volumes were observed (P > .05). Mean misregistration values perpendicular to the ultrasound beam axis were 0.8 mm ± 1.2 in feet-head direction and 0.1 mm ± 1.0 in and left-right direction and -0.7 mm ± 3.1 along the axis. CONCLUSIONS: Safe, accurate ablation of uterine leiomyomata was achieved with an MR-guided HIFU system with novel treatment monitoring capabilities, including ablation control via volumetric thermal feedback.

Adverse events due to suspected nickel hypersensitivity in patients with essure micro-inserts.

STUDY OBJECTIVE: To review reported adverse events associated with suspected nickel hypersensitivity and subsequent clinical outcomes in patients with Essure implants and to evaluate the correlation of nickel allergy-related adverse events with positive results of nickel patch testing. DESIGN: Case series (Canadian Task Force classification II-3). MEASUREMENTS AND MAIN RESULTS: Reports of suspected nickel hypersensitivity reported from 2001 through July 21, 2010, were collected from de-identified data obtained from the MAUDE (Manufacturer and User Facility Device Experience) database and reports to the manufacturer directly from treating physicians, and published results for the 650 patients in the Phase II and Pivotal trials. Clinical outcomes and symptom resolution, when available, were obtained from de-identified information provided by the treating physicians to the manufacturer. Patients were not directly contacted for the study, and patient files were not reviewed. Patch testing was performed at the discretion of the treating physicians. Results were reported as positive or negative, without mention of the method or brand of patch testing used. CONCLUSION: Even considering the possibility of underreporting by several orders of magnitude, the reported incidence of adverse events suspected to be related to nickel hypersensitivity in patients with Essure micro-inserts is extremely small (0.01%). The incidence of confirmed nickel reactions is even smaller. This very low incidence of clinical reactions is consistent with data from other nickel-containing implantable devices and is reassuring, raising the question of whether nickel reactions are clinically relevant in the use of nitinol-containing micro-inserts for hysteroscopic sterilization.

The effect of a gynecologist-interventional radiologist relationship on selection of treatment modality for the patient with uterine myoma.

BACKGROUND: On the basis of consistent published scientific evidence, the American College of Obstetricians and Gynecologists has given uterine artery embolization (UAE) a level A recommendation as a viable alternative treatment for uterine myomas, describing it as a safe and effective option for appropriately selected women who wish to retain their uteri. Despite the growth of favorable clinical outcome information, many gynecologists do not routinely offer UAE as an alternative to abdominal hysterectomy or abdominal myomectomy. The percentage of laparoscopic hysterectomies in the United States remains less than 20%, reflecting the reluctance or inability of gynecologic surgeons to perform other minimally invasive procedures such as hysteroscopic myomectomy, laparoscopic myomectomy, laparoscopic hysterectomy, or even vaginal hysterectomy. Of great significance, many patients do not wish to have any kind of surgery, no matter how "minimally invasive." As a result, patients seeking less invasive treatments may bypass the gynecologist and be referred directly to an interventional radiologist by their primary care physician, or they may self-refer. Little has been published on the referral relationship between gynecologists and the interventional radiologist who performs uterine artery embolization. The absence of a structured routine referral relationship causes some women to undergo treatments that potentially are not aligned with all of her treatment desires. This study was undertaken to gain insight into the interventional radiologist-gynecologist dynamic and the benefit to patients who are informed of all of their options for the treatment of myomas. STUDY OBJECTIVES: Investigate the course of myoma treatment in a cohort of patients either self-referred to an interventional radiologist or referred to the interventional radiologist by their gynecologist. Determine the effect of a cooperative referral network of interventional radiologists and gynecologists that informs patients about the options of UAE and minimally invasive surgical alternatives on the choice of myoma treatment. STUDY DESIGN: Prospective data acquisition of patient referral source, UAE evaluation, patient decision on treatment options, and continued follow-up with a network gynecologist. SETTING: Hospital-based interventional radiologist and gynecologist both practicing in a large urban teaching setting. PATIENTS: A total of 226 women, representing 73% of women presenting to an interventional radiologist in 2007 seeking UAE for symptomatic myomas. One hundred thirty-eight of these patients were referred to the interventional radiologist by a gynecologist, and 88 were self-referred. Patient outcome relative to referral was traced with 76 patients in the myoma surgery group treated from 2007-2008 by a gynecologist in the referral network. INTERVENTIONS: Evaluation for suitability for UAE procedure, followed either by UAE procedure with return to referring gynecologist for follow-up, return to referring gynecologist for treatment, or referral to another gynecologist for minimally invasive surgical management when the primary gynecologist is unable to perform alternative treatment. MEASUREMENTS AND MAIN RESULTS: All patients in the study initially evaluated by the interventional radiologist were referred to a gynecologist. Overall, 62% of patients were candidates for UAE, and 38% underwent the procedure during the study period. Patients who did not receive UAE were returned to the referring gynecologist for further evaluation and treatment. Patients who underwent UAE were referred to a gynecologist for ongoing care. In all, 70% of self-referred patients and 92% of gynecologist-referred patients expressed satisfaction with their original gynecologist and were referred back to that physician. Patients who did not have a gynecologist or who were dissatisfied with their original gynecologist were referred to a network gynecologist for continued gynecologic care. In our study 26 self-referred women were sent as new patients to gynecologists in the interventional radiologist's referral network, resulting in a 119% return on the original 138 gynecologist-to-interventional radiologist-referred patients. Among the 8% of gynecologist-referred women who switched to a different gynecologist within the referral network, the primary reasons for dissatisfaction were the gynecologist's failure to fully disclose treatment options or offer desired minimally invasive procedures. On follow-up with a network gynecologist, 8 newly referred patients underwent myoma surgery, and 8 newly referred patients continued to be seen by that gynecologist. Four patients referred to the gynecologist for treatment were originally referred by the gynecologist to the interventional radiologist for UAE evaluation. Ten patients switched from their named gynecologist to a different gynecologist willing to disclose all treatment options for uterine myomas and able to provide minimally invasive surgical treatment as medically indicated. Of the 10 women who switched to this network gynecologist, 8 underwent myoma surgery. CONCLUSIONS: Establishing a referral relationship with an interventional radiologist for comprehensive uterine myoma treatment supports a trusting, collaborative, long-term, noncompetitive "win-win" relationship between the gynecologist and radiologist, meets the patient's desire for full disclosure of all myoma treatment options, improves the patient's overall medical care and physician/patient experience, and has been demonstrated to improve patient flow to a gynecologist practice. With the guidelines established in this study, no patients were inappropriately left to the gynecologist for post-UAE care. The authors acknowledge that this dynamic is dependent on the individual interventional radiologist and their relationships and open communication with the gynecologist. Finally, the study revealed that failure to fully disclose alternative treatment options, or offer minimally invasive surgical techniques may result in a loss of patients due to patient dissatisfaction.

Adenomyosis in the adolescent population: a case report and review of the literature.

BACKGROUND: This report presents a rare cause of dysmenorrhea in the adolescent female and the usefulness of magnetic resonance imaging (MRI) with T2 weighted sequence in the identification of adenomyosis. CASE: Two adolescents who presented with persistent pelvic pain in the absence of outflow tract obstruction or biopsy confirmed endometriosis had MRI-findings consistent with adenomyosis. SUMMARY AND CONCLUSION: In the adolescent female presenting with persistent dysmenorrhea, a diagnosis of adenomyosis is rare but should remain a possibility as one considers the differential diagnosis.

Innovations in contraception: a review.

New forms of contraception have been developed to improve the safety and tolerability of contraceptive methods without compromising efficacy. The newest developments in contraception including low and ultra-low doses of estrogen, less-androgenic 19 nor-testosterone progestins, and the nonsteroidal progestin drospirenone, the Quick Start method to improve compliance of oral contraceptives, and the contraceptive transdermal patch, the vaginal estrogen-progestin ring, the levonorgestrel intrauterine system, and the hysteroscopic transcervical sterilization techniques are discussed.

A large pelvic mass in an adolescent patient with granulomatous nephritis: case report and discussion of treatment challenges.

BACKGROUND: An adolescent patient with granulomatous nephritis presents with a large, solid pelvic mass. Pertinent differential diagnosis for this solid ovarian mass as well as discussion regarding treatment challenges for this patient is delineated. CASE: A 15-year-old female presented to her primary care doctor with fatigue and syncope. Initial laboratory workup revealed a hemoglobin of 7.9 g/dL, an elevated creatinine of 3.5 mmol/L, and an elevated ionized calcium of 13.1 mg/dL. Renal biopsy revealed diffuse non-caseating granulomatous nephritis with rare acid-fast bacilli. Renal ultrasound first noted a pelvic mass. Pelvic ultrasound revealed a 15.0 x 8.4 x 12.2 cm mass, characterized as mostly solid with diffuse spaces, in the location of the right ovary. CA-125 and the lactate dehydrogenase (LDH) tumor markers were elevated. The patient underwent a left salpingo-oophorectomy and pelvic staging. Intra-operative frozen section revealed a dysgerminoma. Final pathology report revealed extensive non-caseating granulomatous inflammation within the ovarian tumor. Special stains showed no evidence of acid-fast organisms. CONCLUSION: Dysgerminoma is the most likely solid ovarian tumor in a patient of this age. In light of her initial renal biopsy with acid-fast bacilli, pelvic tuberculosis needs to be considered. Due to its extreme rarity, sarcoidosis of her genital tract should be lower on the differential, yet this patient presented with pathology consistent with non-caseating granulomas suggesting this diagnosis. Once ovarian dysgerminoma was diagnosed, the possibility that this patient's renal findings may represent paraneoplastic syndrome also becomes important for her treatment.

A case of autoimmune progesterone dermatitis in an adolescent female.

BACKGROUND: Progesterone-induced dermatitis is a rare disorder. It typically occurs in females due to an autoimmune phenomenon to endogenous progesterone production, but can also be caused by exogenous intake of a synthetic progestin. Here, we present a case of autoimmune progesterone dermatitis (AIPD) seen in an adolescent female. CASE: The patient is a 15-year-old Caucasian female with no significant past medical history and no prior exogenous hormone use, who presented to her primary care physician complaining of cyclic skin eruptions. She noted that her dermatologic symptoms occurred monthly, just prior to her menses. An intradermal skin test using 0.1 cc of progesterone was performed. The patient immediately developed a wheal, confirming the diagnosis of AIPD. The patient was begun on a continuous regimen of an oral contraceptive pill with 30 micrograms of ethinyl estradiol and 0.15 mg of levonorgestrel. The skin eruptions have not returned since the initiation of this therapy. CONCLUSION: Autoimmune progesterone dermatitis manifests via the occurrence of cyclic skin eruptions. Women with the disorder commonly present with dermatologic lesions in the luteal phase of the menstrual cycle. Diagnosis of AIPD is confirmed by performing a skin allergen test using progesterone. Due to its rarity, AIPD should be considered a diagnosis of exclusion. In cases believed to be due to an endogenous production of progesterone, several methods of therapy have been attempted. The ultimate goal of therapy is the suppression of ovulation, which will prevent endogenous hormone production as progesterone is only produced in ovulatory cycles. Currently, the first-line choice of therapy is a combination oral contraceptive. If this treatment is ineffective, patients have been treated with danazol, gonadotropin releasing hormone analogs, tamoxifen, and oophorectomy with varying success.

Does a minimally invasive surgery fellowship impact surgical experience among gynecology residents?

STUDY OBJECTIVE: To examine the impact of a minimally invasive surgery (MIS) fellowship on resident experience and to survey the general attitude toward effects of fellowship programs on resident education. DESIGN: Survey (Canadian Task Force classification III). SETTING: An accredited obstetrics and gynecology program in the United States. SUBJECTS: Obstetrics and gynecology residents. INTERVENTION: Residents received a survey regarding the potential impact of a MIS surgery fellowship on resident experience. MEASUREMENTS AND MAIN RESULTS: One year after creation of a MIS fellowship at our institution, we conducted an anonymous survey among residents. We also compared total number of surgical procedures and laparoscopic procedures performed before and after the fellowship commenced. We had a response rate of 70%. The overall impact of the newly established fellowship was regarded as positive. The median approval rating of endoscopic training before and after institution of the fellowship was 3.0 and 4.0, respectively (p < .001). There were no statistically significant changes in caseload between the two periods. CONCLUSION: A fellowship in MIS at an academic institution does not detract from resident experience in gynecologic surgery, with most residents viewing the fellowship positively.

Management of menstrual problems and contraception in adolescents with mental retardation: a medical, legal, and ethical review with new suggested guidelines.

The controversial history of the reproductive rights of the mentally retarded has led to the formulation of laws in the past century designed to protect women from forced sterilization. Significantly, however, in their official ethical guidelines, The American College of Obstetricians and Gynecologists states that "sterilization should not be denied to individuals simply because they also may be vulnerable to coercion" (Int J Gynaecol Obstet 1999; 65:317). Recent advances in medical and surgical methods of contraception and control of menstrual abnormalities have led to a re-evaluation of the management of adolescents with special needs. Physicians, the courts, parents, and caretakers need to be aware of the latest medical and surgical options available, the current applicable laws in each state if such exist, and the ethical guidelines to determine what treatment option is in the best interests of the patient. This review examines the history of the sterilization of the mentally retarded, the latest surgical and pharmacologic treatments available, and the current legal environment and proposes an algorithm to facilitate the management of menstrual hygiene and contraception.