Simplification of Vaginoscopic Surgery Using a Self-Retaining External Vulvar Sheet (Darwish sheet).

OBJECTIVE: One of the main difficulties of vaginoscopy is continuous leakage of distension medium from the introitus hindering proper visualization. This study evaluates the effectiveness and success of performing diagnostic or operative vaginoscopic surgery via a tight self-retaining external vulvar sheet (Darwish sheet) expressed as tight vaginoscopy (TV) compared with conventional vaginoscopy (CV). PATIENTS AND METHODS: Females referred for vaginoscopy were initially examined by diagnostic CV followed by TV, and whenever indicated, operative TV via Darwish sheet was performed. RESULTS: Diagnostic TV was more feasible with excellent visualization if compared with CV. The mean infused distension fluid volume was 325 ml versus 485 ml, and the mean leaked fluid volume was 37 ml versus 94 ml in diagnostic TV versus CV, respectively. Operative TV via Darwish sheet was done in 21 cases (56.7%) that required surgery with 100% success rate without any reported complications. CONCLUSIONS: Accomplishing vulvar tightness using a cheap self-retaining external vulvar sheet (Darwish sheet) during vaginoscopy (TV) is associated with a clearer visualization of vagina or cervix, a lesser amount of irrigating fluid and lesser leakage as compared with CV.

A Novel Technique for the Reconstructive Formation of an Annular Hymen in Cases of Postpubertal Imperforate Hymen.

OBJECTIVES: Imperforate hymen (IH) is a common genital tract anomaly in women which usually presents after puberty. However, surgical treatment is often considered controversial in religious or conservative communities for sociocultural reasons. This study therefore aimed to assess the efficacy of a novel reconstructive technique involving the preservation of the annular hymen. METHODS: This prospective interventional study was performed between July 2013 and October 2019 at the minimally invasive surgery unit of a tertiary university hospital in Egypt. A total of 36 women presenting with primary amenorrhoea and haematocolpus were diagnosed with postpubertal IH. A circular hymenotomy was performed on each patient using a 10 mm laparoscopy trocar tip and sleeve to form a new annular hymen under general anaesthesia while preserving the annular hymen. The primary outcome measure was the persistence of hymenal patency and integrity at follow-up. The secondary outcome measure included post-operative patient satisfaction and pain relief. RESULTS: The reported technique was feasible in all cases without intraoperative complications. Patency of the reconstructed annular hymen was confirmed at follow-up in all cases; moreover, no intraoperative complications were reported. There was a significant post-operative improvement in pain scores (P <0.001). Both the patients and their parents/guardians reported a high level of satisfaction with the technique. CONCLUSION: This novel technique for the correction of IH involving the reconstruction of an annular hymen was found to be a safe, minimally invasive and effective procedure. This technique should be considered a feasible alternative to a conventional hymenotomy as it allows for the resumption of normal hymenal anatomy without overtreatment.

Bakri balloon versus condom-loaded Foley's catheter for treatment of atonic postpartum hemorrhage secondary to vaginal delivery: a randomized controlled trial.

OBJECTIVE: To assess the efficacy and safety of condom-loaded Foley's catheter versus Bakri Balloon in the management of primary atonic post partum hemorrhage (PPH) secondary to vaginal delivery. STUDY DESIGN: This study was single blinded randomized controlled trial conducted at Assiut Woman's Health Hospital, Egypt in the period between October 2014 and December 2015. It Comprised 66 women with primary atonic PPH following vaginal delivery. Eligible participants were randomly assigned to Bakri balloon (group A) or condom-loaded Foley's catheter (group B). The primary outcome was the success of tamponade to stop the uterine bleeding without additional surgical interventions. Secondary outcomes included time between insertion and stoppage of the bleeding, the amount of blood transfusion and maternal complications. RESULTS: Both treatment modalities successfully controlled the primary atonic PPH without a statistically significant difference [30/33(91.0%) and 28/33(84.84%), p = .199; respectively]. However; Bakri balloon required shorter time to stop the uterine bleeding (9.09 min vs. 11.76 min, p = .042; respectively). There was no statistically significant difference between both groups regarding postpartum maternal complications, the vital signs, urine output, hemoglobin and hematocrit levels from before to after tamponade insertion. CONCLUSIONS: Condom-loaded Foley's catheter is as effective as Bakri balloon in the management of primary atonic PPH following vaginal delivery but requires a significant bit longer time to stop the attack.

Reliability of unaided naked-eye examination as a screening test for cervical lesions in a developing country setup.

OBJECTIVE: This study aimed to test the reliability of unaided naked-eye examination (UNEE) of the cervix as a sole cervical cancer screening test in a developing country setup compared with the standard cervical cytology. MATERIALS AND METHODS: A total of 3,500 nonpregnant women aged between 25 and 55 years were included. An unlubricated bivalve speculum was inserted into the vagina under good light to visualize the cervix. A thorough UNEE of the cervix was done to detect any apparent lesions. Cervical smears were obtained using the long tip of an Ayre spatula. An additional endocervical sample was obtained by cytobrush. Women with abnormal Pap smears or visible cervical lesions by UNEE were scheduled for colposcopic examination. A biopsy specimen was obtained in every abnormal colposcopic examination. RESULTS: Of 3,500 cases, there were 9 (2.57%) preinvasive cervical lesions (cervical intraepithelial neoplasia 1-3) diagnosed with various diagnostic tools used in the study and confirmed by histopathologic examination. Of 3,500 cases, invasive cervical lesions were diagnosed in 6 (1.71%). The sensitivity of UNEE is much better than that of Pap smear (80% vs 60%) but less than that of colposcopy (86.7%). However, the specificity of UNEE (100%) is lower than that of Pap smear (91.16%) and better than that colposcopy (83.12%). The UNEE has a poor positive predictive value (3.75%) when compared with Pap smear (100%) and colposcopy (20%). The negative predictive values of the 3 tests were nearly comparable. CONCLUSIONS: Whenever access to Pap smear is limited, UNEE performed by general gynecologists and well-trained nurses is an acceptable alternative for detecting cervical premalignant or malignant lesions especially in low-resource settings.

Biological effects of distension media in bipolar versus monopolar resectoscopic myomectomy: a randomized trial.

AIM: To estimate the effect of 0.9% saline during bipolar resectoscopy and 1.5% glycine during monopolar resectoscopy on hemodynamic, biochemical and hematological parameters. MATERIAL & METHODS: A prospective randomized study in a tertiary care university hospital and comprising of 155 patients scheduled for hysteroscopic myomectomy. They were subjected to bipolar resectoscopic myomectomy utilizing 0.9% saline in group A, and monopolar resectoscopic myomectomy utilizing 1.5% glycine in group B. Perioperative measurements of hemodynamic, hematological, and biochemical changes in all cases were reported. Likewise, intrauterine pressure throughout the different procedures was recorded. MAIN OUTCOME MEASURES: intraoperative difference with regards to fluid volume and subsequent systemic changes specially osmolarity. RESULTS: A significant increase of central venous pressure, end diastolic volume, end diastolic index, stroke volume, stroke index, cardiac output, cardiac index, postoperative prothrombin time and postoperative partial thromboplastin time in both groups with positive correlations between the absorbed fluid volume and these measurements in both groups. Moreover, there was a significant decrease in systemic vascular resistance, postoperative hemoglobin concentration, postoperative hematocrit value ratio, postoperative platelet count and postoperative prothrombin concentration in both groups and there were negative correlations between the absorptive fluid volume and these measurements in both groups. There were significant decrease in serum sodium concentration and postoperative serum osmolarity in glycine group (B) with negative correlations between the absorptive fluid volume and both serum sodium concentration and serum osmolarity in glycine group (B). CONCLUSIONS: The use of bipolar resectoscope utilizing 0.9% saline as a distention media is not associated with hyponatremia or hyposmolarity unlike monopolar resectoscope utilizing 1.5% glycine distending media in cases with submucous myoma of considerable size.

Tactile cold scissor metroplasty as a novel backup method for hysteroscopic metroplasty.

OBJECTIVE: To study the operative, anatomic, and functional outcome of tactile cold scissor metroplasty (TCSM) as a backup method for hysteroscopic metroplasty. DESIGN: Case series with description of the technique. SETTING: Assiut University Women's Health Center. PATIENT(S): Three cases with failed hysteroscopic metroplasty out of 127 cases with uterine septa scheduled for hysteroscopic resection. INTERVENTION(S): The TCSM procedure was performed in three cases under direct laparoscopic monitoring. MAIN OUTCOME MEASURE(S): Operative time, complications, hysteroscopic appearance of the cavity, reproductive outcome, and reintervention rates. RESULTS: The TCSM procedure was performed successfully in the three cases with a short total operative time (10-12 minutes). Subsequent office hysteroscopic appearance was satisfactory. Patients were then followed up for a period of time ranging from 3 to 28 months. One case had a successful pregnancy outcome, one has an ongoing pregnancy, and the last one did not get pregnant so far. CONCLUSION(S): Tactile cold scissor metroplasty is a useful, safe, and effective backup procedure for hysteroscopic metroplasty.

Prevalence and predictors of deficient dietary calcium intake during the third trimester of pregnancy: the experience of a developing country.

AIM: To assess the prevalence and predictors of dietary calcium deficiency in the third trimester of pregnancy. METHODS: Using an analytic cross-sectional research design we assessed antenatal out-patient clinics with a total of 503 pregnant women in the third trimester with parity less than 5, aged from 18-45 years, whether primi- or multigravida, and free from medical and gynecological diseases. Patients were screened for dietary calcium deficiency using an interview questionnaire, a food survey questionnaire and a record form for lab tests and investigations to determine the average amount of dietary calcium intake supported by normal levels of total serum calcium. RESULTS: About two thirds of the women assessed (66.0%) were deficient in dietary calcium. The mean daily dietary intake of calcium was 879.1 mg/day. Fifty-seven point seven percent of the women had total serum calcium levels less than 9 mg/dL, while 76.8% had levels less than 10 mg/dL. Mean total serum calcium was 8.9 mg/dL. Women with deficient dietary calcium had a lower level of education, larger family size and were more likely to be rural (P < 0.001). More underweight women were seen in the deficiency group (2.4%), and more obese women in the sufficient group (19.9%). As regards the association between dietary and total serum calcium, the regression analysis showed no correlation among the values. CONCLUSIONS: Calcium intake in the sample studied was low. Independent predictors of dietary calcium were age (negative predictor), urban residence (positive indicator) and body mass index (BMI; positive predictor). As for the level of total serum calcium, dietary calcium and gravidity were the only statistically significant independent predictors, with gravidity being a negative predictor.

Extended resectoscopic versus sequential cold knife-resectoscopic excision of the unclassified complete uterocervicovaginal septum: a randomized trial.

OBJECTIVE: To determine if resectoscopic sectioning of complete uterocervicovaginal septum is as effective as cold knife excision of the vaginal part followed by resectoscopic cutting of the cervicouterine part in symptomatic patients. DESIGN: Randomized controlled clinical trial. SETTING: University hospital. PATIENT(S): Thirty-two women with a diagnosis of complete uterocervicovaginal septum who had a history of pregnancy wastage or infertility. They were randomized into two groups: Group A underwent resectoscopic excision of the complete septum starting from the vaginal interoitus; group B underwent cold knife excision of the vaginal part followed by resectoscopic excision of the cervical and uterine parts. INTERVENTION(S): Hysteroscopic metroplasty alone or preceded by cold knife excision of the vaginal part. MAIN OUTCOME MEASURE(S): Operating time, perioperative bleeding, complications, reproductive outcome, and patient and husband satisfaction. RESULT(S): Patients in group A showed significantly less operative time and scar-related dyspareunia. There were no significant differences in the reproductive outcome in the two groups. CONCLUSION(S): Resection of the vaginal part of symptomatizing complete vaginocervicouterine septum using resectoscopic metroplasty makes the procedure faster with less possibility of scar-related dyspareunia than cold knife excision.

Clinical efficacy of novel unidirectional buccoadhesive vs. vaginoadhesive bromocriptine mesylate discs for treating pathologic hyperprolactinemia.

OBJECTIVE: To test the clinical effectiveness of new bioadhesive unidirectional buccal and vaginal bromocriptine methylate discs in hyperprolactinemic patients. DESIGN: A preliminary randomized comparative study. SETTING: A pharmaceutical phase at the departments of Pharmaceutics, Faculties of Pharmacy, Assiut and El-Minea universities and a clinical phase at the Infertility Out-patient Clinic of Women's Health University Center, Assiut University, Assiut, Egypt. PATIENT(S): A total of 42 patients with pathologic hyperprolactinemia. INTERVENTION(S): Patients were randomly divided into two groups. Group A comprised 21 patients who used unidirectional buccoadhesive bromocriptine methylate discs once daily for 1 month. Group B included 21 patients who used vaginoadhesive bromocriptine methylate discs once daily for 1 month. Serum prolactin (PRL) was measured before and after therapy in all cases. MAIN OUTCOME MEASURE(S): Decline of serum PRL level after 1 month of therapy. RESULT(S): Pharmaceutically, tests for swelling, surface pH, in vitro and in vivo bioadhesion and in vitro release expressed satisfactory results. The in vitro release of vaginal bromocriptine from the discs is increased in pH 4.5 media. Both groups showed a highly statistically significant reduction of serum PRL levels after 1 month of therapy without any significant difference between both groups. The decline of serum PRL was not correlated with age, parity, or indication of entering into this study. CONCLUSION(S): Both buccoadhesive and vaginoadhesive discs containing bromocriptine are of equal efficacy for treating pathologic hyperprolactinemia. Buccoadhesive discs have the advantages of being gender nonspecific (i.e., could be used by men), avoiding manipulating the vagina, which could be inconvenient to some patients, such as virgins; not being dependent on cyclic estrogen (E) levels; and could be easily used during menstruation.

Is there a role for hysteroscopic tubal occlusion of functionless hydrosalpinges prior to IVF/ICSI in modern practice?

OBJECTIVES: To determine whether hysteroscopic tubal occlusion will produce the same efficacy as laparoscopic tubal occlusion of functionless hydrosalpinx prior to IVF/ICSI. DESIGN: A prospective comparative study. Setting. Endoscopy Unit of the Women's Health Center, Faculty of Medicine, Assiut University, Assiut, Egypt. SUBJECTS: A pilot safety phase included 10 uteri removed by hysterectomy in perimenopausal women subjected to roller ball coagulation of the peritubal bulge. The study phase included 27 patients with uni- or bilateral functionless hydrosalpinges, who were randomly divided into 2 groups. Group A comprised 14 patients who were randomly allocated for laparoscopic occlusion. Group B included 13 patients scheduled for a hysteroscopic approach. Interventions. Laparoscopic occlusion of the isthmic part of the fallopian tube was carried out using bipolar diathermy in 9 (64%) cases or clips in 3 (21.4%) cases in Group A. Roller ball electrode of the resectoscope was utilised for occlusion of the tubal ostium under local, spinal, or general anesthesia in Group B. Second-look office hysteroscopy was performed in Group B whenever possible. In both groups, hysterosalpingography or sonohysterography was carried out 1 month later to confirm tubal occlusion. MAIN OUTCOME MEASURES: Safety phase aimed at confirming tubal occlusion with minimal harm to adjacent tissues. Confirmed tubal occlusion of the functionless hydrosalpinx. RESULTS: The safety phase resulted in bilateral complete occlusion of the proximal part of the tubes with secondary coagulation <8 mm, as shown in the histopathologic sections. The suspected main cause of functionless hydrosalpinges was iatrogenic (pelvic surgery) in 9 (64%) and 8 (61.5%) cases in both groups, respectively. The mean number of abdominal scars/patient was 1.4 and 1.5 in both groups, respectively. Unilateral functionless hydrosalpinx was encountered in 7 (50%) and 5 (38%) cases in both groups, respectively. In Group A, the procedure was possible and successful in 10 cases (76.9%), while in Group B, hysteroscopic access and occlusion were achieved in 12 (85.7%) and 9 (64.2%) cases, respectively. In Group B, diagnostic hysteroscopy showed fine marginal adhesions in 2 cases (15%), and a small polyp in 1 case (7.7%). Hysteroscopic tubal occlusion showed shorter operative time (9+/-2.8 versus 24+/-4.8 min, p=0.0001) and hospital stay (2+/-1.8 versus 5+/-1.1h, p=0.0001). Second-look office hysteroscopy was performed in 8 cases in Group B and revealed no significant corneal lesions at the site of hysteroscopic occlusion. CONCLUSIONS: This preliminary study demonstrates the feasibility of hysteroscopic tubal occlusion of functionless hydrosalpinx in all cases with acceptable efficacy. It has the advantage of adding a valuable evaluation of the endometrial cavity prior to IVF/ICSI. It should be an option for treatment protocol in cases of functionless hydrosalpinges. Further large sample-sized studies are required to test its impact on the implantation rate and clinical outcome.

Superiority of newly developed vaginal suppositories over vaginal use of commercial bromocriptine tablets: a randomized controlled clinical trial.

The objective of this study is to verify the safety and efficacy of new vaginal bioadhesive suppositories as compared with vaginal use of commercial bromocriptine tablets in hyperprolactinemic patients. This study is a randomized, double-blind, active comparator clinical trial in which a subset of patients had some pharmacokinetic measurements. The setting was an outpatient private infertility clinic in a developing country, and the subjects were 171 patients with hyperprolactinemia. A pilot phase comprised 32 patients who were divided into 2 groups. Group A comprised 16 patients who used vaginal suppositories containing 2.5 mg bromocriptine mesthylate with pluronics and bioadhesive agents once daily for 1 month, while group B included 16 patients who used commercial 2.5-mg bromocriptine mesthylate tablets inserted vaginally once daily for 1 month. The clinical phase comprised 139 patients who were again divided into 2 groups in the same way (group A, 68 patients; group B, 71 patients). Serum prolactin (SP) was measured before and after therapy in all cases. The main outcome measure was the decline of SP level after 1 month of therapy. In both groups, there was a significant decline of the SP. However, it was more significant in group A. Patient convenience was more evident, and local side effects were less in group A than group B in the clinical phase. The introduction of bioadhesive technology for bromocriptine mesylate/pluronic F-126 administration is valuable in achieving prominent serum prolactin reduction in hyperprolactinemic patients in a relatively short duration of therapy. The formulated vaginal suppositories expressed better convenience with minimal local side effects when compared with vaginally administered commercial bromocriptine tablets.

Evaluation of a novel vaginal bromocriptine mesylate formulation: a pilot study.

Because of the frequent side effects found with oral bromocriptine, we created two formulas of vaginal bromocriptine suppositories to compare with vaginal application of bromocriptine tablets. The formula containing bromocriptine and a releasing agent (Pluronic F127) showed an increased dissolution rate, 39-fold greater than that of the pure drug alone, and subsequently was effective in lowering serum prolactin.

Evaluation of postmyomectomy uterine scar.

PURPOSE: To determine preoperative and intraoperative factors that affect the healing pattern of a myomectomy uterine incision and to estimate the incidence and outcome of postmyomectomy hematoma demonstrated with sonography. METHODS: This observational longitudinal prospective study followed the course of patients diagnosed with at least 1 leiomyomata. Each patent was scheduled for abdominal myomectomy. Preoperative assessments included sonographic measurement of the uterine volume as well as identification of the numbers and sites of the leiomyomata. Detailed operative notes were reported for every patient. Transvaginal sonography was performed for all cases on day 2, day 7, and at 1 month and 3 months postoperatively. The main outcome measure was the occurrence of postoperative hematoma versus preoperative and postoperative factors that possibly affect uterine healing. RESULTS: We found a statistically significant reduction of the uterine volume on follow-up (P < 0.001) of the 169 women enrolled. Hematoma in the myomectomy bed was observed postoperatively in 40 (24%) 28 (17%) and 12 (7%) patients on day 2, day 7, and 1 month, respectively. A preoperative myoma size greater than 110 cm(3), the use of a tourniquet, and the experience of the surgeon were significantly correlated with formation of uterine scar hematomas. CONCLUSIONS: The postoperative sonographic diagnosis of wound hematoma may be used as an indicator of wound healing that is usually complete within 3 months. Use of a tourniquet is frequently associated with hematoma formation. Myomectomy should usually be performed by an experienced surgeon without a tourniquet, using microsurgical principles, especially when the sizes of the leiomyomata exceed 110 cm(3).

Laparoscopic management of paratubal and paraovarian cysts.

OBJECTIVES: To define the proportion, methods of diagnosis, and a simplified laparoscopic technique for treating paratubal and paraovarian cysts. METHODS: We conducted a prospective cross-sectional study in the Gynecologic Endoscopy Unit of Assiut University Hospital in Assiut, Egypt in 1853 patients undergoing video-assisted laparoscopy. Transvaginal ultrasonography (TVS) was performed to detect paratubal or paraovarian cysts. Tubal shape and patency were evaluated with hysterosalpingography (HSG) in the infertile group. Diagnostic laparoscopy was performed to confirm the diagnosis of paratubal or paraovarian cysts. Small cysts were punctured and coagulated, and larger cysts required cystectomy and extraction of the cysts by using bipolar electrosurgery. Cystectomy was preceded by endocystic visualization in all cases. The primary outcomes measured included (1) correlation of the preoperative TVS, HSG, or both of these, with the laparoscopic diagnosis; (2) estimation of the success of the laparoscopic management of paratubal cysts; (3) assessment of the value of endocystic visualization prior to cystectomy; and (4) evaluation of tubal patency after laparoscopic management. RESULTS: Laparoscopically, only 118 patients (15.7%) were proved to have paratubal or paraovarian cysts. Preoperatively, TVS confirmed paratubal or paraovarian cysts in 52 (44%) patients. Cysts less than 3 cm in size (34 cases) were treated with simple puncture and bipolar coagulation of the cyst wall, whereas larger cysts (84 cases) were treated by cystectomy. Endocystic visualization using the 4-mm rigid hysteroscope was performed in 84 (71%) patients with large cysts. Statistically significant improvement occurred in tubal patency after laparoscopic management. CONCLUSIONS: Sonographic diagnosis of not uncommon paratubal and paraovarian cysts is not always feasible and requires greater awareness and accuracy. The characteristic laparoscopic differentiation of ovarian cysts is the crossing of vessels over them. Endocystic-endoscopic visualization is a simple, valuable step prior to cystectomy. Bipolar coagulation or extraction of these cysts diagnosed at laparoscopy is easy, not time-consuming, and should be routinely performed in all cases following microsurgical laparoscopic principles.

Evaluation of the impact of laparoscopic ovarian drilling on Doppler indices of ovarian stromal blood flow, serum vascular endothelial growth factor, and insulin-like growth factor-1 in women with polycystic ovary syndrome.

OBJECTIVE: To study the serum levels and correlation of vascular endothelial growth factor (VEGF), insulin-like growth factor 1 (IGF-1), hormonal profile, and Doppler blood flow changes within the ovarian stroma before and after laparoscopic ovarian drilling (LOD) in women with clomiphene-resistant polycystic ovary syndrome (PCOS). DESIGN: Prospective controlled study. SETTING: University teaching hospital. PATIENT(S): Twenty-five women with clomiphene-resistant PCOS (group 1) and 20 women with regular menstrual cycles as a comparison group (group 2). INTERVENTION(S): Laparoscopic ovarian drilling. MAIN OUTCOME MEASURE(S): Serum levels of VEGF, IGF-1, and Doppler indices of ovarian stromal blood flow. RESULT(S): The serum levels of VEGF, IGF-1, T, and LH were significantly higher in group 1 before LOD than in group 2. The Doppler indices (pulsatility index and resistance index) of ovarian stromal blood flow were also significantly lower in group 1 before LOD than in group 2. The serum levels of VEGF, T, and LH were significantly reduced in group 1 after LOD compared with in group 1 before LOD. Doppler indices (pulsatility index and resistance index) of ovarian stromal blood flow were significantly increased after LOD. The VEGF levels before LOD were positively correlated with IGF-1, LH, and T. After LOD, the VEGF levels were positively correlated with LH and T. CONCLUSION(S): Higher serum levels of VEGF and IGF-1 may explain the increased vascularity that was demonstrated by Doppler blood flow measurements in PCOS. Laparoscopic ovarian drilling reduced serum VEGF, IGF-1, T, and LH and reduced ovarian blood flow velocities, which may explain the reduction of ovarian hyperstimulation syndrome in women with PCOS after LOD.