Endoscopic management of uterine fibroids: an update.

Recent technological advances in endoscopy have allowed gynecological surgeons to expand the operative approaches that can be utilized in the conservative management of uterine myomas. Commonly used approaches in gynecological practice now include laparoscopic myomectomy, laparoscopic-assisted myomectomy through a mini-laparotomy incision and robotic-assisted laparoscopic myomectomy. Adequate preoperative evaluation with careful selection of the best operative approach for each particular patient constitutes the basis of safe and effective surgery for the operative management of uterine myomas.

Post-menopausal endometriosis with inferior vena cava invasion requiring surgical management.

Post-menopausal endometriosis is rare after hysterectomy, and preliminary data support treatment with aromatase inhibitors (AIs). Sites for extrapelvic recurrent disease are wide-ranging; however, no previous case reports have described endometriosis invading the inferior vena cava. A 59-year-old woman status post hysterectomy and bilateral salpingo-oophorectomy for endometriosis developed a periaortic mass with ureteral obstruction. Computerized tomography-guided biopsy confirmed recurrent endometriosis and the lesion enlarged despite treatment with AIs. Vascular surgery, urology and gynecology were involved. The mass was resected surgically and pathology confirmed invasion of the inferior vena cava. Medical management with AIs can be attempted for extra-pelvic endometriosis status post hysterectomy; however, the efficacy in this setting is limited. Surgical management may be necessary for bulky or invasive disease.

Robotics in reproductive surgery: strengths and limitations.

Minimally invasive surgical techniques are becoming increasingly common in gynecologic surgery. However, traditional laparoscopy can be challenging. A robotic surgical system gives several advantages over traditional laparoscopy and has been incorporated into reproductive gynecological surgeries. The objective of this article is to review recent publications on robotically-assisted laparoscopy for reproductive surgery. Recent clinical research supports robotic surgery as resulting in less post-operative pain, shorter hospital stays, faster return to normal activities, and decreased blood loss. Reproductive outcomes appear similar to alternative approaches. Drawbacks of robotic surgery include longer operating room times, the need for specialized training, and increased cost. Larger prospective studies comparing robotic approaches with laparoscopy and conventional open surgery have been initiated and information regarding long-term outcomes after robotic surgery will be important in determining the ultimate utility of these procedures.

Outcome of pregnancies complicated by systemic sclerosis and mixed connective tissue disease.

Systemic sclerosis (SSc) and mixed connective tissue disease (MCTD) are rare autoimmune diseases which share the common feature of non-inflammatory vasculopathy. Studies evaluating pregnancy outcomes in these patients have yielded conflicting results. We sought to describe the outcomes of pregnancies associated with SSc and MCTD followed at our center utilizing a retrospective review of all pregnant women with SSc and MCTD followed at Stanford University from 1993 to 2003. We identified 20 pregnancies occurring in 13 women with SSc or MCTD. Twelve pregnancies occurred in seven women with SSc and eight pregnancies occurred in six women with MCTD. The overall preterm delivery rate was 39% and small for gestational age infants occurred in 50% and 63% of pregnancies associated with SSc and MCTD, respectively. Fetal loss complicated two pregnancies in women with severe diffuse SSc and the antiphospholipid antibody syndrome. There were no cases of congenital heartblock among infants, and only one case of pre-eclampsia was observed. Maternal flares of disease during pregnancy were generally mild. Most pregnancies in women with SSc and MCTD in this cohort were uncomplicated. The high rates of prematurity and small for gestational age infants underscore the risk for growth restriction consistent with the vasculopathy associated with these diseases.