Superficial Peritoneal Endometriosis Vaporization Using a CO2 Laser: A Long-Term Single-Center Experience.

Background: The validation of laser usage during laparoscopic procedures, notably by Camran Nezhat in the late 1980s, has been significant. Lasers offer precision and depth control in tissue vaporization without bleeding. Surgical intervention remains central in managing endometriosis-associated pain and infertility, especially for patients unresponsive to hormonal therapy. Methods: This retrospective cohort study included 200 patients with superficial peritoneal endometriosis (SPE) who underwent laparoscopic laser vaporization. Surgery was performed using a CO2 laser, and histological confirmation of endometriosis was obtained for all cases. Pain scores and SF-36 questionnaire domains were assessed preoperatively and postoperatively. Fertility outcomes were evaluated among patients desiring pregnancy. Results: Significant improvements in pain score and SF-36 questionnaire domains were observed postoperatively (p-value < 0.01), indicating enhanced quality of life. Among infertile patients with an active desire for pregnancy, surgical treatment showed an overall pregnancy rate after surgery of 93.7% (p-value < 0.01), including 75.7% natural pregnancies and 24.3% IVF. Laser vaporization enabled precise lesion removal with minimal tissue damage, short operative time, and minimal blood loss. Conclusions: Laparoscopic laser vaporization is an effective treatment for SPE, offering pain relief, improved quality of life, and favorable fertility outcomes. Further research is needed to validate these results in terms of pain control and fertility.

Comparison of practice vs theory model training for vacuum-assisted delivery: A randomized controlled trial.

OBJECTIVE: To assess the effect of two modalities of simulation training on acquisition/retention of skills for performing operative vaginal delivery. DESIGN: Randomized, controlled, single-centre study. SETTING: A tertiary referral hospital in Italy. PARTICIPANTS: Twenty residents from a single university programme and two young specialists. INTERVENTION: Group 1 had an individual training session with a single senior specialist using a fixed simulator model. After the session, trainees watched a pre-recorded 1-h lecture on vacuum-assisted operative vaginal delivery. Group 1 repeated the simulator session using the same test after 8-12 weeks and 12 months. Group 2 watched the pre-recorded lecture then undertook the same sessions as Group 1. Video recordings of all test performances were evaluated by five specialists in a blinded manner. MAIN OUTCOME MEASURE: Each procedure was evaluated using a Global Rating Scale (GRS), scored with 0-5 points for each item on an Objective Structured Assessment of Technical Skills (OSATS) dataset with seven items (total 35 points). OSATS were evaluated over time, compared for the whole population, and weighted for route and year of residency. The primary outcome was comparison of the effectiveness of training between the two groups based on year of residency by assessing videos of the baseline test and GRS for OSATS scores. The secondary outcome was overall retention of skills at 8-12 weeks and 12 months. RESULTS: Twenty-two participants were recruited and randomized to either Group 1 (n = 11) or Group 2 (n = 11). Five participants did not complete follow-up. The primary outcome of GRS for OSATS scores at time 0 differed significantly between groups for total GRS score, and 'Call for help' and 'Explanation to woman and relatives' item scores (p = 0.002 and p = 0.007, respectively). In a multiple linear regression analysis, OSATS scores were not independently influenced by year of residency. At 8-12-week follow-up, the 'Call for help' item score showed a significant improvement in Group 1 (p = 0.018), although this was not confirmed when year of residency was included as an independent variable. At 12-month follow-up, none of the item scores demonstrated a significant change (p = 0.033). Year of residency did not influence the difference between groups. One-way analysis of variance found significant differences between the groups for 'Localization of the flexion point' (p = 0.005), 'Traction of vacuum cup' (p = 0.039) and 'Use of second hand of the operator' (p = 0.009) item scores and total GRS score (p = 0.007). The values weighted by year of residency did not demonstrate any significant difference. The secondary outcomes evaluated all the candidates of both groups for retention of technical skills over time. A significant effect of time was found for total GRS score (p < 0.001) and OSATS item scores. CONCLUSIONS: Independent of the sequence of theoretical teaching and simulation training, trainees demonstrated high retention - and, actually, improvement - of technical skills for operative vaginal delivery at 12-month follow-up.

Firefly® System and Organ Transillumination in Robotic Gynecologic Surgery.

BACKGROUND AND OBJECTIVES: Near-infrared fluorescence (NIRF) of the Firefly® system has become a useful and widespread technique for the visualization and detection of tumors, sentinel lymphnodes, and vascular/anatomical structures. METHODS: Between February 1, 2017 to September 30, 2019, a total of 25 patients affected by benign and malignant pathologies underwent robotic surgery by the use of organ transillumination with the concomitant Firefly®. We analyzed the pre-operative patients' characteristics (age and body mass index [BMI], previous abdominal surgeries and systemic disease); pre-operative diagnosis, surgical procedure and approach (multiport or single site), transilluminated organ, surgical outcomes (operating time, incidence of intraoperative complications, and incidence of conversion to other surgery); and postoperative outcome. The surgical procedures included: four bladder endometriosis nodules resections, one pelvic lymphadenectomy with ureterolysis, and 23 hysterectomies. RESULTS: The average operating time was 283.3 (+/- 76.9) minutes, there were no intra-operative complications or laparotomic conversions. The average recovery days were 5.9. There have been three grade 2 post-surgical complications, following the Memorial Sloan Kettering Cancer Center Surgical Secondary Events System classification. The combination of NIRF and transillumination allows a clear view of the anatomical landmarks and the resection margins. CONCLUSIONS: It's likely that improvement in the anatomical detail could confer a greater surgical safety with lower percentage of intra and post-surgical complications and sparing of safe tissue. To evaluate the validity of these techniques in a larger number of patients and compare these new surgical procedures with standard ones, further studies are needed.

Operative Gynecological Laparoscopy Under Conscious Sedation.

BACKGROUND AND OBJECTIVES: Operative laparoscopy is generally performed under general anesthesia. Local anesthesia and conscious sedation may be useful in select short procedures. In the present study, we evaluated safety and efficacy of operative laparoscopy under conscious sedation. METHODS: Retrospective observational study evaluating patients undergoing gynecologic laparoscopy. Laparoscopy under conscious sedation was performed for each patient with umbilical direct insertion of a 12-mm port, followed by 2 ancillary ports at 1 cm medially to the anterior superior iliac spine. Conversion to conventional laparoscopy or laparotomy was recorded. Conscious sedation was obtained using Remifentanil and Propofol, administered by an infusion system based on pharmacokinetic and pharmacodynamic models. Local anesthesia was administered at port insertion sites and for paracervical block. Pain intensity was evaluated with the Visual Analog Scale (VAS). Adverse events and drug concentrations throughout the procedure were retrieved. RESULTS: Our study population included 166 patients. They underwent laparoscopic unilateral versus bilateral salpingo-oophorectomy, ovarian cystectomy, bilateral salpingo-oophorectomy and omentectomy for a borderline ovarian tumor, myomectomy; or underwent surgery for unexplained infertility evaluation, pelvic pain, staging of ovarian cancer. Mean duration of pneumoperitoneum was 22.3 ± 7.2 min. Rate of conversion to laparoscopy under general anesthesia was 17/166 (10.2%) and there were only 3 cases of patients with low tolerability to the procedure. No severe adverse events occurred. Hospital discharge occurred in all unconverted cases after 6 to 18 h. CONCLUSIONS: Operative laparoscopy under conscious sedation and local anesthesia appears to be a feasible technique in gynecologic surgery with no adverse patient outcomes.

Laparoscopic Salpingo-oophorectomy in Conscious Sedation.

INTRODUCTION: Conscious sedation has traditionally been used for laparoscopic tubal ligation. General anesthesia with endotracheal intubation may be associated with side effects, such as nausea, vomiting, cough, and dizziness, whereas sedation offers the advantage of having the patient awake and breathing spontaneously. Until now, only diagnostic laparoscopy and minor surgical procedures have been performed in patients under conscious sedation. CASE DESCRIPTION: Our report describes 5 cases of laparoscopic salpingo-oophorectomy successfully performed with the aid of conventional-diameter multifunctional instruments in patients under local anesthesia. Totally intravenous sedation was provided by the continuous infusion of propofol and remifentanil, administered through a workstation that uses pharmacokinetic-pharmacodynamic models to titrate each drug, as well as monitoring tools for levels of conscious sedation and local anesthesia. We have labelled our current procedure with the acronym OLICS (Operative Laparoscopy in Conscious Sedation). Four of the patients had mono- or bilateral ovarian cysts and 1 patient, with the BRCA1 gene mutation and a family history of ovarian cancer, had normal ovaries. Insufflation time ranged from 19 to 25 minutes. All patients maintained spontaneous breathing throughout the surgical procedure, and no episodes of hypotension or bradycardia occurred. Optimal pain control was obtained in all cases. During the hospital stay, the patients did not need further analgesic drugs. All the women reported high or very high satisfaction and were discharged within 18 hours of the procedure. DISCUSSION AND CONCLUSION: Salpingo-oophorectomy in conscious sedation is safe and feasible and avoids the complications of general anesthesia. It can be offered to well-motivated patients without a history of pelvic surgery and low to normal body mass index.

A review on the role of laparoscopic sacrocervicopexy.

PURPOSE OF REVIEW: To provide an update on the outcomes and complications of laparoscopic (or robot-assisted) sacrocervicopexy with and without supracervical hysterectomy, and highlight the differences with sacrocolpopexy technique based on the most recent evidence. RECENT FINDINGS: Laparoscopic and robot-assisted sacrocervicopexy with supracervical hysterectomy and sacrohysteropexy have good success rates, with a mean objective success rate of 96% (range 90-100%), subjective success rates of 80-95% and mean reoperation rate of 3%. Also, pelvic symptoms and quality of life improved after laparoscopic sacrocervicopexy. These results are similar to laparoscopic and abdominal sacrocolpopexy, and are confirmed by the results of two comparative studies. Mesh erosion risk is very low in patients treated with laparoscopic sacrocervicopexy. Studies that compare laparoscopic sacrocolpopexy with concomitant total hysterectomy and sacrocervicopexy with subtotal hysterectomy show that total hysterectomy is associated with a greater prevalence of vaginal mesh exposure when compared with a subtotal hysterectomy. In case of sacralpexy, if it is decided to proceed with a hysterectomy, it is recommended to limit this to a subtotal. SUMMARY: The benefits of laparoscopic sacrocervicopexy with or without supracervical hysterectomy in terms of outcomes and reduced risk of mesh erosion in comparison with sacrocolpopexy and concomitant total hysterectomy have to be confirmed by randomized controlled trials. Moreover, standardization of surgical technique is mandatory.

Efficacy of laparoscopic sacrocervicopexy for apical support of pelvic organ prolapse.

BACKGROUND AND OBJECTIVES: To evaluate the efficacy of laparoscopic sacrocervicopexy for apical support in sexually active patients with pelvic organ prolapse. METHODS: One-hundred thirty-five women with symptomatic prolapse of the central compartment (Pelvic Organ Prolapse Quantitative [POP-Q] stage 2) underwent laparoscopic sacrocervicopexy. The operating physicians used synthetic mesh to attach the anterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory with subtotal hysterectomy. Anterior and posterior colporrhaphy was performed when necessary. The patients returned for follow-up examinations 1 month after surgery and then over subsequent years. On follow-up a physician evaluated each patient for the recurrence of genital prolapse and for recurrent or de novo development of urinary or bowel symptoms. We define "surgical failure" as any grade of recurrent prolapse of stage II or more of the POP-Q test. Patients also gave feedback about their satisfaction with the procedure. RESULTS: The mean follow-up period was 33 months. The success rate was 98.4% for the central compartment, 94.2% for the anterior compartment, and 99.2% for the posterior compartment. Postoperatively, the percentage of asymptomatic patients (51.6%) increased significantly (P < .01), and we observed a statistically significant reduction (P < .05) of urinary urge incontinence, recurrent cystitis, pelvic pain, dyspareunia, and discomfort. The present study showed 70.5% of patients stated they were very satisfied with the operation and 18.8% stated high satisfaction. CONCLUSION: Laparoscopic sacrocervicopexy is an effective option for sexually active women with pelvic organ prolapse.

Preliminary evaluation of the safety and efficacy of standard intravenous immunoglobulins in pregnant women with primary cytomegalovirus infection.

Hyperimmune globulins were reported to prevent and treat fetal cytomegalovirus (CMV) infection during pregnancy. Here, we report that infusions of standard human intravenous immunoglobulin significantly increase CMV IgG titers and avidity indexes in pregnant women, paving the way to their use for passive transfer of maternal CMV humoral immunity to fetuses. Preliminary data on perinatal outcomes of the first 67 newborns are encouraging.

Single port laparoscopically assisted hysterectomy with the TriPort system. A case report and review of the literature.

AIM: We report our recent experience with the TriPort system (trademark of Advanced Surgical Concepts, Wicklow, Ireland) to perform a laparoscopically assisted hysterectomy via a single periumbilical incision. CASE REPORT: A 48-year-old multiparous woman was referred to us on March 2009 because of menometrorrhagia and uterine fibroids. RESULTS: The procedure was performed without intraoperative complications. The weight of the uterus was 360 gr. At the 10 months follow-up the patient did not refer any problem. DISCUSSION: Although our experience represented a potentially difficult surgery because of the size of the uterus, severe adhesions (two previous caesarean sessions) and the lack of experience with the new system, the procedure demonstrated to be feasible. As for our knowledge the present report represents the first case of single port laparoscopically assisted hysterectomy performed with the TriPort system in Italy. CONCLUSION: Single port laparoscopy is feasible and could potentially decrease postoperative pain as well as increase patient satisfaction. Although the early experience with TriPort system is promising, experienced laparoscopic skills are essential for the safe and effective performing of the procedure.

Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative ureteral endometriosis.

The aim of the study was to assess the safety and efficacy of laparoscopic treatment of distal infiltrative ureteral endometriosis with segmental ureteral resection, ureteroneocystostomy, and vesicopsoas hitch. We performed a retrospective analysis of perioperative data and looked at follow-up outcomes of patients with deep endometriosis with ureteral involvement treated by laparoscopic vesicopsoas hitch. Six patients were treated for left ureteral endometriosis in the study period. Four of those were diagnosed during previous laparoscopies. A ureteroneocystostomy (Lich-Gregoir reimplantation procedure) with vesicopsoas hitch was fashioned laparoscopically in all cases, and a double-J stent was applied intraoperatively. There were no intraoperative or postoperative complications and no cases of extravasation of contrast at cystogram one week after surgery. The median follow-up time was 38 months (range 12-56). All patients had normal renal ultrasound or intravenous pyelogram results at one year follow-up. This study confirmed that laparoscopic ureteroneocystostomy and vesicopsoas hitch is a safe and effective option in the management of distal ureteral endometriosis. In view of the small size of this series, multicenter studies are needed to confirm these conclusions.

Long-term outcome of hysteroscopic endometrial ablation without endometrial preparation.

OBJECTIVE: To describe the three-step hysteroscopic endometrial ablation (EA) technique without endometrial preparation, and its long-term outcomes. STUDY DESIGN: Four hundred and thirty-eight premenopausal women with menorrhagia or menometrorrhagia underwent three-step hysteroscopic EA, which consists of rollerball ablation of the fundus and cornual regions, a cutting loop endomyometrial resection of the rest of the cavity, and rollerball redessication of the whole pre-ablated uterine cavity. The main outcome measures were menstrual status, level of satisfaction with the procedure, and the need for repeat ablation or hysterectomy. Questionnaires were completed for 385 women (87.9%) with a mean follow-up of 48.2 months. RESULTS: One hundred and eighty-four responders (47.8%) reported amenorrhea; 177 (46%) had light to normal flow. One patient (0.3%) underwent repeat ablation and 20 (5.2%) underwent hysterectomy: 15 (3.9%) because of endometrial ablation failure and 5 (1.3%) because of indications unrelated to the ablation (three cases of atypical endometrial hyperplasia and two cases of fibroids). Two hundred and ninety-two patients (75.8%) were very satisfied, and 78 (20.3%) satisfied with the results. No major complications occurred and three women (0.8%) became pregnant during the follow-up period. CONCLUSIONS: EA is safe and effective means of treating of menorrhagia and menometrorrhagia in premenopausal women, and helps avoid hysterectomy in 95% of patients suffering from heavy bleeding, with or without uterine fibroids. Women should be informed that the procedure is not contraceptive and that pregnancy is possible after treatment.

Determinants of short term recurrence rate of endometriosis.

OBJECTIVE: To analyse the frequency and the determinants of recurrence rate of clinically detectable endometriosis. STUDY DESIGN: Prospective cohort multicenter study. Eligible for the study were all women observed for the first time during the period January-June 1998 at the participating centres with a laparoscopically confirmed first diagnosis of endometriosis. After diagnosis, patients were treated according to standard care of each centre and desire for pregnancy. The protocol required all women to be followed up at the centre each year for 2 years with a clinical examination, an ultrasound pelvic examination and a CA125 assay, unless pregnancy occurred. Second look laparoscopy was performed on a clinical basis. RESULTS: A total of 311 women (median age 36 years) entered the study. The two-year recurrence rate was 5.7% among cases stage I-II and 14.4% among stage III-IV (chi(1)2 adjusted for indication for surgery, p < 0.05). The recurrence rates tended to increase with age, being 4.6% among women aged 20-30 and 13.1% among women aged >30, but this finding was not statistically significant. CONCLUSION: The recurrence rate of clinically detectable endometriosis tends to be higher in older women with advanced stages of the disease and lower in women with infertility.