First uterine transplant case at the Royal Prince Alfred Hospital.

Uterine transplantation (UT) is an emerging medical treatment for women affected by absolute uterine factor infertility (AUFI). To date there have been over 90 documented cases of UT performed worldwide, with over 50 live births. UT allows women affected by AUFI the opportunity to carry and deliver a childd. The Royal Prince Alfred Hospital (RPAH) introduced a UT study in 2019; however, due to the impacts of the COVID pandemic the study was placed on hold for two years. In February 2023, RPAH performed the centre's first UT from a living unrelated donor to a 25-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome. The donor and recipient surgeries were uncomplicated and both are recovering well in the early post-operative period.

Rectal disc resection improves stool frequency in patients with deep infiltrating endometriosis: A prospective study.

BACKGROUND: Gastrointestinal symptoms occur with deeply infiltrating endometriosis (DIE) of the rectum. AIMS: To explore the medium-term gastrointestinal functional outcomes after rectal disc resection for endometriosis. METHODS: All women undergoing laparoscopy for stage IV endometriosis at a tertiary referral hospital between November 2016 and January 2018 and had evidence of DIE of the rectum were included. Low anterior resection syndrome (LARS) score was measured using a validated questionnaire. RESULTS: Thirty-six women formed the cohort of the study. The mean age was 37 years (range 20-72 years). All women underwent a laparoscopic anterior rectal disc resection for DIE. The response rate was 100%. There was an increase in the percentage of patients having no LARS postoperatively compared to preoperatively (an increase of 78-83%). There was a reduction in LARS scores postoperatively observed in 18 patients (50%) and the prevalence of major LARS decreased postoperatively from 10% to 1%. Comparison of individual symptoms revealed a significant improvement in postoperative stool frequency scores (P = 0.02). Multivariate analysis using logistic regression analysis demonstrated that reduction in postoperative stool frequency scores remained an independent factor (P = 0.008). CONCLUSION: Rectal disc resection is feasible and safe, achieving observable improvements in stool frequency in patients with rectal DIE.

The effect of laparoscopic salpingectomy for ectopic pregnancy on ovarian reserve.

BACKGROUND: Salpingectomy may damage ovarian reserve by direct vascular interruption to the ovary or thermal vascular injury from electrosurgery. It is plausible that this risk may increase in the context of salpingectomy conducted for ectopic pregnancy due to the distension of the fallopian tube and vascular changes associated with pregnancy. AIM: To report anti-Müllerian hormone (AMH) concentrations before and after laparoscopic salpingectomy for ectopic pregnancy as an indicator of change in ovarian reserve. MATERIALS AND METHODS: Women aged 18-44 years scheduled for salpingectomy for tubal ectopic pregnancy were prospectively recruited. Serum AMH concentrations were measured immediately prior to surgery, then repeated four months post-operatively. In all cases, salpingectomy was conducted laparoscopically using bipolar electrosurgery and mechanical scissors. A group of women scheduled for uterine curettage for first trimester miscarriage was recruited to ensure any observed change in AMH concentration in the women undergoing salpingectomy was secondary to surgery, rather than an effect of pregnancy. RESULTS: Paired pre- and post-operative serum AMH concentrations were obtained from 32 women with tubal ectopic pregnancy. The mean age of the women was 33.6 ± 4.6 years. There was no significant difference in the median pre- and post-operative AMH concentrations (13.00 pmol/L (range 5-67 pmol/L) vs 15.25 pmol/L (range 3-96 pmol/L), P = 0.575). Median AMH concentrations also remained stable in women experiencing a first trimester miscarriage (10.40 pmol/L (range 3.9-37.8 pmol/L) vs 13.67 pmol/L (range 2.8-30.5 pmol/L), P = 0.185). CONCLUSION: Laparoscopic salpingectomy using electrosurgery and mechanical scissors does not damage ovarian reserve. AMH concentrations do not fluctuate from baseline in the first trimester of pregnancy.

Medium to long-term gastrointestinal outcomes following disc resection of the rectum for treatment of endometriosis using a validated scoring questionnaire.

OBJECTIVE: To assess the gastrointestinal functional outcomes and symptoms of low anterior resection syndrome after disc resection for deeply infiltrative endometriosis (DIE) using a validated scoring system. DESIGN: Retrospective study to assess the gastrointestinal functional outcomes after rectal disc resection for DIE using a validated scoring system. SETTING: University tertiary referral centre. PATIENTS: Women who underwent disc resection for endometriosis at Royal Hospital for Women and Prince of Wales Private Hospital between January 2012 and December 2013 were included. MAIN OUTCOME MEASURE: Low anterior resection syndrome (LARS) score using a validated questionnaire. RESULTS: Forty-one women met the inclusion criteria. The mean age was 40 ± 10 years (range 22-75 years). All procedures were performed laparoscopically. Eleven women (27%) underwent a hysterectomy in addition to rectal disc resection and endometriosis surgery. Mean operative time for the entire cohort was 158 ± 64 minutes, and mean length of hospital stay was 5 ± 2 days. Completed questionnaires were received from 31 women, a response rate of 76%. The mean length of follow-up was 17 ± 10 months (range 3-34 months). The LARS scores ranged from 0 to 34 (median 15, interquartile range 0-24). Eight women (26%) had a LARS score of 0. Nineteen women (61%) had a LARS score less than 21 (the threshold for LARS). CONCLUSION: Conservative treatment of DIE with rectal disc resection is safe and feasible and is associated with mild gastrointestinal dysfunction in the medium to long term.

Bowel and bladder function after resection of deeply infiltrating endometriosis.

AIMS: To compare bowel and bladder function following uterosacral or rectovaginal excision of endometriosis with excision of endometriosis from other sites of the pelvis. METHODS: A retrospective cohort study was performed via a questionnaire derived from validated questionnaires in the literature. This was applied to the two groups of women who have had endometriosis resected in the last 15 years--those with deeply infiltrating endometriosis (DIE) and those with endometriosis from other sites. In the questionnaire, voiding dysfunction, urinary stress incontinence, urinary urge incontinence, stool evacuation and overall symptoms post-surgery were investigated. The higher the score, the higher the level of dysfunction. RESULTS: Women with DIE had higher levels of urinary stress dysfunction than the control group (mean 1 vs 0, IQR 3 vs 2, P = 0.047). Women with DIE also expressed a higher level of bowel dysfunction (mean 2 vs 2, IQR 1 vs 0, P = 0.002). However, women with DIE also reported significant improvement in urinary and bowel dysfunction postoperatively. There were no significant differences between the other variables. CONCLUSION: The study demonstrated no clear association between the depth of excision of endometriosis with urinary and bowel dysfunction. The differences in urinary stress incontinence and bowel dysfunction may be explained by DIE itself causing damage to the hypogastric plexus.

Does occiput posterior position in the second stage of labour increase the operative delivery rate?

OBJECTIVES: To assess the impact of occipito-posterior position in the second stage of labour on operative delivery. METHODS: Double-blinded prospective cohort study of ultrasound determined occiput-posterior position during the second stage of labour compared with occiput-anterior position. The primary outcome was operative (caesarean section, forceps or vacuum) delivery. RESULTS: A total of 68% (13/19) women in the occiput-posterior group, and 27% (39/141) in the occiput-anterior group had an operative delivery (unadjusted: P < 0.001). Caesarean section was performed in 37% and 5%, respectively (P < 0.001). The occiput-posterior group had a longer second stage (mean 2 h 59 minutes vs 1 h 54 minutes; P = 0.001) and larger infants (mean 3723 g vs 3480 g, P = 0.024). In the logistic regression, occiput-posterior position, nulliparity, abnormal second stage cardiotocograph and epidural analgesia were independent predictors for operative delivery. CONCLUSIONS: Occiput-posterior position early in the second stage of labour is strongly associated with operative delivery. There is potential to explore interventions such as manual rotation.

Has the true prevalence of voiding difficulty in urogynecology patients been underestimated?

Voiding difficulty has been relatively overlooked as a diagnosis. Previous estimates of its prevalence have generally been no more than 14% with one exception at 24%. The aim of this study is to determine the true prevalence and associations of voiding difficulty using a validated definition [urine flow rate under 10th centile of the Liverpool Nomograms and/or residual urine volume (by transvaginal ultrasound) more than 30 ml]. This study involved 592 women referred for an initial urogynecological assessment including urodynamics. Data were separated according to the presence or absence of voiding difficulty. The prevalence of voiding difficulty was 39%, far higher than previous estimates. It is the third most common urodynamic diagnosis behind urodynamic stress incontinence (USI-72%) and uterine/vaginal prolapse (61%) and ahead of the overactive bladder (13%). Voiding difficulty significantly increased in prevalence with age and increasing grades of all types of uterine/vaginal prolapse. Prolapse appeared to be the main factor in the age deterioration. Other significant positive relationships with voiding difficulty were prior hysterectomy and prior continence surgery, whilst USI and the symptom and sign of stress incontinence had significant inverse relationships.