Use of a microsurgical vascular clip system for temporary bilateral occlusion of the four main uterine vessels for laparoscopic enucleation of very large intramural uterine fibroids.

OBJECTIVES: The goal of this study was to examine the safety, feasibility, and effectiveness of the use of a microsurgical temporary vascular clip system to facilitate the laparoscopic enucleation of very large intramural uterine fibroids. METHODS: In this retrospective study, the surgical outcomes of 26 patients who underwent laparoscopic myomectomy with temporary uterine vessel clipping for very large (the largest measured diameter ≥ 9 cm) symptomatic intramural uterine fibroids in two tertiary referral hospitals between September 2017 and March 2020 were examined. Titan-made vascular clips (YASARGIL® Aneurysm Clip System) were used to temporarily occlude the bilateral uterine arteries and utero-ovarian vessels. Main outcomes included operating time, blood loss, number of leiomyomas and weight, conversion rate, intra- and postoperative complication rates, and length of hospital stay. RESULTS: Twenty six patients were included. Dominant intramural uterine fibroid diameters were 9-22 cm. The general characteristics of the patients were similar. The mean surgery duration and intraoperative blood loss were 175.3 ± 32.7 (range 120-250) min and 241.1 ± 103 (range 100-450) ml, respectively. The median postoperative drop in hemoglobin was 0.89 ± 0.75 g/dL. No patient required blood transfusion. No procedure was converted to laparotomy. No major intra- or postoperative complication occurred. CONCLUSIONS: Laparoscopic myomectomy for very large intramural uterine fibroids can be performed safely and effectively, with less intraoperative blood loss, using vascular clips for temporary clamping of the bilateral uterine vessels.

Evidence for disseminated tumor cells in lymphatic vessels afferent to sentinel lymph nodes in patients diagnosed with cervical cancer.

BACKGROUND: In patients diagnosed with cervical cancer, the purpose of lymphadenectomy is the removal of lymph nodes for diagnosis and potential treatment of metastasized tumor cells. It is unclear if afferent lymphatic vessels harbor tumor cells and, thus, may pose additional risk for recurrence or progression if not removed. AIM: In this feasibility study, we analyzed the lymphatic vessels afferent to sentinel lymph node (SLN) using a highly sensitive and specific molecular marker for cervical cancer cells. METHODS AND RESULTS: Twenty patients diagnosed with cervical cancer of FIGO stage IA1 to IIB2 underwent laparoscopic SLN removal. Labeling was done using patent blue and the afferent lymphatic vessels were harvested from the parametric tissue and frozen at -80°C. HPV DNA type was evaluated in the primary tumor. Lymphatic vessels afferent to the sentinel lymph nodes were analyzed for the presence of viral oncogene transcripts of the respective HPV type. In one of 18 patients, all with tumor stage ≤IBI and pN0 by conventional histopathology, HPV mRNA could be detected in two of four lymphatic vessels, whereas at least one of the lymphatic vessel biopsies of both patients with tumors ˃4 cm and pN1 status was HPV mRNA positive. No clinical correlation with recurrence after a median follow-up of 9 years was noticed. CONCLUSION: HPV mRNA indicative of disseminated tumor cells could be detected in lymphatic vessels. The relevance of harvesting lymphatic vessels afferent to SLN in order to increase oncologic safety will have to be investigated in a future prospective study.

Use of a microsurgical vascular clip system (Yasargil clip) in laparoscopic fibroid enucleation

This video demonstrates the use of a microsurgical temporary vascular clip system to facilitate laparoscopic enucleation of uterine fibroids. Throughout the course of the last three decades, the laparoscopic route has been established as the approach of choice in the surgical treatment of uterine fibroids. Laparoscopic fibroid enucleation is characterized by a low morbidity rate and a high patient satisfaction level. Especially when treating a large fibroid or multiple fibroids, the well-vascularized myometrium can constitute a technical challenge in endoscopic fibroid enucleation. Diffuse bleeding may lead to significant intraoperative hemorrhage. The extensive use of bipolar or monopolar diathermy, in order to achieve hemostasis, might lead to post-operative uterine wall necrosis with a potential risk of uterine rupture during subsequent pregnancies. To address this clinical challenge, we developed a technique with temporary interruption of the uterine blood supply by applying a microsurgical vascular clip (Yasargil vascular clip system, Aesculap, Tuttlingen, Germany) to the uterine artery and the utero-ovarian vessel arcade to minimize bleeding during endoscopic fibroid enucleation.

Postoperative non-traumatic compartment syndrome (PNCS) in gynecologic surgery.

PURPOSE: The postoperative non-traumatic compartment syndrome (PNCS) is a rare, but serious postoperative complication. Etiology, risk factors and clinical manifestation of PNCS are not well characterized since data in gynecologic and obstetric patients are limited. METHODS: We performed a retrospective monocentric study of patients who underwent surgery for gynecologic or obstetrics conditions and identified five cases of PNCS, which were analyzed and compared to a control cohort in regard of incidence, clinical presentation, risk factors and clinical outcome. RESULTS: Five cases of PNCS were identified among 19.432 patients treated between 2008 and 2019 with an incidence rate of 0.026%. The clinical examination was shown to be unreliable, lacking sensitivity in most clinical signs. Young age, obesity and long operation time were risk factors for the development of a PNCS. Fasciotomy for the treatment of a PNCS should not be delayed, since permanent function loss may occur early. CONCLUSION: A low threshold of clinical suspicion might be prudent to identify PNCS following gynecologic surgery. In the presence of the described risk factors, any suspicion of a PNCS should be evaluated further and if necessary treated with fasciotomy urgently.

Patient satisfaction with personal patient care (PPC) in the inpatient treatment of endometriosis.

PURPOSE: The aim of this retrospective cohort study was to validate patient's satisfaction and surgical complication rate in patients treated at a certified endometriosis centre with personal patient care (PPC). METHODS: The implementation of PPC at a gynaecologic treatment centre was retrospectively evaluated by analysing perioperative complications using the Clavien Dindo (CD) classification and patient satisfaction utilizing the Picker Patient Experience Questionnaire (PPE-15) for a total of 219 symptomatic endometriosis patients treated surgically at a certified endometriosis centre (Agaplesion Diakonie Hospital, Kassel, Germany) between November 2018 and April 2019. Data from our sample on complication rates and satisfaction were compared with those from reference samples published by Radosa et al. and Jenkinson et al. RESULTS: An overall complication rate of 10.96% (24 out of 219 patients) was observed. Four endometriosis patients (1.83%) had major complications with complications grade III according to the CD classification system. 155 patients out of 219 chose to answer the PPE-15 (return rate 70.78%). 92 patients (59.35%) reported about problems during their treatment in our hospital in their PPE-15. "Doctors sometimes talked as if I was not here" was the best rated item (1.2%) in our cohort. "Staff gave conflicting information" was the most mentioned item (33.55%) by patients during their hospital stay in relation to patient dissatisfaction. CONCLUSION: Incorporation of PPC in the surgical inpatient treatment of endometriosis patients resulted in a low postoperative complication rate and a high patient satisfaction in our study cohort. Furthermore, nursing staff of endometriosis patients also needs particular attention.

Evaluating the use of Clavien-Dindo classification and Picker Patient Experience Questionnaire as quality indicators in gynecologic endoscopy.

PURPOSE: Over the last few decades, laparoscopy has become a standard procedure within gynecological surgery. Validated quality indicators for the determination of the objective (perioperative complications) and subjective (patient satisfaction) quality of treatment as a surrogate parameter for the success of the treatment have so far found no regular application in the clinical routine. The purpose of this study was to evaluate the use of the Clavien-Dindo (CD) classification for postoperative complications and the Picker Patient Experience Questionnaire (PPE-15) as tools in the evaluation of endoscopic therapies in clinical routine. METHODS: Retrospectively, perioperative complications using the CD classification and patient satisfaction utilizing the PPE-15 were reviewed for a total of 212 consecutive patients at a gynecologic endoscopic referral center (Agaplesion Diakonie Kliniken, Kassel, Germany) in September 2018. RESULTS: An overall complication rate of 13.21% (28 out of 138 patients) was observed. Five patients (2.36%) had complications grade III and above according to the CD classification system. 138 patients out of 212 chose to answer the PPE-15 (return rate 65.01%). 112 patients (81.16%) reported about problems during their treatment in our hospital in their PPE-15. "Purpose of medicines not explained" was the most mentioned item (28.99%) by patients during their hospital stay. CONCLUSION: CD classification and PPE-15 may be helpful instruments to evaluate the quality of care in gynecology. The application of both instruments for the assessment of treatment quality in clinical routine should be further investigated in prospective studies.

Ultramicro-trauma in the endometrial-myometrial junctional zone and pale cell migration in adenomyosis.

OBJECTIVE: To determine if ultrastructural tissue trauma occurs in the junctional zone in uteri in adenomyosis. DESIGN: A case-control experimental study. SETTING: Endometriosis research center. PATIENT(S): Twelve uteri with adenomyosis, and 9 uteri without adenomyosis, were gained during laparoscopy-assisted vaginal hysterectomy. INTERVENTION(S): Transmission electron microscopic study of the junctional zone, as well as immunohistochemical staining for epithelial cadherin, and van Gieson staining and immunofluorescence for CD45 and CD68. MAIN OUTCOME MEASURE(S): Analysis of the electron microscopy photos and the immunoreactive scores of the staining. RESULT(S): The inner myometrial muscle fibers were diversely arranged in adenomyosis; they were parallel to the basal endometrial glands in nonadenomyosis. Nuclear membrane infolding of the basal glandular epithelium and the disruption of the interface between basal endometrium and inner myometrium in adenomyosis (but not in nonadenomyosis) were evident. Intraepithelial pale cells were seen in the basal endometrial glands in both groups, but they lacked CD45 and CD68 expression. They were seen actively migrating into the stroma in adenomyosis only. CONCLUSION(S): The myofiber disarray in the inner myometrium, and the nuclear membrane irregularities in adenomyosis, are evidence for ultramicro-trauma in adenomyosis. The migrating nonleukocytic pale cells may be involved in pathogenesis of adenomyosis.

Ligneous cervicitis in a woman with plasminogen deficiency associated with an atypical form of microglandular hyperplasia: a case report and review of literature.

A 19-yr-old woman with previously diagnosed clear cell adenocarcinoma was referred to the Charité for further treatment. Biopsies were taken from the cervix, the endometrium, pseudomembranes in the peritoneum, and sentinel lymph nodes. The morphologic picture of pseudomembranes and inflammation together with the provided information about plasminogen deficiency of the patients led to the hypothesis of ligneous cervicitis. The previously taken biopsies of the adenocarcinoma were reevaluated and showed a clear cell lesion. Further immunohistochemical examination with antibodies against p16, Ki67, CEA, and p53 could not prove its malignant character. As a result we diagnosed an atypical form of microglandular hyperplasia in a patient with ligneous cervicitis. Ligneous cervicitis is a rare inflammatory condition that might affect all mucus membranes in patients with plasminogen deficiency. This case shows the importance of correlating pathologic and clinical findings in the diagnosis of ligneous cervicitis because of the rarity of the disease and the heterogeneity at presentation.