Time of ureteral ejection of sodium fluorescein in the cystoscopic assessment of ureteral patency in patients undergoing total laparoscopic hysterectomy

Objective: To evaluate the time of ureteral ejection of intravenous sodium fluorescein in the assessment of ureteral patency in patients undergoing total laparoscopic hysterectomy (TLH). Material and Methods: Fifty-four women undergoing TLH were studied in a public teaching hospital in Culiacan, Sinaloa, Mexico. They underwent cystoscopic evaluation of ureteral patency after intravenous administration of 100 mg of sodium fluorescein. The present study analyzed the time elapsed in minutes from the intravenous administration of fluorescein to the outflow of stained urine by one or both ureteral meatus, the degree of urine staining, and the impact of body mass index (BMI) (BMI; normal, overweight, and obesity) on ejection time. Results: The overall average time elapsed to visualize the ejection of fluorescein through at least one ureteral meatus was 7.5 minutes [95% confidence interval (CI): 6.3-8.7]. There were no significant differences in the time of ureteral ejection of fluorescein taking BMI into account (p=0.579), with a mean time for normal BMI of 8.1 minutes (95% CI: 5.1-11.2), for overweight of 7.0 minutes (95% CI: 5.5-8.5), and for obesity of 7.8 minutes (95% CI: 5.3-10.3). Conclusion: Intravenously administered 10% sodium fluorescein dye is rapidly eliminated and strongly stains urine, which makes it useful for identifying ureteral patency during cystoscopy after TLH. Fluorescein excretion is not affected by patient BMI.

Estrógeno tópico vaginal y dehiscencia de la cúpula vaginal en pacientes con histerectomía total laparoscópica / Topical vaginal estrogen and vaginal vault dehiscence in patients rather than a laparoscopic total hysterectomy

Resumen OBJETIVO: Comparar la frecuencia de dehiscencia de la cúpula vaginal en pacientes tratadas con y sin estrógenos equinos conjugados por vía vaginal antes de la histerectomía total laparoscópica. MATERIALES Y MÉTODOS: Ensayo clínico controlado, comparativo, ciego simple, efectuado en pacientes atendidas entre enero de 2013 y agosto de 2016 en el Hospital Civil de Culiacán con indicación de histerectomía total laparoscópica por enfermedad benigna. Criterios de inclusión: haber recibido durante tres semanas previas al procedimiento estrógenos equinos conjugados por vía vaginal (grupo de estudio) o crema lubricante vaginal como placebo (grupo control). Criterios de exclusión: pacientes con diabetes mellitus tratadas con esteroides y antecedente de un evento tromboembólico reciente. Se evaluó la frecuencia de dehiscencia de la cúpula vaginal a los 7 y 30 días posteriores a la cirugía. Se utilizó la prueba t de Student para comparar medias y la χ2 para la comparación de proporciones, con cálculo de riesgo relativo para evaluar el riesgo de dehiscencia de la cúpula vaginal. RESULTADOS: Se estudiaron 236 pacientes con edad promedio, en ambos grupos, de 47.1 y 47.7 años, respectivamente (p > .05). Los antecedentes ginecoobstétricos y las indicaciones para histerectomía fueron similares en ambos grupos (p = .340). La incidencia total de dehiscencia de la cúpula vaginal fue de 4.6% (n = 11/236) con frecuencia de 6.8% (n = 8/118) en las pacientes del grupo tratado con lubricante vaginal y de 2.5% (n = 3/118) en el grupo tratado con estrógenos equinos conjugados por vía vaginal, sin diferencias entre ambos grupos (p = .123; RR=.359; IC95%: .093-1.387). CONCLUSIONES: El riesgo de dehiscencia de la cúpula vaginal fue similar entre el grupo que recibió lubricante y el de estrógenos tópicos vaginales, pero con una tendencia menor en la frecuencia de dehiscencia de la cúpula vaginal en el grupo tratado con estrógenos tópicos.

Abstract OBJECTIVE: To compare the frequency of vaginal cuff dehiscence in patients managed with and without conjugated equine estrogens vaginally prior to total laparoscopic hysterectomy (TLH). MATERIALS AND METHODS: In a single-blind controlled clinical trial, 236 patients with indications for laparoscopic total hysterectomy for benign pathology at the Hospital Civil de Culiacán and who agreed to participate in the study were randomly assigned to receive vaginally conjugated equine estrogens (study group) or vaginal lubricating cream as a placebo (control group) for 3 weeks prior to the procedure. Patients with diabetes mellitus, treated with steroids and history of a recent thromboembolic event were excluded. The frequency of vaginal cuff dehiscence was evaluated at 7 and 30 days after surgery. The student's t-test was used to compare means and the Chi-square test was used to compare proportions, with relative risk (RR) calculation to evaluate the risk of vaginal cuff dehiscence. RESULTS: We studied 236 patients with average age, in both groups, 47.1 and 47.7 years, respectively (p > .05). The mean age of the patients was similar between the groups (47.1 vs 47.7 years, p>.05). The gynecological-obstetric history and indications for hysterectomy were similar between both groups (p = .340). The incidence of vaginal cuff dehiscence was 2.5% (n = 3) in the group treated with conjugated equine estrogens vaginally and 6.8% (n = 8) in the patients of thse group treated with vaginal lubricant (p= .123; RM= .359; IC95%: .093-1.387). CONCLUSIONS: The risk of presenting vaginal cuff dehiscence was similar between the group of lubricant and topical vaginal estrogens, but with a lower tendency in the frequency of vaginal cuff dehiscence in the group of topical estrogens.

Patrón menstrual y reserva ovárica en pacientes con salpingectomía y oclusión tubárica para esterilización definitiva / Menstrual pattern and ovarian reserve in patients undergoing to salpingectomy and tubal occlusion for definitive sterilization

Resumen Objetivo: Evaluar el patrón menstrual y la reserva ovárica mediante la determinación de FSH y conteo de folículos antrales en pacientes con salpingectomía y oclusión tubárica bilateral como métodos de esterilización definitiva. Material y métodos: Estudio prospectivo, longitudinal, comparativo, experimental, con asignación al azar, ciego simple, al que se incluyeron pacientes con deseos de esterilización definitiva como método anticonceptivo. Las pacientes se asignaron al azar a dos grupos, el primero con oclusión tubárica bilateral y el segundo con salpingectomía. A los seis meses posprocedimiento se evaluaron en forma ciega el patrón menstrual y la determinación sérica de hormona folículo estimulante (FSH) y el recuento de folículos antrales por ultrasonido transvaginal como marcadores de reserva ovárica. El análisis estadístico se llevó a cabo con t de Student para muestras independientes (comparación entre los grupos) y dependientes (comparación intragrupo) para comparación de medias y la prueba x2 para comparación de proporciones. Resultados: Se estudiaron 60 pacientes, 31 con oclusión tubárica bilateral y 29 con salpingectomía. Se registraron aumentos significativos en los días de sangrado menstrual con respecto a la basal después de la oclusión tubaria bilateral (p = .002) y salpingectomía (p = .008). No hubo diferencias entre oclusión tubárica bilateral y salpingectomía con respecto al tiempo quirúrgico para llevar a cabo la técnica de esterilización (p = .83), duración del ciclo menstrual (p = .35), duración de los días de sangrado menstrual (p = .40). Tampoco resultaron diferencias en las concentraciones séricas de FSH (p = 0.75) ni en el recuento de folículos antrales (p = .44) entre los grupos. Conclusiones: El patrón menstrual y la reserva ovárica son muy similares en pacientes con oclusión tubárica bilateral o salpingectomía. Ambas técnicas incrementan la duración del sangrado menstrual posterior al procedimiento. La salpingectomía implica un aumento ligero en el tiempo quirúrgico, sin diferencias en la frecuencia de complicaciones.

Abstract Objective: To evaluate the menstrual pattern and ovarian reserve in patients undergoing salpingectomy and bilateral tubal occlusion as definitive sterilization methods. Material and methods: A prospective, longitudinal, comparative, experimental, randomized, single blind study was carried out in patients with a desire for definitive sterilization as a contraceptive method. Patients were randomly assigned to perform bilateral tubal occlusion or salpingectomy. Six months after the procedure in each patient, the menstrual pattern and the serum determination of follicle stimulating hormone (FSH) and the antral follicle count were evaluated by transvaginal ultrasound as markers of ovarian reserve. The statistical analysis was carried out using the student's t-test for independent samples (comparison between groups) and dependent samples (intra-group comparison) for comparison of means and the x2 test for comparison of proportions. Results: Sixty patients were studied, 31 with bilateral tubal occlusion and 29 with salpingectomy. Significant increases were observed in the days of menstrual bleeding with respect to the baseline after bilateral tubal occlusion (p = .002) and salpingectomy (p = .008). No differences were observed between bilateral tubal occlusion and salpingectomy with respect to the surgical time to carry out the sterilization technique (p = .83), menstrual cycle duration (p = .35), duration of the days of menstrual bleeding (p = .40). No differences were observed in the serum levels of FSH (p = .75) nor in the antral follicle count (p = .44) between the groups. Conclusions: The menstrual pattern and the ovarian reserve are very similar in patients who undergo bilateral tubal occlusion and salpingectomy, although the two techniques increase the duration of menstrual bleeding after the procedure.

[Laparoscopic myomectomy and use of electromechanical morcellator: clinical results in a series of cases]. / Miomectomía laparoscópica y uso de morcelador electromecánico: resultados clínicos en una serie de casos.

OBJECTIVE: to describe the clinical and operative characteristics of patients undergoing laparoscopic myomectomy and use of electromechanical morcellator for removal of tissue. MATERIAL AND METHODS: An observational, descriptive and retrospective study was done with the medical records of 65 patients that underwent laparoscopic myomectomy from July 2008 to July 2013. The clinical outcomes, including body mass index (BMI), pregnancies number, parity, previous abortions, indication of myomectomy, surgical findings, length of the procedure, operative bleeding, entry into the endometrial cavity, operative complications and conversion rate to laparotomy were collected and analyzed. RESULTS: The mean age and BMI of the patients were 33.1 years and 26.1 kg/m2, respectively. 64% of patients did not have any pregnancy and 33% had a history of one or more abortions. The most frequent indications for myomectomy were infertility (40%) and abnormal uterine bleeding (53%). The most frequent location of the fibroids was the intramural fundal (46%), with an average size of 6.5 cm (SD ± 3.6). The number of myomas extracted ranged from 1 to 6. The mean operative time was 107.8 min (SD ± 27.5) and the operative bleeding was 145.4 mL (SD ± 42.2). There were no operative complications. The conversion rate to laparotomy was 2%. Power morcellation was used in all cases without complications. CONCLUSIONS: Laparoscopic myomectomy with electromechanical morcellator for tissue extraction in low risk patients for malignancy is a feasible procedure with a low conversion rate, minimal operative bleeding and the operative time similar to that reported for myomectomy performed by laparotomy.

[Uterine leiomyomas during pregnancy and its impact on obstetric outcome]. / Miomas uterinos durante el embarazo y su repercusión en el resultado obstétrico.

BACKGROUND: The association of uterine leiomyoma and pregnancy is increasing due to the tendency of couples to delay first pregnancy after age 30. The risk of uterine fibroids is greater with advancing age of the woman. OBJECTIVE: To evaluate the impact of fibroids on the incidence of complications during pregnancy, labor and delivery. PATIENTS AND METHODS: We observed 65 pregnant patients with uterine fibroids and 165 pregnant patients without fibroids. Follow-up ultrasound was performed at weeks 20 to 24, 30 to 32 and 36 to 40. We analyzed the following variables: threatened abortion, pregnancy loss, preterm birth, premature rupture of membranes, abnormal fetal presentation, mode of termination of pregnancy, uterine atony, postpartum hemorrhage and perinatal outcome. RESULTS: The frequency of threatened abortion, risk of pregnancy loss in the second trimester, preterm births, premature rupture of membranes and abnormal fetal presentation was significantly higher in patients with uterine fibroids compared to patients without fibroids. It was not demonstrated that fibroids grow during follow-up even, there was a trend toward reduction in size as pregnancy progressed and until its completion. No significant differences in the frequency of cesarean section between groups (52.3 vs. 47.9%, RR 1.09; 95% CI 0.82-1.45, p = 0.646). Uterine atony was more frequent in patients with fibroids than in patients without fibroids (12.3 vs 4.2%, RR = 2.9, 95% CI 1.2-7.6, p = 0.036). There were no differences in perinatal outcomes between the groups. CONCLUSIONS: Uterine fibroids increase the risk of complications during pregnancy and childbirth. Could not be demonstrated an increased risk of caesarean section.

[Sociodemographic and obstetric factors associated with preterm birth]. / Factores sociodemográficos y obstétricos asociados con nacimiento pretérmino.

BACKGROUND: Preterm birth is the major cause of neonatal morbidity and mortality and is responsible for 75 to 90% of neonatal deaths unrelated to congenital malformations. OBJECTIVE: To evaluate preterm birth association with sociodemographic and obstetric risk factors. MATERIAL AND METHOD: A retrospective, comparative, longitudinal and observational study was carried out in which were analyzed all preterm births registries found in 2001-2006 period in the Civil Hospital of Culiacan, Sinaloa, México. As controls were selected at random the clinical registries of patients who presented term birth (n = 755). Were analyzed the association between preterm birth with sociodemographic factors (maternal age, socioeconomic level, tobacco use, alcoholism, begin intercourse age, number of sexual partners) and obstetric factors (transvaginal bleeding in the first half of pregnancy, previous preterm birth, post abortion and pregnancy at term interval, premature rupture of membranes, anemia and urinary infection). RESULTS: Significant differences were found between cases and controls about socioeconomic level (OR: 0.71; IC 95%: 0.5-0.9; p = 0.0191), vaginal bleeding in first half of pregnancy (OR: 31.06; IC 95%: 7.5-127.6; p < 0.05), previous preterm birth antecedent, (OR: 9.33; IC 95%: 2-59.1; p = 0.0006), pregnancy at term interval < or = one year (OR: 1.79; IC 95%: 1.2-2.5; p = 0.0021), premature rupture of membranes (OR: 9.24; IC 95%: 6.1-13.9; p < 0.05) and urinary infection (OR: 3.72; IC 95%: 2.1-6.4; p < 0.05). There were not association with the other factors analyzed. CONCLUSION: Preterm birth was significantly associated to socioeconomic level, transvaginal bleeding in first half of pregnancy, preterm birth previous, interpregnancy interval equal or less than one year, premature rupture of membranes and urinary infection.

[Effect of post-abortion interpregnancy interval on obstetric and perinatal outcomes]. / Efecto del intervalo intergenésico postaborto en los resultados obstétricos y perinatales.

BACKGROUND: The interval between pregnancies is important because it allows the mother to recover after an obstetric event. OBJECTIVE: To evaluate if postabortion short interpregnancy intervals affect the obstetrics and perinatal outcome. MATERIAL AND METHODS: A cases and controls study was carried out. We studied 858 patients with a history of early pregnancy loss in the previous pregnancy, of which 286 were cases (interval postabortion < or = 6 months) and 572 controls (interval postabortion > 6 months). Abortion, preterm birth and perinatal outcomes: apgar < or = 7, morbidity, mortality, and weight of newborns were analyzed. RESULTS: The risk of abortion was similar in both groups (14.68% and 13.28%, for the cases and controls respectively (OR: 1.12; IC 95%: 0.75-1.69), and there were no differences in preterm birth (5.59% vs 8.21%; OR: 0.66; IC 95%: 0.37-1.19). Apgar was similar between the groups; there were not differences in the perinatal morbidity (RM: 0.77; IV 95%: 0.27-2.17; p = 0.8005), mortality (RM: 1.14; IC 95%: 0.33-3.94; p = 0.9145) and weight of the newborns between cases and control group. CONCLUSIONS: A short interpregnancy interval less than or equal to six months is not a risk factor for adverse obstetrical and perinatal outcome.

[Misoprostol and oxytocin for induction of cervical ripening and labor in patients with term pregnancy and premature membrane rupture]. / Misoprostol y oxytocina para inducción de madurez cervical y trabajo de parto en pacientes con embarazo a término y ruptura prematura de membranas.

OBJECTIVE: To evaluate the effect of the concurrent administration of intravaginal misoprostol and oxytocin for cervical ripening and labor induction on length labor, mode of delivery and perinatal outcomes. PATIENTS AND METHODS: One hundred seven patients with singleton pregnancy at term, vertex presentations, premature rupture of membranes and Bishop scores of < or = 4 were randomly assigned to receive one of three treatments: Group I: Intravenous oxytocin plus intravaginal misoprostol (n = 36); Group II: Intravenous oxytocin plus placebo intravaginal (n = 34); Group III: Intravaginal misoprostol plus intravenous placebo. The time interval from induction to beginning of the labor, from induction to delivery, mode of delivery and perinatal outcomes were measured. RESULTS: The mean time from induction to beginning of labor was different between the groups: Group I: 48.75 minutes, Group II: 107.50 minutes, Group III: 95.94 minutes (p = 0.0024). The mean time in minutes from induction to delivery was different between the groups: Group I: 359.83; Group II: 537.05; Group III: 474.54 (p < 0.05). The frequency of tachysystole, mode of delivery and perinatal outcomes were similar among the three groups. CONCLUSIONS: Oxytocin that is administered simultaneously with intravaginal misoprostol for cervical ripening and labor induction in patients with pregnancies at term, premature rupture of membranes and Bishop scores < 4 make the labor beginning quickly, significantly shortens induction to delivery times without affecting the mode of delivery and with no apparent adverse maternal and perinatal effects.