Barbed versus conventional suture in laparoscopic myomectomy: A randomized controlled study.

Objective: To compare the surgical and clinical results of traditional absorbable polyglactin 910 and barbed sutures in laparoscopic myomectomy. Materials and Methods: This single-center randomized study included 75 women who underwent laparoscopic myomectomy. The uterine wall defects were closed with a continuous conventional absorbable polyglactin 910 suture (Vicryl; Ethicon, Somerville, NJ, USA) in 41 women and with a unidirectional barbed suture (V-Loc 180; Covidien, Mansfield, MA, USA) in 34 women. Results: The time required to suture the uterine wall defect was lower in the V-Loc group than in the Vicryl group (p=0.007). However, no significant difference was observed in the operative time between the two study groups. The intraoperative blood loss and need for postoperative blood transfusion were significantly lower in the barbed group than in the Vicryl group (p=0.018 and p=0.048, respectively). Conclusion: In laparoscopic myomectomy cases, the unidirectional barbed suture is more effective than the conventional absorbable suture. Barbed sutures facilitate the suturing process and reduce the time required to suture the uterine wall defect, blood loss, and the need for postoperative blood transfusion.

McCall culdoplasty vs. vaginally assisted laparoscopic sacrocolpopexy in the treatment of advanced uterine prolapse: A randomized controlled study.

OBJECTIVE: The primary aim of this study was to compare the anatomic outcomes of vaginally assisted laparoscopic sacrocolpopexy (VALS) with those of McCall culdoplasty (McCC) in patients undergoing concurrent vaginal hysterectomy. MATERIALS AND METHODS: This randomized controlled study presents the outcomes of 68 patients who underwent hysterectomy and vaginal suspension for apical prolapse ≥ Stage III according to the Pelvic Organ Prolapse Quantification (POP-Q) system between October 2017 and December 2020. Among these patients, 33 underwent VALS and 35 underwent McCC. Clinical features, surgical data, concomitant surgical procedures, postoperative complications, and recurrence rates were assessed. Before and after one year of surgery, the short form of the Pelvic Floor Impact Questionnaire and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire were used to evaluate subjective symptoms. Patient Global Impression of Improvement Questionnaire was used to assess patient satisfaction. RESULTS: The mean follow-up durations were 25.5 ± 7.63 months and 25.6 ± 5.96 months in the VALS and McCC groups, respectively. Prolapse recurrence occurred in 3 (9.1%) women in the VALS group versus 12 (34.3%) women in the McCC group (p = 0.031). CONCLUSION: The McCC operation was associated with a shorter operation time, whereas the VALS operation had a significantly higher objective success rate. Based on this study, it may be concluded that McCC is not an effective procedure for advanced uterine prolapse.

Comparison of laparoscopic lateral suspension and laparoscopic sacrocolpopexy with concurrent total laparoscopic hysterectomy for the treatment of pelvic organ prolapse: a randomized controlled clinical trial.

INTRODUCTION AND HYPOTHESIS: We compared the outcomes of women who underwent laparoscopic lateral suspension with concurrent total laparoscopic hysterectomy (LLS-TLH) with those of women who underwent laparoscopic sacrocolpopexy with concurrent total laparoscopic hysterectomy (LSC-TLH) for apical and/or anterior vaginal wall prolapse. METHODS: Eighty women underwent LLS-TLH or LSC-TLH operations. According to the Pelvic Organ Prolapse Quantification System (POP-Q), women with symptomatic pelvic organ prolapse of stage 2 or higher apical and/or anterior compartment prolapse were enrolled in the study. The objective cure rate according to the POP-Q system was the primary (objective) outcome. The International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and Patient Global Impression of Improvement (PGI-I) questionnaire scores were the secondary (subjective) outcomes. The primary and secondary outcomes were evaluated at 1 year after surgery. RESULTS: The primary and secondary outcomes indicated significant improvements in both groups (p < 0.05). The objective cure rate was 92.5% for apical and 78.6% for anterior compartment prolapse in the LLS-TLH group; the respective rates were 100% and 74.1% in the LSC-TLH group. The subjective cure rate was 87.5% for the LLS-TLH group and 90% for the LSC-TLH group. No statistically significant differences between groups were found in the objective cure rate, subjective cure rate, or ICIQ-VS, ICIQ-SF, or PGI-I scores at 1 year (p > 0.05). CONCLUSIONS: LLS-TLH can serve as a safe, effective, and feasible alternative to LSC-TLH, with low complication rates and similar short-term objective and subjective outcomes.

Risk of uterine niche following single-layer locked versus unlocked uterine closure: a randomized study.

INTRODUCTION: The primary objective of the present study is to evaluate the effect of single-layer locked versus single-layer unlocked uterine closure techniques on the development of uterine niche. The secondary objective is to evaluate the effect of the ratio of lower uterine segment (LUS) to upper uterine segment (UUS) on the development of uterine niche, which was not previously investigated in literature but which the authors consider to be a major risk factor for the development of uterine niche. METHODS: Included in this randomized study were 194 patients who were admitted to the Department of Obstetrics and Gynecology at Health Sciences University Antalya Training and Research Hospital and who underwent cesarean section (CS) due to any reason between October 2017 and May 2018. Two different techniques were used in the closure of hysterotomy: Single-layer locked continuous suturing (Group 1) and single-layer unlocked continuous suturing (Group 2). During surgery, the thicknesses of the LUS and UUS were measured using a sterile scale prior to hysterotomy closure. The patients were evaluated for the development of uterine niche at postoperative six months by transvaginal ultrasound. RESULTS: Control transvaginal ultrasound performed at six months after surgery revealed uterine niches in 58 out of 194 patients (29.29%; 34 patients in Group 1 [34.3%] and 24 patients in Group 2 [25.3%]). No significant difference was noted in terms of the development of uterine niche between the two groups (p = .167). The mean LUS and UUS in patients without uterine niche development were 6.81 ± 1.26 mm and 9.38 ± 1.26 mm, whereas the mean LUS and UUS in patients with uterine niche development were 4.24 ± 1.15 mm and 9.21 ± 2.15, respectively (p = .001 and p = .236). The mean UUS/LUS ratio is 1.4 ± 0.16 among patients without uterine niche and 2.21 ± 0.31 in patients with uterine niche (p < .001). CONCLUSIONS: The present study found no statistically significant difference in niche size between the two groups. However, the study reports that the ratio of upper to lower uterine segment that was not previously investigated in literature is a major risk factor for the development of uterine niche.

Comparison of the effects of bilateral and unilateral laparoscopic ovarian drilling on pregnancy rates in infertile patients with polycystic ovary syndrome.

AIM: This study aims to investigate the effects of unilateral and bilateral laparoscopic ovarian drilling (LOD) on pregnancy rates in patients with clomiphene citrate (CC) resistant infertile polycystic ovary syndrome. METHODS: This prospective cohort study included 75 patients who were admitted to the Department of Obstetrics and Gynecology of the Antalya Training and Research Hospital between July 2016 and December 2017 and underwent LOD operation. Among these patients, 37 underwent unilateral laparoscopic ovarian drilling (ULOD) and 38 underwent bilateral laparoscopic ovarian drilling (BLOD). The drilling procedure was carried out using the following equation: Number of punctures (np) = 60 J/cm3 /30 watt × 4 s by selecting the larger ovary in the patients who underwent ULOD and by taking the ovarian volume of each ovary in the BLOD group. RESULTS: During the 1-year follow-up, 20 of the ULOD patients (54.1%) and 13 of the BLOD patients (34.2%) were observed to be pregnant. Although a higher number of pregnancies were obtained in the ULOD group, no statistically significant difference was found between the two groups (P = 0.083). The pregnancies occurred more in the first 6 months during the postoperative follow-ups of the patients. A total of 14 (70%) of the 20 pregnancies in the ULOD group and 9 (69.2%) of the 13 pregnancies in the BLOD group occurred in the first 6 months. CONCLUSION: ULOD with respect to a larger ovarian volume should be preferred to BLOD for CC-resistant PCOS patients because of the high pregnancy rates and fewer potential side effects.

Laparoscopic lateral suspension to treat neovaginal prolapse in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome: A rare case report.

Various methods have been described to treat neovaginal prolapse in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. In this case report, we describe neovaginal prolapse of a 21-year-old patient with MRKH syndrome which had been created by sexual intercourse dilation. Herein, the laparoscopic lateral suspension was performed for the surgical correction of neovaginal prolapse which is not available in the literature as far as we search. Prolapse was successfully corrected and vaginal length was provided at a sufficient length of 7 cm. Since after 1-year of operation, she has remained satisfied with her surgical outcome anatomically, sexually and psychologically. Laparoscopic lateral suspension is a safe and effective treatment in a patient who has neovaginal prolapse with MRKH syndrome and also can be used as a potentially alternative management in the treatment of neovaginal prolapse in patients with MRKH syndrome.

Awareness and practice of ergonomics by gynecological laparoscopists in Turkey.

OBJECTIVES: Ergonomics in laparoscopy has been gaining increasing attention. The research literature on ergonomics is growing worldwide; however, there are no studies or data from Turkey. Our study provides information on the awareness and use of ergonomics in laparoscopic gynecology in Turkey. MATERIAL AND METHODS: A questionnaire consisting of 25 questions was sent by email to 225 laparoscopists who are members of the Turkish Society of Gynecological Endoscopy. RESULTS: In response, 45.7% of the questionnaires were returned. Six respondents (5.9%) had never experienced pain, and two respondents (1.9%) always experienced pain during or after laparoscopy. The shoulders, neck, and back were the most common sites where respondents experienced pain. Most of the respondents (64.1%) utilized one monitor during laparoscopic surgery, and only 2% of respondents utilized a monitor below eye level. Less than 50% of the respondents were aware of ergonomic guidelines. CONCLUSIONS: Even though less than half of the Turkish gynecological laparoscopist respondents were aware of ergonomic guidelines, more than half used appropriate visual systems, operating tables, hand instruments, and had large enough operating rooms. Only the number and level of monitors used by respondents were not in accordance with ergonomic guidelines.

The rectal vaginal opacification with water and the antiperistaltic agent in magnetic resonance scanning of the intestinal endometriosis.

The diagnosis of deep intestinal endometriosis is mandatory to plan treatment and for follow-up; however, there is no consensus worldwide in the use of rectal/ vaginal opacification and anti-peristaltic agents for magnetic resonance imaging (MRI) scanning, being defined as an option for the examination. The transvaginal ultrasound images of previous MRI with the standard protocol, and recent MRI in our institution with rectal/vaginal opacification with water and the anti-peristaltic agent are presented in four cases for comparison, respectively. The technique in our institution seems to be more effective than routine pelvic MRI scans in the intestinal endometriosis.

Comparison of the efficacy and safety of two advanced vessel sealing technologies in total laparoscopic hysterectomy.

AIM: Adequately powered, randomized controlled studies evaluating efficacy and safety of advanced bipolar energy devices in gynecologic laparoscopic surgery are very few. We aimed to compare the two most commonly used devices in total laparoscopic hysterectomy. METHODS: This randomized controlled trial was carried out in the department of obstetrics and gynecology in an education and research hospital. One hundred thirty-two women who underwent total laparoscopic hysterectomy for benign indications were included. Women with age younger than 18 years, suspected malignancy, stage 3-4 endometriosis and cervical/intraligamentary leiomyoma were excluded. Patients were randomized preoperatively to LigaSure or Articulating Enseal. One experienced surgeon performed all operations. RESULTS: LigaSure was used in 67 patients and Enseal was used in 65 patients. Primary outcomes of the study were operative time (time from start of sealing and transection of the round ligament until completion of colpotomy) and total operative time (time from skin incision to skin closure). Secondary outcomes were intraoperative blood loss (blood lost during operative time period) and perioperative complications. Operative time was significantly shorter in LigaSure group (P = 0.001). Total operative time, intraoperative blood loss and perioperative complications were similar. When two groups were further classified according to uterine weight taking 300 g as cut-off value, operative time was significantly shorter in LigaSure group in both subgroups (P = 0.003 and P = 0.007). CONCLUSION: LigaSure use in total laparoscopic hysterectomy shortens operative time when compared with Enseal; without an apparent increase in intraoperative blood loss and perioperative complications. On the other side, total operative time remains unaffected.

Modified Laparoscopic Lateral Suspension: The Mulayim Technique.

STUDY OBJECTIVE: To demonstrate a modified technique of laparoscopic lateral suspension for pelvic organ prolapse (POP). DESIGN: A video illustrating this modified technique of laparoscopic lateral suspension (Canadian Task Force classification III). SETTING: The benign gynecology department at a university hospital. INTERVENTIONS: Laparoscopic lateral suspension using mesh is a minimally invasive technique that effectively treats POP [1-4]. We present a modified technique of laparoscopic lateral suspension that differs from previously described methods [1-4]. The prominent differences are as follows: first, our modified technique uses Mersilene tape on a 48-mm round-bodied needle (Ethicon Inc, Somerville, NJ,USA). We suspend the vaginal vault, taking a double bite using Mersilene tape without knotting placed as a transversal hammock. Thanks to the Mersilene tape, meshes, sutures, tackers, or fasteners are not needed. Mersilene tape ensures much easier suturing and an inexpensive artificial material. The second difference is that port placement sites (Fig. 1). The third difference is the number of incisions we make (Fig. 1). We do not need 2 additional incisions as used in previously described methods references [1-4]. We use the same incision for lateral trocar insertion and for pulling out the distal end of the Mersilene tape, which is 2 cm above the iliac crest and 4 cm posterior to the anterior superior iliac spine (Fig. 1). Our technique has the potential to be easier, shorter, more cost-efficient, less invasive, and safer when compared with previously described methods. CONCLUSION: Modified laparoscopic lateral suspension, the so-called Mulayim technique, might be considered as an alternative treatment for POP surgery; however, studies should be conducted in a larger number of patients with longer postoperative follow-up periods (Fig. 1).

Do We Need Mechanical Bowel Preparation before Benign Gynecologic Laparoscopic Surgeries A Randomized, Single-Blind, Controlled Trial.

AIMS: The primary objective of this study was to compare the effect of mechanical bowel preparation (MBP) with oral sodium phosphate (NaP) solution vs. MBP with NaP enema vs. fasting only with respect to intraoperative visualization of the surgical field, ease of bowel handling, and overall ease of surgery in patients undergoing benign gynecologic laparoscopic procedures. METHODS: The patients were randomized into one of 3 groups: oral NaP, NaP enema, or fasting only. The primary surgeon and assistant(s) remained blinded to the randomization assignments. Intraoperative visualization of the surgical field, ease of bowel handling, and overall ease of surgery were assessed using a surgeon questionnaire based on Visual Analog Scales. RESULTS: We enrolled 293 women, of whom 278 were randomized to receive oral NaP solution (n = 96), undergo NaP enema (n = 92), or perform fasting only (n = 90). No significant differences were found between the 3 groups. CONCLUSIONS: No differences were observed among patients who underwent MBP with oral NaP or NaP enema and those without MBP, with respect to intraoperative visualization of the surgical field, ease of bowel handling, and overall ease of surgery. No benefit of MBP was found when removing large uteri or when operating on patients with a high body mass index.

The relationship between the umbilicus and the aortic bifurcation in Turkish women: implications for laparoscopic entry.

PURPOSE: We aimed to determine the location and vertical distance of the umbilicus relative to the aortic bifurcation using computed tomography (CT), and assess their relationship with BMI among Turkish women and their implications for laparoscopic entry. METHODS: This cross-sectional study included a total of 209 women undergoing abdominopelvic CT; the vertical distance between the aortic bifurcation and the umbilicus was evaluated on coronal sections. The distance between the skin and the parietal peritoneum was measured from the umbilical pit to the peritoneum, and the distance between the skin and the aorta was measured from the umbilical pit to the surface of the aortic bifurcation. The measurements were performed along the sagittal plane. The age, height, and weight of the patients were recorded. For comparison, women were divided into three groups according to BMI. RESULTS: The aortic bifurcation was located above (cephalic to) the umbilicus in 30 patients in the non-obese group (48.4%), 54 patients in the overweight group (55.7%), and 34 patients (68%) in the obese group. The mean distances between the umbilicus and the parietal peritoneum were 15.1 ± 6.4, 19 ± 5.5, 27.2 ± 10.8 mm, respectively, in the non-obese group, overweight group, and obese group. The mean distances between the umbilicus and the aorta were 85.8 ± 26.3, 110 ± 2.9, 132.1 ± 26.7 mm, respectively, in the non-obese group, overweight group, and obese group. CONCLUSIONS: The location of the umbilicus relative to the aortic bifurcation can vary according to age, BMI and ethnicity or nationality of patients; therefore, a surgeon should not stick to a particular angle of insertion during laparoscopic entry. It is better for surgeons to know their unique patient population.

Unaware of a large leiomyoma: A case report with respect to unusual symptoms of large leiomyomas.

INTRODUCTION: Uterine leiomyoma, which arises from uterine smooth muscle, is the most common benign gynecologic tumor of the female pelvis. Clinically, these leiomyomas are diagnosed in approximately 25% of women, the prevalence increases during reproductive age, decreases after menopause, and they are rare in adolescents. In addition to uterine leiomyoma, there are also extrauterine leiomyomas. PRESENTATION OF CASE: A 48-year-old multiparous woman visited our outpatient clinic for routine control. She had no symptoms or complaints. Her last health service visit was over 5 years ago, in which she was told that she had a small uterine leiomyoma, which did not require further management. Abdominal examination revealed a large mass extended above the umbilicus, and there was no abdominal tenderness. Abdominal ultrasonography showed a large solid mass occupying the abdomen. Routine laboratory test results were normal, except the hemoglobin level, which was 7.88 g/dl. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. The final diagnosis was a 17-cm, 3985-g intramural, myomatous, cellular leiomyoma that occurred without secondary changes, necrosis, cellular atypia, or mitosis. DISCUSSION: The most common presenting symptoms of large uterine leiomyomas are abnormal bleeding, dysmenorrhea, pelvic pain, and tumor bulk-related signs. Moreover, there are unusual symptoms or clinical manifestations such as acute edema, thrombosis, ulcer, plethora, calcified pelvic masses, hematometra, severe pulmonary hypertension, and respiratory failure; hence, they can be even life threatening. CONCLUSION: Patients might have no symptoms or might be unaware of the presence of a large uterine leiomyoma, as in our case; however, large leiomyomas have various unusual symptoms in addition to the common ones. These symptoms should not be disregarded or underestimated.

Effects of amifostine on endometriosis, comparison with N-acetyl cysteine, and leuprolide as a new treatment alternative: a randomized controlled trial.

PURPOSE: To assess the effects of amifostine, N-acetyl cysteine (NAC), and leuprolide as a scavenger in a rat endometriosis model. METHODS: This is a prospective randomized animal study. Setting The Animal Laboratory of Medical University. Animals 40 rats were used for transplantation of an autologous fragment of endometrial tissue onto the inner surface of the abdominal wall. After allowing 3 weeks for growth, laparotomies were performed to check the implants. Then animals were randomized into four groups: Group I amifostine (200 mg/day loading dose after 20 mg/kg/day, p.o.); Group II NAC (200 mg/day, p.o.); Group III leuprolide acetate 1 mg/kg single dose, sc; and Group IV (controls) no medication. Three weeks later, implants were evaluated morphologically. Serum and peritoneal TNF-alpha levels were evaluated. The transmission electron microscopic examination of the peritoneal samples and ovaries was also performed. RESULTS: Leuprolide acetate, amifostine and NAC caused significant decreases in the mean implant areas and significant decreases in serum and peritoneal TNF-alpha levels. On comparing all groups, these reductions were higher in Group II. According to the transmission electron microscopic findings, leuprolide seems to be protecting normal structure of peritoneum best when compared to the other groups. CONCLUSIONS: Amifostine, NAC and leuprolide caused regression of endometriosis in this experimental rat model by a yet unsettled mechanism.

Sublingual misoprostol for cervical ripening before diagnostic hysteroscopy in premenopausal women: a randomized, double blind, placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of sublingual misoprostol for cervical ripening before diagnostic hysteroscopy in premenopausal women. DESIGN: Placebo-controlled, double-blind, randomized trial. SETTING: University hospital. PATIENT(S): Fifty-two women with an indication for diagnostic hysteroscopy. INTERVENTION(S): Randomized women who had received either 200 mug of misoprostol (n = 25) or placebo (n = 27) sublingually 2 hours before hysteroscopy. Two subgroups (women with or without previous vaginal delivery) were formed. MAIN OUTCOME MEASURE(S): Number of women requiring cervical dilatation, duration of dilatation, ease of dilatation, and complications during procedure. RESULT(S): In the misoprostol group, 14 patients needed cervical dilatation, versus 21 in the placebo group. Duration of dilatation was longer in the placebo group than in the misoprostol group. In subgroup 1, seven patients in the misoprostol group (n = 13) and nine patients in the placebo group (n = 12) needed cervical dilatation. The duration of the dilatation was similar between the groups. In subgroup 2, both the need for cervical dilatation (58.3% vs. 80.0%) and the duration of dilatation (31.0 +/- 18.8 vs. 73.0 +/- 82.0 seconds) were found to be lower in the misoprostol (n = 15) than in the placebo (n = 12) group, respectively. Those differences were all not significant. CONCLUSION(S): Sublingual misoprostol before diagnostic hysteroscopy did not seem to facilitate cervical ripening statistically; however, the results are remarkable and are promising clinically. Further studies are required to reassess the use of sublingual misoprostol in patients before hysteroscopy.

Pubertal failure and primary amenorrhea with uterine hypotrophy due to hypogonadotropic hypogonadism.

BACKGROUND: Primary amenorrhea can be a sign of either delayed puberty or Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. CASE: A virgin 27-year-old woman with pubertal failure, primary amenorrhea, and uterine hypotrophy due to hypogonadotropic hypogonadism sought treatment at our institution. She was diagnosed as having MRKH syndrome 10 years ago at another institution after pelvic ultrasonography revealed no uterus or ovaries. Unfortunately, no further investigations had been made or treatments implemented during the ensuing decade. SUMMARY AND CONCLUSION: In female patients in whom the uterus cannot be visualized with ultrasonography, magnetic resonance imaging and/or laparoscopy should be considered to ensure that the diagnosis is correct. Besides further imaging, hormonal assessment and breast development should always be initially considered for the diagnosis of delayed puberty and MRKH syndrome.

Doxycycline causes regression of endometriotic implants: a rat model.

BACKGROUND: Doxycycline (Dox) has a number of non-antibiotic properties. One of them is the inhibition of matrix metalloproteinase (MMP) activity. The aim of this study was to assess the effects of Dox in a rat endometriosis model. METHODS: Endometriosis was surgically induced in 40 rats by transplanting of endometrial tissue. After 3 weeks, repeat laparotomies were performed to check the implants and the animals were randomized into four groups: Group I, low-dose Dox (5 mg/kg/day); Group II, high-dose Dox (40 mg/kg/day); Group III, leuprolide acetate 1 mg/kg single dose, s.c.; and Group VI (controls), no medication. The treatment, initiated on the day of surgery and continuing for 3 weeks, was administered to the study groups. Three weeks later, the rats were euthanized and the implants were evaluated morphologically and histologically for immunoreactivity of MMP-2 and -9, and interleukin-6 (IL-6) concentration in the peritoneal fluid was assayed. RESULTS: Treatment with leuprolide acetate, or high-dose or low-dose Dox caused significant decreases in the implant areas compared with the controls (P = 0.03, P = 0.006, and P = 0.001, respectively). IL-6 levels in peritoneal fluid decreased in Group I (P = 0.02) and Group III (P < 0.05). MMP H scores were significantly lower in the group that received low-dose Dox in both epithelial and stromal MMP-2 and -9 immunostaining when compared with the control group [P = 0.048, P = 0.002, P = 0.007 and P = 0.002, respectively, MMP-2 (epithelia), MMP-2 (stroma), MMP-9 (epithelia) and MMP-9 (stroma)]. CONCLUSIONS: Low-dose Dox caused regression of endometriosis in this experimental rat model.