Uterine dehiscence: a laparoscopic uterine repair in early pregnancy.

OBJECTIVE: To review the existing literature on uterine cesarean scar defect repair in pregnancy and describe an approach to minimally invasive surgical repair in early pregnancy to facilitate a term live birth. DESIGN: A case study and literature review, followed by a demonstration of the procedure with surgical video and concurrent ultrasound footage. SETTING: Academic medical center. PATIENT(S): This video is a case presentation of a 35-year-old, gravida 2, para 1 woman with a previous cesarean section. She presented at 10 weeks and 3 days gestational age with complete uterine dehiscence at the site of her previous cesarean section scar, which was diagnosed by ultrasound. Surgical video and medical images have been extracted from this patient's chart after consent was obtained. INTERVENTION(S): Ultrasound-guided laparoscopic repair of cesarean scar defect at 11 weeks and 3 days of gestation. MAIN OUTCOME MEASURE(S): The video showed a large 2.6-cm uterine scar defect in early pregnancy confirmed using ultrasound and magnetic resonance imaging. This diagnosis was confirmed by direct visualization at the time of surgery. This video demonstrates our surgical approach as follows: careful uterine manipulation and identification of the defect with laparoscopy and concurrent transvaginal ultrasound; reflection of the bladder using an ultrasound-guided approach to confirm the borders of the defect; and repair with a running 2-layer closure under transvaginal ultrasound guidance. RESULT(S): Through ultrasound-guided laparoscopic repair, we were able to demonstrate a restoration of approximately 8 mm of myometrial thickness across the cesarean scar defect on antenatal follow-up. The patient had a term live birth via cesarean section. CONCLUSION(S): With an increased number of cesarean sections and improved quality of ultrasound imaging, an increase in the incidental findings of cesarean scar defects has been observed. The risk of spontaneous prelabor uterine rupture remains unknown. There is a literature gap in this area regarding the appropriate standard of care. This video demonstrates that ultrasound-guided laparoscopic repair was possible, safe, and effective in our patient. However, further studies are required to establish the safety and efficacy of this approach.

Minimally Invasive Management of Second Trimester Placenta Percreta.

STUDY OBJECTIVE: To describe the diagnostic and surgical challenges in the management of second trimester placenta percreta. DESIGN: Stepwise demonstration of the surgical technique with the use of an educational video. SETTING: Second trimester placenta percreta is a rare entity, with very few case reports in the literature. Our video demonstrates the challenges of a minimally invasive approach toward definitive surgical management with hysterectomy. A 39-year-old G7P3 (3 previous cesarean deliveries) female at 17 weeks and 2 days gestation presented with acute abdominal pain to a community hospital. This was a spontaneously conceived pregnancy. Her hemoglobin level on admission was 92 g/L. An ultrasound showed a normal uterus, and the appendix was not visualized. One unit of packed red blood cells was transfused, and she underwent exploratory laparoscopy for a possible retrocecal hematoma/mass seen on computerized tomography. In the operating room, acute hemoperitoneum was visualized with placenta-like tissue invading through the anterior lower uterine segment (Figures 2 & 3). A hemostatic agent (Floseal, Baxter) was placed over the bleeding, and she was then transferred to a tertiary academic center for further management. INTERVENTIONS: Magnetic resonance imaging was performed on the following day after transfer to our facility, which confirmed placenta percreta at the level of the bladder (Figure 1). Following counseling with a multidisciplinary team and given that there was ongoing bleeding from the invading placental tissue, pregnancy continuation and uterine conservation were not possible. The patient was offered preprocedure termination of pregnancy with intra-cardiac injection of potassium chloride and 350 cc of amniotic fluid was drained at that time. This was done to facilitate visualization for a minimally invasive approach. We describe 5 main challenges of minimally invasive hysterectomy for placental percreta and provide a stepwise approach to mitigating them: visibility, vascular control, bladder dissection, colpotomy, and specimen retrieval. We adapted the previously described laparotomy techniques of progressive uterine devascularization and approach to bladder dissection and colpotomy to laparoscopy [1,2]. In addition, we performed dilatation and evacuation to allow for vaginal specimen removal. The patient's postoperative course was uncomplicated, and she was discharged home in a stable condition. CONCLUSION: Midtrimester placenta percreta poses significant challenges in diagnosis and surgical management. Total laparoscopic hysterectomy for this condition poses unique challenges but is feasible and safe.

Retrograde Bladder Filling After Outpatient Gynecologic Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review and meta-analyze randomized controlled trials (RCTs) comparing postoperative bladder retrofilling to passive filling after outpatient gynecologic surgery to evaluate effects on postoperative outcomes. DATA SOURCES: We searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and ClinicalTrials.gov from 1947 to August 2020. METHODS OF STUDY SELECTION: Two reviewers screened 1,465 articles. We included RCTs that compared postoperative bladder retrofilling to passive filling in patients who underwent outpatient gynecologic surgery by any approach. The primary outcome was the time to first void. Secondary outcomes included time to discharge, postoperative urinary retention, urinary tract infection, and patient satisfaction. Mean differences and relative risks (RRs) were calculated for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias Tool. TABULATION, INTEGRATION, AND RESULTS: We included eight studies with 1,173 patients. Bladder retrofilling in the operating room resulted in a significant decrease in the time to first void (mean difference -33.5 minutes; 95% CI -49.1 to -17.9, 4 studies, 403 patients) and time to discharge (mean difference -32.0 minutes; 95% CI -51.5 to -12.6, eight studies, 1,164 patients). Bladder retrofilling did not shorten time to discharge when performed in the postanesthetic care unit (mean difference -14.8 min; 95% CI -62.6 to 32.9, three studies, 258 patients) or after laparoscopic hysterectomy (mean difference -26.0 min; 95% CI -56.5 to 4.5, five studies, 657 patients). There were no differences in postoperative urinary retention (RR 0.77; 95% CI 0.45-1.30, five studies, 910 patients) or risk of urinary tract infection between the retrofill and passive fill groups (RR 0.50; 95% CI 0.14-1.77, four studies, 387 patients). Patient satisfaction was comparable between groups. CONCLUSION: Retrofilling the bladder in the operating room after outpatient gynecologic surgery modestly reduces the time to first void and discharge with no increase in adverse events. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42020203692.

Outcomes for patients with the same disease treated inside and outside of randomized trials: a systematic review and meta-analysis.

BACKGROUND: It is unclear whether participation in a randomized controlled trial (RCT), irrespective of assigned treatment, is harmful or beneficial to participants. We compared outcomes for patients with the same diagnoses who did ("insiders") and did not ("outsiders") enter RCTs, without regard to the specific therapies received for their respective diagnoses. METHODS: By searching the MEDLINE (1966-2010), Embase (1980-2010), CENTRAL (1960-2010) and PsycINFO (1880-2010) databases, we identified 147 studies that reported the health outcomes of "insiders" and a group of parallel or consecutive "outsiders" within the same time period. We prepared a narrative review and, as appropriate, meta-analyses of patients' outcomes. RESULTS: We found no clinically or statistically significant differences in outcomes between "insiders" and "outsiders" in the 23 studies in which the experimental intervention was ineffective (standard mean difference in continuous outcomes -0.03, 95% confidence interval [CI] -0.1 to 0.04) or in the 7 studies in which the experimental intervention was effective and was received by both "insiders" and "outsiders" (mean difference 0.04, 95% CI -0.04 to 0.13). However, in 9 studies in which an effective intervention was received only by "insiders," the "outsiders" experienced significantly worse health outcomes (mean difference -0.36, 95% CI -0.61 to -0.12). INTERPRETATION: We found no evidence to support clinically important overall harm or benefit arising from participation in RCTs. This conclusion refutes earlier claims that trial participants are at increased risk of harm.