Ultrasound Prediction of Segmental Bowel Resection in Women with Rectovaginal Endometriosis: A Single-Center Experience.

STUDY OBJECTIVE: To retrospectively evaluate the ability of routinely collected preoperative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis. DESIGN AND SETTING: Patients at the University College London Hospital who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (British Society for Gynaecological Endoscopy) database. Imaging data were collected and analyzed to determine associations with the requirement for bowel resection. PATIENTS: We evaluated 228 consecutive women undergoing bowel surgery (shave, disc resection, or segmental resection) for rectovaginal endometriosis. INTERVENTIONS: The patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection, and segmental resection of the bowel. All patients underwent a preoperative transvaginal ultrasound to assess the extent of endometriosis. MEASUREMENTS AND MAIN RESULTS: There were 206 rectal shaves (90.4%), 2 disc resections (0.9%), and 20 segmental bowel resections (8.8%). A multivariable analysis demonstrated an association between bowel resection and ≥2 nodules located in the rectovaginal space (odds ratio [OR] 6.85; 95% confidence interval [CI], 1.37-34.2), nodules in the vesicouterine pouch (OR 5.87; 95% CI, 1.03-33.3), and increasing nodule size (OR 2.39 per 1 cm increase per 1 cm diameter increase; 95% CI, 1.56-3.64). CONCLUSION: Ultrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counseling and surgical planning in the preoperative setting for women with rectovaginal endometriosis.

Long-term mesh complications and reoperation after laparoscopic mesh sacrohysteropexy: a cross-sectional study.

INTRODUCTION AND HYPOTHESIS: The paucity of long-term safety and efficacy data to support laparoscopic mesh sacrohysteropexy is noteworthy given concerns about the use of polypropylene mesh in pelvic floor surgery. This study is aimed at determining the incidence of mesh-associated complications and reoperation following this procedure. METHODS: This was a cross-sectional postal questionnaire study of women who underwent laparoscopic mesh sacrohysteropexy between 2010 and 2018. Potential participants were identified from surgical databases of five surgeons at two tertiary urogynaecology centres in the UK. The primary outcome was patient-reported mesh complication requiring removal of hysteropexy mesh. Secondary outcomes included other mesh-associated complications, reoperation rates and Patient Global Impression of Improvement (PGI-I) in prolapse symptoms. Descriptive statistics and Kaplan-Meier survival analyses were used. RESULTS: Of 1,766 eligible participants, 1,121 women responded (response proportion 63.5%), at a median follow-up of 46 months. The incidence of mesh complications requiring removal of hysteropexy mesh was 0.4% (4 out of 1,121). The rate of chronic pain service use was 1.8%, and newly diagnosed systemic autoimmune disorders was 5.8%. The rate of reoperation for apical prolapse was 3.7%, and for any form of pelvic organ prolapse it was 13.6%. For PGI-I, 81.4% of patients were "much better" or "very much better". CONCLUSIONS: Laparoscopic mesh sacrohysteropexy has a low incidence of reoperation for mesh complications and apical prolapse, and a high rate of patient-reported improvement in prolapse symptoms. With appropriate clinical governance measures, the procedure offers an alternative to vaginal hysterectomy with apical suspension. However, long-term comparative studies are still required.

Female Urology and Urogynecology: The Outcome of Patients Participating in Live Surgical Broadcasts.

INTRODUCTION: The aims of this study were to assess the complications and short- and long-term outcomes of patients involved in live surgical broadcasts (LSBs) of female urology and urogynecological surgery and compare the surgical success with operations performed outside this setting by the same surgeons. METHODS: We reviewed our prospectively collected database of all patients who had taken part in LSBs between 2008 and 2015 for the annual female urology and urogynecology course. Data on intraoperative and 30- and 90-day complications and primary outcomes from surgery were collected. Procedure-specific success rates were determined and compared with the center's previously published success rate for these procedures. RESULTS: Overall, 53 females with a median age of 50 years (range, 23-77 years) underwent 62 procedures during these LSBs. There were no intraoperative complications. There was 1 Clavien-Dindo grade II complication within 30 days of surgery. Within 90 days of surgery, there was 1 Clavien-Dindo grade III complication, which occurred in a patient having removal of anterior pelvic organ prolapse mesh for urethral erosion and simultaneous colposuspension. The majority of operations, 57 (92%) of 62, achieved their intended primary outcome. CONCLUSIONS: With careful planning, LSB can offer a safe way of sharing current operative techniques and decision making with similar 30- and 90-day complication rates to standard practices and comparable functional outcomes to standard practice.

Feasibility of using a novel non-invasive ambulatory tibial nerve stimulation device for the home-based treatment of overactive bladder symptoms.

BACKGROUND: To evaluate safety, acceptability and pilot efficacy of transcutaneous low-frequency tibial nerve stimulation (TNS) using a novel device as home-based neuromodulation. METHODS: In this single-centre pilot study, 48 patients with overactive bladder (OAB) (24 with neurogenic and 24 with idiopathic OAB) were randomized to use a self-applicating ambulatory skin-adhering device stimulating transcutaneously the tibial nerve at 1 Hz for 30 minutes, either once daily or once weekly, for 12 weeks. Changes in OAB symptoms and QoL were measured at baseline, weeks 4, 8, and 12 using validated scoring instruments (ICIQ-OAB and ICIQ-LUTSqol), 3-day bladder diary and a Global Response Assessment (GRA) at week 12. RESULTS: Thirty-four patients completed the study (idiopathic n=15, neurogenic n=19). No significant adverse effects were noted. Patients found the device acceptable. Eighteen patients (53%) reported a moderate or marked improvement in symptoms from the GRA. Between baseline and week-12, ICIQ-OAB part A sub-scores improved from mean (SD) 9.3 (2.5) to 7.5 (3.1), and from 9.1 (1.9) to 5.9 (1.7) in the daily and the weekly arms, respectively. ICIQ-LUTSqol part A sub-scores improved from mean (SD) 51 (12.8) to 44.2 (13.1) and 44.9 (9.0) to 35.9 (8.8) in the daily and the weekly arms, respectively. Bladder diary mean 24-hour frequency episodes improved from 11.5 to 8.8 at week 12 for both arms. CONCLUSIONS: This novel ambulatory transcutaneous TNS (TTNS) device is safe and acceptable for use in patients reporting OAB symptoms as a form of home-based neuromodulation. A larger study however is required to confirm clinical efficacy.

Laparoscopic Myomectomy: A Single-center Retrospective Review of 514 Patients.

STUDY OBJECTIVE: To review surgical outcomes and histopathological findings after laparoscopic myomectomy by a team at a university teaching hospital. DESIGN: This was a retrospective review of consecutive cases of laparoscopic myomectomy performed by members of our minimal access surgery team between January 2004 and December 2015 (Canadian Task Force classification II-3). SETTING: A university teaching hospital. PATIENTS: Women undergoing laparoscopic myomectomy. INTERVENTIONS: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: We collected women's demographic data, clinical histories, and surgical outcomes, including complication rates and the incidence of undiagnosed uterine malignancy. Five hundred fourteen women were booked for laparoscopic myomectomy during the study period. Five hundred twelve of 514 (99.6%; 95% confidence interval [CI], 99.05-100.00) procedures were successfully completed. Two cases were converted to open surgery: one because of suspected uterine malignancy and another because of bowel injury at initial entry. The median number of myomas removed at laparoscopy was 1 (range, 1-12; mode = 1). The median size of the largest myoma removed at each procedure was 70 mm (range, 10-200 mm) as assessed subjectively by the operating surgeon. The median blood loss was 73 mL (range, 5-3000 mL). The median length of stay in the hospital was 2 nights (range, 0-24 nights). Breach of the uterine cavity occurred in 50 of 514 (9.7%; 95% CI, 7.17-12.29) cases. Electromechanical morcellation was used in 496 of 514 (96.5%; 95% CI, 94.9-98.1) patients. Eighteen of 514 (3.5%; 95% CI, 1.91-5.09) women suffered significant complications including blood loss >1000 mL (n = 15), bowel injury (n = 1), bladder injury (n = 1), and small bowel obstruction secondary to port site hernia (n = 1). There were no cases of undiagnosed uterine malignancies after myoma morcellation. CONCLUSION: Laparoscopic myomectomy can be conducted with a low rate of major complications, and, in our experience, the chance of discovering occult malignancy is very low.

Laparoscopic wrap round mesh sacrohysteropexy for the management of apical prolapse.

INTRODUCTION AND HYPOTHESIS: Interest in uterine-conserving surgery for apical prolapse is growing. Laparoscopic sacrohysteropexy is one of the conservative surgical options, although different surgical approaches have been described. We report medium-term outcome data using a bifurcated mesh implant, employing 'wrap round' uterine attachment. METHODS: All procedures undertaken at our unit were reviewed. Study inclusion was contingent on the collection of baseline and 3-month anatomical and symptomatic outcome data. Medium-term follow-up data were collected by telephone review. Anatomical outcome was reported using the Pelvic Organ Prolapse Quantification scale. Symptom prevalence and treatment response were assessed using validated instruments including the Patient Global Impression of Improvement scale (PGI-I), and the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI) and Vaginal Symptoms (ICIQ-VS) questionnaires. Patient satisfaction was reported using Kaplan-Meier survival analysis. RESULTS: Data were available for 110 patients. Of 80 patients providing PGI-I data at 3 months, 75 (94 %) described their prolapse symptoms as 'much better' or 'very much better'. Anatomical success in the apical compartment was 98 %. ICIQ-UI and ICIQ-VS responses demonstrated significant improvement. Despite a concurrent vaginal repair in only 11 % of patients, satisfaction at a mean follow-up of 2.6 years was 96 %. Repeat surgery for vaginal wall prolapse was required in only 5 % of patients. No safety concerns or graft complications were recorded. CONCLUSIONS: This surgical variant of laparoscopic sacrohysteropexy is safe and highly effective. These data also cast doubt on the need for correction of modest vaginal wall prolapse at the time of surgery, and imply that apical prolapse may play a dominant role in the generation of symptoms.

Women's views on autologous cell-based therapy for post-obstetric incontinence.

AIM: Fecal and urinary incontinence are devastating consequences of obstetric-related perineal injury. The aim of the present study is to determine acceptability to parous women of autologous cell-based therapy for fecal and urinary incontinence that arises due to pelvic diaphragm tearing during vaginal childbirth. MATERIALS & METHODS: A multiple choice questionnaire survey was offered to 76 parous women at the Maternity Unit, University College Hospital, London, UK. Seventy completed questionnaires - response rate: 92%. RESULTS: In total, 84% of women indicated a willingness to accept autologous cell-based therapy for obstetric injury-induced incontinence rather than surgery. CONCLUSION: These observational data provide an indication of likely acceptance of autologous cell-based therapies for birth injury incontinence and will help with designing new therapeutic approaches.

New procedures for uterine prolapse.

Traditionally, vaginal hysterectomy and Manchester repair were the surgical approaches to treating uterine prolapse; however, both are associated with a relatively high subsequent vaginal vault recurrence. Laparoscopic uterine suspension is a new way of maintaining uterine support. Many women are keen to keep their uterus for a variety of reasons, including maintaining reproductive capability and the belief that the uterus, cervix, or both, may play a part of their gender identity. Non-removal of the uterus may retain functional (e.g. bowel, bladder and sexual) benefits. Therefore, the concept of uterine preservation for pelvic-organ prolapse has been of interest to pelvic-floor surgeons for many decades. In this review, we provide an overview of the available evidence on treating uterine prolapse surgically. We describe techniques to support the vault during hysterectomy, and examine the evidence for uterine-sparing surgery. Comparative outcomes for vaginal, abdominal and laparoscopic routes will be made.

Diathermy-induced injury may affect detection of occult tubal lesions at risk-reducing salpingo-oophorectomy.

BACKGROUND: Electrosurgery-induced tubal thermal injury obscures cellular detail and hampers histomorphological assessment for occult pathology. OBJECTIVE: The objectives of this study were to report on diathermy-related thermal injuries to the fallopian tube observed at RRSO and explore its potential impact on the detection of occult tubal epithelial lesions. DESIGN: This study was composed of high-risk women from breast and/or ovarian cancer families attending a tertiary high-risk familial gynecologic cancer clinic. This was a retrospective case-control analysis of high-risk women who underwent RRSO. Cases were all women detected to have occult lesions (tubal atypia/carcinoma in situ/cancer) between January 2005 and December 2010. Control subjects were all women with normal tubal/ovarian histology between August 2006 and December 2007. METHODS: Two pathologists performed histopathologic assessment for grade of thermal injury. Tubal diathermy injury rates were compared between cases and controls. Statistical analysis was undertaken using SPSS version 18. The Mann-Whitney U test compared age distributions; χ/Fisher tests, the difference between proportions, and γ test, the difference in ordinal variables between the groups. RESULTS: A novel tubal thermal index to describe the severity of injury is reported. Lack of fimbrial thermal injury is twice as likely (odds ratio, 2.04; 95% confidence interval, 1.06-3.92) to be associated with detection of occult tubal pathology, whereas isthmic injury does not affect detection rate (P = 0.744). The groups were comparable with respect to age at RRSO (P = 0.531) and the presence of BRCA mutations (P = 0.192). CONCLUSIONS: This report highlights the potential impact of electrosurgical thermal injury on detection of occult tubal pathology following RRSO. It is important for surgeons to avoid thermal injury to the distal end of the tube.

Laparoscopic sacrocolpopexy to treat prolapse of the neovagina created by vaginal dilation in Rokitansky syndrome.

BACKGROUND: Vaginal dilation is the first choice of treatment for women with a short vagina due to Rokitansky syndrome. Although the neovagina lacks pelvic support, prolapse of the neovagina is a surprisingly rare complication of treatment. Laparoscopic sacrocolpopexy is recommended in the treatment of posthysterectomy vault prolapse in younger women but has not been used to treat neovaginal prolapse. CASE: A 23-year-old woman with Rokitansky syndrome presented with a symptomatic prolapse of the neovagina. This was successfully treated with a laparoscopic sacrocolpopexy. SUMMARY AND CONCLUSIONS: Laparosopic sacrocolpopexy appears to be an effective treatment in the unusual situation of vaginal prolapse after dilation.

Voiding dysfunction in women undergoing laparoscopic treatment for moderate to severe endometriosis.

We conducted a prospective study to evaluate the incidence and the surgical factors determining the development of postoperative voiding dysfunction following this surgery. The presence of rectovaginal dissection was significantly associated with the development of voiding dysfunction, and we suggest vigilance among practitioners about the possibility of the development of voiding dysfunction in this group of women.

A double-blind placebo-controlled study to evaluate the effect of progestelle progesterone cream on postmenopausal women.

OBJECTIVE: To evaluate the effect on climacteric symptoms and quality of life, and the safety of four doses of progestelle progesterone cream administered for 24 weeks to postmenopausal women complaining of moderate to severe menopausal symptoms. Design Single-centre, double-blind, randomized, placebo-controlled study. Population Two hundred and twenty-three healthy postmenopausal women, aged between 40 and 60 years and complaining of severe menopausal symptoms were recruited through newspaper advertisements. METHODS: Women were randomly allocated to progestelle progesterone cream 60, 40, 20, 5 mg or placebo, to be applied daily for six months. Main outcome measures The primary efficacy variable was the psychological, somatic and vasomotor components of the Greene Climacteric Scale after six months. Secondary endpoints were incidence of hot flushes and night sweats, the nine subscales of the Medical Outcome Survey Short Form-36 (SF-36), serum progesterone, endometrial thickness and histology after six months. Adverse events were sought and recorded and followed up to resolution. RESULTS: There were no statistically significant differences between any of the treatment groups and placebo for any of the components of the Greene Score. A statistically significant difference between the 20 mg group and placebo was found for the physical functioning (95% confidence interval [CI] 1.7-12.3; P=0.01) and social functioning (95% CI 1.9-16.7; P=0.01) scales of SF-36 after six months. No other statistically significant differences were found between any treatment group and placebo for any of the other secondary efficacy variables. There appeared to be a higher incidence of headache in the groups treated with progesterone cream. CONCLUSIONS: Progesterone cream was no more effective than placebo for relief of menopausal symptoms.

Bleeding profiles and effects on the endometrium for women using a novel combination of transdermal oestradiol and natural progesterone cream as part of a continuous combined hormone replacement regime.

OBJECTIVE: Many women are seeking alternatives to conventional forms of hormone replacement. This study evaluates the endometrial effects of natural progesterone cream used in conjunction with transdermal oestradiol. DESIGN: Open plan study conducted over 48 weeks. SETTING: Tertiary referral London teaching hospital. POPULATION: Women at least two years postmenopausal. METHODS: Women were recruited nationally. They applied 40 mg transdermal natural progesterone cream and 1 mg transdermal oestradiol daily. MAIN OUTCOME MEASURES: Endometrial histology, assessed by pipelle endometrial biopsy, ultrasound assessment of endometrial thickness and bleeding diaries. RESULTS: Fifty-four women were recruited of which 41 completed the study. Mean age was 57.4 years. Thirty-two percent of women had evidence of inadequate endometrial opposition (proliferative or hyperplastic) at the end of 48 weeks. At baseline, women had a mean endometrial thickness of 3.3 mm, which had significantly thickened to a mean of 5.3 mm by 24 weeks (P < 0.001). By 48 weeks, there was significantly greater increase in endometrial thickness from baseline in those women who displayed inadequate endometrial opposition, compared with those women who had adequate endometrial opposition (P= 0.004). At 24 weeks, 48% of women had remained entirely amenorrhoeic. By the end of the study, 35% of women had been entirely amenorrhoeic and 50% had had either no bleeding or spotting alone. The number of bleeding episodes did not reduce with time. CONCLUSIONS: The dose of natural progesterone cream in this study was insufficient to fully attenuate the mitogenic effect of oestrogen on the endometrium. We would not recommend this combination of hormones to be used by postmenopausal women.

A study to look at hormonal absorption of progesterone cream used in conjunction with transdermal estrogen.

Natural progesterone creams are gaining popularity as a possible treatment for menopausal symptoms, and many women may be using them with estrogen. We planned to evaluate, using an open plan study, the systemic absorption of a combination of transdermal estrogen and progesterone. Women applied transdermal progesterone 40 mg and transdermal estrogen 1 mg daily over 48 weeks. Women were assessed at intervals of 12 weeks. Significant increases in plasma levels of progesterone and estradiol were seen after 12 weeks, although only low plasma progesterone levels were found (median 2.5 nmol/l) and no further increase was noted over the remainder of the study period. A significant correlation was found between plasma levels of the two hormone (r = 0.315, p = 0.045). Women reported significant reductions in menopausal symptoms, as measured by the Green Climacteric Scale, after 24 and 48 weeks of combined treatment. There may be similar mechanisms of absorption of the two hormones, although the doses used in our study produced sub-luteal levels of progesterone. There was no evidence of accumulation of progesterone with time, and further study is needed to assess the efficacy and safety of this combination of hormones.