RESUMEN
Urinary incontinence affects 25-45 % of women with the gold standard surgical approach being placement of mid-urethral synthetic slings; tension-free vaginal tape (TVT) and trans-obturator tape (TOT). Due to the controversies regarding vaginal mesh the last decade, an increasing demand has evolved for incontinence treatment without vaginal synthetic mesh. The short term results of autologous rectus fascia sling for TOT surgery have shown similar success rates compared to those after the use of synthetic mesh, but the harvesting of the mesh is less minimally invasive and is associated with longer surgical time. vNOTES is a combination of a vaginal entrance to the abdomen and endoscopy via the vagina. The aim with the video is to show a new surgical technique with a fully vaginal, scarless vNOTES approach for harvesting the posterior rectus fascia for TVT and TOT procedures.
RESUMEN
BACKGROUND: There is a growing body of evidence indicating that second degree tears cause both short-, and long-term consequences. Very few preventative measures have been found to reduce the incidence of these tears. OBJECTIVE: To investigate if the use of a perineal protection device during vaginal birth reduces severe perineal tearing (≥grade 2 tear) in primiparous women compared to routine manual perineal support. STUDY DESIGN: A single center randomized controlled trial was performed in Sweden 2019-2021. Primiparous women at term were randomly allocated to the intervention group (n=43) where a perineal protection device was used, or to receive routine care (n=49). Main outcome measurement was grade of perineal tear. Secondary outcomes were vaginal and labial tearing. Continuous data was analyzed with Student's T-test or Mann-Whitney U-test. Dichotomous data were analyzed with Pearson X2 test, Fisher's Exact test, and ordinal logistic regression. RESULTS: Women in the intervention group had a significantly lower risk of sustaining more extensive perineal tearing as compared to the control group. Use of the perineal protection device decreased risk of ≥grade 2 tears, in relation to grade 0-1 tears (OR 0.40 [95% CI 0.17-0.94]). Ordinal logistic regression analyses revealed an OR of 0.36 (0.16-0.81) for one-grade-injury increment, using the perineal protection device vs control group (p=0.013). Number needed to treat using the perineal protection device was 4.3 to avoid one ≥grade 2 tear. Women in the treatment group had less labial tearing (p=0.016). No adverse effects were detected. CONCLUSIONS: Use of the perineal protection device reduced the risk of perineal tearing ≥grade 2 tear by 60% as well as labial tearing.
RESUMEN
Background: The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines. Methods: This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field. Results: The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials. Conclusions: vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).
RESUMEN
INTRODUCTION: The current standard treatment for endometrial cancer is a laparoscopic hysterectomy with adnexectomies and bilateral sentinel node resection. A retroperitoneal vNOTES sentinel node resection has several theoretical potential advantages. These include being less invasive, leaving no visible scars, operating without Trendelenburg, and therefore offering the anesthetic advantage of easier ventilation in obese patients and following the natural lymph node trajectory from caudally to cranially and therefore a lower risk of missing the sentinel node. The aim of this study is to determine the feasibility of a retroperitoneal vNOTES approach to sentinel lymph node dissection for staging of endometrial cancer. MATERIAL AND METHODS: A prospective multicenter case series was performed in four hospitals. A total of 64 women with early-stage endometrial carcinoma suitable for surgical staging with sentinel lymph node removal were operated via a transvaginal retroperitoneal vNOTES approach. The paravesical space was entered through a vaginal incision after injecting the cervix with indocyanine green. A vNOTES port was placed into this space and insufflation of the retroperitoneum was performed. Sentinel lymph nodes were identified bilaterally using near-infrared light followed by endoscopic removal of these nodes. RESULTS: A total of 64 women with early-stage endometrial cancer underwent sentinel lymph node removal by retroperitoneal vNOTES technique. All patients also underwent subsequent vNOTES hysterectomy and bilateral salpingo-oophorectomy. The median age was 69.5 years, median total operative time was 126 min and the median estimated blood loss was 80 mL. In 97% of the cases bilateral sentinel nodes could be identified. A total of 60 patients had negative sentinel nodes, three had isolated tumor cells and one had macroscopically positive sentinel nodes. No complications with sequel occurred. CONCLUSIONS: This prospective multicenter case series demonstrates the feasibility of the vNOTES approach for identifying and removing sentinel lymph nodes in women with endometrial carcinoma successfully and safely. vNOTES allows sole transvaginal access with exposure of the entire retroperitoneal space, following the natural lymph trajectory caudally to cranially, and without the need for a Trendelenburg position.
Asunto(s)
Neoplasias Endometriales , Escisión del Ganglio Linfático , Estadificación de Neoplasias , Biopsia del Ganglio Linfático Centinela , Femenino , Humanos , Neoplasias Endometriales/cirugía , Neoplasias Endometriales/patología , Estudios Prospectivos , Persona de Mediana Edad , Espacio Retroperitoneal , Anciano , Biopsia del Ganglio Linfático Centinela/métodos , Escisión del Ganglio Linfático/métodos , Laparoscopía/métodos , Estudios de Factibilidad , Adulto , Ganglio Linfático Centinela/patología , Ganglio Linfático Centinela/cirugíaRESUMEN
INTRODUCTION: Hysterectomy is one of the most common surgeries performed in women. Minimally invasive methods are on the rise globally as they have been shown to decrease surgical morbidity compared with abdominal hysterectomy. Hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) is the latest innovation. It combines the vaginal approach and endoscopy via the vagina. Large pragmatic randomised controlled trials (RCTs) are lacking comparing outcomes after vNOTES, vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). METHODS: Multicentre pragmatic RCT aiming to recruit 1000 women aged 18-75 years undergoing hysterectomy for benign disease. The RCT includes two identical substudies (groups A and B). If VH is considered safe and feasible, the patient will be randomised within group A (VH vs vNOTES). If VH is not considered safe or feasible, patients will be randomised within group B (LH vs vNOTES). ANALYSIS: Primary outcome is the proportion of women leaving the hospital within 12 hours after surgery. Secondary outcomes are hospitalisation time, conversion rates, duration of the surgical procedure, intraoperative complications, postoperative complications and readmission. ETHICS AND DISSEMINATION: The Ethical Board Committee at Imelda Hospital, Bonheiden, Belgium, has approved the research protocol 230704 (principal investigator). Before including patients, all centres will require local or national ethical approval. The results of the study will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05971875.
Asunto(s)
Histerectomía Vaginal , Laparoscopía , Cirugía Endoscópica por Orificios Naturales , Humanos , Femenino , Cirugía Endoscópica por Orificios Naturales/métodos , Laparoscopía/métodos , Persona de Mediana Edad , Adulto , Histerectomía Vaginal/métodos , Anciano , Adolescente , Adulto Joven , Ensayos Clínicos Controlados Aleatorios como Asunto , Complicaciones Posoperatorias/prevención & control , Histerectomía/métodos , Estudios Multicéntricos como Asunto , Tiempo de Internación/estadística & datos numéricosRESUMEN
OBJECTIVE: Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potential long-term consequences. Maternal origin has been proposed to affect the overall risk, but the association and underlying explanation are uncertain. The objective was to assess the association between maternal country of birth and OASIS. METHODS: A Swedish nationwide cohort study including singleton term vaginal births during 2005-2016. Data were extracted from the Swedish Medical Birth Registry and Statistics Sweden. Modified Poisson regression analyses were performed to obtain crude and adjusted risk ratios (RRs). Adjustments were made in four cumulative steps. Sub-analyses were performed to investigate the risk of OASIS associated with female genital circumcision (FGC). RESULTS: In all, 988 804 births were included. The rate of OASIS in Swedish-born women was 3.5%. Women from East/Southeast Asia had an increased risk of OASIS (adjusted RR [aRR] 1.71, 95% confidence interval [CI] 1.60-1.83), as did women born in Sub-Saharan Africa (aRR 1.60, 95% CI 1.49-1.72). The risk remained significantly increased also after adjustment for maternal height. By contrast, women from South/Central America had a decreased risk of OASIS (aRR 0.65, 95% CI 0.56-0.76). FGC was associated with an increased risk of OASIS (aRR 3.05, 95% CI 2.60-3.58). Episiotomy appeared to have an overall protective effect (aRR 0.95, 95% CI 0.92-0.98), but not significantly more protective among women with female genital mutilation. CONCLUSIONS: Country of birth plays an important role in the risk of OASIS. Women from East/Southeast Asia and Sub-Saharan Africa are at significantly increased risk as compared with Swedish-born women, whereas women from South/Central America are at lower risk. FGC is also a significant risk factor for OASIS.
Asunto(s)
Canal Anal , Complicaciones del Trabajo de Parto , Humanos , Femenino , Canal Anal/lesiones , Suecia/epidemiología , Embarazo , Adulto , Factores de Riesgo , Complicaciones del Trabajo de Parto/epidemiología , Circuncisión Femenina/efectos adversos , Circuncisión Femenina/estadística & datos numéricos , África del Sur del Sahara , Sistema de Registros , Estudios de Cohortes , Adulto Joven , Parto Obstétrico/efectos adversos , Asia Sudoriental , Asia Oriental , Episiotomía/estadística & datos numéricos , Episiotomía/efectos adversosRESUMEN
OBJECTIVE: To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The procedure was performed vaginally, minimally invasively, via vaginal natural orifice transluminal endoscopic surgery. DESIGN: Description of the surgical technique using original video footage. This study was exempted from requiring hospital institutional review board approval. SETTING: Teaching hospital. PATIENT(S): A 34-year-old woman (G8P3) with a medical history of 2 cesarean sections, 1 partial mole, and a missed abortion with 2.8 L of blood loss. The patient presented after 10 weeks of amenorrhea. Ultrasound revealed a large blood-filled niche in the cesarean section scar with a thin overlying myometrium. A partial mole was suspected as well as increased vascularization in the myometrium and enhanced myometrial vascularity with arterial flow velocities of 100 cm/s. A risk of heavy blood loss in conjunction with curettage was anticipated. The patient had a strong preference for a fertility-preserving treatment, and after informed consent, she opted for transient occlusion of the uterine arteries with subsequent suction evacuation of the molar pregnancy. The patient signed a consent form accepting the procedure. The patient included in this video provided consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites. Institutional review board approval was not required in accordance with the IDEAL guidelines. INTERVENTION(S): A vaginal incision was made over the bladder, and the vaginal mucosa was dissected. The paravesical space was dissected over the arcus tendinous, and the pelvic retroperitoneal space was opened. A small (7 cm) GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) was inserted into the obturator fossa and insufflated with 10 CO2 mm Hg. Standard laparoscopic instruments were used through the gel port. Under endoscopic view, dissection to the right obturator fossa and iliac vessels was made, and the internal iliac artery was identified. A removable clip was placed on the origin of the right uterine artery. The same procedure was performed on the left side where the internal iliac artery was clipped. Different vessels were clipped to demonstrate and investigate the feasibility of both approaches. Both vessels were equally accessible. Care should be taken not to injure the uterine vein at the time of clipping. Dilation and evacuation was performed under transanal ultrasound surveillance. When hemostatic control was assured, first, the right clip was removed from the iliac artery. Hemostatic control was ensured, and after 10 minutes, the second clip on the left iliac artery was removed. The GelPOINT was removed, and the vaginal incision was sutured. The patient bled in total 500 mL. MAIN OUTCOME MEASURE(S): Not applicable. RESULT(S): The patient recovered swiftly without complications. Pathology confirmed a partial molar pregnancy. CONCLUSION(S): Uterine or internal iliac artery ligation can be lifesaving in situations with massive bleeding from the uterus. Current minimally invasive approaches are laparoscopic vessel ligation and, more commonly, uterine artery embolization, which has unclear impact on fertility and has shown an increased risk of intrauterine growth restriction, miscarriage, and prematurity. As the patient was undergoing a vaginal evacuation of pregnancy, a vaginal and retroperitoneal approach of artery ligation was deemed least invasive. In patients with fertility-preserving wishes, care should to be taken to avoid as much trauma as possible to the endometrium. Optimized blood control, and a shorter duration of using a curette, may potentially reduce the risk of endometrial damage. We present a novel minimally invasive approach via vaginal natural orifice transluminal endoscopic surgery-retroperitoneal transient occlusion of the internal iliac or uterine artery. The whole procedure can be performed by the operating gynecologist, and the occlusion is transient and can be reversed in a stepwise controlled manner.
Asunto(s)
Hemostáticos , Mola Hidatiforme , Laparoscopía , Neoplasias Uterinas , Humanos , Embarazo , Femenino , Adulto , Arteria Uterina/diagnóstico por imagen , Arteria Uterina/cirugía , Cesárea/efectos adversos , Espacio Retroperitoneal , Laparoscopía/métodos , Hemorragia Uterina/etiología , Hemorragia Uterina/cirugía , Neoplasias Uterinas/cirugíaRESUMEN
vNOTES hysterectomy is a scarless minimally invasive method with a vaginal approach to the abdominal cavity combined with endoscopic overview. Studies have shown that patients who underwent vNOTES hysterectomy had less pain and shorter hospital stay than after laparoscopic hysterectomy.
Asunto(s)
Procedimientos Quirúrgicos Ginecológicos , Histerectomía , Humanos , Femenino , Histerectomía/efectos adversos , Hospitales , DolorRESUMEN
Acquired arteriovenous malformations (AVM) of the uterus can cause life-threatening vaginal bleeding and are associated with previous pregnancy, abortion or pelvic trauma. The pathophysiology is not well understood and the diagnosis is usually made by greyscale ultrasound often with nonspecific imaging findings, hence making it difficult to establish a correct diagnosis and therefore also the true incidence. However, case reports have previously described a connection between AVM formation and placental invasive disorders. In this report we demonstrate a case of a woman diagnosed with an AVM by ultrasound, presenting with menorrhagia after a termination of pregnancy, resulting in an emergency hysterectomy where subsequently a vascular malformation was found in conjunction with a remnant of a placenta increta and a placental site nodule. We hence suggest the hypothesis that these conditions are part of the same pathological process in the spectrum of abnormal invasive placental disorders, and that in the setting of previous trophoblastic processes, vascular malformations may mimic AVMs and ought not in fact to be considered as true AVMs.
RESUMEN
INTRODUCTION AND HYPOTHESIS: The Manchester procedure is a classic native tissue prolapse technique with low recurrence and low complication rate. vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a vaginal approach to enter the intra or retroperitoneal space, with the guidance of endoscopic visualization. Different studies have shown women to prefer uterus-preserving correction of prolapse over hysterectomy, as they worry about complications, impact on sexual function and self- sense. At the same time, an increasing caution and awareness of mesh related complications has evolved, giving a need for the development of additional non-mesh uterus preserving surgical techniques for prolapse. The aim with the video is to show a new surgical technique for prolapse, combining the Manchester procedure with vNOTES retroperitoneal non-mesh promontory hysteropexy.
Asunto(s)
Prolapso Uterino , Útero , Femenino , Humanos , Espacio Retroperitoneal , Resultado del Tratamiento , Útero/cirugía , Histerectomía/métodos , Prolapso Uterino/cirugíaRESUMEN
Purpose: No consensus exists whether to administer prophylactic antibiotics in conjunction with manual placenta removal. This study aimed to investigate the postpartum risk of a new prescription of antibiotic treatment, a possible indirect variable for infection, after manual placenta removal. Methods: Obstetric data were merged with data from the Anti-Infection Tool (Swedish antibiotic registry). All vaginal deliveries (n = 13 877) at Helsingborg Hospital, Helsingborg, Sweden, from January 1st, 2014 until June 13th, 2019 were included. Diagnosis codes for infection can be lacking, while the Anti-Infection Tool is complete as it is unavoidable in the computerized prescription system. Logistic regression analyses were performed. The risk of a prescription of antibiotics 24 h to 7 days postpartum was analyzed in the entire study population, and in a subgroup of women not having received any antibiotics 48 h prior to delivery until 24 h after delivery, referred to as "antibiotic-naïve." Results: Manual placenta removal was associated with an increased risk of an antibiotic prescription, adjusted (a) OR = 2.9 (95%CI 1.9-4.3). In the antibiotic-naïve subgroup, manual placenta removal was associated with an increased risk of antibiotic prescription, in general, aOR = 2.2 (95%CI 1.2-4.0), endometritis-specific antibiotics, aOR = 2.7 (95%CI 1.5-4.9), and intravenous antibiotics, aOR = 4.0 (95%CI 2.0-7.9). Conclusion: Manual placenta removal is associated with an increased risk of antibiotic treatment postpartum. An antibiotic-naïve population might benefit from prophylactic antibiotics to reduce the risk of infection, and prospective studies are needed.
RESUMEN
INTRODUCTION: There is growing evidence that induction of labor at 41 completed weeks improves neonatal outcome, at least among primiparous women. This study was performed to investigate whether maternal body mass index (BMI) should be considered when deciding on timing of intervention in term pregnancies. MATERIAL AND METHODS: The study design was a historical cohort study using data from the Swedish Medical Birth Register, singletons in cephalic presentation with births 39+0 to 41+6 weeks, with available information on maternal BMI 2005-2017 (n = 352 567). Modified Poisson regression analyses were used to investigate the association between gestational duration and stillbirth or death before 45 postmenstrual weeks (primary outcome) and Apgar score <7 at 5 minutes (secondary outcome) by BMI, respectively. Adjustments were made for maternal age, smoking, country of birth and educational level. RESULTS: The adjusted relative risk (ARR) of stillbirth or death before 45 weeks among infants born at 41+0 to 41+6 vs 40+0 to 40+6 weeks, was 1.26 with a 95% confidence interval (CI) of 1.07-1.48. Among women with BMI ≥30, the offspring mortality risk in pregnancies lasting 39+0 to 39+2 weeks was significantly above the corresponding risk among women of normal BMI who delivered at 41+0 to 41+2 weeks (ARR = 1.95; 95% CI 1.07-3.56) but no statistically significant heterogeneity was found regarding the magnitude of the association between gestational duration and offspring mortality. The ARR, for Apgar <7 at 5 minutes (41+0 to 41+6 vs 40+0 to 40+6 weeks, regardless of BMI), was 1.36 (95% CI 1.27-1.45). The risk for low Apgar score at 41+0 weeks was 1.5% among all children regardless of maternal BMI. Among children to women with BMI ≥30, this magnitude of risk was found already at 39+3 weeks. CONCLUSIONS: In primiparous women with obesity the risk of stillbirth or death before 45 postmenstrual weeks were increased throughout all full-term gestational age categories, compared with women with overweight or normal BMI. Children to obese women had the same risk for Apgar scores <7 at 5 minutes compared with women overall at earlier gestational age. The results suggest that maternal BMI needs to be considered when discussing timing of elective induction in term healthy pregnancies of primiparous women.
Asunto(s)
Obesidad , Mortinato , Recién Nacido , Lactante , Niño , Embarazo , Femenino , Humanos , Índice de Masa Corporal , Mortinato/epidemiología , Estudios de Cohortes , Puntaje de Apgar , Edad Gestacional , Obesidad/complicaciones , Factores de Riesgo , Resultado del EmbarazoRESUMEN
INTRODUCTION: Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potentially serious long-term consequences and large impact on quality of life. The aim was to determine risk and protective factors for OASIS. MATERIAL AND METHODS: We performed a retrospective register-based observational study. A cohort of 988 988 singleton term deliveries 2005-2016 in Sweden were included. Data from the Swedish Medical Birth Registry and Statistics Sweden were extracted to identify cases of OASIS and maternal and fetal characteristics. Modified Poisson Regression analyses were performed to assess risk factors. RESULTS: The rate of OASIS was 3.5% (n = 34 583). Primiparity (adjusted risk ratio [aRR] 3.13, 95% CI 3.05-3.21), vacuum extraction (aRR 2.79, 95% CI 2.73-2.86), forceps (aRR 4.27, 95% CI 3.86-4.72), and high birthweight (aRR 2.61, 95% CI 2.50-2.72) were associated with a significantly increased risk of OASIS. Increasing maternal age and decreasing maternal height also increased the risk of OASIS. Obesity increased the risk of OASIS (aRR 1.04, 95% CI 1.04-1.08), if fetal birthweight was not adjusted for. Smoking (aRR 0.74, 95% CI 0.70-0.79) and low maternal education (aRR 0.87, 95% CI 0.83-0.92) were associated with a decreased frequency of reported OASIS. Previous cesarean section increased the risk of OASIS (aRR 1.41, 95% CI 1.36-1.47). CONCLUSIONS: Primiparity, instrumental delivery, and high birthweight significantly increased the risk of OASIS. Obesity, low height, increasing age, and previous cesarean section also increased the risk whereas smoking and low maternal educational level were associated with a lower OASIS rate.
Asunto(s)
Complicaciones del Trabajo de Parto , Embarazo , Humanos , Femenino , Complicaciones del Trabajo de Parto/epidemiología , Complicaciones del Trabajo de Parto/etiología , Canal Anal/lesiones , Cesárea/efectos adversos , Estudios Retrospectivos , Calidad de Vida , Parto Obstétrico/efectos adversos , Peso al Nacer , Factores de Riesgo , Obesidad/complicacionesRESUMEN
INTRODUCTION: Rates of delivery by cesarean section have gradually risen in many parts of the world, and it is regarded as a safe surgical procedure with expanded indications. We assessed maternal complications within 6 weeks postpartum after planned cesarean section and after planned vaginal delivery among patients without medical indication for cesarean section. MATERIAL AND METHODS: This was a retrospective cohort study based on Swedish national registers and included 714 326 deliveries from 2008 to 2017. The study group consisted of cephalic, singleton, term pregnancies and excluded those with previous cesarean or pregnancy conditions that would qualify for cesarean section. We compared the risks of short-term complications between planned cesarean section and planned vaginal delivery. We obtained adjusted risk ratios (ARRs) using modified Poisson regression models adjusting for maternal age, parity, body mass index, smoking, country of birth, and county. RESULTS: The outcomes studied were infections and thromboembolism. In the planned cesarean section group (n = 22 855), 15% had a postpartum infection compared with 10% in the planned vaginal group (n = 691 471) (ARR 1.6; 95% confidence interval [CI] 1.5-1.6), and 0.08% vs 0.05% had a postpartum pulmonary embolism (ARR 1.7; 95% CI 1.0-2.6). The obtained risk estimates corresponded to "number needed to harm" estimates of 17 and 3448, respectively. When dividing the infections into subgroups, the risk of endometritis (ARR 1.2; 95% CI 1.1-1.3), wound infection (ARR 2.7; 95% CI 2.4-3.0), urinary tract infection (ARR 1.5; 95% CI 1.3-1.7), and mastitis (ARR 2.0; 1.9-2.2) was higher after planned cesarean section. CONCLUSIONS: Among patients without medical indication for planned cesarean section, the risks of short-term maternal complications were higher with planned cesarean section than with planned vaginal delivery.
Asunto(s)
Cesárea , Parto Obstétrico , Parto Obstétrico/efectos adversos , Parto Obstétrico/métodos , Femenino , Humanos , Edad Materna , Parto , Embarazo , Estudios RetrospectivosRESUMEN
Vaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel technique for minimally invasive gynecological surgery. Adequate training and standardization are key elements to patient safety and quality of care. Based on consensus statements and expert opinion; we report a step-by-step guidance for hysterectomy via natural orifice transluminal endoscopy. A detailed description is presented of pre- and postoperative care, and the instruments and equipment used, and surgical steps are illustrated by photographic images. This report can guide surgeons in their training to perform a hysterectomy via NOTES.
Asunto(s)
Laparoscopía , Cirugía Endoscópica por Orificios Naturales , Cirujanos , Femenino , Humanos , Histerectomía , Histerectomía Vaginal/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos , Cirugía Endoscópica por Orificios Naturales/métodos , Vagina/cirugíaRESUMEN
PURPOSE: The aim of the study was to investigate the association between the initial grade of obstetrical anal sphincter injury (OASIS), and Wexner score parameters, with ultrasonographic findings by endoanal ultrasound (EAUS, golden standard) and transperineal ultrasound (TPUS) 6 months post-partum. METHODS: Fifty-nine women after primary repair of OASIS were included at Helsingborg Hospital, Sweden, 2016-2017. Six months post-partum the women filled in a questionnaire regarding symptoms of anal incontinence by the Wexner score and were scanned with EAUS and TPUS (resting state and contracting state) for classification of the residual defect by a modified Starck score. RESULTS: Correlations were found between the OASIS grade and residual defects; length (rs = 0.41, P = 0.003), depth (rs = 0.38, P = 0.006) and angle (rs = 0.40, P = 0.004) of the external anal sphincter (EAS) measured with TPUS in resting state. Using EAUS, correlation between OASIS grade and EAS depth (rs = 0.35, P = 0.007) and angle (rs = 0.37, P = 0.004) were similar, but there was no correlation with length (rs = 0.20, P = 0.14). Between incontinence to gas and the angle of the residual defect in the IAS using TPUS in resting state, correlation was moderate (rs = 0.42, P = 0.003). Regarding incontinence to liquid stool, measurements by TPUS in resting state of EAS residual defect depth (rs = 0.46, P < 0.001) and angle (rs = 0.44, P = 0.001) also correlated moderately. Both corresponding correlations using EAUS were weaker. CONCLUSION: Defects measured with EAUS and TPUS six months post-partum correlated to initial OASIS grade and symptoms of anal incontinence. Specific symptoms correlated with specific anatomical defects, and TPUS was not an inferior method to EAUS.
Asunto(s)
Canal Anal , Incontinencia Fecal , Complicaciones del Trabajo de Parto , Adulto , Canal Anal/diagnóstico por imagen , Canal Anal/lesiones , Incontinencia Fecal/diagnóstico por imagen , Incontinencia Fecal/etiología , Femenino , Humanos , Complicaciones del Trabajo de Parto/diagnóstico por imagen , Periodo Posparto , Embarazo , Encuestas y Cuestionarios , Ultrasonografía , Adulto JovenRESUMEN
OBJECTIVES: To study the association between induction and outcome among two-parous women in uncomplicated pregnancies ≥ 41+3, stratified by first labour delivery mode and conditions present at first delivery. METHODS: The Swedish Medical Birth Register was used to identify 58,964 uncomplicated singleton pregnancies among women with one previous birth between 1998 and 2014. Women with any registered pregnancy complications were excluded to minimise the risk for indication bias. The outcomes considered were emergency caesarean section (CS), and poor neonatal outcome (Apgar score <7 at 5 min, neonatal death, or meconium aspiration). RESULTS: Women who were induced at their second labour had higher emergency CS rates compared to women in spontaneously started deliveries (adjusted risk ratio, ARR: 2.11; 95% CI: 2.00-2.23). Low Apgar score was more common after induction compared to spontaneously started labours (1.0 vs. 0.7%) (ARR: 1.44; 95% CI: 1.18-1.77). Increased CS rates were also found when comparing induction at 41 + 3 to 41 + 6 weeks to labour at 42 weeks or more, regardless of labour start (ARR 1.39; 95% CI: 1.26-1.52). CONCLUSIONS: We found an increased risk of CS and poor neonatal outcome after second labour induction in prolonged pregnancies. The second labour vaginal success rate after induction was highly dependent, on first labour delivery mode, but also on diagnoses and conditions present at the first delivery.
Asunto(s)
Cesárea/estadística & datos numéricos , Trabajo de Parto Inducido/estadística & datos numéricos , Resultado del Embarazo/epidemiología , Adulto , Femenino , Humanos , Recién Nacido , Embarazo , Estudios Retrospectivos , Suecia/epidemiología , Adulto JovenRESUMEN
INTRODUCTION: Endoanal ultrasound is considered the gold standard when assessing the obstetric anal sphincter complex. Due to its relative intrusiveness and economic cost, other ultrasound modalities are on the rise, such as transperineal ultrasound with a convex probe. The aim of our study was to evaluate the agreement between endoanal ultrasound scores (EAUS score) and transperineal ultrasound scores (TPUS score) in assessing residual obstetric anal sphincter defects. MATERIAL AND METHODS: Fifty-nine women were examined 6 months after primary suturing of obstetric anal sphincter injury with two ultrasound modalities. A standardized scoring system analyzing the length, depth and radial extent of both the external (EAS) and internal (IAS) sphincter was used. Wexner fecal incontinence score was used to assess the patients' symptoms. RESULTS: Transperineal ultrasound scores score showed a strong significant correlation with EAUS score during both pelvic floor relaxation and contraction: Spearman's rho [rs ] = 0.74, P < 0.001, and rs = 0.77, P < 0.001, respectively. For both EAS and IAS, significant correlations were found for all parameters, that is, length, depth and angle between both EAUS and TPUS. A statistically significant correlation was found between EAUS score and Wexner score (rs = 0.36, P = 0.005). A significant correlation between the EAS-EAUS score (rs = 0.36, P = 0.005) and Wexner score was found, but no significance was found between IAS-EAUS score and Wexner score (rs = 0.22, P = 0.097). Significant correlations were found for Wexner score and TPUS score in resting state (rs = 0.36, P = 0.01) and contracting state (rs = 0.28, P < 0.05), and between Wexner score and EAS-TPUS score in resting state (rs = 0.32, P = 0.02). CONCLUSIONS: The results indicated a strong agreement between endoanal and transperineal ultrasound in assessing residual obstetric anal sphincter defects 6 months after primary suturing. Furthermore, a weak significant correlation was found between the ultrasound scores and the patients' Wexner fecal incontinence score.