Bilateral salpingectomy as an option of permanent contraception at time of caesarean section: A survey of practice.

BACKGROUND: Opportunistic bilateral salpingectomy during benign gynaecologic surgery is advocated as a risk-reducing strategy due to the inverse association of epithelial ovarian cancers observed in epidemiological studies in a low-risk setting. Currently, no formal guidance exists for permanent surgical contraception at time of caesarean section in Australia. AIMS: Our aim was to survey Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) regarding bilateral salpingectomy compared to other procedures offered for permanent contraception at the time of caesarean section. MATERIALS AND METHODS: An online survey was utilised to collect clinician demographics, opinions, barriers, and justifications in regard to options of permanent surgical contraception at time of caesarean section. RESULTS: Bilateral salpingectomy was identified as the most effective method of permanent contraception at time of caesarean section. However, only 62% of respondents offer the procedure as a method of permanent contraception. The two most common reasons for clinicians to offer bilateral salpingectomy at time of caesarean section were evidence suggesting a link between the fallopian tube and gynaecological cancer (80%) and efficacy as a permanent form of contraception (16%). The primary barrier identified by 51% of respondents was perceived increased risk of surgical complications, followed by reasoning that it would not allow the possibility of future tubal reversal. CONCLUSION: This study identifies diverse opinions on surgical approach to permanent contraception at time of caesarean section and offered by clinicians of RANZCOG. Further research is required to establish safety profiles and short- and long-term risks of bilateral salpingectomy.

Inadvertent cystotomy at laparoscopic hysterectomy--Sydney West Advanced Pelvic Surgery (SWAPS) Unit January 2001 to June 2009.

OBJECTIVE: To review the rate of inadvertent cystotomy during laparoscopic hysterectomy performed by the Sydney West Advanced Pelvic Surgery Unit (SWAPS). To compare this rate with other published data. To identify the risk factors for bladder injury at laparoscopic hysterectomy and to review the management and outcome following such injury. METHOD: This was a retrospective observational study. All hysterectomies where the SWAPS clinical fellow was involved were included. The study period was from January 2001 to June 2009. Simple statistical formulae were used to analyse data in this study. RESULTS: There were 1223 hysterectomies performed during this period. Eighty-one percent of these were performed laparoscopically. There were 14 (1.1%) bladder injuries reported during this period. All bladder injuries occurred in the laparoscopic group. The majority were managed by laparoscopic repair or conservative management (86%). Two cases (14%) were converted to laparotomy. There were no short- or long-term sequelae. With increasing experience, a fall in the incidence of inadvertent cystotomy was noted during the study period. CONCLUSION: Inadvertent cystotomy is a recognised complication at hysterectomy. The rate in the SWAPS unit is comparable to that of other published series. Overall, there has been a decline in the rate of bladder injury, which appears attributable to more experience gained with an acquisition of increased skill levels and improved techniques.

Is there a role for use of levonorgestrel intrauterine system in women with chronic pelvic pain?

This review focuses on the available evidence for the use of levonorgestrel (LNG) intrauterine system (IUS) in women with chronic pelvic pain (CPP). We have searched MEDLINE, Pubmed, Embase, and the Cochrane electronic library with the keywords "chronic pelvic pain," "endometriosis," "Mirena IUS," and "levonorgestrel IUS" from 1956 through April 2008. Review articles, randomized trials, prospective cohort studies, and retrospective studies were analyzed and the available evidence included in this review. Case reports were not included in the analysis. Laparoscopic surgery was shown to be useful in clarifying the underlying cause in women with CPP, with 70% having abnormal findings at laparoscopy. Endometriosis, particularly deep infiltrating endometriosis, is found in 40% to 60% of women with dysmenorrhea. Laparoscopic excision of endometriosis was shown to be associated with improvement of symptoms in 70% to 80% of women. Up to 36% need repeated surgery during a 5-year period after the primary procedure. The absolute reduction in recurrence of dysmenorrhea in women who also had the LNG IUS inserted at the time of surgery was 35% (95% CI 9%-61%). The LNG IUS was shown also to reduce the blood flow in the uterine artery and the subendometrial spiral arteries. This may explain the reduction in primary dysmenorrhea in women who have the LNG IUS inserted. Insertion of the LNG IUS at the time of primary laparoscopic surgery in women with CPP caused by endometriosis has the potential to reduce postoperative pain scores. This medical approach is also a promising alternative to repeated laparoscopic surgery especially in those women who have continuing symptoms after laparoscopic excision of endometriosis. This nonsurgical option could potentially reduce the rate of repeated laparoscopies in women with CPP and, in turn, reduce overall intervention rates. Although growing evidence exists that the LNG IUS can be useful in this group of women, large randomized controlled studies are needed to validate its benefits in day-to-day practice.