Vaginal Fractional Carbon Dioxide Laser Treatment and Changes in Vaginal Biomechanical Parameters.

BACKGROUND AND OBJECTIVES: Vaginal fractional carbon dioxide (CO2 ) laser treatment has emerged in the past two decades as a non-surgical option for vaginal tightening. Mounting evidence supports the effectiveness and safety of this treatment for female sexual dysfunction. A newly developed vaginal tactile imaging (VTI) technique accurately evaluates the biomechanical parameters of the female pelvic floor and vagina, including tissue elasticity, pelvic support, and pelvic muscle function in high definition. In the current study, we evaluated changes in objective biomechanical parameters using VTI, following vaginal CO2 laser treatment for vaginal tightening and sexual dysfunction. STUDY DESIGN/MATERIALS AND METHODS: We conducted a prospective cohort between June 2018 and January 2020. Inclusion criteria were vaginal looseness, decreased local sensation during sexual intercourse, and sexual dysfunction. All the participants were treated with a vaginal carbon dioxide laser. They underwent a gynecological evaluation based on the Vaginal Health Index (VHI) and sexual function assessment according to the Female Sexual Function Index (FSFI). Vaginal biomechanical parameters were assessed by VTI. Initial evaluations were performed at the pre-treatment consult visit, 1 week prior to the first treatment and at a 6-month post-treatment follow-up visit. RESULTS: Twenty-five women were included in the final analysis. Compared with baseline, the post-treatment mean scores for vaginal elasticity and tightening were higher (54.8 ± 5.2 vs. 41.5 ± 6.3, P = 0.0027 and 1.97 ± 0.25 vs. 1.32 ± 0.31, P = 0.0014, respectively). Post-treatment increases were demonstrated in pelvic muscle contraction strength (25.9 ± 3.5 vs. 16.5 ± 4.2, P = 0.0011) and in reflex pelvic muscle contraction (2.93 ± 0.44 vs. 2.12 ± 0.47, P = 0.0022); the mean FSFI and VHI scores were higher following treatment (28.47 ± 1.73 vs. 21.12 ± 1.58, P = 0.036 and 19.15 ± 1.27 vs. 11.6 ± 0.97, P = 0.0032). CONCLUSIONS: The quantification of vaginal biomechanical parameters using VTI technology offers objective evidence of the beneficial effect of vaginal CO2 laser treatment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) Hysterectomy Learning Curve: Feasibility in the Hands of Skilled Gynecologists.

BACKGROUND: During Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) the surgeon operates exclusively through a single vaginal entry point, leaving no external scarring. OBJECTIVES: To evaluate the learning curve of vNOTES hysterectomy by experienced gynecologists based on surgical times and short-term outcomes. METHODS: A retrospective study was conducted of the first 25 vNOTES hysterectomy surgeries performed from July to December 2018 at Rambam Health Care Campus by a single surgeon. The primary outcome was hysterectomy time. Secondary outcomes included intra-operative bleeding, length of hospitalization, postoperative pain, and need for analgesia. Socio-demographic and clinical data were retrieved from patient electronic medical charts. RESULTS: Median age was 64.5 years (range 40-79). Median hysterectomy time was 38 minutes (range 30-49) from the first cut until completion. Comparisons between median hysterectomy time in the first 10 hysterectomies and in the 15 subsequent procedures demonstrated a significant decrease in median total time: 45 minutes (range 41-49) vs. 32 minutes (range 30-38), respectively (P = 0.024). The median estimated intraoperative blood loss decreased from 100 ml (range 70-200) in the first 10 hysterectomies to 40 ml (range 20-100) in the subsequent procedures (P = 0.011). CONCLUSIONS: vNOTES hysterectomy is feasible by an experienced gynecologist, with an exponential improvement in surgical performance in a short period as expressed by the improvement in hysterectomy time, low complication rates, negligible blood loss, minimal post-surgical pain, fast recovery, and short hospitalization. vNOTES allows easier and safer access to adnexal removal compared to conventional vaginal surgery.

Single-port versus multi-port robotic sacrocervicopexy: Establishment of a learning curve and short-term outcomes.

OBJECTIVES: The purpose of this study was to compare the learning curves, surgical outcomes and complications of multi-port access robotic-assisted laparoscopic sacrocervicopexy (MP-RSC) to single-port robotic access (SP-RSC) for vaginal apex prolapse. METHODS: A retrospective study of the first 52 MP-RSC procedures compared with the first 52 SP-RSC procedures performed at one medical center. Primary outcomes were intraoperative bleeding, operative time, and hospitalization. Secondary outcomes were surgical complications. RESULTS: There was a statistically significant difference in mean operative times between the MP-RSC and SP-RSC procedures: 206.5 ±â€¯39.4 and 187.8 ±â€¯46.2, respectively, P = 0.028. The mean estimated intraoperative blood loss was 35 [20-87.5] ml and 20 [10-47.5] ml, respectively, P = 0.008. Respective mean operative times decreased from the first 15 to the subsequent 15 cases: in the MP-RSC group from 224.2 ±â€¯43.2 to 198.4 ±â€¯36.3 min, P = 0.088, and in the SP-RSC group from 222.4 ±â€¯53.1 to 161.3 ±â€¯28.2 min, P < 0.001. The subsequent 22 cases showed different trends. Hospitalization (days) and level of pain at 24 h postoperative, according to a 1-10 point visual analogue scale, did not differ. Adverse events were rare in both groups. CONCLUSIONS: MP-RSC and SP-RSC are feasible and the short term outcomes and learning curves for both procedures are comparable.

Effects of Pneumoperitoneum and the Steep Trendelenburg Position on Heart Rate Variability and Cerebral Oxygenation during Robotic Sacrocolpopexy.

STUDY OBJECTIVE: The aim of this study was to investigate how steep Trendelenburg positioning with pneumoperitoneum modifies brain oxygenation and autonomic nervous system modulation of heart rate variability during robotic sacrocolpopexy. DESIGN: Prospective study (Canadian Task Force classification III). SETTING: Rambam Health Care Campus. PATIENTS: Eighteen women who underwent robotic sacrocolpopexy for treatment of uterovaginal or vaginal apical prolapse. INTERVENTIONS: Robotic sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: A 5-minute computerized electrocardiogram, cerebral O2 saturation (cSO2), systemic O2 saturation, heart rate (HR), diastolic blood pressure (BP), systolic BP, and end-tidal CO2 tension were recorded immediately after anesthesia induction (baseline phase) and after alterations in positioning and in intra-abdominal pressure. HR variability was assessed in time and frequency domains. Cerebral oxygenation was measured by the technology of near-infrared spectrometry. cSO2 at baseline was 73% ± 9%, with minor and insignificant elevation during the operation. Mean HR decreased significantly when the steep Trendelenburg position was implemented (66 ± 10 vs 55 ± 9 bpm, p < .05) and returned gradually to baseline with advancement of the operation and the decrease in intra-abdominal pressure. Concomitant with this decrease, the power of both arms of the autonomic nervous system increased significantly (2.8 ± .8 vs 3.3 ± .9 ms2/Hz and 2.5 ± 1.2 vs 3.2 ± .9 ms2/Hz, respectively, p < .05). All these effects occurred without any significant shifts in systolic or diastolic BP or in systemic or cerebral oxygenation. CONCLUSION: This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in HR rate and HR variability.

Single Port Robotic Assisted Sacrocolpopexy: Our Experience With the First 25 Cases.

OBJECTIVES: In single-port surgery, the surgeon operates almost exclusively through a single entry point, typically the patient's navel, leaving only a single small scar. The aims of this study were to share some tips and tricks of single-port robotic-assisted sacrocolpopexy and to evaluate the learning curve of mastering the skills to operate this procedure. METHODS: This is a retrospective study of the first 25 single-port; robotic-assisted sacrocolpopexy surgeries performed during July to December 2015 at Rambam Health Care Campus by a single surgeon.Primary points of interest included intraoperative bleeding, length of surgery, length of hospitalization, and surgical complications. RESULTS: The median age was 59 years (range, 35-74); the median "pelvic organ prolapse quantification" stage was 3 (range, 2-4). The median total operative time was 190 minutes (range, 114-308), and console time was 130 minutes (85-261). Comparisons between the first 15 cases and the following 10 cases demonstrated significant decreases in median total operative and console times: 226 minutes (range, 142-308) versus 156 minutes (range, 114-180), and 170 minutes (range, 85-261) versus 115 minutes (range, 90-270), respectively (P < 0.008). There were no intraoperative adverse events. Postoperative adverse events were also rare, including 1 case of small bowel adhesions that required a second laparoscopic surgery for adhesiolysis. After this incident, we peritonalized the mesh in all 13 successive cases; median time was 8 minutes (range, 5-15 minutes). CONCLUSIONS: Single-port robotic-assisted sacrocolpopexy is a feasible procedure with low complication rates, minimal blood loss and postsurgical pain, fast recovery, short hospitalization, and virtually scar-free results. Outcomes of long-term follow-up should be investigated.

Prenatal diagnosis of scrotal-inguinal hernia: two case reports and review of the English literature.

We present two cases of a prenatal diagnosis of inguinal hernia and the fetal outcome. Initial differential diagnosis included sacrococcygeal teratoma and testicular termatoma, while the final diagnosis was scrotal-inguinal hernia based on sonographic visualization of bowel loop movement in the scrotal mass.

Sonographic evaluation of the superior sinus sagittalis.

OBJECTIVE: The aim of this study was to characterize the normal ultrasonographic growth of the fetal superior sinus sagittalis (SSS) throughout gestation. PATIENTS AND METHODS: In a prospective cross-sectional study, measurements of the fetal sinus sagittalis were obtained in patients undergoing elective fetal anatomical surveys or fetal growth scan at between 16.6 and 34.7 weeks of gestation. Special attention was given to the SSS of the fetal brain. On the coronal plane, the SSS may be easily identified immediately below the frontal bone, and anterior to the fetal head parenchyma. RESULTS: 206 fetuses were scanned. A regression line of the SSS was created throughout gestation and a first-degree correlation was found between gestational age (GA) and the SSS height (r = 0.418; p < 0.0001; SSS = -0.015 + 0.0178 × GA). Normal values were established for different gestational weeks. CONCLUSION: We provide ultrasonographic dimensions of the fetal SSS across pregnancy. This data potentially allows for prenatal diagnosis of abnormal appearance of the SSS.

Sonographic study of the relationship between gestational diabetes mellitus and fetal activity.

OBJECTIVE: To evaluate the relationship between gestational diabetes mellitus (GDM) and fetal activity. MATERIALS AND METHODS: We prospectively studied 18 pregnant patients with GDM and 20 pregnant patients with normal glucose screening test. An ultrasound equipment was used to perform a 30 min transabdominal sonographic recording for each patient. Each ultrasound exam was recorded using a DVD recorder. Fetal activity was analyzed using duration and number of episodes of fetal breathing and body movements. The recordings were analyzed using a stopwatch in order to accurately evaluate each recording. The data was statistically analyzed using the parametric and non-parametric t-test. RESULTS: The results of the study indicated that there was a significant correlation (p = 0.007) between the duration of fetal breathing movement and GDM. Fetuses of mothers suffering from GDM had a significantly longer duration of fetal breathing movements compared with fetuses of non diabetic mothers. In addition, the total duration of fetal activity (time of fetal body movements plus fetal breathing movements) was significantly higher (p = 0.005) in GDM compared with non GDM pregnancies. The difference in fetal body movements between GDM and normal pregnancies was not statistically significant. CONCLUSION: The results of this study support the hypothesis that GDM has a direct influence on fetal activity. The significance of this finding should be further evaluated.

[Domestic violence--the physician's role: screening, diagnosis and primary intervention].

In 1997, the WHO declared domestic vioLence to be a health issue requiring medical attention. According to epidemiological data, it is a highly prevalent disease, with considerable short and long-term effects. Its treatment mandates diverse skills, such as clinical knowledge, emotional consideration, systemic vision and multi-disciplinary cooperation. There is controversy as to the effectiveness of screening for the disease. There is no agreement as to a single screening questionnaire and its use. Therefore, there are no recommendations for or against screening. Nevertheless, according to the Israeli Health Ministry's directives, it is the duty of physicians to perform screening for domestic violence in women and it is mandatory, according to criminal law, to report the abuse of children and helpless elderly to the proper authorities. Although there is no direct evidence from controLLed trials that medical intervention reduces the occurrence of the disease and prevents its recurrence, some medical organizations recommend that physicians should screen their patients for it, provide primary intervention, support, information, protection and connection with supportive authorities.

Individual and societal reactions to ongoing terror in Israel.

Since the beginning of the Al-Aqsa Intifada until the end of 2003, belligerent acts have led to the deaths of more than 275 members of the security forces and above 650 civilians; more than 1700 members of the security forces and above 4400 civilians also sustained injuries. Data from Israel and around the world shows that, during the first few days following a terror attack, those directly or indirectly exposed will develop a wide range of symptoms of a depressive and/or anxious nature, which will disappear spontaneously after a few weeks or months. A minority at risk will develop posttraumatic stress disorder, with accompanying psychiatric morbidity, particularly anxiety and depression. In recent years, Israelis have faced an increasing level of anxiety regarding their personal security, and have become more pessimistic regarding the prospects of securing national security in the wake of the terrorist attacks sustained since September 2000. In spite of that, data show a surprising level of optimism and communal resilience, which deserves explanation.

Facing war, terrorism, and disaster: toward a child-oriented comprehensive emergency care system.

The combination of the overwhelming nature of disasters and the massive losses they engender gives rise to a complex clinical and social picture with longterm physical, psychological, and social effects on children, families, and communities. The authors suggest that to assess the damage properly, implement interventions on a large scale, keep tabs on rising needs, and restore societal function, mental health professionals must adopt an ecologic systems approach. This approach entails working within and together with related institutions (education, health, local government) and assisting other committed professionals within these institutions to mediate care. This is of utmost importance in the area of children's care because of their particular vulnerability and their special importance for families and society. For this reason, the authors suggest that emergency mental health systems be better designed and implemented while keeping children at the center of their focus. An essential component of the ecologic systems approach is improved education for mental health professionals, providing them the appropriate tools to cope with widespread disaster and the expertise to apply these tools. This approach, however, is not enough. A good outcome cannot be achieved without preparedness on the part of the other relevant institutions and the community as a whole. Greater awareness is needed among local and national authorities of the importance of metaadaptive systems and of local, national, and international networking. In the current global village that is threatened by pervasive terrorism, no community must face it alone. The challenge of a disaster to one community is a challenge to all. By working together we can lessen the devastating impact of these events, save countless lives, prevent untold suffering, and maintain hope for a better world for children.