Does the New National Cervical Screening Programme Guideline Detect Cases of High-Grade Squamous Intraepithelial Lesions That Previously Would Have Been Missed?

OBJECTIVE: The aim of this study was to determine the number of patients undergoing large loop excision of the transformation zone (LLETZ), for biopsy-confirmed high-grade squamous intraepithelial lesions (HSIL), where the original cervical screening test (CST) reported oncogenic human papillomavirus (HPV) and negative liquid-based cytology (LBC). This reflects the number of patients where a LLETZ procedure would not have occurred under the previous guideline. METHODS: Retrospective observational chart review of all patients (n = 477) who underwent LLETZ procedure in a single tertiary unit over a 36-month period. Prevalence of negative histopathology, positive margins, incidental cervical cancer, and accuracy of HSIL identification at colposcopy were measured. Diagnostic accuracy of HSIL diagnosis from initial colposcopic impression was calculated; factors influencing accuracy were evaluated using multivariable logistic regression analysis. There were no comparators. RESULTS: Of 477 LLETZs, 5.9% (n = 28) were for oncogenic HPV and normal LBC on referral CST. Demographics between the "study" (oncogenic HPV and normal LBC on referral CST) and the "standard" group were similar, except the study group was less likely to be using contraception (25% vs 47%, p = .023). In the study group, initial colposcopic cervical biopsy confirmed HSIL in 91.6% (n = 27) and low-grade squamous intraepithelial lesions in 3.6% (n = 1). Histopathological analysis of LLETZ specimens confirmed HSIL in 20 patients (71.4%) and low-grade squamous intraepithelial lesions in 2 (7.1%). No microinvasion was detected. CONCLUSIONS: The renewed National Cervical Screening Programme (NCSP), is detecting more "at risk" patients, predicted to lead to a further reduction in incidence of cervical cancer in adequately screened patients.

Association between pelvic pain bothersomeness and pain sensitivity: A community-based cross-sectional study of young adult females in the Raine Study.

OBJECTIVE: Pelvic pain has been associated with augmented nociceptive processing, but large studies controlling for multiple potential confounding factors are lacking. This study investigated the association between pelvic pain bothersomeness and pain sensitivity in young adult women, accounting for potential confounding factors. DESIGN: Cross-sectional study. SETTING: Community-dwelling sample. POPULATION: The Raine Study Gen2-22 year follow-up (n = 475). MAIN OUTCOME MEASURES: The experience of bothersomeness related to pelvic pain was determined from a question in the Urogenital Distress Inventory short form. Pain sensitivity was measured using pressure pain and cold pain thresholds. Potential confounding factors included ethnicity, marital status, highest level of education, income, waist-hip ratio, level of activity, sleep quality, smoking, comorbidity history, C-reactive protein level, musculoskeletal pain experience and psychological distress. RESULTS: Three hundred and sixty-two women (76.2%) reported no pelvic pain bothersomeness, 74 (15.6%) reported mild pelvic pain bothersomeness and 39 (8.2%) reported moderate-severe pelvic pain bothersomeness. After adjusting for marital status (and test site), moderate-severe pelvic pain bothersomeness was associated with a lower pressure pain threshold (i.e. greater pressure pain sensitivity) (coefficient -51.46, 95% CI -98.06 to -4.86, p = 0.030). After adjusting for smoking, moderate-severe pelvic pain bothersomeness was also associated with a higher cold pain threshold (i.e. greater cold pain sensitivity) (coefficient 4.35, 95% CI 0.90-7.79, p = 0.014). CONCLUSIONS: This study suggests augmented nociceptive processing as a contributing factor in pelvic pain bothersomeness for some women. Thorough assessment of women who present clinically with pelvic pain should consider pain sensitivity as a potential contributing factor to their presentation.

The effect of obesity on cost of total laparoscopic hysterectomy.

STUDY OBJECTIVE: To test for the association between increasing patient body mass index (BMI) and the cost of total laparoscopic hysterectomy (TLH). Secondary outcomes include the relationship between increasing BMI and both peri- and post-operative morbidity. MATERIALS AND METHODS: Retrospective cohort study of patients (N = 510) who underwent TLH between January 2017 and December 2018 at a single public tertiary teaching hospital. RESULTS: Morbid obesity (n = 63) was associated with significantly higher total admission costs ($19 654 vs $17 475 Australian dollars, P = 0.002), operative costs ($9447 vs $8630, P = 0.017) and total costs including readmissions ($20 476 vs $18 399, P = 0.016) when compared to patients with normal BMI (n = 103) and adjusting for age, indication for surgery, additional procedures and conversion to total abdominal hysterectomy. Costs for overweight (n = 134) and obese (n = 210) BMI groups did not differ from costs for the normal BMI group. Increased operative costs observed in the morbidly obese group, were largely driven by the time associated with set-up, transfer and anaesthetic time while surgical and recovery times were not statistically significant. CONCLUSION: The total cost of TLH is increased in the morbidly obese category of patients. The operative costs appear to be related to pre-operative measures such as theatre set-up and anaesthetic requirements. TLH in the obese and morbidly obese category group is not associated with increased intra-operative or post-operative complications. There may be a role for exploring improvements in managing morbidly obese patients in the pre-operative setting.

Interposition of a biological mesh may not affect the rate of rectovaginal fistula after excision of large rectovaginal endometriotic nodules: a pilot study of 209 patients.

AIM: The aim of this work was to assess whether placement of a biological mesh (Permacol® ) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula in patients with deep rectovaginal endometriosis. METHOD: We report a retrospective, comparative study enrolling patients with vaginal infiltration of more than 3 cm in diameter and rectal involvement in two centres. They benefited from complete excision of rectovaginal endometriotic nodules with or without a biological mesh placed between the vaginal and rectal sutures. The rate of rectovaginal fistula was compared between the two groups. RESULTS: Two hundred and nine patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). Ninety-two per cent of cases and 86.2% of controls had rectal infiltration more than 3 cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a smaller distance between the rectal staple line and the anal verge (4.4 ± 1.4 cm vs. 6 ± 2.9 cm). Rectovaginal fistulas occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adjusted OR 1.6, 95% CI 0.3-9.5). A distance of less than 7 cm between the rectal staple line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistula (adjusted OR 15.1, 95% CI 1.7-132). CONCLUSION: Our results suggest that the placement of a biological mesh between the vagina and rectal sutures may not affect the rate of formation of postoperative rectovaginal fistula following excision of deep infiltrating rectovaginal endometriosis.

The cumulative success of ovulation induction therapy with gonadotrophins in therapy-naïve anovulatory women: An observational study.

BACKGROUND: The use of gonadotrophins as a first-line treatment for anovulatory infertility has been limited by a perception of a risk of multi-fetal gestation and ovarian hyperstimulation syndrome (OHSS). However, it has recently been recognised as an acceptable first-line treatment if appropriate monitoring is performed. AIMS: To determine the cumulative live birth rate, incidence of multiple gestation, cycle cancellation rate and incidence of OHSS for therapy-naïve anovulatory women undergoing ovulation induction with gonadotrophins. MATERIALS AND METHODS: A prospective observational study of 258 patients undergoing ovulation induction with a 'low-dose step-up' protocol was performed over a three-year period across two fertility centres (40% of patients were currently or recently prescribed metformin). RESULTS: Twenty-six percent of patients required concurrent use of luteinising hormone. The cumulative pregnancy and live birth rates were 22.5% and 18.2%, 40.3% and 34.5%, 47.7% and 41.1% after completion of the first, second and third cycles of stimulation, respectively, with a median duration of stimulation of 15 days. No patients developed OHSS and 10.5% of cycles were cancelled due to an excessive or no follicular response. The multiple pregnancy rate was 2%. The cumulative pregnancy rate was reduced for women over 35 years of age (23.8 vs 55.3%, P = 0.006) and for women with a body mass index greater than 25 kg/m2 (40.6 vs 56.7%, P = 0.027). CONCLUSIONS: This study demonstrated that ovulation induction with gonadotrophin therapy, in the context of appropriate monitoring, is a safe and effective treatment for young therapy-naïve patients with anovulatory infertility.

Are obstetric and gynaecological trainees in Australia and New Zealand adequately trained in the management of the infertile couple?

BACKGROUND: Increasingly, couples are seeking assistance to conceive. It is not clear whether obstetric and gynaecological trainees in Australia and New Zealand receive adequate training and exposure to infertility training. AIMS: To determine the perspectives of Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) trainees regarding their experience of infertility management during training, in order to better inform discussions of training in this area. MATERIALS AND METHODS: RANZCOG trainees were invited to participate in an anonymous online survey containing 17 questions. Data collected included demographic details, training year, cumulative infertility experience as a trainee, and perspectives regarding infertility experience during training. RESULTS: Of the 191 RANZCOG trainees who participated in the study (25.7% response rate), the majority reported they had never had the opportunity to attend an infertility clinic as part of their training (53.2%). Lack of experience in infertility medicine was associated with a high dissatisfaction rate (89.8%). CONCLUSIONS: Trainees in Australia and New Zealand have limited access to infertility medicine during training with associated high dissatisfaction rates. Access to training in a private healthcare setting or the expansion of public in vitro fertilisation may improve trainees' experiences.

Hysteroscopic guided, laparoscopic excision of caesarean scar defect: video presentation of a combined technique.

With increasing rates of delivery by caesarean section has come an increase in rates of associated complications, including caesarean scar defect. Whilst the management of this issue remains controversial, evidence is building for surgical management of such a defect for resolution of menstrual symptoms, pain and subfertility. We present a case report and surgical video of a hysteroscopic guided, laparoscopic excision of a caesarean scar defect. Following the successful management of this case and a literature review of the technique, we conclude this to be a safe, feasible and effective procedure with a low rate of complications.

The interval transfer of a frozen-thawed embryo is more successful than a fresh embryo transfer for women undergoing IVF with recurrent implantation failure after cleavage stage embryo biopsy.

BACKGROUND: Recurrent implantation failure (RIF) is repeated unsuccessful embryo transfers (ETs). AIMS: To identify predictive embryonic markers of implantation in RIF, following pre-implantation genetic screening (PGS) of cleavage stage embryos, after accounting for male and female factors. MATERIALS AND METHODS: Retrospective analysis of RIF patients undergoing PGS after correction of modifiable causes. RESULTS: Eighty-four patients underwent 140 in vitro ferilisation cycles. Forty-one cycles were excluded: 12 (no embryo for transfer), four (double ETs) and 25 (no biopsy). Sixty-three patients underwent 99 single euploid ETs (48 fresh, 51 frozen) resulting in 11 biochemical pregnancies, 36 clinical pregnancies (CP), and six miscarriages and 30 live births (LB). Frozen ET was more successful than fresh; respective live birth rate (LBR) and clinical pregnancy rate (CPR), 39.2% versus 20.8%, (P = 0.02), 45.1% versus 27.1% (P = 0.04). LBR and CPR were lower when 5-6 blastomeres were present at embryo biopsy, compared to embryos with ≥7 blastomeres: 15.4% versus 32.6% (P = 0.185) and 15.4% versus 39.5% (P = 0.074) respectively. Serum ß human chorionic gonadotropin (ßhCG) concentration was greater when a more developed embryo was biopsied (r = 0.448, P = 0.017 and r = 0.476, P = 0.118, fresh and frozen transfers, respectively). Embryo morphokinetic analysis demonstrated faster development to blastocyst stage when more cells were present at biopsy: mean 103.3, 102.2 and 96.0 h for biopsy at the 5-6, 7-8 or ≥9 cell stage respectively (P = 0.040 for difference between 7-8 cells vs ≥9). CONCLUSIONS: After cleavage stage biopsy, frozen ET was more successful than fresh ET. Chance of conception and serum ßhCG concentration correlated with number of cells present at time of biopsy.

Case report and surgical video presentation: Combined laparoscopic and cystoscopic partial bladder cystectomy for excision of deeply infiltrating endometriosis.

INTRODUCTION: Whilst endometriosis is a relatively common condition, deeply infiltrating endometriosis (DIE) of the bladder is less so, and when medical treatment fails, surgical management is an effective option. We present a case report and surgical video of a patient undergoing combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder. DESIGN: Case report (Canadian Task Force Classification III) and step-by-step explanation of the surgery using video. Exemption was granted from the local institutional review board. PRESENTATION OF CASE: We present a case report and surgical video of a 36-year-old nulliparous patient presenting with a 12-month history of sudden onset cyclical dysuria and haematuria. Imaging demonstrated a deeply infiltrating endometriotic nodule involving the bladder. The patient underwent a combined laparoscopic and cystoscopic excision of deeply infiltrating endometriosis of the bladder. The procedure was uneventful and the patient progressed to a full recovery. DISCUSSION: DIE is a highly invasive form of endometriosis which is defined arbitrarily as endometriosis infiltrating beneath the peritoneum by 5mm or greater. When medical therapy is declined or fails, surgical excision by partial cystectomy would appear to be the most effective management option. A combination of cystoscopy and laparoscopy has been shown to be a safe and feasible procedure, with a low rate of complications. It represents the ideal way by which to identify the resection limits for complete excision of the lesion, and allows for optimal repair of the bladder defect. CONCLUSION: Combined laparoscopic and cystoscopic partial cystectomy for excision of deeply infiltrating bladder endometriosis is a safe and feasible procedure in our institution.

Early intrauterine pregnancy during major surgery: the importance of preoperative assessment and advice.

We present a case of a live birth occurring post radical laparoscopic excision of endometriosis, hysteroscopy, curettage and test of tubal patency in the presence of an early intrauterine gestation.

Do Groin Drains Reduce Postoperative Morbidity in Women Undergoing Inguinofemoral Lymphadenectomy for Vulvar Cancer?

OBJECTIVE: Sentinel lymph node biopsy has been widely adopted in the surgical management of women with early-stage vulvar cancer, but many patients require inguinofemoral lymphadenectomy (IFL). Following IFL, many surgeons drain the groin to prevent lymphocyst formation despite a lack of evidence to support this practice. Our objective was to investigate whether groin drains after IFL are associated with reduced postoperative morbidity in women undergoing surgery for vulvar cancer. METHODS: A retrospective cohort study of women diagnosed as having primary vulvar cancer who underwent vulvectomy/radical local excision and unilateral or bilateral IFL was conducted. Cases were ascertained from the weekly outcome reports of a statewide tertiary gynecologic oncology tumor board. Data including postoperative outcomes were abstracted from medical records. Patients were stratified into 1 of 2 groups according to whether a groin drain had been used. RESULTS: Seventy-one patients were included. Inguinal drains were used in 48 patients (67.6%) and 23 patients (32.4%) did not have their groin wound(s) drained. The most common postoperative complications recorded were wound infection (59.2%), groin lymphocyst (32.4%), and cellulitis (25.4%). The mean length of hospital admission was 11.5 days (2-40 days). Compared with patients in whom inguinal drains were placed, those in the "no drain" group had a significantly lower incidence of postoperative groin cellulitis (8.7% vs 25.4% P = 0.039). No significant differences were observed between patients in the "drain" and "no drain" groups in lymphocyst formation, wound infection, return to the operating room, duration of hospital stay, readmission post-discharge, and lower-limb lymphedema. CONCLUSIONS: In this study of patients undergoing inguinofemoral dissection for primary vulvar cancer, postoperative cellulitis occurred less frequently in patients without an inguinal drain. The incidence of other postoperative complications was no different whether or not a groin drain was used. Prospective studies may be warranted.

Angiomatosis of the uterus, cervix and fallopian tubes: a rare and benign cause of intractable, heavy menstrual bleeding.

Angiomatosis of the uterus, cervix and fallopian tubes is a rare and benign entity that has not been reported in the literature previously. We present a case of a 27-year-old patient with severe and intractable heavy menstrual bleeding unresponsive to all conservative and conventional forms of treatment. Following a laparoscopic hysterectomy, the histopathological finding of angiomatosis, a vascular abnormality in the uterus, cervix and fallopian tubes, provided a plausible explanation in this situation.

Onsite midwife-led birth units (OMBUs) for care around the time of childbirth: a systematic review.

INTRODUCTION: To ensure timely access to comprehensive emergency obstetric care in low- and middle-income countries, a number of interventions have been employed. This systematic review assesses the effects of onsite midwife-led birth units (OMBUs) embedded within hospitals which provide comprehensive emergency obstetric and newborn care. METHODS: Both interventional and observational studies that compared OMBUs with standard medical-led obstetric care were eligible for inclusion. Cochrane Central Register of Controlled Trials, PubMed/Medline, EMBASE, CINAHL, Science Citation and Social Sciences Citation Index, Global Health Library and one Chinese database were searched. Meta-analysis was conducted to synthesise data from randomised controlled trials (RCTs). Findings of observational studies were summarised by forest plots with brief narratives. RESULTS: Three RCTs, one controlled before-and-after study and six cohort studies were included. There were no or very few maternal and perinatal deaths in either OMBUs or standard obstetric units, with no significant differences between the two. Women giving birth in OMBUs were less likely to use epidural analgesia (risk ratio (RR) 0.67, 95% CI 0.55 to 0.82; three trials, n=2431). The UK national cohort study and two other cohorts in China and Nepal found less oxytocin augmentation, more spontaneous vaginal deliveries, fewer caesarean sections and fewer episiotomies performed in OMBUs than in standard obstetric units. These differences were not statistically significant in RCTs and the remaining cohorts. One study investigated satisfaction with midwife-led birth care among women and midwives, with positive findings in both groups favouring OMBUs. In addition, two studies found that the total cost of birth was lower in OMBUs than in standard obstetric units. CONCLUSIONS: OMBUs could be an alternative model for providing safe and cost-effective childbirth care, which may be particularly important in low- and middle-income countries to meet the growing demand for facility-based birth for low-risk women and improve efficiency of health systems.