Fully percutaneous fetoscopic repair of myelomeningocele: 30-month follow-up data.

OBJECTIVE: This observational study reports on the postnatal mortality and 30-month outcome of children who underwent fully percutaneous fetoscopic repair of myelomeningocele (MMC) at a single center in Giessen, Germany. METHODS: Between October 2010 and August 2014, a total of 72 patients underwent fully percutaneous fetoscopic MMC closure at 21 + 0 to 29 + 1 (mean, 23 + 5) weeks' gestation. Of these, 52 (72%) participated in this study; however, 30-month mortality data are available for all 72 children. Children were examined at four timepoints: shortly after birth and at 3 months, 12 months and 30 months of corrected age. The patients underwent age-specific standardized neurological examinations and assessment of leg movements and ambulation at all timepoints. Cognitive and motor development were assessed using the Bayley Scales of Infant Development, second edition (BSID-II), at 30 months. RESULTS: All 72 children survived the intrauterine procedure, however, four (5.6%) infants died postnatally (including two of the 52 comprising the study cohort). Of the 52 patients included in the study, 11.5% were delivered before the 30th week of gestation (mean, 33 + 1 weeks) and, of the survivors, 48.1% had ventriculoperitoneal shunt placement. Of the 50 infants that were alive at 30 months, independent ambulation, without orthosis, was feasible for 46%. At 30 months of follow-up, 46% of children presented with a functional level that was at least two segments better than the anatomical level of the lesion. At 30 months, 70% of the children presented with BSID-II psychomotor development index score of ≥ 70 and 80% with BSID-II mental development index score of ≥ 70. CONCLUSION: Intrauterine repair of MMC by percutaneous fetoscopy shows largely similar outcomes to those reported for open repair, with respect to mortality, prematurity, shunt-placement rates, motor and mental development and free ambulation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

MRI technique for the preoperative evaluation of deep infiltrating endometriosis: current status and protocol recommendation.

Endometriosis is a common cause of chronic pelvic pain and infertility. It is defined as the occurrence of endometrial tissue outside the uterine cavity and can manifest as a peritoneal, ovarian or infiltrating form, the latter being referred to as deep infiltrating endometriosis (DIE). Surgery is essential in the treatment of DIE and depending on the severity of the disease, surgery can be difficult and extensive. Beside clinical examination and ultrasound, magnetic resonance imaging (MRI) has proven its value to provide useful information for planning surgery in patients with suspected DIE. To optimise the quality of MRI examinations, radiologists have to be familiar with the capabilities and also the limitations of this technique with respect to the assessment of DIE. MRI yields morphological information by using mainly T1- and T2-weighted sequences, but can also provide functional information by means of intravenous gadolinium, diffusion-weighted imaging or cine-MRI. In this article, these techniques and also adequate measures of patient preparation, which are indispensable for successful MRI imaging for the preoperative evaluation of DIE, are reviewed and a comprehensive protocol recommendation is provided.

Percutaneous minimal-access fetoscopic surgery for spina bifida aperta. Part II: maternal management and outcome.

OBJECTIVE: To assess maternal morbidity and outcome in women undergoing minimal-access fetoscopic surgery for spina bifida aperta. METHODS: This was a retrospective study of 51 women undergoing minimal-access fetoscopic surgery to improve postnatal neurological outcome of spina bifida aperta, at a mean gestational age of 24 weeks, at our center between July 2010 and June 2013. We analyzed various perioperative complications of surgery, namely: maternal and fetal death, need for maternal blood transfusion, placental abruption, pulmonary edema, spontaneous labor, oligohydramnios, chorioamnionitis, chorioamniotic membrane separation, duration of hospitalization, amniotic fluid leakage, gestational age at delivery and status of hysterotomy site. RESULTS: In none of the 51 women was there maternal demise, spontaneous labor, placental abruption or a need for maternal blood transfusion in the perioperative period. Chorioamniotic membrane separation occurred in one patient, mild pulmonary edema occurred in one and oligohydramnios occurred in seven. All fetuses survived surgery, but there was one very early preterm delivery 1 week after the procedure and this neonate died immediately, from early postoperative chorioamnionitis. Amniotic fluid leakage occurred in 43 patients, at a mean gestational age of 29.7 (range, 22.6-37.3) weeks; two of these patients developed chorioamnionitis. Duration of maternal hospitalization after surgery was 7.2 (range, 4-12) days. Mean gestational age at delivery was 33 (range, 24.6-38.1) weeks. All abdominal and uterine trocar insertion sites healed well. CONCLUSION: Minimal-access fetoscopic surgery for spina bifida aperta is apparently safe for most maternal patients. Despite the common occurrence of amniotic leakage, the majority of women deliver beyond 32 weeks of gestation.

The analysis of the human plasma N-glycome in endometriosis patients.

OBJECTIVE: Analysis of the plasma N-glycome in endometriosis patients compared with controls. STUDY DESIGN: In a case-control study, blood samples were collected from patients who underwent either diagnostic or operative laparoscopy between 2008 and 2011 in the Semmelweis University, Budapest, I. Department of Obstetrics and Gynaecology. From these patients, 92 with endometriosis (30 stage I-II and 62 stage III-IV, including altogether 18 deep infiltrating cases) and 62 controls were selected for glycan analysis. After release, plasma N-glycans were subjected to hydrophilic interaction high performance liquid chromatography, which resulted in 19 chromatographic glycan peaks (GP). The abundances of the GPs were compared between the study groups. For statistical analysis a non-parametric test, the Mann-Whitney-U test, was used. RESULTS: We found a statistically significant decrease of GP1 and increase of GP14, GP17 and GP18 in endometriosis patients. The latter peaks consist of glycans which play a role in inflammatory processes and malignancy. We also found significant differences in GP2, GP4, GP6, and GP9 between controls and the different endometriosis stage groups. The observed alterations in GP2, GP4 and GP6 may be related to altered glycosylation and remodelling of the glycan branches of the IgG molecule. The alterations of GP9 are presumably associated with changes of transferrin glycosylation. Furthermore we detected a highly significant decrease of GP1 in patients with deep infiltrating endometriosis compared with controls. CONCLUSIONS: This is the first analysis of the plasma N-glycome in endometriosis. The observed changes in GP14, GP17 and GP18 and in GP2, GP4, GP6 and GP9 provide new aspects to the pathophysiology of the disease and the alterations of the GP1 may serve as a new potential marker in the future.

A new variable-view rigid endoscope evaluated in advanced gynecologic laparoscopy: a pilot study.

BACKGROUND: This pilot study aimed to evaluate the optical performance and clinical handling of a new variable-view rigid endoscope with angulation from 0 º to 120 º in gynecologic laparoscopic surgery. METHODS: The EndoCAMeleon endoscope was assessed by experienced surgeons and assistants during a variety of advanced gynecologic laparoscopic procedures. After each procedure, both the surgeon and the assistant each completed questionnaires designed to assess the endoscope's ease of handling and optical performance. RESULTS: The endoscope was assessed during 21 advanced procedures. Questionnaire responses confirmed surgeon and assistant satisfaction with the mechanical handling and vision provided by the endoscope. In particular, the ability to vary the viewing angles enabled the surgeon to visualize the surgical site without moving the endoscope shaft. CONCLUSIONS: The new endoscope performed well in the hands of experienced surgeons and assistants undertaking advanced procedures. The variable-view rigid endoscope allows the use of visual ports during primary port entry and enhances vision. Further study is required to evaluate its performance in routine practice.

Transvaginal NOTES with semi-rigid and rigid endoscopes that allow adjustable viewing angles.

PURPOSE: To evaluate semi-rigid and rigid endoscopes for transvaginal NOTES surgery. METHODS: One rigid endoscope (EndoCAMeleon, KARL STORZ GmbH & Co. KG, Tuttlingen Germany) and one semi-rigid endoscope (EndoEYE LTF-VH, Olympus Deutschland GmbH, Hamburg, Germany) that allow adjustable viewing angles have been used during four transvaginal gynecological NOTES procedures for chronic pelvic pain and infertility. RESULTS: Feasibility of transvaginal access to enter the abdominal cavity was shown. Posterior peritoneum, ovaries and tubal patency were evaluated. The evaluated endoscopes did not overcome the inability to explore the anterior pelvic structures. CONCLUSIONS: Rigid and semi-rigid endoscopes that allow adjustable viewing angles during transvaginal NOTES approaches cannot explore the whole pelvic anatomical structures.

Establishing transvaginal NOTES for gynecological and surgical indications: benefits, limits, and patient experience.

Gynecologists have been performing transvaginal surgery for over a century and consequently the transvaginal approach was advocated for establishing natural orifice transluminal endoscopic surgery (NOTES) in gynecological and surgical practice. From 2008 the NOTES alternative has been offered to selected patients. Transvaginal cholecystectomies were intended in 13 patients and completed in 12. Various additional procedures were performed. All surgical procedures and postoperative courses were uneventful. The mean operating time for transvaginal cholecystectomy only was 88.4 minutes (standard deviation [SD] 17.3). A questionnaire was posted to the patients after a mean follow-up of 8.5 months. Patients primarily chose transvaginal NOTES because of the lack of scarring. Vaginal sensation was not affected. Patients perceived transgastric, transvesical, and transrectal surgery to be less acceptable approaches. The feasibility of transvaginal NOTES was proven for different indications. Patients' experiences and perceptions concerning transvaginal NOTES were excellent.

Uterine surgery in postpartum hemorrhage.

Uterine atony accounts for the majority of primary postpartum hemorrhage. Timely recognition and intervention are fundamental in preventing serious maternal morbidity and mortality. Combinations of conservative manual and medical therapies are adequate and successful treatment options in most cases. However, when the hemorrhagic process continues and when either clotting abnormalities or hemodynamic instability develop, the next step must be an invasive intervention. Depending on the mode of delivery a vaginal approach (i.e. curettage and uterine packing) after spontaneous delivery or an abdominal surgical approach (i.e. compression sutures and systematic devascularization) after a Cesarean delivery can be performed. Uterine compression sutures are especially highly effective and a straightforward and easy emergency procedure which conserves fertility. The ultima ratio in all cases of persistent haemorrhage after conservative and uterus preserving surgical therapy is the emergent hysterectomy. It might be of advantage to perform a subtotal or supracervical hysterectomy compared to a total hysterectomy in an emergency setting.

Uterine compression U-sutures in primary postpartum hemorrhage after Cesarean section: fertility preservation with a simple and effective technique.

BACKGROUND: Transmural uterine compression suturing methods are a fertility-preserving alternative in patients with atonic primary postpartum hemorrhage (PPPH), which does not respond to manual compression or drugs. This study evaluated the effectiveness of a modified U-suturing technique in effecting uterine compression in patients with PPPH after Cesarean section. METHODS: U-suture uterine compression was introduced at our hospital at the beginning of 2005. The medical records of patients with PPPH after Cesarean section who had undergone this treatment, and results of a follow-up and questionnaire were evaluated and our experience with this method was reviewed. RESULTS: Between January 2005 and September 2007, seven patients underwent uterine compression with U-sutures after PPPH. In all cases, treatment was successful, the hemorrhage was controlled and the uterus preserved. Normal menstruation patterns returned in the five patients who returned the questionnaire and no surgery related morbidities were noted at the follow-up examinations of six patients. The technique was simple to perform in an emergency situation. CONCLUSIONS: Uterine compression with U-sutures is a highly effective and straightforward emergency procedure which conserves the uterus in these patients.

Multiple machine implementation of enhanced dynamic wedge.

PURPOSE: After acquiring 4 years of experience with Dynamic Wedge, a software-driven one-dimensional (1D) compensation system, we implemented a new software version called Enhanced Dynamic Wedge (EDW). The EDW allows larger (30 cm) and asymmetric field sizes and additional angles for wedged fields. We implemented this software on four similar dual-energy accelerators that also possess upper and lower physical wedge sets. Our goal was to implement EDW with one common wedge factor (WF) table and one set of treatment-planning files. METHODS AND MATERIALS: We measured WFs with an ionization chamber and isodose profiles with both film and a diode array. We used a calculation scheme that requires only entry of the wedge angle and fixed jaw value. Filters for computerized treatment planning were configured for each wedge angle. We also examined to what degree the multileaf collimation (MLC) orientation, which is orthogonal to the EDW direction, was compromised for specific treatment sites. As a comparative test, we examined the dosimetric consistency for the 8 sets of physical wedges on the four machines. Finally, we updated our DW quality assurance program for EDW. RESULTS: The measured EDW WF was common for all four machines to within +/- 1.5% and the calculation scheme held to within 1.5%. The EDW isodoses were consistent among the machines as measured by film and diode array. The treatment-planning filters provided computed isodose profiles that were nearly identical to measured profiles. Regarding MLC orientation, we found that the collimator angle needed for EDW did not compromise isodose distributions, as apparent in measured isodoses and calculated dose-volume histograms. The consistency of the physical wedges did not fare as well. Two of the lower wedge sets had Wfs and profiles different (> 3%) from the other wedge sets. CONCLUSIONS: We have successfully implemented EDW on four machines using only one WF table and one set of treatment-planning filters. The EDW provides for improved treatment techniques for particular sites due to the large field sizes and additional angles available. Daily treatment efficiency has increased because of the remote capability provided by EDW.