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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.
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Cistoadenoma Mucinoso , Cistoadenoma , Laparoscopía , Morcelación , Neoplasias Ováricas , Cistoadenoma/cirugía , Cistoadenoma Mucinoso/diagnóstico , Cistoadenoma Mucinoso/cirugía , Femenino , Humanos , Laparoscopía/métodos , Neoplasias Ováricas/diagnóstico , Neoplasias Ováricas/cirugíaRESUMEN
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.
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Salpingectomía , Esterilización Reproductiva/métodos , Esterilización Tubaria , Femenino , Humanos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
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; pâ¯=â¯.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; pâ¯=â¯.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.
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Cerclaje Cervical , Laparoscopía , Nacimiento Prematuro , Incompetencia del Cuello del Útero , Femenino , Humanos , Recién Nacido , Embarazo , Primer Trimestre del Embarazo , Incompetencia del Cuello del Útero/cirugíaRESUMEN
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.
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Bupivacaína , Dolor Postoperatorio , Anestésicos Locales , Femenino , Procedimientos Quirúrgicos Ginecológicos , Humanos , Tiempo de Internación , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & controlRESUMEN
INTRODUCTION: Clinically, vaginal packing provides the benefit of hemostasis and is designed to prevent the formation of postoperative hematomas. Despite the common use of vaginal packing in pelvic surgery, there is limited data to indicate which material has the ideal characteristics for vaginal packing. MATERIALS AND METHODS: Three packing materials were used: DeRoyal® Fluftex™ (DeRoyal Industries, Inc., Powell, Tennessee), NHP Surgi-Pak™ vaginal packing (NHP Industries, Inc., City of Industry, California), and Curad® Plain Packing Strips (Medline Industries, Inc., Northfield, Illinois). A fluid with similar viscosity to human blood, defibrinated sheep's blood (Remel Laboratories, Nenexa Kansas) was used to saturate the materials. The primary outcome was the amount of fluid absorbance of each product in both the handpacked and unpacked state. The number of drops used to saturate each material were counted and converted to mL/g. Each product was tested three times and the results were measured by counting the number of drops needed to saturate the material in each experiment. Experiment: Three materials were obtained and conducted into two different experiments to test absorbance. The packed trial consisted of 0.1g of material and was compacted in a 146mm standard Pasteur pipette (Sigma-Aldrich Corp., St. Louis, Missouri). Droplets of sheep's blood were dispensed until each material had reached its capacity, which was determined by counting the last sequential drop received onto the respective material before the first of the fluid fell from the material into the collecting container. Trials were conducted three times per material and an average of the three trials was calculated. The second experiment tested 1g of each material unpacked and folded into eight layers. Droplets of blood were placed onto the material until each material leaked, which was defined again as the first fluid to fall from the material into the collecting container that it was suspended above. The number of drops needed to produce this effect was recorded. All droplets were counted and converted to mL/g. Standard deviation was calculated for each material in both experiments and an analysis of variance (ANOVA) single factor test was done. RESULTS: Three trials were conducted per material and there was a difference in absorbance between each packing material (p=0.02 packed, p=0.001 unpacked). Additionally, the plain packing strip absorbed the least amount of blood product in the packed and unpacked state compared to DeRoyal® Fluftex™ and NHP Surgi-Pak™ vaginal packing. The average absorbance of the packed materials was 7.7mL/g for DeRoyal® Fluftex™, 9.8mL/g for NHP Surgi-Pak™ vaginal packing, and 7.5mL/g for the Curad® Plain Packing Strips. There was a standard deviation of 2.08 drops for DeRoyal® Fluftex™, 3.51 drops for NHP Surgi-Pak™ vaginal packing, and 1.73 drops for Curad® Plain Packing Strips. Absorbance for DeRoyal® Fluftex™ unpacked was 8.2mL/g, NHP Surgi-Pak™ vaginal packing unpacked was 7.00mL/g, and Curad® Plain Packing Strips was 4.8mL/g. The standard deviation for the unpacked experiment was 29.02 drops for DeRoyal® Fluftex™, 13.61 drops for NHP Surgi-Pak™ vaginal packing, and 15.59 drops for Curad® Plain Packing Strips. A p-value of less than .05 in a confidence interval of 95% was determined. CONCLUSION: Even though there are studies showing the clinical benefits of vaginal packing after a variety of gynecological surgeries, there is less known about the characteristics of the ideal material. Minimal foreign body reaction, decreased adherence to surgical scars, X-ray visualization, low cost, and easy availability are among the ideal characteristics of the presumed ideal material used for vaginal packing. In this study, we compared the absorbance between three commonly used materials and did not find any statistical differences. Further studies are needed to show the clinical benefits and mechanical characteristics of material used for vaginal packing. Due to the lack of a statistically significant difference in absorbance between the materials, evaluation of mechanical characteristics may be beneficial in determining an ideal vaginal packing product.
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Vagina , Animales , Vendajes , California , Femenino , Humanos , OvinosRESUMEN
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.
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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.
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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.
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Cerclaje Cervical , Laparoscopía , Nacimiento Prematuro , Incompetencia del Cuello del Útero , Femenino , Edad Gestacional , Humanos , Lactante , Recién Nacido , Embarazo , Resultado del Embarazo , Nacimiento Prematuro/etiología , Nacimiento Prematuro/prevención & control , Incompetencia del Cuello del Útero/cirugíaRESUMEN
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 59â¯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.
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Uso de la Marihuana/efectos adversos , Exposición Materna/efectos adversos , Complicaciones del Embarazo/epidemiología , Resultado del Embarazo , Adulto , Femenino , Retardo del Crecimiento Fetal/inducido químicamente , Edad Gestacional , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Recién Nacido Pequeño para la Edad Gestacional , Unidades de Cuidado Intensivo Neonatal/estadística & datos numéricos , Masculino , Embarazo , Complicaciones del Embarazo/inducido químicamente , Nacimiento Prematuro/inducido químicamenteRESUMEN
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.
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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.
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Laparoscopía , Neoplasias Ováricas , Neoplasias Uterinas , Femenino , Humanos , Histerectomía , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos , Neoplasias Ováricas/cirugía , Neoplasias Uterinas/cirugíaRESUMEN
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.
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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.
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Nacimiento Prematuro , Tocolíticos , Femenino , Humanos , Piperazinas , Embarazo , Receptores de Oxitocina , Tocólisis , Tocolíticos/efectos adversosRESUMEN
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.
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Acetaminofén/uso terapéutico , Analgésicos no Narcóticos/uso terapéutico , Histerectomía/efectos adversos , Laparoscopía/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Recuperación Mejorada Después de la Cirugía , Femenino , Humanos , Histerectomía/métodos , Laparoscopía/métodos , Manejo del Dolor/métodos , Dimensión del Dolor , Dolor Postoperatorio/etiología , Resultado del TratamientoRESUMEN
OBJECTIVE: Following the publication of several high quality randomized controlled trials regarding the comparison of similar laparoscopic gynecologic procedures being performed with or without robotic assistance, we aimed to perform a systematic review to identify any differences in patient safety and expected incidence of complications in these procedures. DATA SOURCES: Articles on ClinicalTrials.Gov, Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were retrieved and screened for eligibility up to April 1st 2021. METHODS OF STUDY SELECTION: In addition to meeting our screening algorithm, we included studies that met all the following: randomized control trials (RCT), enrolling patients for indicated laparoscopic gynecologic procedures, and comparing Robotic Surgery (RS) with Laparoscopic Surgery (LS) in terms of safety or complications. TABULATION, INTEGRATION, AND RESULTS: Data was pooled as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI). Ultimately, six studies were included in this meta-analysis. Pooled data revealed that RS and LS have similar risk for intraoperative complications (RR = 0.87; 95% CI [0.23, 3.36], P = 0.84), postoperative complications (RR = 1.07; 95% CI [0.57, 2.01], P = 0.83), significant intraoperative hemorrhage (RR = 1.40; 95% CI [0.59, 3.34], P = 0.44), postoperative hemorrhage (RR = 0.43; 95% CI [0.15, 1.22], P = 0.11), vaginal cuff dehiscence (RR = 1.13; 95% CI [0.24, 5.41], P = 0.88), postoperative wound infection, urinary tract infection, and urinary bladder or ureteral injury. RS had "surgeon declared" lower estimated blood loss (MD = 85.27; 95% CI [46.45, 124.09], P < 0.00001) and shorter postoperative hospital stay (MD = 1.20; 95% CI [0.38, 2.01], P = 0.004). CONCLUSION: There was a statistically significant decrease in hospital stay and "surgeon declared" blood loss seen in the RS group. There was no statistically significant increase in risk of developing other postoperative complications between the LS and R groups.
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Laparoscopía , Procedimientos Quirúrgicos Robotizados , Femenino , Humanos , Tiempo de Internación , Ensayos Clínicos Controlados Aleatorios como Asunto , Procedimientos Quirúrgicos Robotizados/efectos adversosRESUMEN
Office hysteroscopy (OH) is a common procedure in gynecology. Pain is the most frequently reported problem in OH. In this study, we aimed to investigate the role of tramadol administration in relieving pain in women undergoing OH. We searched PubMed, the Cochrane Library, ClinicalTrials.gov, MEDLINE, Scopus, and Web of Science databases for relevant clinical trials based on our search terms. We included randomized controlled trials and included all published trials in all six searched databases from their inception until February 28th 2021. We included pain as the primary outcome, and the incidence of adverse events of tramadol as secondary outcomes. We performed the analysis of continuous data using mean difference (MD) and dichotomous data using risk ratio (RR). We found that tramadol led to significantly less pain during the actual procedure [MD=-1.27, 95% confidence interval (CI): (-1.66, -0.88); p<0.001], immediately after the procedure [MD=-1.03, 95% CI: (-1.40, -0.67); p<0.001], and 30 minutes after the procedure [MD=-0.74, 95% CI: (-1.06, -0.41); p<0.001]. Regarding safety endpoints, no significant difference was noted for dizziness [RR=1.88, 95% CI: (0.79, 4.47); p=0.16] or vomiting [RR=1.80, 95% CI: (0.40, 8.18); p=0.45]. Based on the available data, we conclude that tramadol administration seems to be both effective and safe for patients undergoing office hysteroscopy.
RESUMEN
BACKGROUND: Several authors have recently compared the outcomes and complications of surgical procedures that preserve or remove the uterus in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Following the publication of several high quality randomized control trials on this topic we performed a new systematic review and meta analysis of this data. METHODS: We performed a systematic literature search in ClinicalTrials.gov, PubMed, Scopus, Ovid, EBSCO host, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled and cohort trials of uterine sparing prolapse repair (hysteropexy) versus hysterectomy with suspension. A total of 1285 patients from 14 studies were included in our systematic review and meta-analysis. RESULTS: Uterine sparing procedures (hysteropexy) were comparable to hysterectomy with suspension for recurrence rates (RR = 0.908, 95% CI [0.385, 2.143]), reoperation rates (RR = 1.517, 95% CI [0.802, 2.868]), length of hospital stay, (SMD = - 0.159 days, 95% CI [-0.375, 0.057]), voiding dysfunction (RR = 1.089, 95% CI [0.695, 1.706]), and intraoperative blood loss (SMD = - 0.339, 95% CI [-0.631, 0.047]). However, hysteropexy had shorter operative time than hysterectomy with suspension (SMD = - 1.191 h, 95% CI [-1.836, -0.545]), and fewer visceral injuries (RR = 0.421, 95% CI [0.244, 0.725]). CONCLUSION: We found no significant differences in the outcomes or major complications of uterine preserving surgical procedures versus those which include hysterectomy in the treatment of POP. Hysteropexy procedures may be associated with a shorter operative time and fewer visceral injuries. This is consistent with older analyses.
Asunto(s)
Prolapso de Órgano Pélvico , Prolapso Uterino , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Histerectomía/efectos adversos , Tempo Operativo , Prolapso de Órgano Pélvico/cirugía , Resultado del Tratamiento , Prolapso Uterino/cirugía , Útero/cirugíaRESUMEN
Interstitial pregnancy is a rare, life-threatening condition that requires high clinical suspicion for diagnosis. Most cases are discovered after complications have occurred. Many authors have described laparoscopic management. Although previous systematic reviews have compared the attributes and complications associated with interstitial pregnancy, we endeavored to complete the first systematic review and meta-analysis to compare the laparoscopic treatment of interstitial pregnancy with the open approach in the modern age of laparoscopic surgery. We systematically searched PubMed, ClinicalTrials.gov, Scopus, Web of Science, and Cochrane until June 2020 using relevant keywords and screened them for eligibility. We found a statistically significant difference in blood loss between laparoscopic and open surgery (168 mL compared to 1,163 mL). Further, cumulative meta-analysis has revealed that blood loss in laparoscopy has been decreasing over time from 1991 to 2020. Laparoscopic patients took less operative time (63.2 minutes) compared to laparotomy patients (78.2 minutes). Patients in the laparoscopic group spent less time hospitalized (3.7 days) compared to laparotomy patients (5.2 days). Our findings add strength to the position that laparoscopic approaches to interstitial pregnancy can be considered first-line in most situations. The laparoscopic approach was found to have a mean blood loss of 168 mL, and this blood loss seems to decrease over time. Increased gravidity and duration of amenorrhea are positive factors that increase bleeding during the procedure. We are unable to find enough high-quality data to significantly compare successful pregnancy following surgery or risk of mortality in these populations.
RESUMEN
BACKGROUND: Mood and anxiety disorders are common in women of childbearing age, especially during the peripartum period. As more women seek medical management for these conditions, there is an increasing need for studies to better examine the effects of exposure to selective serotonin reuptake inhibitors (SSRIs), and other antidepressants, on newborns at the time of delivery. CASE PRESENTATION: We report the case of a term Caucasian infant born to a 17-year-old white female taking 100 mg of sertraline daily for depression and anxiety who exhibited respiratory depression and hypoxia after an uncomplicated vaginal delivery. The neonate was treated with the use of continuous positive airway pressure (CPAP) and supplemental oxygen and subsequently the symptoms resolved without complication. CONCLUSIONS: We present this case with the suspicion of poor neonatal adjustment syndrome as the possible cause of the respiratory depression and hypoxia in this newborn.