What is the impact of simulation on the learning of hysteroscopic skills by residents and medical students? A systematic review.

INTRODUCTION: Hysteroscopy is a critical procedure in gynecology for diagnosing and managing intrauterine pathology. Traditional hands-on training faces ethical and safety challenges, leading to an increased reliance on simulation training. This review systematically assesses the effectiveness of hysteroscopic simulation training in enhancing the technical skills of obstetrics and gynecology residents and medical students. METHODS: A PRISMA-guided literature search was conducted, covering English-language articles from January 2000 to December 2023. Studies were selected based on pre-defined criteria, focusing on the impact of simulation training on the targeted educational group. Metrics for evaluating skill improvement included machine-recorded metrics, Objective Structured Assessment of Technical Skills (OSATS), and global rating scales. RESULTS: The review included nine studies with varied designs, demonstrating significant improvements in hysteroscopic skills following simulation training. Virtual reality (VR) simulators showed substantial benefits in skill acquisition, while physical simulators provided valuable tactile feedback. However, long-term skill retention and the impact on non-technical skills were not adequately assessed. CONCLUSIONS: Simulation-based training effectively enhances hysteroscopic skills in medical students and residents. Further research is needed to explore long-term skill retention and the development of non-technical competencies. Robust studies, including randomized trials, are required for definitive validation.

Unus Pro omnibus, omnes Pro uno: a commentary on the eternal dilemma of endometrial cancer screening in postmenopausal asymptomatic women. Is it time to team up?

INTRODUCTION: The diagnostic workflow for endometrial carcinoma in postmenopausal asymptomatic women remains an ongoing dilemma. Whereas an ultrasonographic endometrial thickness greater than 4.0 or 5.0 mm is adequate for warranting further investigations in women with postmenopausal vaginal bleeding, there is still no unanimous consensus on what the ideal endometrial thickness cut-off should be, justifying additional inspection through endometrial sampling when bleeding is absent. METHODS: A comprehensive overview of the most recent literature to summarize the clinical pathway necessary for the diagnostic assessment of a postmenopausal asymptomatic woman with increased ultrasonographic endometrial thickness. RESULTS: An endometrial thickness cut-off between 3.0 and 5.9 mm seems to show the lowest specificity while also reducing the chances of missing malignancy. If endometrial thickness can be a valid starting point, a careful evaluation of the other ultrasonographic endometrial features and a thorough scrutiny of patients' risk factors are pivotal to standardizing the diagnostic process while avoiding overtreatment. Although preventing unnecessary procedures is crucial, stratifying the risk and proceeding with further investigations (preferably through outpatient or office hysteroscopically-guided targeted biopsies) should be the goal. CONCLUSIONS: Closer collaboration between different fields of medicine (ultrasonography, hysteroscopy, and oncology) is strongly encouraged to facilitate early diagnosis of asymptomatic postmenopausal women at risk of developing endometrial malignancy.

Hysteroscopy: where did we start, and where are we now? The compelling story of what many considered the "Cinderella" of gynecological endoscopy.

Hysteroscopy has truly revolutionized the field of diagnostic and operative gynecology. It is presently regarded as the gold standard method for both the diagnosis and treatment of intrauterine diseases and it has fundamentally altered the way gynecologists treat patients with such conditions. These pathologies can now be diagnosed and treated in an outpatient setting, thanks to technological advancements and instrument downsizing. Two hundred years of development and notable innovation are now reflected in the present hysteroscopic practice. This review attempts to trace the boundaries-pushing history of hysteroscopy by highlighting the advancements in technology and the therapeutic and diagnostic benefits offered by this groundbreaking approach.

Hysteroscopic subchorionic injection of methotrexate followed by laparoscopic excision of the gestational sac for the management of cesarean scar ectopic pregnancy: an innovative dual approach of a challenging pathology.

OBJECTIVE: To describe an effective two-step surgical approach for the management of cesarean scar ectopic pregnancies (CSEPs). CSEPs occur at an estimated frequency of 1 in 1,800 pregnancies, constituting approximately 6% of ectopic pregnancies in women with a history of prior cesarean delivery [1, 2]. Despite numerous recommended therapeutic approaches, the most effective treatment strategy remains uncertain [3]. DESIGN: We present an innovative double-step technique for the management of a patient with a CSEP involving hysteroscopic subchorionic injection of methotrexate (MTX), followed by laparoscopic resection of the residual gestational sac and simultaneous repair of the uterine defect. SETTING: Academic tertiary hospital. PATIENT: A 34-year-old G2P1001 with a history of prior cesarean section presented at 10 weeks of gestation. Ultrasound revealed a gestational sac within the niche of the previous cesarean scar, confirming the diagnosis of a CSEP. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus, among others), and other applicable sites. INTERVENTION: The initial treatment involved hysteroscopic administration of MTX within the placental intervillous spaces, ensuring precise medication delivery. The administered dose of MTX was 1 mg/kg. Following the normalization of beta-human chorionic gonadotrophin (ß-hCG) levels, laparoscopic resection of the remaining gestational sac and reconstruction of the uterine wall defect were performed. MAIN OUTCOME MEASURES: We have implemented a management strategy focusing on ectopic pregnancy removal and addressing defect revision. The hysteroscopic approach allows for a clear assessment of the ectopic pregnancy and facilitates precise MTX administration, enhancing its effectiveness by increasing drug concentration within the placental intervillous space. Delaying surgical repair until after the ß-hCG levels have decreased reduces the risk of excessive bleeding during the procedure, as lower ß-hCG levels are associated with reduced vascularity at the ectopic site. Subsequent laparoscopic resection allows for complete removal of the remaining products of conception and repair of the defect, preserving the uterus and restoring normal anatomy. Compared to other surgical approaches, our two-step approach enables a more precise evaluation of placental implantation, making it a highly effective surgical method. RESULTS: We successfully managed a CSEP using a double-step technique. This involved hysteroscopic injection of subchorionic MTX, followed by laparoscopic resection of the residual gestational sac. Concurrently, we repaired the uterine defect. Both procedures were performed in an outpatient setting without complications detected during or after treatment. At the follow-up visit, the patient reported good health, and subsequent ultrasound confirmed an empty isthmocele. CONCLUSION: This sequential hysteroscopic and laparoscopic approach represents a definitive and effective minimally invasive surgical option for the treatment of CSEP.

Postoperative cognitive disorders and delirium in gynecologic surgery: Which surgery and anesthetic techniques to use to reduce the risk?

Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age-related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk-benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post-surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery.

Surgical impact of bilateral transient occlusion of uterine and utero-ovarian arteries during laparoscopic myomectomy.

The objective of this article is to compare the amount of intraoperative blood loss during laparoscopic myomectomy when performing bilateral transient clamping of the uterine and utero-ovarian arteries versus no intervention. It´s a randomized controlled prospective study carried out in the Department of Obstetrics and Gynecology Ramón y Cajal University Hospital and HM Montepríncipe-Sanchinarro University Hospital, Madrid, Spain, in women with fibroid uterus undergoing laparoscopic myomectomy. Eighty women diagnosed with symptomatic fibroid uterus were randomly assigned to undergo laparoscopic myomectomy without additional intervention (Group A) or temporary clamping of bilateral uterine and utero-ovarian arteries prior to laparoscopic myomectomy (Group B). Estimated blood loss, operating time, length of hospital stay, and postoperative hemoglobin values were compared in both groups. The number of fibroids removed was similar in both groups (p = 0.77). Estimated blood loss was lower in the group of patients with prior occlusion of uterine arteries (p = 0.025) without increasing operating time (p = 0.17) nor length of stay (p = 0.17). No patient had either intra or postoperative complications. Only two patients (2.5%) required blood transfusion after surgery. We conclude that temporary clamping of bilateral uterine arteries prior to laparoscopic myomectomy is a safe intervention that reduces blood loss without increasing operative time.

Efficacy, safety, and feasibility of the treatment of intrauterine pathologies with the mini-resectoscope: A systematic review.

BACKGROUND: Hysteroscopy represents the gold standard for the diagnosis and treatment of intrauterine pathologies. The advent of the mini-resectoscope heralded a new era in intrauterine surgery, both in inpatient and outpatient settings. OBJECTIVES: To evaluate the effectiveness, safety, and feasibility of the mini-resectoscope for the treatment of intrauterine pathologies. SEARCH STRATEGY: Electronic databases were searched for English-language trials describing surgical procedures for uterine pathologies performed with a mini-resectoscope until 30 April 2023. SELECTION CRITERIA: Retrospective or prospective original studies reporting the treatment of uterine pathologies with mini-resectoscope were deemed eligible for the inclusion. DATA COLLECTION AND ANALYSIS: Data about study features, characteristics of included populations, surgical procedures, complications, and results/outcomes were collected. RESULTS: Seven papers that met the inclusion criteria were included in this systematic review. Quantitative analysis was not possible due to data heterogeneity. A descriptive synthesis of the results was provided accordingly to the pathology hysteroscopically removed/corrected: polyps and myomas, uterine septum, intrauterine synechiae, and isthmocele. CONCLUSIONS: The mini-resectoscope is poised to play a leading role in hysteroscopic surgery for many pathologies, both in inpatient and outpatient settings. Since some applications of the mini-resectoscope have not yet been thoroughly investigated, future studies should address current knowledge gaps, designing high-quality comparative trials on specific applications.

Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity.

BACKGROUND: To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal. PURPOSE: In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition. METHODS: The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included. RESULTS: Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments. CONCLUSIONS: Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

Efficacy of Hysteroscopy in Improving Fertility Outcomes in Women Undergoing Assisted Reproductive Technique: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Usefulness of hysteroscopy before assisted reproductive technique (ART) was considered debatable. However, over the last decade, several new trials have been added to available literature. We aimed to assess the impact of diagnostic and operative hysteroscopy on reproductive outcomes of infertile women with and without intrauterine abnormalities. MATERIALS AND METHODS: MEDLINE, Scopus, SciELO, Embase, Cochrane Library at CENTRAL, PROSPERO, CINAHL, grey literature, conference proceedings, and international controlled trials registries were searched without temporal, geographical, or language restrictions. Randomized controlled trials (RCTs) of infertile women comparing hysteroscopy versus no hysteroscopy prior to the first ART or after at least one failed attempt were included. RCTs of infertile women with intrauterine pathology comparing diagnostic versus operative hysteroscopy were included in separate analysis. Random-effect meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Grading of Recommendations, Assessment, Development and Evaluation and Cochrane criteria were used for quality of evidence and risk of bias assessment. Primary outcome was live birth rate (LBR). Secondary outcomes were clinical pregnancy (CPR) and pregnancy loss rate. RESULTS: Fifteen studies (5,038 women) were included. Compared to no hysteroscopy before first or after failed ART attempts, moderate-quality evidence showed that hysteroscopy increased the LBR (relative risk [RR] 1.24, 95% confidence interval [CI] 1.09-1.43, I2 = 21%), confirmed by subgroup analysis for women with failure after one or more ART cycles (RR 1.43, 95% CI: 1.19-1.72, I2 = 0%) but not before the first ART. Moderate-quality evidence showed that it increased the CPR (RR 1.36, 95% CI: 1.18-1.57; I2 = 51%), confirmed in subgroup analysis for both implantation failure (RR 1.40, 95% CI: 1.12-1.74, I2 = 52%) and before first ART (RR 1.32, 95% CI: 1.11-1.57, I2 = 42%). Low-quality data suggest that operative hysteroscopy increases CPR when used to treat intrauterine pathologies (RR 2.13, 95% CI: 1.56-2.92, I2 = 0%). CONCLUSIONS: Although moderate-quality evidence supports performing hysteroscopy before ART in women with history of implantation failure, hysteroscopic evaluation of uterine cavity should be considered a first-line technique in all infertile women undergoing ART. Additional high-quality RCTs are still needed, particularly to assess yield during couple's initial evaluation even before ART is considered.

Diode laser use in hysteroscopic surgery: current status and future perspectives.

Recent advances in surgical technology and innovative techniques have revolutionized surgical gynecology, including transcervical hysteroscopic procedures. Surgical lasers (Nd-Yag, Argon, diode, and CO2 lasers) have been promoted to remove a variety of gynecological pathologies. For hysteroscopic surgery, the diode laser represents the most versatile and feasible innovation, with simultaneous cut and coagulate action, providing improved hemostasis compared with CO2 laser. The newest diode laser devices exhibit increased power and a dual wavelength, to work precisely with reduced thermal dispersion and minimal damage to surrounding tissues. Their efficacy and safety have been validated both in the hospitals as well as in the office setting. Updated evidence reports that several hysteroscopic procedures, including endometrial polypectomies, myomectomies and metroplasties can be successfully performed with a diode laser. Therefore, this review aimed to give a deeper understanding of the role of laser energy in gynecology and subsequently in hysteroscopy in order to safely incorporate this technology into clinical practice.

Rapidly evolving pelvic lymphangioleiomyomatosis (LAM) mimicking bilateral hydrosalpinx: report of a rare case and literature review.

Lymphangioleiomyomatosis (LAM) represents a rare neoplasm affecting almost exclusively women of reproductive age. This condition mainly affects the lungs, but extrapulmonary locations such as the pelvis and the retroperitoneum are possible. Clinical evaluation and ultrasound imaging are usually non-specific, and the diagnosis is obtained through surgical excision and histopathological examination. We report a very rare case of abdominal LAM in a young female patient. A thorough literature review of this rare condition with emphasis on gynecologic implications will be presented. The patient was referred for gynecologic consultation due to pelvic pain and infertility. Unfortunately, despite prompt diagnosis and treatment, the course of the disease was severe and led to patient's exitus in a short time. We encountered an extremely rare deadly pathology mimicking a very common gynecologic condition. The gynecologist must always be alert of possible unexpected conditions that will require prompt attention.

Laparoscopic oocyte retrieval for fertility preservation in a patient with squamous cell carcinoma of the vagina.

OBJECTIVE: To describe a feasible fertility preservation strategy in a woman with vaginal carcinoma. DESIGN: Video case report demonstrating the diagnostic work-up and laparoscopic oocyte retrieval performed under regional anesthesia. SETTING: University tertiary care hospital. PATIENT(S): A 35-year-old nulliparous woman presented with vaginal bleeding and foul-smelling vaginal discharge. After a comprehensive diagnostic work-up, a final diagnosis of squamous cell carcinoma of the vagina stage II (Federation International Obstetrics and Gynecology classification) was made. As per the patient's desire, before undergoing chemoradiotherapy, the patient underwent oocyte cryopreservation. Transvaginal retrieval of oocytes was not feasible because of stenosis of the vaginal introitus and the potential risk of intracavitary tumor cell spillage. Transabdominal ultrasound-guided oocyte retrieval was not possible because of the body's habitus. INTERVENTION(S): The patient underwent ovarian stimulation for in vitro fertilization. To minimize estrogen levels, letrozole was used during controlled ovarian stimulation. Laparoscopic oocyte retrieval was performed under spinal anesthesia. MAIN OUTCOME MEASURE(S): Successful laparoscopic egg retrieval and cryopreservation in a woman with squamous cell carcinoma of the vagina. RESULT(S): A total follicular count of nine was estimated before the oocyte retrieval. Eight oocytes were retrieved at laparoscopy, and eight mature oocytes were successfully cryopreserved. No complications were encountered, and the patient was discharged on the same day of surgery. CONCLUSION(S): To our knowledge, this is the first published case of fertility preservation using the laparoscopic approach in a patient with vaginal cancer. Letrozole is a valuable strategy to reduce high estrogen in patients with gynecological cancer undergoing controlled ovarian stimulation. Laparoscopy oocyte retrieval, performed under regional anesthesia, can be performed in an ambulatory setting and should be considered an effective fertility preservation strategy in patients with large vaginal tumors.