Two-Port Laparoscopic Removal of Large Ovarian Cystadenoma.

An ovarian mucinous cystadenoma is a common benign tumour of the ovary that tends to reach very large sizes. Although traditional morcellation in the abdominal cavity is largely avoided in gynaecologic surgery, several authors have proposed other systems and techniques for the removal of large masses without resorting to laparotomy. We proposed an extremely minimally invasive technique to remove a large mass with a very low suspicion of malignancy, and created a video demonstration of the procedure. In this short film we illustrate our novel technique using only 2 laparoscopic ports, which maximizes both cosmesis and speed of recovery. The technique is not a completely closed system, therefore the potential for spreading an undiagnosed malignancy still exists. Accordingly, the authors do not suggest this technique for masses with a high potential for malignancy. However, in properly consented patients where there is very little suspicion for malignancy, our technique may be a reasonable option to promote fast recovery and provide excellent cosmesis.

Salpingectomy vs tubal ligation for sterilization: a systematic review and meta-analysis.

OBJECTIVE: After strong evidence and major organizations recommending salpingectomy over tubal ligation, we sought to perform a systematic review and meta-analysis comparing the intraoperative attributes and complication rates associated with these 2 procedures. DATA SOURCES: We searched PubMed, the Cochrane Library, Embase, and clinical trials registries without time or language restrictions. The search was conducted in February 2020. Database searches revealed 74 potential studies, of which 11 were examined at the full-text level. Of these, 6 studies were included in the qualitative analysis and 5 studies were included in the meta-analysis. STUDY ELIGIBILITY CRITERIA: We included randomized controlled trials comparing salpingectomy with tubal ligation in women seeking sterilization. We included studies that also had at least 1 outcome listed in the population/patient problem, intervention, comparison, outcome, and time. Articles were excluded if they did not meet the inclusion criteria or if data were not reported and the authors did not respond to inquiries. STUDY APPRAISAL AND SYNTHESIS METHODS: Abstracts and full-text articles were assessed by 2 authors independently using the blinded coding assignment function or EPPI-Reviewer 4. Conflicting selections were resolved by consensus. The quality of included studies was determined using the Cochrane Collaboration tool for assessing the risk of bias in randomized trials. Two authors independently assessed the risk of bias for each study; disagreements were resolved by consensus. RESULTS: There were few differences between the procedures, with no differences in most important clinical outcomes (antimüllerian hormone, blood loss, length of hospital stay, pre- or postoperative complications, or wound infections). A single study reported a reduced rate of pregnancies with salpingectomy (risk ratio, 0.22; 95% confidence interval, 0.05-1.02), but this did not reach statistical significance (P=.05). CONCLUSION: We conclude from these data that salpingectomy is as safe and efficacious as tubal ligation for sterilization and may be preferred, where appropriate, to reduce the risk of ovarian cancer.

Complications of Laparoscopic and Transabdominal Cerclage in Patients with Cervical Insufficiency: A Systematic Review and Meta-analysis.

OBJECTIVE: Cervical insufficiency is a defect of the cervix that leads to failure to preserve a full-term intrauterine pregnancy. Laparoscopic cerclage and open transabdominal cerclage (TAC) are effective ways to manage patients with cervical insufficiency. We performed this systematic review and meta-analysis to investigate the complications of laparoscopic cerclage and open TAC in the management of cervical insufficiency. DATA SOURCES: We searched PubMed, Cochrane, Scopus, and Web of Science using our search strategy and screened the results for our criteria. We extracted the results reported and analyzed them using Open Meta-Analyst (OpenMeta[Analyst], Brown School of Public Health, Providence, RI) and Review Manager (Cochrane Collaboration, London, United Kingdom) software. METHODS OF STUDY SELECTION: We included all randomized controlled and observational trials performed on patients with cervical insufficiency undergoing open TAC or laparoscopic cerclage that matched our search strategy. We excluded letters to the editor, reviews, meetings/conference abstracts, non-English or nonhuman studies, and instances where the full text was not available. TABULATION, INTEGRATION, AND RESULTS: We included a total of 33 trials. Both interventions of laparoscopic cerclage and open TAC were associated with significantly less total fetal loss (laparoscopic cerclage, relative risk [RR] 0.03; 95% confidence interval [CI], 0.01-0.08; p <.001, and open TAC, RR 0.19; 95% CI, 0.07-0.51; p <.009). The overall blood loss in open TAC was 110.589 mL (95% CI, 93.737-127.44; p <.001), and in laparoscopic cerclage, it was 24.549 mL (95% CI, 9.892-39.205; p = .001). In addition, open TAC had a positive effect regarding incidence of hemorrhage >400 mL (RR 0.077; 95% CI, 0.033-0.122; p <.001). Preterm premature rupture of membranes was significant in the open TAC (RR 0.037; 95% CI, 0.019-0.055; p <.001) and laparoscopic cerclage groups (RR 0.031; 95% CI, 0.009-0.053; p = .006). CONCLUSION: Laparoscopic cerclage may be safer than open TAC in the management of cervical insufficiency because we found a statistically significant lower incidence of fetal loss, blood loss, and rate of hemorrhage in the laparoscopic cerclage group. Clinically, this evidence may help support favoring a laparoscopic approach over an open one in appropriate patients, although it is unclear whether this benefit is limited to cerclages placed either before pregnancy or placed in the first-trimester or both.

A Systematic Review and Meta-Analysis of the Effect of Intraoperative Bupivacaine in Gynaecologic Surgery After 24 Hours or 9 Half-Lives.

OBJECTIVE: To review all high quality available evidence regarding the effect of intraoperative bupivacaine 24 hours (or 8.9 half-lives) after intraoperative administration at time of gynaecologic surgery and to ascertain whether a second mechanism of action, beyond the initial prevention of sodium channel depolarization and blockade of nerve impulses, may be occurring. DATA SOURCES: We searched all major databases with an algorithm designed to include all randomized trials that used any form of local bupivacaine, regardless of dose or route of administration, at the time of any gynaecologic surgery and compared its use with saline placebo. RESULTS: As expected, we found that bupivacaine showed a significant improvement for all gynaecologic surgeries with respect to pain intensity at 6 hours after surgery when compared with a saline group (mean difference [MD] -1.28; 95% CI -1.96 to -0.61], P = 0.07). We also found a significant difference at 24 hours after surgery, giving evidence to the possibility of a second mechanism of action (MD -0.57; 95% CI -1.10 to -0.05], P = 0.01). Further subgroup analysis for pain levels at 24 hours showed significant decreases in pain for the laparoscopy (MD -0.74; 95% CI -0.93 to -0.54, P < 0.01) and laparotomy (MD -2.60; 95% CI -2.93 to -2.27, P < 0.01)) subgroups but not for the vaginal hysterectomy (MD 0.20; 95% CI -0.69 to 1.09, P = 0.66) or prolapse surgery (MD -0.11; 95% CI -0.41 to 0.19, P = 0.48) subgroups. There was no significant difference with respect to the length of hospital stay (MD -0.11; 95% CI -0.59 to 0.38, P = 0.67). CONCLUSION: As expected, bupivacaine significantly reduced visual analog pain scores when compared with placebo at 6 hours after surgery, but also showed a significant difference at 24 hours after surgery, giving evidence of a second mechanism of action following the initial sodium channel blockade.

First and second-generation endometrial ablation devices: A network meta-analysis.

OBJECTIVE: First-generation and second-generation endometrial ablation (EA) techniques, along with medical treatment and invasive surgery, are considered successful lines of management for abnormal uterine bleeding (AUB). We set out to determine the efficacy of first and second-generation ablation techniques compared with medical treatment, invasive surgery and different modalities of the EA techniques themselves. DESIGN: Systematic review and network meta-analysis using a frequentist network. DATA SOURCES: We searched Medline (Ovid), PubMed, ClinicalTrials.gov, Cochrane CENTRAL, Web of Science, EBSCO and Scopus for all published studies up to 1 March 2021 using relevant keywords. ELIGIBILITY CRITERIA: We included all randomised controlled trials (RCTs) that compared premenopausal women with AUB receiving the intervention of second-generation EA techniques. DATA EXTRACTION AND SYNTHESIS: 49 high-quality RCTs with 8038 women were included. We extracted and pooled the data and then analysed to estimate the network meta-analysis models within a frequentist framework. We used the random-effects model of the netmeta package in R (V.3.6.1) and the 'Meta-Insight' website. RESULTS: Our network meta-analysis showed many varying results according to specific outcomes. The uterine balloon ablation had significantly higher amenorrhoea rates than other techniques in both short (hydrothermal ablation (risk ratio (RR)=0.51, 95% CI 0.37; 0.72), microwave ablation (RR=0.43, 95% CI 0.31; 0.59), first-generation techniques (RR=0.44, 95% CI 0.33; 0.59), endometrial laser intrauterine therapy (RR=0.18, 95% CI 0.10; 0.32) and bipolar radio frequency treatments (RR=0.22, 95% CI 0.15; 0.31)) and long-term follow-up (microwave ablation (RR=0.11, 95% CI 0.01; 0.86), bipolar radio frequency ablation (RR=0.12, 95% CI 0.02; 0.90), first generation (RR=0.12, 95% CI 0.02; 0.90) and endometrial laser intrauterine thermal therapy (RR=0.04, 95% CI 0.01; 0.36)). When calculating efficacy based only on calculated bleeding scores, the highest scores were achieved by cryoablation systems (p-score=0.98). CONCLUSION: Most second-generation EA systems were superior to first-generation systems, and statistical superiority between devices depended on which characteristic was measured (secondary amenorrhoea rate, treatment of AUB, patient satisfaction or treatment of dysmenorrhoea). Although our study was limited by a paucity of data comparing large numbers of devices, we conclude that there is no evidence at this time that any one of the examined second-generation systems is clearly superior to all others.

Systematic Review and Meta-analysis of laparoscopic radical hysterectomy vs. Robotic assisted radical hysterectomy for early stage cervical cancer.

OBJECTIVE: Following compelling evidence that open techniques may be related to better survival and disease free survival rates, many gynecologic oncologists in the US have turned away from performing laparoscopic radical hysterectomy (LRH) and robotic radical hysterectomy (RRH) for the treatment of early-stage cervical cancer. While this may be warranted as a safety concern, there is little high-quality data on the head-to-head comparison of LRH and RRH and therefore little evidence to answer the question of where this decrease in patient survival is originating from. In our systematic review, we aimed to compare the complications and outcomes of LRH against those of RRH. DATA SOURCES: We searched PubMed, Cochrane CENTRAL, Medline, ClinicalTrials.Gov, SCOPUS, and Web of Science from database inception until February 1st, 2022. METHODS OF STUDY SELECTION: A total of 676 studies were identified and screened through a manual three-step process. Ultimately 33 studies were included in our final analysis. We included all studies that compared LRH and RRH and included at least one of our selected outcomes. We included retrospective cohorts, prospective cohorts, case-control, and randomized clinical trials. TABULATION, INTEGRATION, AND RESULTS: Data was independently extracted manually by multiple observers and the analysis was performed using Review Manager Software. PRISMA guidelines were followed. We analyzed homogenous data using a fixed-effects model, while a random-effects model was used for heterogeneous outcomes. We found that following RRH, women had a decreased hospital stay (MD = 0.80[0.38,1.21],(P < 0.002). We found no differences in estimated blood loss (MD = 35.24[-0.40,70.89],(P = 0.05), blood transfusion rate ((OR = 1.32[0.86,2.02],(P = 0.20), rate of post-operative complications (OR = 0.84[0.60,1.17],(P = 0.30), the operative time (MD = 6.01[-4.64,16.66],(P = 0.27), number of resected lymph node (MD = -1.22[-3.28,0.84],(P = 0.25) intraoperative complications (OR = 0.78[0.51,1.19],(P = 0.25), five-year overall survival (OR = 1.37[0.51,3.69],(P = 0.53), lifetime disease free survival (OR = 0.89[0.59,1.32],(P = 0.55), intraoperative and postoperative mortality (within 30 days) (OR = 1.30[0.66,2.54],(P = 0.44), and recurrence (OR = 1.14[0.79,1.64],(P = 0.50). CONCLUSIONS: RRH seems to result in the patient leaving the hospital sooner after surgery. We were unable to find any differences in our ten other outcomes related to complications or efficacy. These findings suggest that the decreased survival seen in minimally invasive RH in previous studies could be due to factors inherent to both LRH and RRH. PROSPERO PROSPECTIVE REGISTRATION NUMBER: CRD42022273727.

Maternal and neonatal outcomes of COVID-19 vaccination during pregnancy, a systematic review and meta-analysis.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is associated with increased pregnancy complications. Despite effective vaccination strategies for the general population, the evidence on the safety and efficacy of Coronavirus disease 2019 (COVID-19) vaccinations in pregnancy is limited due to a lack of well-powered studies. The present study compares the maternal, neonatal, and immunological outcomes between vaccinated pregnant and unvaccinated pregnant women using a systematic review and meta-analysis approach. We included 37 studies with a total of 141,107 pregnant women (36.8% vaccinated) spread across all outcomes. Our evidence indicates a higher rate of cesarean section in the 1898 vaccinated pregnant women compared to the 6180 women who did not receive vaccination (OR = 1.20, CI = (1.05, 1.38), P = 0.007, I2 = 45%). Regarding immunological outcomes, the risk of SARS-CoV-2 infection during pregnancy or postpartum was significantly reduced in 6820 vaccinated pregnant women compared to 17,010 unvaccinated pregnant women (OR = 0.25, CI = 0.13-0.48, P < 0.0001, I2 = 61%), as evident from qualitative assessment indicating significantly higher postpartum antibody titers compared to that observed in both unvaccinated mothers and mothers who have recently recovered from a SARS-CoV-2 infection. Our analysis represents high quality evidence showing that COVID-19 vaccination effectively raises antibody titers against SARS-CoV-2. This may confer protection against infection during pregnancy and the postpartum period. In addition to being protective against SARS-CoV-2, the vaccine was associated with decreased odds of preterm delivery. Furthermore, COVID-19 vaccination may also be associated with higher odds of cesarean section.

Systematic review and meta-analysis of the efficacy of gabapentin in chronic female pelvic pain without another diagnosis.

Background: While widely used for the treatment of chronic pelvic pain, limited data exists on efficacy of gabapentin, especially in the subgroup of women suffering from chronic pelvic pain without a known diagnosis, such as endometriosis. Objective: This study aimed to assess the efficacy of gabapentin when administered to women with chronic pelvic pain without another diagnosis. Study Design: We performed a Systematic Review and Meta Analysis including all controlled clinical trials addressing the use of gabapentin for the treatment of chronic pelvic pain without another diagnosis. We searched PubMed, Scopus, Web of Science, ClinicalTrials.Gov, MEDLINE, and The Cochrane Library from inception of each database to April 30, 2021. We included all the studies that fulfilled the following criteria: (1) population: women suffering from chronic pelvic pain without another identified diagnosis (such as endometriosis); (2) intervention: gabapentin (regardless of the dosage); (3) comparator:placebo; (4) outcomes: pain score (visual analog scale) after 3 months and pain score (visual analog scale) after 6 months as primary outcomes; and (5) study design: we only included randomized or controlled clinical trials. Our exclusion criteria included (1) uncontrolled clinical trials, (2) studies that did not report data or measures for any of our selected outcomes, (3) studies that included patients with surgically or clinically diagnosed endometriosis, or (4) studies with no full-text manuscript available. Risk of bias assessment was performed using the Cochrane risk of bias tool. We analyzed dichotomous outcomes as percentages and totals, whereas continuous outcomes were analyzed using mean difference, standard deviations, and relative 95% confidence intervals using the inverse variance method. Results: We included 4 placebo-controlled randomized controlled trials. Analysis was hindered because half of the studies (n=2) used the visual analog scale pain score and the other half (n=2) used the numerical rating scale. The analysis showed that when compared with the placebo, gabapentin significantly lowered the visual analog scale pain score at 3 months (mean difference, 0.79; 1.23 to 0.35; P=.005) and 6 months (mean difference, 1.68; 2.30 to 1.05; P=.001) and the numerical rating scale pain score at 3 months (mean difference, 0.20; 0.25 to 0.15; P=.001). However, in terms of the numerical rating scale pain score after 6 months, the 2 groups showed no significant difference (mean difference, 0.27; 0.80 to 0.26; P=.32). CONCLUSION: Gabapentin may hold benefit for the management of chronic pelvic pain, with significant improvement in pain seen in both scales at 3 months when compared with the placebo, but only in the visual analog scale group at 6 months of usage. Secondary to the differences in the nature of the 2 scales, a further weighted combined analysis was not possible.

Salpingectomy, tubal ligation and hysteroscopic occlusion for sterilization.

INTRODUCTION: Sterilization of females is considered one of the most prevalent contraceptive techniques among women in the United States. There are many surgical sterilization procedures including salpingectomy, tubal ligation, and hysteroscopic occlusion of the fallopian tubes. We provide an overview of these methods from the clinical data and latest studies available on this topic. EVIDENCE ACQUISITION: In order to review the latest literature on the topic, we searched electronic databases including PubMed, Web of Science, Scopus, and Cochrane library for all eligible studies from May 1st 2018 until May 1st 2022 using the following strategy: ("fallopian tube removal" OR Salpingectomy OR "fallopian tube excision" OR "tubal sterilization") AND ("tubal ligation" OR "bipolar coagulation" OR "tubal clip" OR "tubal ring" OR fimbriectomy). We reviewed every study that met our criteria and subjectively considered their results and methodology into this narrative review. EVIDENCE SYNTHESIS: In addition to reviewing major guidelines in the United States, 19 recent studies met our eligibility criteria and were included in this review. We grouped the findings under the following headings: anatomical and physiological considerations, sterilization, salpingectomy, tubal ligation, and hysteroscopic tubal occlusion. CONCLUSIONS: Bilateral salpingectomy and techniques of tubal ligation or occlusion continue to be effective procedures with good safety profiles. All techniques have similar surgical outcomes and long-term success rates. As salpingectomy has the advantage of reducing the risk of occurrence of ovarian cancer, this is preferential when feasible. Hysteroscopic occlusion techniques may be more minimally invasive but have the disadvantages of delayed efficacy, the need for a second invasive diagnostic procedure, and limited availability.

Systematic review and meta-analysis of COVID-19 maternal and neonatal clinical features and pregnancy outcomes up to June 3, 2021.

OBJECTIVE: COVID-19 is a rapidly changing and developing emergency that requires constant re-evaluation of available data. We report a systematic review and meta-analysis based on all published high-quality data up to and including June 3, 2021 on the maternal and neonatal outcomes in pregnant women infected with COVID-19. DATA SOURCES: PubMed, SCOPUS, MEDLINE, ClinicalTrials.gov, and Web of Science databases were queried from inception up to June 3, 2021. STUDY ELIGIBILITY CRITERIA: We included all clinical studies (prospective and retrospective cohort studies, case-control studies, case series, and rapid communications) that reported data on any maternal and neonatal outcomes of pregnant women with COVID-19. METHODS: The data were analyzed as pooled proportions or odds ratios and 95% confidence intervals in meta-analysis models. RESULTS: We included 111 studies enrolling 42,754 COVID-19-positive pregnant women. From COVID-19-positive pregnant women, the incidence rates were 53.2% (95% confidence interval, 48-58.4) for cesarean delivery, 41.5% (95% confidence interval, 36.3-46.8) for spontaneous vaginal delivery, and 6.4% (95% confidence interval, 4.5-9.2) for operative delivery. The rates of some adverse neonatal events, including premature delivery (16.7%; 95% confidence interval, 12.8-21.5) and low birthweight (16.7%; 95% confidence interval, 12.8-21.5) were relatively high in mothers infected with COVID-19. Vertical transmission (3.5%; 95% confidence interval, 2.7-4.7), neonatal death (3%; 95% confidence interval, 2-4), stillbirth (1.9%; 95% confidence interval, 1.5-2.4), and maternal mortality (0.012%; 95% confidence interval, 0.010-0.014) were rare adverse events. The mean birthweight was 3069.7 g (95% confidence interval, 3009.7-3129.8 g). In the comparative analysis, COVID-19 significantly increased the risk of premature delivery (odds ratio, 1. 48 [95% confidence interval, 1.22-1.8]), preeclampsia (odds ratio, 1.6 [95% confidence interval, 1.2-2.1]), stillbirth (odds ratio, 2.36 [95% confidence interval, 1.24-4.462]), neonatal mortality (odds ratio, 3.35 [95% confidence interval, 1.07-10.5]), and maternal mortality (odds ratio, 3.08 [95% confidence interval, 1.5-6.3]). The pooled analyses were homogenous, with mild heterogeneity in premature delivery and preeclampsia outcomes. CONCLUSION: The data must be interpreted with caution as limited data are available, and no complete assessment of bias is possible at this time. Our data suggest that pregnant women who test positive for COVID-19 seem to be at a higher risk of lower birth weights and premature delivery. There is no evidence at this time of the sharply increased maternal mortality that was seen previously with both the 2003 SARS and 2012 MERS pandemics.

Efficacy of laparoscopic and trans-abdominal cerclage (TAC) in patients with cervical insufficiency: A systematic review and meta-analysis.

BACKGROUND: Cervical insufficiency (CI) may result in preterm delivery. We sought out to perform this review and analysis to compare the efficacy of laparoscopic and open transabdominal cerclage (TAC) in patients suffering with CI. METHODS: Our search included PubMed, Scopus, MEDLINE, ClinicalTrials.Gov, Cochrane and Web of Science. We analyzed the data with Open Meta-Analyst Software as well as Review Manager Software. We included observational and randomized controlled trials that included patients with CI that underwent laparoscopic cerclage or TAC. RESULTS: We included a total of 43 studies. Laparoscopic and TAC had a positive effect by increasing gestational age (GA); for the laparoscopic group (mean deviation (MD)) = 14.86 weeks (W), 95% CI [10.67, 19.05], P < 0.001) and TAC (MD = 12.79 W, 95% CI [10.97, 14.61], P < 0.001). Furthermore, improvements in all outcomes assessed (total fetal survival rate, neonatal weight, and prevention of delivery at a gestational age of<24 weeks) were all significant with the exception of the prevention of all preterm deliveries<37 weeks; for both laparoscopic at (RR = 0.116, 95% CI [-0.006, 0.238], P = 0.063) and TAC at (MD = 1, 95% CI [0.45, 2.24], P = 1), and for prevention of deliveries<34 weeks for the laparoscopic group (RR = 0.446, 95% CI [-0.323, 1.215], P = 0.256) only. CONCLUSIONS: Although limited data prevented pregnancy and prepregnancy subgroups as well as a head-to-head comparison, we still found that in patients suffering from CI, both TAC and laparoscopic approaches to cerclage revealed a positive effect in preserving the pregnancy.

Systematic review and meta-analysis of Veress needle entry versus direct trocar entry in gynecologic surgery.

Objective: Although many studies have been performed, no consensus exists as to the ideal entry for laparoscopic gynecologic surgery. We sought out to compare the safety of direct trocar insertion with that of the Veress needle entry technique in gynecologic laparoscopic surgery. Design: Systematic review with meta-analysis. Setting: We searched Medline, ClinicalTrials.Gov, PubMed, Cochrane CENTRAL, SCOPUS, and Web of Science from their inception through 31 July 2021 for relevant studies. We included only controlled trials and ultimately seven trials were included in our meta-analysis. Participants: Inclusion criteria included women undergoing gynecological laparoscopic surgery. Intervention: The intervention of direct trocar insertion technique compared with Veress needle entry technique. Main outcome measures: We compared five different outcomes associated with the efficacy and complications of laparoscopic entry. Results: The pooled analysis showed that Veress needle entry was associated with a significant increase in the incidences of extraperitoneal insufflation (RR=0.177, 95% Cl (0.094 to 0.333), p<0.001), omental injury (RR=0.418, 95% Cl (0.195 to 0.896), p<0.001), failed entry (RR=0.173, 95% Cl (0.102 to 0.292), p<0.001), and trocar site infection (RR=0.404, 95% Cl (0.180 to 0.909), p<0.029). There was no significant difference between the two groups regarding the visceral injury (RR=0.562, 95% Cl (0.047 to 6.676), p<0.648). Conclusions: When excluding all data apart from gynecologic surgery, the Veress needle entry technique may have an increased incidence of some, but not all complications of laparoscopic entry. It may also have a higher incidence of failed entry compared with direct entry techniques. Care should be taken in extrapolating these general results to specific surgeon experience levels. Trial registration number: CRD42021273726.

Birth Outcomes of Neonates Exposed to Marijuana in Utero: A Systematic Review and Meta-analysis.

Importance: While some studies have found an association between marijuana use and adverse neonatal outcomes, results have not been consistent across all trials. Objective: To assess available data on neonatal outcomes in marijuana-exposed pregnancies. Data Sources: PubMed, Medline, ClinicalTrials.gov, Cochrane, Scopus, and Web of Science were searched from each database's inception until August 16, 2021. Study Selection: All interventional and observational studies that included pregnant women who were exposed to marijuana compared with pregnant women who were not exposed to marijuana and that reported neonatal outcomes were included. Data Extraction and Synthesis: Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Data were extracted by 2 authors for all outcomes, which were pooled using a random-effects model as mean difference or risk ratio (RR) and 95% CI. Data were analyzed from August through September 2021. Main Outcomes and Measures: All outcomes were formulated prior to data collection. Outcomes included incidence of birth weight less than 2500 g, small for gestational age (defined as less than the fifth percentile fetal weight for gestational age), rate of preterm delivery (defined as before 37 weeks' gestation), gestational age at time of delivery, birth weight, incidence of neonatal intensive care unit (NICU) admission, Apgar score at 1 minute, Apgar score at 5 minutes, incidence of an Apgar score less than 7 at 5 minutes, fetal head circumference, and fetal length. Results: Among 16 studies including 59 138 patients, there were significant increases in 7 adverse neonatal outcomes among women who were exposed to marijuana during pregnancy vs those who were not exposed during pregnancy. These included increased risk of birth weight less than 2500 g (RR, 2.06 [95% CI, 1.25 to 3.42]; P = .005), small for gestational age (RR, 1.61 [95% CI, 1.44 to 1.79]; P < .001), preterm delivery (RR, 1.28 [95% CI, 1.16 to 1.42]; P < .001), and NICU admission (RR, 1.38 [95% CI, 1.18 to 1.62]; P < .001), along with decreased mean birth weight (mean difference, -112.30 [95% CI, -167.19 to -57.41] g; P < .001), Apgar score at 1 minute (mean difference, -0.26 [95% CI, -0.43 to -0.09]; P = .002), and infant head circumference (mean difference, -0.34 [95% CI, -0.63 to -0.06] cm; P = .02). Conclusions and Relevance: This study found that women exposed to marijuana in pregnancy were at a significantly increased risk of some adverse neonatal outcomes. These findings suggest that increasing awareness about these risks may be associated with improved outcomes.

Efficacy of hyoscine in pain management during hysteroscopy: a systematic review and meta-analysis

We conducted a systematic review and meta-analysis of relevant clinical trials from full-text, scientific journal archives to assess the efficacy of hyoscine for the management of pain during in-office hysteroscopy (OH) procedures. Cochrane CENTRAL, ClinicalTrials.Gov, MEDLINE, PubMed, SCOPUS and the Web of Science were searched for all clinical trials that matched our search criteria. A full assessment of bias was made using the Cochrane Group tool-set. The following outcomes were included: visual analogue scale (VAS) score for postoperative pain, postoperative need for analgesia, and procedure time. In the case of homogeneous data, the analysis was performed using a fixed effects system, and the random effects system was used with heterogeneous data. Inclusion criteria included only randomized clinical trials, and interventions that included patients receiving hyoscine-N-Butyl Bromide during OH, regardless of dose or mode of administration, and compared this with placebo. Three clinical trials were included. The actual mean difference (MD) of the VAS pain score showed no significant difference between hyoscine or placebo [MD: -0.28 (-1.08, 0.52), (p=0.49)]. For postoperative analgesia, the overall MD showed no significant difference between hyoscine or placebo [MD: 0.43 (0.16, 1.14), (p=0.09)]. For procedure time, the combined effect estimate failed to show any significant difference between hyoscine and placebo [MD: -0.66 (-2.77, 1.44) (p=0.54)]. Contrary to previously published data, our meta-analysis using the latest available RCTs fails to show hyoscine as being effective in reducing pain or the need for other forms of anesthesia in OH.

Contained and uncontained morcellation in hysterectomy and myomectomy: A systematic review and meta-analysis

We sought to analyze all high-quality studies available regarding the possible differences in contained and uncontained techniques for morcellation of fibroids and uteri. We systematically searched PubMed, Cochrane Central, Scopus, ClinicalTrials.Gov, MEDLINE and Web of Science from September 2010 to September 2020 for our search terms. We included studies that specifically enrolled patients undergoing power morcellation myomectomy or power morcellation hysterectomy procedures. In our search, we had no restriction to age, country, or publication date. We extracted data related to study design, baseline characteristics of patients, and perioperative outcomes such as total operative time, total blood loss, and duration of hospital stay. We found no substantial difference in total operative time between contained power morcellation and uncontained manual morcellation myomectomy (p=0.52), but contained power morcellation had a significantly longer total operative time than uncontained power morcellation for hysterectomy and myomectomy [135.50 vs. 93.33 minutes, (p=0.003)]. Total blood loss was comparable for contained power morcellation versus uncontained manual morcellation myomectomy (p=0.32) and contained power morcellation versus uncontained power morcellation myomectomy or hysterectomy (p=0.91). Contained power morcellation and uncontained manual morcellation myomectomy had comparable hospital stay periods (p=0.5). Contained power morcellation leads to a longer operating time than uncontained power morcellation for both hysterectomy and myomectomy. No differences were found in comparisons of blood loss, operative time, or comparison to manual methods of morcellation.

Effect of single- and double-layer cesarean section closure on residual myometrial thickness and isthmocele - a systematic review and meta-analysis

Objective: To determine the incidence of isthmocele, its effect on residual myometrial thickness (RMT), and other complications of Cesarean delivery (CD) in relation to single- and double-layer CD closure. We searched PubMed, SCOPUS, Web of Science, ClinicalTrials.gov, MEDLINE and Cochrane Library for relevant clinical trials assessing the use of single- and double-layer uterine closure in patients undergoing cesarean sections from inception through to March 2021. Materials and Methods: Our population was women undergoing cesarean section with uterine closure by any double-layer method, compared with those undergoing uterine closure through a single-layer method. RMT (in mm) was measured at 6 weeks, niche/isthmocele existence at 6 weeks, RMT (in mm) at 6-24 months and niche/isthmocele existence at 6-24 months. In order to present the highest quality evidence, we only included clinical trials in our analysis. To perform this review, we reported dichotomous outcomes using percent and total, while continuous outcomes were reported using mean ± standard deviations, and relative 95% confidence intervals using the inverse variance method. Results: We found that the RMT in the double-layer closure group was significantly higher at six weeks [mean difference (MD)=-0.43 (-0.77, -0.09)], (p=0.01) and at 6-24 months of follow-up [MD=-1.27 (-2.28, -0.25)], (p=0.01). The incidence of isthmocele in the two groups, as well as the other investigated outcomes were similar across the different groups. Conclusion: High-quality evidence shows that double-layer closure results in a higher RMT compared with a single-layer closure, despite no significant difference in isthmocele formation.

Complete Laparoscopic Removal and Staging of a Large Ovarian Malignancy: A Case Report.

BACKGROUND Advances in minimally invasive surgery are essential for the improvement of patient care, overall health care efficiency, and total cost reductions. Morcellation, the technique used in the present case, is often used to aid minimally invasive laparoscopic procedures, whereby larger tissue specimens are broken down and divided to be removed via smaller incisions. Morcellation has become controversial in the medical community owing to the risk of the procedure spreading an occult malignancy. CASE REPORT A 47-year-old woman with obesity presented with right-sided pelvic pain and suspicion of ovarian torsion. The patient experienced severe acute pain and was taken to the operating room for laparoscopy to remove the left-sided adnexal mass seen on imaging. During surgery, there was no evidence of torsion, and the mass was perfused. During removal of the entire tumor, blunt instruments were utilized for in-bag manual morcellation to avoid spillage of the contents of the bag, which were then sent for frozen section analysis, and a diagnosis of adenocarcinoma of the ovary was made. Once the tumor was removed, a board-certified gynecologic oncologist was consulted to assist with the remainder of the procedure. Following this, the ovarian cancer staging procedure was able to be completed laparoscopically. CONCLUSIONS This technique of in-bag manual morcellation using blunt instruments allows laparoscopic procedures to be performed on large tissue specimens with potential malignancies without spreading cancerous tissue, overcoming the associated risks of dissemination of malignancy. This technique is therefore more beneficial to patients.

Two port laparoscopic trachelectomy without the use of ureteral stents

Trachelectomy is a notoriously difficult laparoscopic procedure, often because of remaining scar tissue from a prior supracervical hysterectomy, as well as the necessity to clear vital organs, including the bladder and the rectum, out of the plane of dissection in order to remove the cervix. Many authors have suggested techniques involving ureteral stents to minimize the chance of ureteral injury. Our institute presents this two-port laparoscopic technique without the use of stents, which we believe safely accomplishes the trachelectomy through very minimally invasive means.

Novel oxytocin receptor antagonists for tocolysis: a systematic review and meta-analysis of the available data on the efficacy, safety, and tolerability of retosiban.

OBJECTIVE: To assess the efficacy, safety, and tolerability of retosiban-a novel tocolytic unavailable in the US-in the management of preterm labor. METHODS: We searched ClinicalTrials.Gov, MEDLINE, PubMed, SCOPUS, Web of Science, and the Cochrane Library for relevant clinical trials using the terms "retosiban" and "preterm labor" through 09/2020. We included all published randomized clinical trials (three) that compared retosiban to placebo for preterm labor, excluding conferences, books, reviews, posters, case reports, and animal studies. We analyzed homogeneous data under the fixed-effects model and heterogeneous data under the random-effects model. RESULTS: We included all randomized clinical trials addressing this topic, which ultimately resulted in three trials with a total of 116 patients. There were no significant differences between retosiban and placebo in births at term (RR = 0.41, p = .02), births ≤7 days from the first study treatment (RR = 0.59, p = .23), or administration of rescue tocolytic (RR = 0.36, p = .07); the maternal adverse events of headache, anemia, constipation, or urinary tract infection (p > .05); or neonatal outcomes of Apgar score at 1 min (p = .88) or 5 min (p = .69), weight (p = .23), head circumference (p = .55), malnutrition (p = .27), hyperbilirubinemia (RR = 0.56, p = .21), jaundice (RR = 1.21, p = .84), respiratory distress (RR = 0.53, p = .49), or tachypnea (RR = 0.40, p = .42). CONCLUSION: With the limited high quality evidence available, retosiban demonstrates no clear benefit over placebo in the management of preterm labor. Nevertheless, its favorable safety profile, oral bioavailability, and novel mechanism of action and the limited number of studies available for review warrant further analysis.

The Efficacy of Acetominophen for Total Laparoscopic Hysterectomy.

OBJECTIVE: Despite limited data, acetaminophen, along with other agents, is commonly included in enhanced recovery after surgery (ERAS) protocols following laparoscopic hysterectomy. We aimed to systematically review the efficacy of acetaminophen on the management of postoperative pain after laparoscopic hysterectomy. METHODS: We searched PubMed, SCOPUS, Web of Science, and Cochrane Library databases for relevant clinical trials investigating the role of acetaminophen in the management of pain after laparoscopic hysterectomy. We performed the risk of bias according to Cochrane's risk of bias tool. We performed the analysis of homogeneous data under the fixed-effects model during the analysis of heterogeneous data under the random-effects model. The primary outcome was the assessment of pain score after 2, 6, 12, and 24 h. RESULTS: A total of 495 patients in 13 trials were included in our meta-analysis. Acetaminophen was not superior at reducing postoperative pain scores. Further analysis at progressive temporal points revealed no further significance; effect size at after 2 h (SMD = -0.020, 95% CI (-0.216; 0.176)), 6 h (SMD = -0.115, 95% CI (-0.312; 0.083)), 12 h (SMD = -0.126, 95% CI (-0.277; 0.025)), or 24 h (SMD = 0.063, 95% CI (-0.065; 0.191)). Pooled analysis was heterogeneous (P < 0.1); therefore, we conducted a sensitivity analysis yielding homogeneous results. The drug did not reduce opioid need (MD = -0.16, 95% CI (-2.39, 2.06), P = 0.89). CONCLUSION: We conclude that acetaminophen is not beneficial for reducing pain after laparoscopic hysterectomy. Other alternatives have better results. Caution should be given to the inclusion of acetaminophen in ERAS protocols designed for laparoscopic hysterectomy, especially as a single agent or to reduce opioid consumption.