Association of cesarean scar defect with abnormal uterine bleeding: The results of a prospective study.

OBJECTIVE: To evaluate the relationship between cesarean scar defect and abnormal uterine bleeding at one year after cesarean section (CS). STUDY DESIGN: A prospective observational cohort study was conducted in 401 women who delivered by CS between January 2016 and January 2017. Women were screened for isthmocele with sonohysterography six months after CS and followed by electronic questionnaires at 12, 13 and 14 months after CS. The main outcome measure was the prevalence of postmenstrual spotting. Secondary outcome measures were the duration of menstrual bleeding, prevalence of postcoital bleeding, dyspareunia or dysmenorrhea, usage of painkillers, and absence from work or other activities. RESULTS: The response rate was 88 %. In the isthmocele group, the prevalence of postmenstrual spotting was 20.0 % compared to 8.3 % in women without isthmocele (OR 2.75 [95 % CI 1.39-5.44]; P = 0.004). Additionally, women with isthmocele reported more frequently postcoital bleeding (8.3 % vs. 2.4 %; OR 3.73 [95 % CI 1.18-11.83]; P = 0.026). The prevalence of postmenstrual spotting was even higher in the subgroup of large isthmoceles, (25.9 % vs. 9.5 %; (OR 3.34 [95 % CI 1.72-6.49]; P < 0.001). CONCLUSION: The prevalence of postmenstrual spotting among isthmocele patients was 20.0 %. Additionally, postmenstrual spotting was associated with the presence of isthmocele inquired at 1 year after CS.

Cesarean scar defect: a prospective study on risk factors.

BACKGROUND: Cesarean scar defect (isthmocele) is a known complication after cesarean delivery. It has become more common due to a rising cesarean delivery rate. Isthmocele has been associated with various gynecological and obstetric problems such as uterine rupture, cesarean scar pregnancy, and bleeding disorders. OBJECTIVE: We sought to prospectively investigate factors associated with the risk for isthmocele assessed by sonohysterography. STUDY DESIGN: A prospective observational cohort study was conducted in 401 nonpregnant women who were recruited within 3 days of cesarean delivery. Women were evaluated with sonohysterography 6 months after cesarean delivery to detect a possible isthmocele. The ultrasonographer was blinded to any clinical information. The main outcome measure was the presence of isthmocele. Type of surgery (elective vs emergency), maternal background variables, and factors related to pregnancy, labor, and postoperative recovery were analyzed in relation to isthmocele. A logistic regression model was used to assess independent risk factors from univariate analysis. RESULTS: In all, 371 women were examined with sonohysterography resulting in a follow-up rate of 92.5%. The prevalence of isthmocele was 45.6%. Independent risk factors for isthmocele development were a history of gestational diabetes (odds ratio, 1.73; 95% confidence interval, 1.02-2.92; P = .042), previous cesarean delivery (odds ratio, 3.14; 95% confidence interval, 1.90-5.17; P < .001), and advanced maternal body mass index (odds ratio, 1.06; 95% confidence interval, 1.01-1.11; P = .012). Every additional unit of body mass index increased the risk of isthmocele by 6%. In the subgroup of emergency cesarean delivery, longer duration of active labor increased the risk for isthmocele (odds ratio, 1.06; 95% confidence interval, 1.01-1.11; P = .032). There was no statistically significant difference in prevalence between the groups of elective and emergency cesarean delivery (P = .898). CONCLUSION: Based on sonohysterographic examination, maternal body mass index, gestational diabetes, and previous cesarean deliveries are associated with an increased risk for incomplete healing of the uterine incision.

Robotic-Assisted Infrarenal Para-aortic Lymphadenectomy in Gynecological Cancers: Technique and Surgical Outcomes.

OBJECTIVE: Mini-invasive surgery has essentially replaced open laparotomy in surgery for endometrial and cervical carcinoma. Of the procedures needed for a complete staging, especially para-aortic lymphadenectomy (PALND) is challenging to perform. The present study was undertaken to investigate the technical and surgical outcomes of robotic-assisted PALND for gynecological cancers in the setting of a tertiary university hospital in Finland. METHODS: This was a retrospective chart review of 283 robotic-assisted para-aortic lymphadenectomies using the single-docking transperitoneal technique performed at the Department of Obstetrics and Gynecology of Tampere University Hospital, in 2009-2016. The primary outcome measure was the extent of the operation in terms of the height, that is, how often the level cranial to the inferior mesenteric artery (IMA) was achieved. The secondary outcome measures included operation time and surgical outcome. RESULTS: The majority of operations (n = 239 [84.4%]) were performed for endometrial carcinoma. The most common operation type was robotic-assisted hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy and PALND, which took a median of 3:38 hours or 218 minutes (range, 140-341 minutes) to perform. The high PALND (above the level of IMA) succeeded in 235 operations (83%). In the total cohort, the median number of para-aortic lymph nodes removed was 12 (range, 0-38), with a learning curve approximately more than 40 operations. Para-aortic lymph node metastases were found in 43 patients (15.2%). Seven conversions to laparotomy (2.5%) were done. The conversion and intraoperative complication rates were 2.5% and 3.5%, respectively, and postoperative complications was 18%, according to the classification of Clavien-Dindo. The median length of the postoperative hospital stay was 2 days (range, 1-8 days). CONCLUSIONS: Using the transperitoneal technique for PALND, the area between IMA and the renal veins can be reached in more than 80% of the operations, with a very low or 2.5% conversion rate.

Costs of Robotic-Assisted Versus Traditional Laparoscopy in Endometrial Cancer.

OBJECTIVES: The purpose of this study was to compare the costs of traditional laparoscopy and robotic-assisted laparoscopy in the treatment of endometrial cancer. METHODS AND MATERIALS: A total of 101 patients with endometrial cancer were randomized to the study and operated on starting from 2010 until 2013, at the Department of Obstetrics and Gynecology of Tampere University Hospital, Tampere, Finland. Costs were calculated based on internal accounting, hospital database, and purchase prices and were compared using intention-to-treat analysis. Main outcome measures were item costs and total costs related to the operation, including a 6-month postoperative follow-up. RESULTS: The total costs including late complications were 2160 &OV0556; higher in the robotic group (median for traditional 5823 &OV0556;, vs robot median 7983 &OV0556;, P < 0.001). The difference was due to higher costs for instruments and equipment as well as to more expensive operating room and postanesthesia care unit time. Traditional laparoscopy involved higher costs for operation personnel, general costs, medication used in the operation, and surgeon, although these costs were not substantial. There was no significant difference in in-patient stay, laboratory, radiology, blood products, or costs related to complications. CONCLUSIONS: According to this study, robotic-assisted laparoscopy is 37% more expensive than traditional laparoscopy in the treatment of endometrial cancer. The cost difference is mainly explained by amortization of the robot and its instrumentation.

Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial.

BACKGROUND: Previous studies comparing robotic-assisted laparoscopic surgery to traditional laparoscopic or open surgery in gynecologic oncology have been retrospective. To our knowledge, no prospective randomized trials have thus far been performed on endometrial cancer. OBJECTIVE: We sought to prospectively compare traditional and robotic-assisted laparoscopic surgery for endometrial cancer. STUDY DESIGN: This was a randomized controlled trial. From December 2010 through October 2013, 101 endometrial cancer patients were randomized to hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy either by robotic-assisted laparoscopic surgery or by traditional laparoscopy. The primary outcome measure was overall operation time. The secondary outcome measures included total time spent in the operating room, and surgical outcome (number of lymph nodes harvested, complications, and recovery). The study was powered to show at least a 25% difference in the operation time using 2-sided significance level of .05. The differences between the traditional laparoscopy and the robotic surgery groups were tested by Pearson χ2 test, Fisher exact test, or Mann-Whitney test. RESULTS: In all, 99 patients were eligible for analysis. The median operation time in the traditional laparoscopy group (n = 49) was 170 (range 126-259) minutes and in the robotic surgery group (n = 50) was 139 (range 86-197) minutes, respectively (P < .001). The total time spent in the operating room was shorter in the robotic surgery group (228 vs 197 minutes, P < .001). In the traditional laparoscopy group, there were 5 conversions to laparotomy vs none in the robotic surgery group (P = .027). There were no differences as to the number of lymph nodes removed, bleeding, or the length of postoperative hospital stay. Four (8%) vs no (0%) patients (P = .056) had intraoperative complications and 5 (10%) vs 11 (22%) (P = .111) had major postoperative complications in the traditional and robotic surgery groups, respectively. CONCLUSION: In patients with endometrial cancer, robotic-assisted laparoscopic surgery was faster to perform than traditional laparoscopy. Also total time spent in the operation room was shorter in the robotic surgery group and all conversions to laparotomy occurred in the traditional laparoscopy group. Otherwise, the surgical outcome was similar between the groups. Robotic surgery offers an effective and safe alternative in the surgical treatment of endometrial cancer.

Effect of aerobic training on menopausal symptoms--a randomized controlled trial.

OBJECTIVE: The aim of this study was to assess whether aerobic training affects menopausal symptoms in recently postmenopausal sedentary women. METHODS: Symptomatic women aged 45 to 63 years (N = 176; 3-36 months since last menstruation) were randomly assigned to an aerobic training or a control group. The intervention included unsupervised aerobic training for 50 minutes four times weekly for 24 weeks, whereas the control group attended health lectures twice a month. Symptoms were reported twice a day using a mobile phone. The perceived disturbance of menopausal symptoms (night sweats, mood swings, irritability, depressive mood, headache, vaginal dryness, and urinary symptoms) was evaluated on a scale from 1 (low) to 5 (high). Multilevel mixed-effect ordinal regression models were based on 17,000 responses during 24 weeks. RESULTS: One hundred fifty-four women continued until the end of the study (88% compliance rate). Baseline prevalence was as follows: night sweats, 50% to 60%; irritability and depression, 20% to 25%; mood swings, 25% to 30%; headache and urinary problems, 15% to 20%; and vaginal dryness, 10% to 15%. The prevalence of all symptoms except vaginal dryness decreased among intervention groups. According to multilevel mixed-effect ordinal regression analysis, night sweats and mood swings (P < 0.001) and disturbance of the mood swings (P < 0.001) and irritability (P < 0.001) were reduced more among the women in the intervention group than in the control group. CONCLUSIONS: In sedentary women, aerobic training for 6 months may decrease the typical menopausal symptoms, especially night sweats, mood swings, and irritability.

Fetal sex determination: obstetricians' attitudes in antenatal screening units in Finland.

AIM: To study obstetricians' attitudes in Finnish antenatal screening units concerning fetal sex determination without medical indication. METHODS: A structured questionnaire to all delivery units (n = 37) and the main outpatient screening units (n = 18) in the country. RESULTS: The majority of units made fetal sex determination without medical indication at patient's request during the second-trimester ultrasonographic screening. This examination was seen to have consequences for maternal-fetal attachment, but it was also considered medically useless and sometimes harmful. Only three out of the responding 32 units maintained quality control of the examination. A false diagnosis resulted extremely seldom in any litigation process. CONCLUSIONS: More precise guidelines are needed for fetal sex determination in healthcare organisation.