Retrograde Bladder Filling after Laparoscopic Gynecologic Surgery: A Double-blind Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate whether retrofilling the bladder on completion of elective laparoscopic gynecologic surgery for benign indications has an effect on the timing of the first postoperative void and the timing of discharge from the hospital. DESIGN: Double-blind randomized controlled trial. SETTING: Single academic surgical day hospital. PATIENTS: Patients undergoing outpatient laparoscopic gynecologic surgery, excluding hysterectomy or pelvic reconstructive surgery. INTERVENTIONS: On completion of surgery, patients were randomized to either retrograde filling of the bladder with 200 mL of saline before catheter removal or standard care (immediate catheter removal). Patients and postanesthesia care unit nurses (outcome assessors) were both blinded. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the time to first void. The secondary outcomes were time to hospital discharge, postoperative urinary tract infection, and patient satisfaction. Over a 3-month period, 47 patients were approached on the day of surgery, 42 consented and were randomized (21 to intervention and 21 to control). There were no significant differences in baseline demographics between the groups. The median time to first void was significantly shorter for patients in the intervention arm than controls (104 ± 75 minutes vs 162 ± 76 minutes, p <.001). Patients who had retrofilled bladders were discharged faster from post-anesthesia care unit compared to controls (155.0 ± 74 minutes vs 227 ± 58 minutes, p = .001). There were no urinary tract infections in either group, and the proportion of satisfied or very satisfied patients was high (93.8% vs 88.2%, p = .512). CONCLUSION: Retrograde filling of the bladder after outpatient laparoscopic gynecologic surgery is a safe, effective method that significantly reduces the length of hospital stay.

Dienogest and the Risk of Endometriosis Recurrence Following Surgery: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: To determine whether dienogest therapy after endometriosis surgery reduces the risk of endometriosis recurrence compared with expectant management. DATA SOURCES: Ovid MEDLINE, Ovid EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov, and International Standard Randomized Controlled Trial Number Registry were searched from inception to March 2019 for observational and randomized controlled trials. METHODS OF STUDY SELECTION: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Medical Subject Heading terms and keywords such as "dienogest," "endometriosis," and "recurrence" were used to identify relevant studies. TABULATION, INTEGRATION, AND RESULTS: The search yielded 328 studies, 10 of which were eligible for inclusion, representing 1184 patients treated with dienogest and 846 expectantly managed controls. Among these studies, 9 looked exclusively at endometrioma recurrence, whereas 1 used reappearance of symptoms as evidence of disease recurrence. Data on both incidence of and time to recurrence of endometriosis were extracted. The incidence rate of endometriosis recurrence in patients treated with dienogest was 2 per 100 women over a mean follow-up of 29 months (95% confidence interval [CI], 1.43-3.11) versus 29 per 100 women managed expectantly over a mean follow-up of 36 months (95% CI, 25.66-31.74). The likelihood of recurrence was significantly reduced with postoperative dienogest (log odds -1.96, CI, -2.53 to -1.38, p <.001). CONCLUSION: Patients receiving dienogest after conservative surgery for endometriosis had significantly lower risk of postoperative disease recurrence than those who were expectantly managed.

Uterine dehiscence: a laparoscopic uterine repair in early pregnancy.

OBJECTIVE: To review the existing literature on uterine cesarean scar defect repair in pregnancy and describe an approach to minimally invasive surgical repair in early pregnancy to facilitate a term live birth. DESIGN: A case study and literature review, followed by a demonstration of the procedure with surgical video and concurrent ultrasound footage. SETTING: Academic medical center. PATIENT(S): This video is a case presentation of a 35-year-old, gravida 2, para 1 woman with a previous cesarean section. She presented at 10 weeks and 3 days gestational age with complete uterine dehiscence at the site of her previous cesarean section scar, which was diagnosed by ultrasound. Surgical video and medical images have been extracted from this patient's chart after consent was obtained. INTERVENTION(S): Ultrasound-guided laparoscopic repair of cesarean scar defect at 11 weeks and 3 days of gestation. MAIN OUTCOME MEASURE(S): The video showed a large 2.6-cm uterine scar defect in early pregnancy confirmed using ultrasound and magnetic resonance imaging. This diagnosis was confirmed by direct visualization at the time of surgery. This video demonstrates our surgical approach as follows: careful uterine manipulation and identification of the defect with laparoscopy and concurrent transvaginal ultrasound; reflection of the bladder using an ultrasound-guided approach to confirm the borders of the defect; and repair with a running 2-layer closure under transvaginal ultrasound guidance. RESULT(S): Through ultrasound-guided laparoscopic repair, we were able to demonstrate a restoration of approximately 8 mm of myometrial thickness across the cesarean scar defect on antenatal follow-up. The patient had a term live birth via cesarean section. CONCLUSION(S): With an increased number of cesarean sections and improved quality of ultrasound imaging, an increase in the incidental findings of cesarean scar defects has been observed. The risk of spontaneous prelabor uterine rupture remains unknown. There is a literature gap in this area regarding the appropriate standard of care. This video demonstrates that ultrasound-guided laparoscopic repair was possible, safe, and effective in our patient. However, further studies are required to establish the safety and efficacy of this approach.

Sex differences in force steadiness in three positions of the forearm.

The purpose of this study was to examine force steadiness in three positions of the forearm in young men and women across a variety of force levels. Eight young men and eight young women performed three maximum voluntary contractions (MVCs) in the neutral, supinated, and pronated forearm positions. Viewing a target line on a computer screen, subjects performed submaximal isometric contractions relative to their own MVC at 2.5, 5, 10, 25, 50, and 75% in each of the three forearm positions. Force steadiness was determined as the coefficient of variation (standard deviation around the mean force). A repeated-measures three-way ANOVA was used to assess the differences in force steadiness between sex, position, and force level. Men were stronger than women in all three forearm positions. Overall, men were steadier than women across all force levels and forearm positions. The neutral and supinated positions were equally strong and steady, and the pronated position was the weakest and least steady position. The forearm was most steady between 25 and 75% MVC, and least steady at the lower force levels. When correlations were run between MVC and coefficient of variation at all force levels and all forearm positions, a strong negative relationship was found (r = -0.49). In conclusion, men were stronger, as well as steadier, than women. The neutral and supinated forearm positions were both stronger and steadier than the pronated position. Results suggest that one of the primary factors influencing sex differences in force steadiness is absolute strength.

Utility of portable electromyography for quantifying muscle activity during daily use.

BACKGROUND: Mobility has been studied using performance, questionnaire, pedometer and accelerometer measures, but these tools do not provide information about muscle activity. To better understand mechanisms associated with movement impairment as they relate to function, it is valuable to quantify muscle activity during everyday activities. OBJECTIVE: This report presents electromyography (EMG) during daily activities from the affected and unaffected limbs of a 74-year-old man who survived a stroke 12 years ago, compared to 7 older healthy men who had not experienced a stroke. METHODS: The biceps brachii, triceps brachii, quadriceps and hamstring muscles were recorded continuously for one 8-hour session in the unaffected limbs of the stroke survivor and control subjects. On a second day, EMG from these same muscles of the affected side was recorded for 4 h. Bursts (amplitude >2% maximum effort, duration >0.1 s) and gaps (amplitude <1% maximum effort, duration >0.1 s) of EMG were quantified for the number of times they occurred, mean event duration (seconds), mean peak amplitude (percent maximum voluntary efforts) and rate of activity (event activity/second). RESULTS: Burst and gap patterns of the unaffected limb muscles were similar between the stroke survivor and controls. Increased numbers of bursts (approx. 40%) and gaps (approx. 44%) were seen in the subject's lower limb muscles of his affected versus unaffected side. Biceps brachii burst activity of the affected limb was increased, whereas triceps brachii burst activity was decreased. These muscle activity changes in the affected limb suggest that the triceps brachii was relatively inactive and the biceps brachii and lower limb muscles were active in an 'on' and 'off' pattern. CONCLUSION: Muscle activity in the unaffected limb of the stroke survivor was similar compared to control subjects, but the affected limb differed from the unaffected after stroke. Portable EMG to monitor muscle activity for prolonged periods was not reported to be an impediment by the case or control subjects. Using this technology, EMG bursts and gaps can be recorded and used to describe muscle activity. Future work may consider the feasibility of this technique to monitor rehabilitation progression or long-term plasticity of muscle activity.

Age-related increase in electromyography burst activity in males and females.

The rapid advancement of electromyography (EMG) technology facilitates measurement of muscle activity outside the laboratory during daily life. The purpose of this study was to determine whether bursts in EMG recorded over a typical 8-hour day differed between young and old males and females. Muscle activity was recorded from biceps brachii, triceps brachii, vastus lateralis, and biceps femoris of 16 young and 15 old adults using portable surface EMG. Old muscles were active 16-27% of the time compared to 5-9% in young muscles. The number of bursts was greater in old than young adults and in females compared to males. Burst percentage and mean amplitude were greater in the flexor muscles compared with the extensor muscles. The greater burst activity in old adults coupled with the unique activity patterns across muscles in males and females provides further understanding of how changes in neuromuscular activity effects age-related functional decline between the sexes.