Robotic-Assisted Laparoscopic Trachelectomy: A Standard Technique.

STUDY OBJECTIVE: To describe a standard reproducible technique for simple robotic- assisted laparoscopic trachelectomy. DESIGN: Step-by-step demonstration of the technique using videos and pictures (Canadian Task Force classification level 3). SETTING: The incidence of trachelectomy after supracervical hysterectomy has been increasing, given the popularity of supracervical hysterectomy. The most common indication for trachelectomy is symptomatic cyclic bleeding. Trachelectomy can be performed vaginally as well as laparoscopically with or without robotic assistance. This video demonstrates a standard reproducible technique for robotic-assisted trachelectomy in 2 women who underwent previous supracervical hysterectomy with a retained cervix. INTERVENTIONS: Robotic-assisted laparoscopic trachelectomy using a standard technique is demonstrated in 2 different examples. The steps include opening the vesicocervical peritoneum, creating a bladder flap and pushing the bladder down beyond the vaginal cuff, opening the remnant of the broad ligament and delineating the course of cervical branch of the uterine artery and ureter bilaterally, inserting a uterine manipulator with a colpotomizer under vision, performing desiccation of the cervical branches of the uterine artery, and performing colpotomy and closure of the vaginal cuff. CONCLUSION: Robotic-assisted laparoscopic trachelectomy is a safe and simple procedure that should be part of all general gynecologists' armamentarium. The described technique is reproducible and efficient and can be adopted for all cases requiring simple trachelectomy.

Technique for the Laparoscopic Management of a Cornual Ectopic Pregnancy.

STUDY OBJECTIVE: To describe a technique for the laparoscopic management of a cornual ectopic pregnancy. DESIGN: Step-by-step explanation of the procedure using video (Canadian Task Force classification III). SETTING: Cornual pregnancy is a rare form of ectopic pregnancy, accounting for up to 2% to 4% of all ectopic pregnancies, with a mortality range of 2.0% to 2.5%, and this accounts for 20% of all deaths caused by ectopic pregnancies. Both medical and surgical treatments have been reported. Although laparotomy hysterectomy and cornuectomy used to be the preferred surgical approaches, more cornual ectopic pregnancies are being managed with the laparoscopic approach through cornuostomy or cornuectomy in recent years. The main concern with surgical treatment is hemorrhage and the need for cornual reconstruction, which necessitate advanced laparoscopic skills and technique. INTERVENTIONS: In this video, we describe our technique for the treatment of a cornual ectopic pregnancy. We present the case of a 21-year-old G3P2002 (gravida 3 para 2002) with the finding of a right live cornual ectopic pregnancy with gestational age of 6 weeks on pelvic ultrasound along with an elevated human chorionic gonadotropin level at 7,192 and right pelvic pain. After counseling regarding treatment options, the patient agreed with proceeding with surgery and underwent a laparoscopic right cornuectomy. Her surgery was uneventful, and she was discharged home a few hours after surgery. She was completely recovered at her postoperative follow-up visit. Her serial serum human chorionic gonadotropin levels were followed until complete resolution a few weeks later. CONCLUSION: Laparoscopic cornuectomy is a safe and effective procedure for the management of cornual ectopic pregnancy. The use of hemostatic agents and suturing can help prevent hemorrhage and allows a safe removal of the ectopic pregnancy and repair of the uterine defect created.

Technique for the Laparoscopic Removal of Essure Microinserts.

STUDY OBJECTIVE: To describe our technique for the laparoscopic removal of Essure microinserts (Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ). DESIGN: Step-by-step explanation of the procedure using video (Canadian Task Force classification III). SETTING: Hysteroscopic sterilization using tubal microinsert devices has generally been reported to be well tolerated in terms of procedure-related pain. Persistent pelvic pain requiring microinsert removal has been described in a few case reports and series and was estimated at 0.16% of cases (7 cases [49/4,274]) in a large retrospective study. Removal is usually performed at the patient's request and/or because of persistent pelvic pain unresponsive to other treatments with no other etiologies found. In general, the pain starts at the initial insertion and persists thereafter. Both laparoscopic and hysteroscopic removal approaches have been described in the few cases reported. INTERVENTIONS: In this video, we describe our technique for the surgical management of pelvic pain resulting from Essure microinserts. We performed laparoscopic removal of bilateral Essure microinserts in a 30-year-old G3P3 (Gravida 3 Para 3) with bilateral Essure devices placed 2 years before the procedure; hysterosalpingogram confirmed appropriate placement. The patient was suffering from bilateral sharp pelvic pain since insertion that was related to positional change and movements but unrelated to periods along with menorrhagia. A pelvic ultrasound showed a small intramural uterine leiomyoma. She failed a trial of treatment of her symptoms with a levonorgestrel intrauterine device. The patient requested removal of her Essure microinserts and endometrial ablation. She underwent laparoscopic bilateral Essure microinsert removal and bilateral salpingectomy along with hysteroscopic removal of the levonorgestrel intrauterine device and endometrial ablation. Her surgery was uneventful, and she was discharged the day of the surgery. Her symptoms resolved completely after the procedure. CONCLUSION: Laparoscopic removal of Essure microinserts in the context of persistent pelvic pain after insertion is a feasible and effective procedure and allows the avoidance of performing a hysterectomy when the patient declines this procedure. Sound knowledge of the Essure components and meticulous surgical technique are paramount for successful results.

Robotic-assisted Laparoscopic Repair of a Cesarean Section Scar Defect.

STUDY OBJECTIVE: To describe our technique for the repair of a cesarean section uterine scar defect after removal of an ectopic pregnancy from the scar in a patient desiring future pregnancies. DESIGN: Step-by-step explanation of the procedure using video (Canadian Task Force classification III). SETTING: Uterine scar dehiscence/defect is a known complications of multiple cesarean deliveries that can result in abnormal bleeding, infertility, and cesarean scar ectopic pregnancy. With the increasing number of cesarean sections performed in the United States, the prevalence of this complication is rising. Nonetheless, there currently are no standardized surgical treatment guidelines available to manage this pathology through a minimally invasive approach. INTERVENTIONS: In this video, we describe our technique for the surgical management of a symptomatic cesarean section scar defect. We performed a robotic-assisted laparoscopic repair of this defect in a 40-year-old G4P3013 with a recent cesarean section scar ectopic pregnancy managed by endometrial curettage, with subsequent persistent abnormal vaginal bleeding. A repeat ultrasound revealed a low uterine segment defect consistent with dehiscence. She was referred to us because she desired a conservative treatment given her desire for future pregnancies. The defect was localized by hysteroscopy and laparoscopy after developing the bladder flap. The scar tissue around the defect was resected, and the freshened edges of the defect were closed using delayed absorbable suture. Chromopertubation confirmed the watertightness of the repair. Postoperatively, the patient had regular normal periods, and her hysterosalpingogram didn't show any uterine defect. CONCLUSION: Robotic-assisted laparoscopic repair of cesarean section scar defect is a feasible and safe procedure when done with respect to anatomy and following sound surgical technique. With the increasing number of cesarean sections, gynecologists will be dealing with this pathology more frequently, and need to become more familiar with different techniques that can be helpful in performing such a repair.

Leiomyomas beyond the uterus; benign metastasizing leiomyomatosis with paraaortic metastasizing endometriosis and intravenous leiomyomatosis: a case series and review of the literature.

Uterine leiomyomas affect 20-30 % of women 35 years and older. Extrauterine leiomyomas are rare and present a greater diagnostic challenge. Those unusual growth patterns occur more often in women of reproductive age with a history of hysterectomy or surgery for uterine leiomyomas. They have been reported in the literature in case reports and small case series and include benign metastasizing leiomyoma (BML), disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis (IVL), parasitic leiomyomas, and retroperitoneal growth. In this case series we present a case of BML with a first report of concomitant endometriosis metastasis to paraaortic lymphnodes, and a case of IVL. The findings and surgical management of those cases, as well as a review of the literature pertinent to those entities, are also presented.

Maldescended ovary associated with Müllerian and kidney dysgenesis: a case report.

BACKGROUND: Maldescended ovary is a rare entity which has been associated with Müllerian and kidney dysgenesis. It can be discovered incidentally during a workup for pelvic or abdominal pain or an infertility workup. While MRI is the best diagnostic tool for the discovery of this entity, it can also be discovered using pelvic or abdominal ultrasound or hysterosalpingogram or by diagnostic laparoscopy. CASE: We present a case of maldescended ovary associated with a unicornuate uterus, normal left ovary and fallopian tube, elongated right fallopian tube and utero-ovarian ligament, and right pelvic kidney, discovered incidentally during a workup for chronic pelvic and abdominal pain. CONCLUSION: It is important to consider looking for a maldescended ovary whenever a patient has a Müllerian and/or kidney anomaly with absence of one or both ovaries on pelvic imaging.

Bladder pain syndrome/interstitial cystitis: a reappraisal for the clinician.

Bladder pain syndrome--formally known as interstitial cystitis--is a chronic bladder disorder characterized by pelvic pain and urinary irritability symptoms. The physiopathology is still unclear but is thought to involve bladder mucosal injury, inflammation and neurologic dysfunction. It is hard to diagnose this entity due to symptoms that are common to several other pathologies such as chronic pelvic pain, endometriosis, overactive bladder, urinary tract infection, and vulvodynia, and due to the lack of specific findings. A combination of history, physical examination, and diagnostic tools helps the establishment of the diagnosis by ruling out other similar pathologies. Treatment is multimodal and combines behavioral changes, drugs administered orally or intravesically and even surgery for refractory cases.

Computed tomography-assisted laparoscopic removal of intraabdominally migrated levonorgestrel-releasing intrauterine systems.

PURPOSE: To report three cases of migrated levonorgestrel intrauterine device (LNG-IUS) into the pelvic/abdominal cavity removed laparoscopically with the aid of preoperative computed tomography (CT) scan imaging. METHODS AND RESULTS: Three patients presenting with a missing LNG-IUS on examination and pelvic ultrasound are presented. A preoperative CT scan was performed, what helped in a successful removal of the LNG-IUS. The patients were discharged home the same day of the procedure. CONCLUSION: Our cases reinforce, besides the diagnosis of a migrated LNG-IUS by ultrasound, the fact that preoperative CT scan imaging assists in the diagnosis of the precise location of a migrated LNG-IUS into the pelvic/abdominal cavity and helps the physician in the prediction of the difficulty of the laparoscopic removal.

Effect of Pegylation and Targeting Moieties on the Ultrasound-Mediated Drug Release from Liposomes.

The use of targeted liposomes encapsulating chemotherapy drugs enhances the specific targeting of cancer cells, thus reducing the side effects of these drugs and providing patient-friendly chemotherapy treatment. Targeted pegylated (stealth) liposomes have the ability to safely deliver their loaded drugs to the cancer cells by targeting specific receptors overly expressed on the surface of these cells. Applying ultrasound as an external stimulus will safely trigger drug release from these liposomes in a controlled manner. In this study, we investigated the release kinetics of the model drug "calcein" from targeted liposomes sonicated with low-frequency ultrasound (20 kHz). Our results showed that pegylated liposomes were more sonosensitive compared to nonpegylated liposomes. A comparison of the effect of three targeting moieties conjugated to the surface of pegylated liposomes, namely human serum albumin (HSA), transferrin (Tf) and arginylglycylaspartic acid (RGD), on calcein release kinetics was conducted. The fluorescent results showed that HSA-PEG and Tf-PEG liposomes were more sonosensitive (showing higher calcein release following the exposure to pulsed LFUS) compared to the control pegylated liposomes, thus adding more acoustic benefits to their targeting efficacy.

Complete hydatidiform mole with a surviving coexistent twin in a woman with sickle cell disease: a case report.

BACKGROUND: Twin pregnancy with an apparently healthy fetus and complete hydatidiform mole (CHMTF) is a rare condition. We present the first reported case in a woman with sickle cell disease. CASE: An 18-year-old woman, para 1, gravida 0, with sickle cell disease was diagnosed at 19 weeks as having a complete molar pregnancy with a coexistent live fetus. The patient presented with abdominal pain, nausea, headaches, body aches, joint pain and chest pain on 2 different occasions. She denied having vaginal bleeding. Whether the patient was having a sickle cell crisis or molar pregnancy symptoms (i.e., thyrotoxicosis) was not clear. She was given intravenous hydration and pain management. All her symptoms resolved, confirming sickle cell crisis as the final diagnosis. The pregnancy was uneventful until 35 weeks, when oligohydramnios prompted induction of labor. Suction curettage was performed after delivery for removal of the molar pregnancy. The patient did not show any evidence of persistent trophoblastic disease 2 months after delivery. CONCLUSION: CHMTF in sickle cell disease patients is challenging. Adequate intravenous hydration and pain management should be started when one suspects a crisis. If the symptoms resolved, thyrotoxicosis due to the molar pregnancy is unlikely. In addition to proper medical management, proper counseling of the patient and close monitoring of both fetus and mother should be undertaken.

Mechanisms of premature ovarian failure: reappraisal and overview.

OBJECTIVE: To present an overview of the potential etiologies of premature ovarian failure (POF), with an emphasis on the chromosomal abnormalities, gene mutations and autoimmune disorders. STUDY DESIGN: This article is based on a literature review of articles on POF using PubMed and MEDLINE for the years 1966-2005 using the keywords premature ovarian failure, trying to ascertain the possible mechanisms of POF reported to date. RESULTS: The etiology of POF is still under investigation, even though a wide range of etiologies has been unveiled, encompassing genetic mutations, chromosomal abnormalities, autoimmune disorders, and iatrogenic (irradiation, chemotherapy) and idiopathic causes. CONCLUSION: In the majority of POF cases, the etiology remains subtle.

Subserosal misplacement of Essure device manifested by late-onset acute pelvic pain.

OBJECTIVE: To increase awareness of the potential to present with late-onset acute pelvic pain secondary to subserosal misplacement of an Essure device (Conceptus Inc., Mountain View, CA). DESIGN: Case report. SETTING: University-affiliated teaching hospital. PATIENT(S): A 30-year-old woman who was seen with severe left lower quadrant pain 4 months after elective sterilization with an Essure device placed under local anesthesia. Mild to moderate resistance was encountered in the placement of the device in the left fallopian tube. INTERVENTION(S): Hysterosalpingogram showing patency of the left fallopian tube and operative laparoscopy. MAIN OUTCOME MEASURE(S): Laparoscopic removal of the Essure device with left salpingectomy. RESULT(S): The patient was free of pain and was discharged home the same day of the laparoscopic procedure. CONCLUSION(S): This report reinforces the need to consider a misplaced Essure device in the differential diagnosis of late-onset acute pelvic pain in women who had difficult placement of the device.

Depot-medroxyprogesterone acetate: an update.

OBJECTIVE: Depo-Provera is a contraceptive approved by the US Food and Drug Administration (FDA) since 1992 and used worldwide by more than 90 million women. AIM OF STUDY: Despite the fact that progestins are endogenous hormones that are secreted by the body, its excess might lead to detrimental health effects. Whether progestins as contraceptives are friends or foes is a questionable matter. In this manuscript, we drive the attention to both usage and side effects Depo-Provera. RESULTS: Depot-medroxyprogesterone acetate (DMPA) is a highly effective, convenient non-daily hormonal contraceptive option that has been available worldwide for many years. The experience with DMPA provides a large body of long-term data regarding the efficacy and safety of this contraceptive method; this long-term experience has established that the use of DMPA does not increase the risk of cardiovascular events, breast cancer, other gynecologic malignancy, or postmenopausal fracture; however, patients are often more concerned about the relatively immediate effects of contraceptives such as potential changes in menstrual cycle, body weight, and mood disturbances. CONCLUSION: Concerns about such issues may lead to reluctance to initiate therapy or premature discontinuation. Counseling and understanding of women's concerns and experiences using Depo-Provera is important and could help health care providers redesign counseling strategies to improve contraceptive continuation and improve patient adherence.