Evaluation of new biomarkers in stage III and IV endometriosis.

OBJECTIVE: To investigate the efficacy of new endometriosis biomarkers in diagnosis and treatment. METHODS: Thirty women with Stage III-IV endometriosis who were given an indication for surgery and 49 control patients were compared. Preoperative and postoperative serum levels of Annexin A5 (ANXA5), soluble intercellular adhesion molecule-1 (sICAM-1), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), soluble vascular cell adhesion molecule-1 (sVCAM-1), vascular endothelial growth factors (VEGF) and Ca-125 measurements were compared. RESULTS: AUCs of ANXA5, sICAM-1, IL-6, TNF-α, VCAM-1, VEGF biomarkers were not found to be significant in diagnosing endometriosis when evaluated alone (p > 0.05). Only the AUC of the Ca-125 biomarker values were found to be significant with 73% sensitivity and 98% specificity (p < 0.001). However, when Ca-125 and ANXA5 were evaluated together, it was concluded that the diagnosis of endometriosis could be made with 73% sensitivity and 100% specificity. CONCLUSION: When Ca-125 and ANXA5 are evaluated together, it seems to be more valuable than Ca-125 alone in diagnosing endometriosis.

Hormonal changes in consecutive clomiphene citrate stimulation cycles and their effect on pregnancy rates.

Objective: To determine the relationship between the cumulative effect of sequential clomiphene citrate (CC) treatments in unexplained infertile women with intercycle and intracycle serum hormone changes. Materials and Methods: Patients who received CC 50 mg in the first cycle (group I, n=34) as ovulation induction and those who received CC 50 mg in the second consecutive cycle (group II, n=18) were compared. Basal (cycle days 2-5) and trigger day (the day that recombinant human chorionic gonadotropin is given) levels of gonadotropin and steroid hormones were measured. Results: The 17OHP increase on trigger day was found to be statistically significantly higher in group II compared to the basal day (p=0.083). The testosterone (T) response on the trigger day of the patients in group II was found to be statistically significantly higher than that in group I (p=0.023). The number of selected follicles was negatively correlated with a follicle-stimulating hormone decrease and positively correlated with an estradiol increase. Endometrial thickness was positively correlated with a luteinizing hormone increase, and cycle cancelation was positively correlated with decreased estradiol. Conclusion: Based on this study, it was concluded that the reason for the increased efficiency rate in successive cycles of CC may be the cumulative increase in T and 17OHP levels. However, this result was found not to affect the clinical pregnancy rate.

Association of Endometrioma Size with Serum Anti-mullerian Hormone.

OBJECTIVE: To evaluate the relationship between the size of endometrioma and serum Anti-mullerian hormone (AMH). STUDY DESIGN: A Descriptive study. PLACE AND DURATION OF STUDY: This study was conducted at the Bagcilar Training and Research Hospital, Istanbul, Turkey, from January 2015 to January 2020. METHODOLOGY: Healthy women of reproductive age, who were found to have unilateral endometrioma in ultrasonography, were included in the study group. There were 82 female patients with unilateral endometrioma in the study group and 96 healthy female patients with male factor infertility in the control group. Women with autoimmune disease, a history of pelvic infection or surgery, polycystic ovary syndrome, pregnancy, those undergoing infertility treatment, family history of premature ovarian failure, and those with atypical or suspected endometrioma were excluded. Age, gravida, serum AMH value, and endometrioma size of the study and control groups were recorded. In addition, the endometrioma group was divided into 2 groups with a cut-off size of greater or less than 40 mm. AMH values ​​were evaluated in these two groups. RESULTS: AMH values ​​of women with endometrioma were significantly lower than the control group (2.03 ng/ml and 3.87 ng/ml, respectively, p<0.001). When the relationship between endometrioma size (greater than 40 mm and less than 40 mm) and AMH was examined, no statistically significant difference was found among serum AMH values (1.89 ng/ml and 2.07 ng/ml, respectively, p=0.65). CONCLUSION: The presence of endometrioma was associated with lower AMH suggesting lower ovarian reserve, but endometrioma size was not associated with significant difference in the AMH values. KEY WORDS: Endometrioma, AMH, Ovarian reserve, Endometrioma size.

Diagnostic office hysteroscopy; why is it still painful procedure despite the surgical experience and mini-hysteroscope?

AIM: To evaluate the effect of cervical canal features on pain during outpatient hysteroscopy performed by experienced surgeons using mini-hysteroscope. METHODS: A prospective observational study was conducted on 303 women undergoing diagnostic hysteroscopy without anesthesia. Pain intensity was evaluated using the visual analog scale (VAS) when the cervical canal was passed. The patients were divided into two groups according to the VAS score: painless or mild pain (VAS <4) and moderate or severe pain (VAS ≥ 4). The relationship between cervical canal characteristics (length, version, and flexion positions, history of cervical intervention, stenosis, synechiae), obstetric and gynecological history, preoperative anxiety level, procedure duration, and pain intensity was examined. RESULTS: Moderate pain (4 ≤ VAS < 7) was observed in 38% of patients (n = 117) and 14 patients (5%) experienced severe pain (VAS ≥ 7). In multivariate analysis, nulliparity (p = 0.01; OR, 4.6; 95% CI, 1.7-13.2), postmenopausal state (p = 0.02; OR, 2.2; 95% CI, 1.2-4.3), excessive flexion of the cervix and retroverted uterus (p <0.001; OR, 4.1; 95% CI, 2.0-8.5) were identified as risk factors for a painful procedure. Diagnostic hysteroscopy was successful in 98% of the patients. The pain was the primary cause of the failed hysteroscopy. CONCLUSION: In addition to nulliparity and postmenopausal status, unfavorable features of the cervical canal, such as the excessive flexion position of the cervix and uterine retroversion are significant causes of pain during outpatient hysteroscopy.

High visceral adiposity index is associated with female orgasmic disorder in premenopausal women: a cross-sectional study.

This study aimed to evaluate the association between the visceral adiposity index (VAI) and female sexual dysfunction (FSD). This cross-sectional study included 165 premenopausal, sexually active women admitted to the gynaecology outpatient clinic between January 2021 and April 2021. Female Sexual Function Index (FSFI) was used to assess the sexual function of the women. After measuring body mass index (BMI) and waist circumference (WC), biochemical serum analysis was performed. The VAI was calculated for all participants. The relationship between VAI and total FSFI and subdomain scores was investigated. Of the participants, FSD was detected in 65.5%. There was no relationship between the total FSFI scores and age, BMI, WC and VAI (p = .126, p = .675, p = .790, p = .220, respectively). Increased VAI levels were associated with dysfunction in orgasm (p = .008). Although VAI seems not to be directly related to FSD, it may predict the orgasmic disorder in women.Impact StatementWhat is already known on this subject? Obesity and female sexual dysfunction (FSD) are common health problems which adversely affect the biopsychosocial well-being. Although the relationship between FSD and obesity, body mass index (BMI) and waist circumference (WC) has been widely discussed in the literature to date, there is not enough evidence for the link between FSD and visceral adiposity index (VAI) which is a reliable indicator of visceral fat dysfunction.What do the results of this study add?The results of this study showed that none of the factors indicating obesity such as BMI, WC and VAI were correlated with the total FSFI scores. However, a significant positive correlation was found between the VAI and female orgasmic disorder (FOD).What are the implications of these findings for clinical practice and/or further research? The VAI may be a useful tool for detecting FOD patients. Diagnosis and treatment of orgasmic disorder would significantly improve the patient's quality of life and general well-being. Further large-scale and high-evidence studies are needed to clarify the impact of obesity on FSD and the relationship between VAI and FOD.

Hormonal Changes in Clomiphene Citrate Cycles in Unexplained Infertility Can Predict Follicle Development?

OBJECTIVES: To examine the intra-cycle and inter-cycle hormonal changes in the clomiphene citrate (CC) cycle in women with unexplained infertility; and to determine the factors that may predict follicle development or CC failure. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: This study was conducted at the Bagcilar Training and Research Hospital, Istanbul, Turkey from August 2019 to March 2020. METHODOLOGY: Fifty-two women with unexplained infertility were included. Fifty-two cycles given 50 mg of CC but without follicle development were accepted as Group I. In the next cycle, 48 cycles given 100 mg of CC were accepted as Group II. During every cycle, serum hormone (FSH, LH, E2, P4, A4, DHEA­S, T, 17­OHP) levels were measured on days 2, 3, 4 or 5 of the cycle (basal day), and on the days when the leading follicle was triggered (trigger day). Endogenous hormone changes were compared in both the groups with and without follicle development as well as in those who could conceive and those who could not conceive. RESULTS: Basal day FSH and DHEA­S values were found to be statistically significantly higher in women with follicle development than those without follicle development (p = 0.02 and p = 0.039, respectively). The trigger day FSH value was found to be significantly lower in women who conceived compared to the basal day value (p = 0.004). The relatively high P4 value (p = 0.008) on the basal day (contingent upon it was not exceeding the 0.5 ng/mL threshold) and the low FSH value (p = 0.015) on the trigger day were found to be statistically significantly different in women who had conceived compared to those who had not. CONCLUSION: Basal serum FSH, P4 and DHEA­S levels can be used as predictors of ovulation in CC cycles in women with unexplained infertility by determining a threshold value with more comprehensive studies to be conducted in the future. Key Words: Androgens, Ovarian stimulation, Clomiphene citrate, Unexplained infertility, Induction of ovulation, Prediction.

Abdominal Hysterectomy with a Uterine Manipulator Minimizes Vaginal Shortening: A Randomized Controlled Trial.

BACKGROUND: We aimed to investigate the impact of adopting an uterine manipulator (UM) on the postoperative (VL) and female sexual function index (FSFI) in patients undergoing abdominal hysterectomy (AH) for benign gynecological disease. MATERIALS AND METHODS: Hysterectomies were performed with the Richardson technique; two variations, a UM or digital guidance, in this technique were used during the colpotomy step. Subjects were randomized and allocated to either hysterectomy with UM guidance (study group) or conventional hysterectomy (control group). Pre- and postoperative VL and FSFI were recorded for each patient. Additionally, surgeons' and residents' satisfaction in locating the colpotomy site was also scored by the surgical team postoperatively. RESULTS: There was a significant reduction in the VL (10.2 ± 1.2 cm vs. 8.3 ± 0.7 cm, p < 0.001) and FSFI score (21.0 ± 4.1 to 17.1 ± 3.6, p < 0.001) between the pre-operation stage and three months post-operation in the control group. However, no such significant changes were observed in the study group. Additionally, surgeons' and residents' satisfaction scores (SSS) for locating the colpotomy site were significantly higher in the study group as compared to the control group (p < 0.001). CONCLUSION: Our findings revealed that implementation of an UM in AH prevented unintended shortening of the postoperative VL and avoided a decline in the sexual function as compared to the standard AH procedure. These benefits were probably due to the precise determination of the colpotomy site that resulted from the use of UM in AH.

Decidualized juvenile cystic adenomyoma mimicking a cornual pregnancy.

OBJECTIVE: To demonstrate the laparoscopic excision technique of a juvenile cystic adenomyoma and show how the decidualization of ectopic endometrial tissue can lead to the misdiagnosis of a focus of ectopic pregnancy. DESIGN: Description and step-by-step demonstration of the surgical procedure using a video recording (Canadian Task Force Classification 3). SETTING: Teaching and research hospital. PATIENT(S): A 27-year-old gravida 2 parity 1 patient with one previous caesarean delivery presented to the emergency department with symptoms of pelvic pain and delayed menses. Her beta-human chorionic gonadotropin level was 2,161 mIU/mL. On transvaginal ultrasonography the uterine cavity appeared empty without any signs of a gestational sac, and a 42×45 mm heterogeneous mass was observed on the right cornual area. An 18×21 mm cystic area was observed within the mass. A diagnosis of cornual pregnancy was made and two doses of systemic methotrexate treatment were administered. On the 12th day following medical treatment, the patient reported increasing abdominal pain and free fluid was observed in the pouch of Douglas on ultrasonography. The decision to perform laparoscopic cornual excision was made. MAIN OUTCOMES AND MEASURE(S): On laparoscopic exploration a tubal ectopic pregnancy was observed within the left fallopian tube. The presence of two simultaneous ectopic pregnancies, located in the left fallopian tube and the right cornual area, was suspected. However, upon careful inspection, the right fallopian tube appeared normal and the mass initially thought to be a right cornual pregnancy appeared more like a degenerated fibroid. A left salpingectomy was performed and the excision of the mass in the right cornual area was planned. An incision was made over the mass and the cystic inner area containing chocolate-brown colored fluid was drained. As there was no pseudo capsule surrounding the mass, the diagnosis of focal adenomyosis instead of degenerated fibroid was made. No endometriotic foci were observed within the pelvis. Different from the enucleation of a fibroid, the mass was dissected from the middle into two halves until healthy myometrium was reached on the floor of the mass. The two halves of the mass were resected totally by dissecting the adenomyotic tissue from the myometrium starting from the caudal end towards the cranial end. The first layer of the remaining myometrial defect was sutured extracorporeally with No.1 polyglactan sutures. The second and third layers were sutured intracorporeally with V-loc sutures. The resected left fallopian tube containing the ectopic pregnancy and the adenomyotic mass were externalized through a posterior colpotomy incision. RESULT(S): The patient was discharged 24 hours postoperatively without any complications. A diagnosis of juvenile cystic adenoma was made upon histopathological examination. The patient reported subsiding of her dysmenorrhea on the postoperative third month. CONCLUSION(S): Juvenile cystic adenomyosis (JCA), is a rare form of focal adenomyosis which is usually located in close proximity to the uterine insertion of the round ligament, contains a cystic inner area larger than 1 cm and is encountered before the age of 30 years. Some authors reported JCA to be an accessory and cavitated uterine mass (ACUM) anomaly developing as a result of gubernaculum dysfunction. The only difference between the two conditions is reported to be the presence of a denser area of adenomyosis surrounding the cystic area lined with endometrium in JCA than in ACUM. This case has shown that decidual changes observed in ectopic endometrial tissue within an adenomyotic area may be misdiagnosed as a focus of ectopic pregnancy. Atypical endometriomas demonstrating decidual changes may also be misdiagnosed as ovarian malignancies. In non-emergency situations, waiting for the decidualization effect of ectopic endometrium to subside can help in the definitive diagnosis of such cases. Our technique for JCA excision is different from enucleation of a fibroid and may aid in the total resection and dissection of the adenomyotic tissue from healthy myometrium.

Endometriomas with low-risk malignancy potential in ultrasonography with high human epididymis protein 4 and risk of ovarian malignancy algorithm: a cases series.

Endometriosis is an estrogen-dependent disease that affects 5 to 15% of women of reproductive age. Data from large-cohort and case-control studies indicate an increased risk for ovarian cancers in women with endometrioma. Recently, as an ovarian cancer biomarker, human epididymal secretory protein E4 (HE4) has been increasingly investigated in the differentiating of endometrioma from ovary malignancy and in confirming the benign structure of the endometrioma. This case series study describes women who underwent surgery due to increased serum HE4 levels and higher Risk of Ovarian Malignancy Algorithm (ROMA) index, in whom the final pathology was reported as benign, although, ultrasonography and magnetic resonance imaging (MRI) findings showed features of "typical" endometrioma.

Do barbed sutures with different surface textures have different effects on adhesion formation and histological features? An experimental blinded study in an animal model.

BACKGROUND: The obstetrics and gynecology literature has expanded in recent years to include clinical trials assessing the use of barbed sutures. The difficulty of intracorporeal suturing continues to be a barrier to a wider use of laparoscopy. Although the use of barbed sutures has been shown to ease the process of laparoscopic suturing considerably, concerns have been raised regarding a potentially increased risk of adhesions or inflammation as a result of their use. OBJECTIVES: The aim of this study was to determine whether differences in surface textures, resulting from the variations in the geometric configurations of barbs, lead to differences in intra-abdominal adhesion formation. MATERIAL AND METHODS: A total of 27 non-pregnant female Wistar Hannover rats, weighing 200-250 g, with intact uteri were used as an adhesion formation model. The rats were randomly assigned to 3 groups: barbed suture group 1, barbed suture group 2 and control group (no intracorporeal suture). A 2-centimeter vertical incision was performed on the anti-mesosalpingeal side of one of the uterine horns. The incision on the uterine horn was reapproximated with a running suture, entailing 3 needle punctures and left untied at one end. Six weeks after the operation, intra-abdominal adhesion formations were investigated both clinically and histopathologically. RESULTS: Clinical adhesion scores and histopathological parameters in both the barbed suture groups were statistically significantly higher than in the control group (p < 0.05). There was no significant difference between the barbed suture groups regarding the adhesion scores. CONCLUSIONS: The 2 types of barbed sutures with different surface textures, used for myometrial closure, form a similar profile with respect to postoperative adhesion formation.

Case report of atypical endometrial stromal cells in an endometrial polyp and osteoclastic like giant cells in leiomyoma in the same patient: Is it a coincidence or is it a result of Tamoxifen treatment?

Atypical stromal cells are rarely identified in the endometrial polyps of the female lower genital system. These cells are suggested to develop due to a degenerative or reactive phenomenon. And osteoclastic like giant cells, which have been reported in many epithelial and mesenchymal tumors of uterus, may develop because of a degenerative or a reactive process. In this case report, we present a breast cancer patient who was commenced on Tamoxifen treatment presenting with formation of both atypical stromal cells in an endometrial polyp and osteoclastic like giant cells in the leiomyoma of the uterus. Patients who are treated with Tamoxifen should be followed meticulously to detect tumoral or proliferative lesions of endometrium and myometrium because of the adverse effects of tamoxifen on uterus. (www.actabiomedica.it).

Comparison of the Thermal Spread of Three Different Electrosurgical Generators on Rat Uterus: A Preliminary Experimental Study.

BACKGROUND/AIMS: The objective of this study was to compare the depth and width of thermal spread caused on rat uterine tissue after application of 3 different electrosurgical generators. METHODS: Alsa Excell 350 MCDSe (Unit A), Meditom DT-400P (Unit M), and ERBE Erbotom VIO 300 D (Unit E) electrosurgical units (ESUs) were used. The number of Wistar Hannover rats required to obtain valid results was 10. The primary objective of the study was to compare the 3 ESUs using the same instrument and the same waveform. The secondary objective of the study was to compare the differences between monopolar and bipolar systems of each ESU separately using the same waveform. RESULTS: The thermal spread caused by each ESU using monopolar instruments with continuous and interrupted waveforms was significantly different. Among the 3 devices, Unit A caused the largest thermal uterine tissue spread. On the other hand, Unit E caused the most superficial thermal tissue spread, and the smallest thermal spread among all ESUs. CONCLUSIONS: Surgeons should note that different ESUs used with the same power output might create different thermal effects especially in the monopolar configuration within the same waveform, for the same duration, and with the same instrument.

Comparison of barbed unidirectional suture with figure-of-eight standard sutures in vaginal cuff closure in total laparoscopic hysterectomy.

The aim of the study was to compare postoperative vaginal cuff complications due to the use of barbed sutures (V-Loc™ 180 unidirectional suture; Covidien, Mansfield, MA) and standard braided sutures (Vicryl®; Ethicon Inc., Somerville, MA) during vaginal cuff closure of patients undergoing a total laparoscopic hysterectomy (TLH) due to benign diseases. Eighty-nine patients were in the standard suture group and 208 patients were included in the barbed suture group. Vaginal cuff dehiscence was identified in only three (3.3%) patients within the standard suture group and none in the barbed suture group. Five (5.6%) patients in the standard suture group and two (0.9%) patients in the barbed suture group developed postoperative cuff infection/cellulitis. Duration of the surgery was significantly shorter in the barbed suture group than in the standard suture group (p < .05). V-Loc™ 180 unidirectional barbed suture, which is used during TLH for vaginal cuff closure, is an applicable, safe and tolerable alternative to a standard suture. IMPACT STATEMENT What is already known on this subject: Barbed sutures are a relatively new type of suture that include sharp barbs inserted on monofilament material in various configurations, and are used for approximating tissues without any need for surgical knotting. They have increasingly been used in obstetrics and gynaecology in recent years, particularly in total laparoscopic hysterectomy and laparoscopic myomectomy. At present, there are a limited number of studies of V-Loc™ suture in the literature. What the results of this study add: We demonstrated that barbed sutures used for enabling vaginal cuff integrity did not cause major morbidity and mortality for the patient. We suggest that V-Loc™ 180 barbed sutures offer a practical, safe and tolerable alternative for surgeons because they are easy to use, do not cause a significant increase in vaginal cuff complications, and shorten the operating time. Our study with V-Loc™ 180 unidirectional barbed suture is the second largest series after the study of Cong et al. What the implications are of these findings for clinical practice and/or further research: We believe that the barbed suture, the surgery results of which are openly discussed in our study, will be more prominent in clinical practice owing to the shortened operating time, and that the use of these sutures does not cause a significant increase in vaginal cuff complications.

Seropositivity for the human heat shock protein (Hsp)60 accompanying seropositivity for Chlamydia trachomatis is less prevalent among tubal ectopic pregnancy cases than individuals with normal reproductive history.

OBJECTIVES: To investigate the role of anti-human heat shock protein 60 (hHsp60) antibody positivity in the pathogenesis of ectopic pregnancy, following Chlamydia trachomatis (CT) infection. STUDY DESIGN: In a case-control study, serological tests for anti-hHsp60 were performed in ectopic pregnancies (study group) and parturients with normal reproductive histories (control group). All participants in both groups were CT IgG(+). hHsp60 IgG(+) prevalences were compared between the two groups, by semiquantitative ELISA. Data were evaluated using nonparametric and parametric tests and multivariable regression. RESULTS: After an initial pilot study, two groups were formed: 63 ectopic gestations (study group) and 95 normal parturients (control group), all CT IgG(+). Blood samples from all cases were tested for anti-hHsp60 IgG. Age, gravidity, and practising contraception were higher in the control group, while a history of pelvic infections were more common in the study group. Hsp60 IgG(+) was found to be significantly higher in the control group (63/95, 66.3%) compared to study group (30/63, 47.6%). Regression analysis revealed anti-hHsp60 positivity was an independent factor delineating the two groups. CONCLUSION: Immunity to hHsp60 is less common in CT IgG(+) ectopic pregnancies than CT IgG(+) fertile subjects without a history of ectopic pregnancies. Hence, our findings suggest that hHsp60 seropositivity may decrease the probability of an ectopic gestation in subjects with previous CT infections.

Laparoscopic Blinded Endometrial Cavity Resection for Robert's Uterus.

STUDY OBJECTIVE: To demonstrate that laparoscopic excision of the endometrial tissue of a blind endometrial cavity in a patient with a Robert's uterus who did not consent to hysteroscopic surgery due to her virgin state and religious beliefs was an effective alternative treatment option for progressive dismenorrhea and pelvic pain. DESIGN: Presentation of a rare müllerian anomaly and a step-by-step demonstration of a laparoscopic excision technique in the endometrium of a blind uterine cavity (educative video) (Canadian Task Force classification III). SETTING: Robert's uterus is a rare müllerian anomaly characterized by the presence of a blind endometrial cavity and an asymmetric septum. Endometriosis may be encountered in 40% of patients with this anomaly. A 15-year-old virgin patient with progressive dysmenorrhea was diagnosed with a Robert's uterus anomaly on magnetic resonance imaging. Hysteroscopic surgery was suggested to form a communication between the blind endometrial cavity and the hemiuterus; however, the patient refused to undergo any vaginal surgery due to her virgin state and religous beliefs. A decision to excise the endometrial tissue of the blind cavity laparoscopically instead of performing a hemihysterectomy was made to prevent any adverse effects on the ovarian blood supply and damage to the myometrial wall of the unicornuate uterus. INTERVENTION: Laparoscopic resection of the blind endometrial cavity in a patient with a Robert's uterus anomaly. CONCLUSION: Laparoscopic resection of a blind endometrial cavity is a safe and effective surgical alternative in patients who refuse vaginal surgery.

Laparoscopic Excision of a Scar Pregnancy and Isthmocele Repair.

STUDY OBJECTIVE: Laparoscopic excision of a scar pregnancy and isthmocele repair with a barbed suture. DESIGN: A step-by-step explanation of the laparoscopic excision technique of a scar pregnancy and isthmocele repair. SETTING: Cesarean scar pregnancy occurs as a result of attachment of the products of conception to the uterine scar [1-3]. In the present case, a 34-year-old, gravida 4, para 1 patient with a history of 1 miscarriage and 1 ectopic pregnancy was diagnosed with type 2 cesarean scar pregnancy at 7 weeks of gestation. Dilation and curretage was performed at the 8th week of gestation to terminate the pregnancy. On ultrasonography performed 1 month later, placental material underlying the isthmocele was observed. Her beta human chorionic gonadotropin level was 13 836 mIU/mL. She was followed up for 1.5 months until the beta human chorionic gonadotropin levels were negative. However, the mass underneath the scar had grown larger, measuring up to 5 × 6 cm. Laparoscopy was performed because the patient reported vaginal spotting and pelvic pain. The incision was sutured with a synthetic absorbable unidirectional barbed suture (Stratafix Knotless Tissue Control Device; Ethicon Inc., Somerville, NJ). No residual scar defect was visible on follow-up ultrasonography 1 week and 1 month after surgery. CONCLUSION: Barbed sutures ease the repair of uterine scar defects and can provide ideal reapproximation of thick myometrial tissue. Laparoscopic treatment of a scar pregnancy and isthmocele repair are effective and safe modes of treatment.

Is there any difference between the distances created by towel clamp lifting and towel clamp plus manual lifting of the anterior abdominal wall for direct trocar entry in laparoscopic gynecologic surgery? A prospective interventional study.

OBJECTIVE: Most surgeons prefer to perform anterior abdominal wall lifting during abdominal entry to avoid damage to intestines or main vessels. Anterior abdominal wall lifting is assumed to prevent vital organ injuries by creating an adequate distance prior to entry into the peritoneal cavity. In this study, we compared the distance created for trocar entry into the peritoneal cavity with towel clamp lifting and towel clamp plus manual elevation of the anterior abdominal wall. MATERIAL AND METHODS: Forty patients who underwent various laparoscopic procedures were enrolled. The study was performed in two steps: first the anterior abdominal wall was lifted using towel clamps (TC group), next the anterior abdominal wall was lifted via maximal manual elevation from the lower abdomen in addition to towel clamps (TCM group). The insertion distance of a plastic ruler into the abdomen was measured from the parietal peritoneum to the intra-abdominal structure in both groups. RESULTS: There was a statistically significant difference between the two groups (TC group 3.9±1.5 cm vs. TCM group 4.5±1.5 cm, p<0.001). Correlation analysis of the relationship of distance with BMI in the study groups revealed a strong negative linear correlation [TC group vs. body mass index (BMI); r=-0.719, p<0.001 and TCM group vs. BMI, r=-0.749, p<0.001]. Correlation analysis of the relationship between the study groups and parity number revealed a weak negative linear correlation (TC group vs. parity number, r=-0.071, p=0.76 and the TCM group vs. parity number, p=0.61), which did not reach statistical significance. CONCLUSION: The recruitment of both towel clamps and manual elevation in anterior abdominal wall lifting provides significantly greater distance for trocar entry in laparoscopic surgery.

Safety and efficacy of using advanced electrosurgical bipolar vessel sealing during vaginal hysterectomy in morbidly obese patients: a retrospective cohort analysis.

OBJECTIVES: To assess the safety and efficacy of electrosurgical bipolar vessel sealing during vaginal hysterectomy in morbidly obese patients MATERIAL AND METHODS: A total of 105 morbidly obese patients who underwent vaginal hysterectomy due to benign gynecologic pathologies between January 2010 and April 2017 were included in the study. Patients were divided into two groups according to whether conventional suture ligation technique (n = 64) or electrosurgical bipolar vessel sealing (n = 41) were used during vaginal hysterectomy. The surgical procedure was performed with the same technique in both study groups. The primary outcomes were duration of surgery and estimated blood loss. The secondary outcomes were intra-operative complications and post-operative complications. RESULTS: The duration of surgery and estimated blood loss in the vessel sealing group was significantly less than in the conventional suture group (p < 0.05). No significant difference was present between the two groups in the rate of intra-operative and post-operative complications. CONCLUSIONS: The primary outcome of our study is that the EBVS system can be used equally and even more effectively in some aspects; and as safe an alternative approach to conventional suture ligation technique during vaginal hysterectomies performed specifically on morbidly obese patients with reduced operation times and blood loss, and without increasing the complication rates.

Robot-assisted laparoscopic pectouteropexy: an alternative uterus-sparing technique for pelvic organ prolapse surgery.

The aim of this video is to demonstrate the alternative technique of robot-assisted laparoscopic pectouteropexy for uterus preservation in obese patients with pelvic organ prolapse. We present the case report of a 44-year-old patient with apical pelvic organ prolapse. A pelvic examination was performed during a Valsalva maneuver in the dorsal lithotomy position and in the standing position, and the patient was diagnosed with stage III apical prolapse in accordance with the Pelvic Organ Prolapse Quantification system of the International Continence Society (POP-Q: Аа -1, Ва 0, Вр 0, С +2). We performed the procedure, which was developed as an alternative to sacrocolpopexy or sacrouteropexy, as described by Banerjee and Noé (Arch Gynecol Obstet 284:24-28, 2011). Pectouteropexy is a new method for prolapse surgery that uses the lateral parts of the iliopectineal ligament for bilateral mesh fixation of the descended structures and provides strong apical support. We believe that robot-assisted laparoscopic pectouteropexy is a valuable alternative approach for uterus-preserving pelvic organ prolapse surgery owing to its better robot maneuverability, reduced operating time, and better visualization in obese patients.