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1.
Isr Med Assoc J ; 22(1): 13-16, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31927799

RESUMO

BACKGROUND: During Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) the surgeon operates exclusively through a single vaginal entry point, leaving no external scarring. OBJECTIVES: To evaluate the learning curve of vNOTES hysterectomy by experienced gynecologists based on surgical times and short-term outcomes. METHODS: A retrospective study was conducted of the first 25 vNOTES hysterectomy surgeries performed from July to December 2018 at Rambam Health Care Campus by a single surgeon. The primary outcome was hysterectomy time. Secondary outcomes included intra-operative bleeding, length of hospitalization, postoperative pain, and need for analgesia. Socio-demographic and clinical data were retrieved from patient electronic medical charts. RESULTS: Median age was 64.5 years (range 40-79). Median hysterectomy time was 38 minutes (range 30-49) from the first cut until completion. Comparisons between median hysterectomy time in the first 10 hysterectomies and in the 15 subsequent procedures demonstrated a significant decrease in median total time: 45 minutes (range 41-49) vs. 32 minutes (range 30-38), respectively (P = 0.024). The median estimated intraoperative blood loss decreased from 100 ml (range 70-200) in the first 10 hysterectomies to 40 ml (range 20-100) in the subsequent procedures (P = 0.011). CONCLUSIONS: vNOTES hysterectomy is feasible by an experienced gynecologist, with an exponential improvement in surgical performance in a short period as expressed by the improvement in hysterectomy time, low complication rates, negligible blood loss, minimal post-surgical pain, fast recovery, and short hospitalization. vNOTES allows easier and safer access to adnexal removal compared to conventional vaginal surgery.


Assuntos
Ginecologia/educação , Histerectomia Vaginal/educação , Curva de Aprendizado , Cirurgia Endoscópica por Orifício Natural/educação , Adulto , Idoso , Feminino , Humanos , Histerectomia Vaginal/métodos , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/métodos , Duração da Cirurgia , Estudos Retrospectivos , Resultado do Tratamento
2.
J Sex Med ; 17(2): 210-237, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31812683

RESUMO

INTRODUCTION: To date, several aspects of inflatable penile prosthesis (IPP) surgical procedure have been poorly studied. AIM: The aim of this study was to review the evidence associated with IPP implantation and provide clinical recommendations on behalf of the European Society for Sexual Medicine (ESSM). Overall, 130 peer-reviewed studies and systematic reviews, which were published from 2007-2018 in the English language, were included. METHODS: MEDLINE and EMBASE were searched for randomized clinical trials, meta-analyses, and open-label prospective and retrospective studies. MAIN OUTCOME MEASURE: The panel provided statements exploring patients and partner expectations, satisfaction in male and phalloplasty cohorts, the impact of penile length, girth and implant type, reservoir placement, the influence of comorbidities, and social circumstances. Levels of evidence were provided according to the Oxford 2011 criteria and graded as for the Oxford Centre for Evidence-Based Medicine recommendations. RESULTS: In the preoperative setting, it is fundamental to identify and interact with difficult patients with the intention of enhancing the surgeon's ability to establish the surgeon-patient relationship, reduce physical and legal risk, as well as enhancing patient satisfaction. To address this need, the mnemonic Compulsive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric ("CURSED") has been suggested to identify patients who are at high risk of dissatisfaction. The current recommendations suggest improving glycemic control in patients with diabetes. Available evidence suggests evaluating transplant recipients with the criteria of Barry, consisting of stable graft function for >6 months, avoidance of intra-abdominal reservoir placement, and low-dose immunosuppression. HIV status does not represent a contraindication for surgery. Smoking, peripheral vascular disease, and hypertension may be associated with an increased risk of revision surgery. Patients with spinal cord injury may receive IPP. Patients aged ≥70 years, as well as obese patients, can be offered IPP. The IPP implantation can be performed in patients with stable Peyronie's disease. Ectopic high submuscular reservoir placement can be considered as an alternative method. CLINICAL IMPLICATIONS: There is a relevant lack of high-level data and definite conclusions in certain areas remain difficult to draw. STRENGTH & LIMITATIONS: All studies have been evaluated by a panel of experts providing recommendations for clinical practice. Because of lack of sufficient prospective data, some of the included studies are retrospective and this could be stated as a limitation. CONCLUSION: This ESSM position statement provides recommendations on optimization of patient outcome by patient selection, and individualized peri- and intra-operative management. ESSM encourages centers to collaborate and to create prospective, multicenter registries in order to address this topic of increasing importance. Osmonov D, Christopher AN, Blecher GA, et al. Clinical Recommendations from the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances. J Sex Med 2020;17:210-237.

3.
Int Urogynecol J ; 2019 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-31853594

RESUMO

INTRODUCTION AND HYPOTHESIS: Conservative treatment is recommended as first-line therapy for stress urinary incontinence (SUI). We hypothesized that CO2 laser treatment would demonstrate safety and efficacy for women with SUI. METHODS: A prospective, open-label, cohort study of 33 women (mean age 43 years) referred from a continence clinic after urologist/urogynecologist assessment, with a verified stress urinary incontinence diagnosis based on urodynamic testing. The participants completed three outpatient treatments with laser therapy and were subsequently evaluated at 1, 3 and 6 months. The independent t and chi-square tests were used to assess changes in sanitary pad usage and SUI symptoms. RESULTS: Sanitary pad usage decreased from a median of 12 per day at baseline to 7 at 1-3 months post-treatment (P < 0.0001) and returned to 12 at 6 months post-treatment. Scores on the Urogenital Distress Inventory and the International Consultation of Incontinence Questionnaire decreased (improved) significantly at 1-3 months post-treatment: from 45 ± 2 and 16 ± 4, respectively, to 29.3 ± 14.7 and 8.15 ± 3.1, respectively (P < 0.0001). The scores returned to levels similar to baseline at 6 months after treatment. Participants reported mild and transient side effects, with significant improvement in quality of life. CONCLUSIONS: Laser therapy can be an optional conservative treatment for women who seek minimally invasive non-surgical treatment for the management of SUI. No serious adverse effects were reported though the sample size was not large, a possible limitation of the study. Further large randomized control trials are needed to appraise the efficacy and safety of laser therapy for stress urinary incontinence and to demonstrate the ultimate utility of this modality.

4.
Am J Obstet Gynecol ; 2019 Oct 04.
Artigo em Inglês | MEDLINE | ID: mdl-31589864

RESUMO

BACKGROUND: Sacrocolpopexy is a commonly performed procedure for repair of apical compartment prolapse. A Y-shaped mesh is attached to the prolapsed cervix or vagina and suspended to the anterior longitudinal ligament of the sacrum. In addition to conventional laparoscopic and multi-port robotic routes, the robotic laparoendoscopic single-site approach has emerged as a viable, feasible, and widely applicable minimally invasive approach to sacrocolpopexy. OBJECTIVE: We compared robotic laparoendoscopic single-site with multi-port robotic sacrocolpopexy for women with either utero-vaginal or vaginal apical prolapse. STUDY DESIGN: In this single-center, randomized controlled trial, 70 women at Pelvic Organ Prolapse Quantitative stages 2-4 were assigned randomly to undergo sacrocolpopexy by robotic laparoendoscopic single-site or multi-port robotic approaches during August 2017 to November 2018. Of 35 women randomized to each group, 32 underwent sacrocolpopexy. Operating time was the primary outcome of the trial. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first postoperative 24 hours (according to a 0-10 visual analogue scale), the need for analgesics, intraoperative and postoperative adverse events. Six weeks and six months after surgery, patients underwent a physical examination according to Pelvic Organ Prolapse Quantitative measurements, to assess the anatomical success of the surgery. The Pelvic Floor Distress Inventory-20 and Pelvic Organ Prolapse/Urinary Incontinence Sexual -12 questionnaires were administered prior to surgery and at six months follow up. The Patient Scar Assessment Questionnaire and the Activity Assessment Scale were administered at six weeks and six months after the surgery. Exclusion criteria included: contraindication for general anesthesia, a history of prior sacrocolpopexy, suspicious adnexal masses, suspicious thickened endometrium and morbid obesity (body mass index of 40 kg/m2 or more). RESULTS: The mean age of the patients was 58.4 years. Most patients (54%) had stage III prolapse. Mean total operative times were 181.3±32.6 and 157.5±42 minutes for robotic laparoendoscopic single-site and multi-port robotic sacrocolpopexy, respectively; the difference was 23.8 minutes, 95% confidence interval (CI) [4.2-43.4], P=0.018. The mean differences in duration between the procedures were: 29.8 minutes, 95% CI [9.2-50.4], P=0.005 for anesthesia time; 33.1 minutes, 95% CI [16.5-49.7], P<0.0001 for console time; 8.6 minutes, 95% CI [1.1-16.3], P=0.025 for supracervical hysterectomy time; 8.3 minutes, 95% CI [1.8-14.8], P=0.03 for mesh suturing and fixation to the promontory; and 4.7 minutes, 95% CI [1.5-7.7], P=0.004 for peritoneum suturing. Statistically significant differences were not observed between the groups in estimated blood loss, intraoperative complications and the demand for analgesics during hospital stay. Quality-of-life parameters were similar. Patients' assessment of their scars was more favorable in the robotic laparoendoscopic single-site group. CONCLUSIONS: For sacrocolpopexy, the operative time was longer for the robotic laparoendoscopic single-site than the multi-port robotic approach. Both approaches are feasible and short-term outcomes, quality-of-life parameters and anatomic repair are comparable. Our Results are generalizable only to the specific robotic platforms used in the study.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31154095

RESUMO

OBJECTIVES: The purpose of this study was to compare the learning curves, surgical outcomes and complications of multi-port access robotic-assisted laparoscopic sacrocervicopexy (MP-RSC) to single-port robotic access (SP-RSC) for vaginal apex prolapse. METHODS: A retrospective study of the first 52 MP-RSC procedures compared with the first 52 SP-RSC procedures performed at one medical center. Primary outcomes were intraoperative bleeding, operative time, and hospitalization. Secondary outcomes were surgical complications. RESULTS: There was a statistically significant difference in mean operative times between the MP-RSC and SP-RSC procedures: 206.5 ±â€¯39.4 and 187.8 ±â€¯46.2, respectively, P = 0.028. The mean estimated intraoperative blood loss was 35 [20-87.5] ml and 20 [10-47.5] ml, respectively, P = 0.008. Respective mean operative times decreased from the first 15 to the subsequent 15 cases: in the MP-RSC group from 224.2 ±â€¯43.2 to 198.4 ±â€¯36.3 min, P = 0.088, and in the SP-RSC group from 222.4 ±â€¯53.1 to 161.3 ±â€¯28.2 min, P < 0.001. The subsequent 22 cases showed different trends. Hospitalization (days) and level of pain at 24 h postoperative, according to a 1-10 point visual analogue scale, did not differ. Adverse events were rare in both groups. CONCLUSIONS: MP-RSC and SP-RSC are feasible and the short term outcomes and learning curves for both procedures are comparable.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Feminino , Humanos , Curva de Aprendizado , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos
6.
Int Urogynecol J ; 2019 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-31197425

RESUMO

INTRODUCTION AND HYPOTHESIS: Since the era of neoadjuvant chemotherapy, complications of pelvic organ prolapse (POP) post-radical cystectomy have become more common; however, the exact incidence is not documented in the literature. The objective was to repair post-radical cystectomy POP, despite the lack of endopelvic fascia normally needed for this type of repair. METHODS: Three patients aged 60 to 80 had symptomatic POP (of all three compartments: apical, anterior, and posterior) following radical cystectomy and ileal conduit urinary diversion, and no interest in maintaining their coital abilities. Two of the three women were status post-hysterectomy. Colpocleisis, which is known to have a success rate of almost 100%, was performed on the first two patients, with a recurrence of the prolapse shortly after this correction (2-4 months), probably due to the lack of endopelvic fascia. Following the failure of the procedure, a side-to-side closure of the vagina was performed. The latter was the procedure of choice performed on the third patient. We present a video clip of the vaginal closure to demonstrate the procedure performed. RESULTS: Repair was successful in all three cases, with no relapse to date (4 months post-surgery). CONCLUSIONS: Closure of the vaginal canal successfully treated POP in our case series. There were no intra- or postoperative complications in any of the cases. Patients were discharged the following day and did not show any signs of recurrence at follow-up (3, 5, and 6 months post-surgery).

7.
Artigo em Inglês | MEDLINE | ID: mdl-31146028

RESUMO

STUDY OBJECTIVE: To introduce and examine a single session of spatial skill training as an efficient means of improving surgical suturing performance in robot-assisted surgery. DESIGN: A randomized, controlled trial. SETTING: A tertiary university medical center in Israel. PARTICIPANTS: A purposive sample composed of 41 residents with no robotic suturing skills. INTERVENTIONS: A computer-based simulator training of spatial skills. MEASUREMENTS AND MAIN RESULTS: Participants were randomly assigned to training (n = 21: mean age of 34 years [standard deviation (SD) = 1.92]) and control (n = 20: mean age of 32 years [SD = 3.17]) conditions. The training group underwent a session of spatial skills training, whereas the control group engaged in a neutral activity. After 1 participant was lost to the follow-up of the posttraining performance test, data of 40 participants were analyzed. Robotic suturing task performance with the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA) was evaluated using the da Vinci Skills Simulator built-in measure of "excess tissue piercing" and an expert rating of "tissue tearing." The mean number of excess tissue piercing after training (but not after the neutral activity) was significantly lower than before training (3.25 [SD = 1.996] vs 6.75 [SD = 3.68], respectively; p <.001), reflecting an improvement of 52% (decreasing the mean number of excess tissue piercing in a single suture by 3.5 excess piercing trials). After the interventions, the extent of tissue tearing was rated lower in the training group (p = .01), and there was no change in the control group (p = .14). CONCLUSION: We showed the efficiency of a training approach that focuses on spatial skills critical in robot-assisted surgery. We showed that surgeons who received a 1 session spatial skill training with a cognitive spatial skill trainer immediately improved the performance of a robotic suturing task compared with surgeons who did not receive such training.

8.
J Minim Invasive Gynecol ; 26(6): 1015, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30980991

RESUMO

STUDY OBJECTIVE: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension. DESIGN: Stepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage. SETTING: An academic tertiary referral center. The ethics committee ruled that approval was not required for this study. PATIENTS: A 53-year-old woman. INTERVENTIONS: vNOTES hysterectomy and apical suspension to the uterosacral ligament. MEASUREMENTS AND MAIN RESULTS: A 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA). CONCLUSION: vNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen.

9.
Artigo em Inglês | MEDLINE | ID: mdl-31003902

RESUMO

Oncology treatments have evolved from intuitive, via empiric, to the present precision medicine, with the integration of molecular targeted therapies in our treatment arsenal. The use of the patients' powerful immune system has long been contemplated and recently led to the integration of immunotherapy to overturn the well-documented inhibitory effects of the tumor on the immune system and restore it to a state of activity against the cancer. Recent favorable results have shown the value and effectiveness of immunotherapy against gynecological cancers. In particular, the checkpoint inhibitors, targeting the programmed death-1 (PD-1) pathway, have shown durable clinical responses with manageable toxicity. Several phase II and III clinical trials testing the association of different regimen of chemotherapy and immunotherapy are ongoing in gynecological cancers, and important results are expected. In this chapter, we outline the main principles of immunotherapy for gynecological cancers and summarize the current strategies used in clinical trials.

10.
PLoS One ; 14(2): e0211329, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30818325

RESUMO

Uterine serous papillary carcinoma (UPSC) is an aggressive tumor, often diagnosed as a metastatic disease and characterized by a high recurrence rate and poor prognosis. UPSC represents a distinct subtype of endometrial cancer which is different in clinical and pathological behaviors from endometrioid endometrial carcinoma (EEC) and resembles more to serous ovarian carcinoma. Since tumors of serous papillary of the ovary are hypothesized to stem from cells of the fallopian tube's fimbria, we hypothesized that UPSC may also origin in the fallopian tubes. In our previous study, using a novel method of computerized morphometry of the fimbrial epithelium we have found significant differences between fimbriae of healthy women and serous ovarian cancer patients. In this study we showed the presence of morphologic differences between twenty-four fimbriae from healthy women, and twenty six fimbriae from uterus cancer (13 from UPSC patients and 13 from EEC patients). All fimbriae reported by the pathologist as "normal" were subjected to a computerized histomorphometric analysis. Two-step method of computerized histomorphometry, i.e. Fast Fourier transformation (FFT) followed by a co-occurrence matrix analysis and an additional analysis of the nuclear symmetry of the tubal fimbrial epithelium were applied. Using these novel methods, we were able to show differences in the morphometric characteristics of the fimbriae in UPSC patients compared to EEC and healthy patients. It is yet to be determined the clinical significance of this observation.


Assuntos
Carcinoma Papilar/patologia , Tubas Uterinas/patologia , Neoplasias Uterinas/patologia , Carcinoma Endometrioide/patologia , Carcinoma Endometrioide/cirurgia , Carcinoma Papilar/cirurgia , Estudos de Casos e Controles , Análise Discriminante , Feminino , Humanos , Histerectomia , Processamento de Imagem Assistida por Computador , Neoplasias Uterinas/cirurgia
11.
J Obstet Gynaecol Can ; 41(4): 450-458, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30529223

RESUMO

OBJECTIVE: In view of the recent controversy concerning the use of minimally invasive radical hysterectomy as primary treatment for early stage cervical cancer, this study compared the survival and perioperative outcomes in a cohort of patients who underwent radical hysterectomy either by laparotomy or by robotics. METHODS: This retrospective study compared all consecutive patients with early stage cervical cancer since the beginning of the Division of Gynecologic Oncology at the Jewish General Hospital in 2003, who underwent robotic radical hysterectomy (n = 74) with a cohort of all consecutive patients from the immediate past who underwent open radical hysterectomy (n = 24) for early stage cervical cancer. All patients were treated at the Jewish General Hospital in Montréal (Canadian Task Force Classification II-2). RESULTS: The median follow-up time for the robotic group was 46 months. During that time, 7% and 17% of patients in the robotic group and the laparotomy group had disease recurrence, respectively (P = 0.12). Cox multivariate regression showed no statistically significant effect of surgical approach on overall survival (hazard ratio 1.50, P = 0.63) or on progression-free survival (hazard ratio 0.29, P = 0.07). Patients in the robotic cohort had significantly shorter median hospital stays (1 day vs. 7 days, P < 0.001), and their overall incidence of postoperative complications was lower (13% vs. 50%, P < 0.001). Median estimated blood loss for robotics was also significantly lower (82 mL vs. 528 mL, P < 0.001). CONCLUSION: Based on the data on a limited number of patients in a Canadian context, robotic radical hysterectomy did not lead to worse oncologic outcomes and was associated with improved short-term surgical outcomes. One might consider the evaluation of more personalized surgical decision making.

12.
Artigo em Inglês | MEDLINE | ID: mdl-30317138

RESUMO

Robotic laparoendoscopic single-site (R-LESS) seems to be the next route in advancing minimal invasive surgery, with the potential for better cosmetic results and reduced patient morbidity compared with multi-port surgery. This review describes the history and development of (R-LESS) gynecologic surgery and outlines the latest advancements in the realm of gynecology. The review was conducted according to the PRISMA guidelines. Pubmed and ClinicalTrials.gov (www.clinicaltrials.gov) were the main search engines utilized for retrieval of study data (1990 - present). The following subject headings and keywords were searched: "robotic laparoscopic single incision", "robotic laparoendoscopic single site", "single incision robotic surgery" and "single-port robotic surgery". All original research articles including randomized, non-randomized controlled trials, cohort studies, patient series, and case reports were included. The search produced a total of 1127 results. After duplicate removal, 452 remained, and each title and abstract was reviewed by 2 reviewers. Subsequently, 56 full texts were selected for full review and an additional 20 excluded, leaving 36 studies that were included in the final review. Based on the data gathered we reached the conclusion that R-LESS surgery is feasible, safe and has equivalent surgical outcomes as conventional LESS surgery; in addition to shorter recovery times, less postoperative pain and better cosmetic outcomes than robotic multi-port surgery. To conclude, R-LESS is a feasible approach with low complication rates, minimal blood loss and postsurgical pain, fast recovery, and virtually scar-free results. However, the lack of large comparative prospective randomized controlled studies prevents drawing absolute conclusions.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Feminino , Doenças dos Genitais Femininos/cirurgia , Neoplasias dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Ginecologia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Dor Pós-Operatória/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos
13.
Artigo em Inglês | MEDLINE | ID: mdl-30237138

RESUMO

INTRODUCTION: We aimed to determine whether daily vaginal progesterone use for the prevention of preterm birth has an effect on the incidence of abnormal glucose challenge test or gestational diabetes. STUDY DESIGN: A retrospective study in a large referral center. Women with cervical length ≤ 25 mm were given 200 mg vaginal micronized progesterone capsules daily at bed time until 36 weeks` gestation or delivery. Each progesterone-treated woman was matched randomly with three untreated controls. The main outcome measures were; mean plasma glucose level following the glucose challenge test and the rate of abnormal 1-hour glucose challenge test. Secondary outcome was the rate of gestational diabetes. RESULTS: We identified 108 progesterone-treated women that were matched by age and BMI to 324 controls during the same time period. The mean plasma glucose level following the glucose challenge test was similar in both groups (115.3 ± 33.8 mg/dL versus 109.2 ± 26.6 mg/dL). Despite a higher rate of an abnormal glucose challenge test in the progesterone-treated group compared to the control group (21.1% vs. 13.9%), it did not reach statistical significance. Similarly, we could not detect any difference in the rate of gestational diabetes in either the study or the control group (2.8% versus 2.5%). CONCLUSION: Daily vaginal progesterone was not associated with higher rates of abnormal glucose challenge test or gestational diabetes. We are in a view that no earlier screening or diagnostic testing for gestational diabetes is required except the standard recommended schedule unless additional risk factors are present.


Assuntos
Diabetes Gestacional/induzido quimicamente , Nascimento Prematuro/prevenção & controle , Progesterona/administração & dosagem , Progesterona/efeitos adversos , Administração Intravaginal , Adulto , Glicemia/análise , Diabetes Gestacional/epidemiologia , Feminino , Idade Gestacional , Teste de Tolerância a Glucose , Humanos , Incidência , Gravidez , Estudos Retrospectivos , Fatores de Risco
14.
J Matern Fetal Neonatal Med ; 31(4): 464-468, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28139951

RESUMO

OBJECTIVE: To test the hypothesis that measuring cervical length (CL) close to the time of delivery is a predictor of successful vaginal birth following a cesarean. METHODS: A prospective longitudinal study included women with singleton pregnancies at 38-41 weeks, who previously underwent a cesarean, and who were interested in trial of labor. Patients who did not have a spontaneous onset of labor were induced at 41 weeks' gestation. CL measurements were performed prior to labor by transvaginal ultrasound, recorded, and blinded from the caring physicians. RESULTS: Vaginal birth was achieved in 63/105 (60%) of patients participating in the study. The mode of delivery significantly correlated with CL, Bishop score, and previous obstetrical history. When multivariate analysis was performed, only CL and previous obstetrical history correlated significantly with mode of delivery. In the subgroup of patients with no previous vaginal delivery, only CL had a significant correlation with mode of delivery. The ROC curve demonstrated a high prediction of vaginal delivery by CL for the entire study group and for the subgroup of patients with no previous vaginal delivery (AUC = 0.8, p < .0001). CONCLUSIONS: CL measurement after 36 weeks has a high predictive accuracy for a successful vaginal birth after cesarean.


Assuntos
Medida do Comprimento Cervical , Prova de Trabalho de Parto , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , Adulto , Feminino , Humanos , Estudos Longitudinais , Valor Preditivo dos Testes , Gravidez , Terceiro Trimestre da Gravidez , Estudos Prospectivos , Curva ROC , Método Simples-Cego
15.
Int J Gynecol Pathol ; 37(5): 460-467, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28863070

RESUMO

Mutations in BRCA genes increase the risk of ovarian cancer, yet no method for early diagnosis is available. Some serous ovarian tumors are hypothesized to stem from cells of the fallopian tube fimbria. Using a novel method of computerized morphometry of the fimbrial epithelium, this study aimed to detect morphologic differences in noncancerous fimbriae between BRCA mutation carriers and noncarriers, and between healthy and serous ovarian cancer patients. Twenty-four fimbriae from healthy women (13 BRCA+, 11 BRCA-) and 21 fimbriae from women with serous ovarian cancer (10 BRCA+, 11 BRCA-), all reported as "normal" by hematoxylin and eosin examination, were subjected to computerized histomorphometric analysis. A Fast Fourier Transformation was applied to images of fimbrial epithelium and the Fast Fourier Transformation 2-dimensional frequency maps were subsequently quantified for nuclear orientation and planar distribution by a cooccurrence matrix analysis. Additional analysis of nuclear contour was applied to the fimbriae of the healthy women. Among the healthy women, significant differences were found in morphometric characteristics between the BRCA mutation carriers and noncarriers. Among the women with ovarian cancer, no significant differences were found between BRCA mutation carriers and noncarriers. Between healthy women and those with ovarian cancer, significant differences were detected, regardless of BRCA mutational status. A novel method, which combined Fast Fourier Transformation with cooccurrence matrix analysis, demonstrated differences in morphometric characteristics in the fimbriae between healthy and ovarian cancer patients, and between BRCA mutation carriers and noncarriers. The clinical significance of these observations should be investigated.


Assuntos
Proteína BRCA1/genética , Proteína BRCA2/genética , Tubas Uterinas/patologia , Adulto , Idoso , Carcinoma Epitelial do Ovário/genética , Carcinoma Epitelial do Ovário/patologia , Cistadenocarcinoma Seroso/genética , Cistadenocarcinoma Seroso/patologia , Feminino , Predisposição Genética para Doença , Heterozigoto , Humanos , Interpretação de Imagem Assistida por Computador , Pessoa de Meia-Idade , Mutação , Projetos Piloto
16.
J Minim Invasive Gynecol ; 25(1): 70-75, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28734974

RESUMO

STUDY OBJECTIVE: The aim of this study was to investigate how steep Trendelenburg positioning with pneumoperitoneum modifies brain oxygenation and autonomic nervous system modulation of heart rate variability during robotic sacrocolpopexy. DESIGN: Prospective study (Canadian Task Force classification III). SETTING: Rambam Health Care Campus. PATIENTS: Eighteen women who underwent robotic sacrocolpopexy for treatment of uterovaginal or vaginal apical prolapse. INTERVENTIONS: Robotic sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: A 5-minute computerized electrocardiogram, cerebral O2 saturation (cSO2), systemic O2 saturation, heart rate (HR), diastolic blood pressure (BP), systolic BP, and end-tidal CO2 tension were recorded immediately after anesthesia induction (baseline phase) and after alterations in positioning and in intra-abdominal pressure. HR variability was assessed in time and frequency domains. Cerebral oxygenation was measured by the technology of near-infrared spectrometry. cSO2 at baseline was 73% ± 9%, with minor and insignificant elevation during the operation. Mean HR decreased significantly when the steep Trendelenburg position was implemented (66 ± 10 vs 55 ± 9 bpm, p < .05) and returned gradually to baseline with advancement of the operation and the decrease in intra-abdominal pressure. Concomitant with this decrease, the power of both arms of the autonomic nervous system increased significantly (2.8 ± .8 vs 3.3 ± .9 ms2/Hz and 2.5 ± 1.2 vs 3.2 ± .9 ms2/Hz, respectively, p < .05). All these effects occurred without any significant shifts in systolic or diastolic BP or in systemic or cerebral oxygenation. CONCLUSION: This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in HR rate and HR variability.


Assuntos
Encéfalo/metabolismo , Colposcopia , Decúbito Inclinado com Rebaixamento da Cabeça/fisiologia , Frequência Cardíaca/fisiologia , Oxigênio/metabolismo , Pneumoperitônio Artificial , Prolapso Uterino/cirurgia , Adulto , Idoso , Colposcopia/efeitos adversos , Colposcopia/instrumentação , Colposcopia/métodos , Feminino , Decúbito Inclinado com Rebaixamento da Cabeça/efeitos adversos , Humanos , Pessoa de Meia-Idade , Consumo de Oxigênio/fisiologia , Posicionamento do Paciente/efeitos adversos , Pneumoperitônio Artificial/efeitos adversos , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Prolapso Uterino/metabolismo , Prolapso Uterino/fisiopatologia
17.
Surg Oncol ; 26(4): 347-351, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29113651

RESUMO

BACKGROUND AND OBJECTIVES: The decision to perform secondary cytoreductive surgery for recurrent ovarian cancer is generally determined by clinical criteria. The aim of this study was to assess the predictive capability of FDG-PET/CT in identifying patients for whom secondary optimal debulking can be obtained. METHODS: We reviewed the records of all women with suspected recurrent ovarian cancer (CA-125 levels >35 U/ml and/or clinical symptoms), at two medical centers, between January 2004 and December 2013. Patients in whom CT scans were negative, indeterminate or indicative of localized disease, were referred for preoperative FDG-PET/CT study. We analyzed the outcomes of those who subsequently underwent cytoreductive surgery. RESULTS: Of 282 women with suspected recurrent ovarian cancer, 48 underwent FDG-PET/CT. The 24 for whom localized disease was detected on PET/CT, subsequently underwent secondary debulking surgery. Patients with PET/CT evidence of multifocal recurrent sites were referred for chemotherapy. Tumor debulking was optimal in 20 patients, and suboptimal in 4. The positive predictive value of PET/CT for optimal debulking was 83.3%. CONCLUSIONS: The findings extend prior reports on the role of FDG-PET/CT in the management of recurrent ovarian cancer, to the prediction of secondary optimal debulking. Future studies should aim to investigate the impact on survival.


Assuntos
Fluordesoxiglucose F18 , Recidiva Local de Neoplasia/patologia , Neoplasias Epiteliais e Glandulares/patologia , Neoplasias Ovarianas/patologia , Seleção de Pacientes , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons/métodos , Compostos Radiofarmacêuticos , Adulto , Idoso , Carcinoma Epitelial do Ovário , Procedimentos Cirúrgicos de Citorredução , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/cirurgia , Neoplasias Epiteliais e Glandulares/diagnóstico por imagem , Neoplasias Epiteliais e Glandulares/cirurgia , Neoplasias Ovarianas/diagnóstico por imagem , Neoplasias Ovarianas/cirurgia , Cuidados Pré-Operatórios , Prognóstico , Estudos Retrospectivos
18.
Urology ; 103: 272, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28982620

RESUMO

OBJECTIVE: Sacrocolpopexy is considered the gold standard for the treatment of pelvic organ prolapse (POP). This procedure was the first technique used to treat POP with robotic assistance and has gone a long way since the open procedure was introduced. Originally, 5 trocars were inserted and there remained issues in terms of scarring, morcellation, and possibly an increased risk of infection. The objective of this video was to demonstrate a surgical technique and a few tips and tricks for a robot-assisted sacrocolpopexy performed via a single port in the umbilicus. METHODS: Since July 2015, women with symptomatic uterine prolapse were selected to be operated on by a single surgeon via a single robotic port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner, using da Vinci S or Si system. CONCLUSION: Robotically assisted laparoscopic repair of POP by sacrocolpopexy via a single port is a feasible technique with promising cosmetic results. This technique avoids morcellation and should also decrease the risk of infection because of the lower number of incisions.


Assuntos
Laparoscopia/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Robóticos/métodos , Prolapso Uterino/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Resultado do Tratamento
19.
Harefuah ; 156(9): 582-585, 2017 Sep.
Artigo em Hebraico | MEDLINE | ID: mdl-28971657

RESUMO

INTRODUCTION: False positive beta-human Chorionic Gonadotropin (hCG) results can lead to unnecessary life-threatening interventions. This article describes two clinical cases of false positive beta-hCG results that lead to unnecessary treatments. In one case the erroneous and unnecessary treatment caused a life-threatening complication. In cases where there is no correlation between the clinical manifestations, imaging and laboratory tests, and there is a suspicion of false positive beta-hCG result, there is a need to repeat the urine and blood beta-hCG analysis, if possible using a different assay method. These tests will raise the possibility of a correct indication for a false positive beta-hCG, thus avoiding unnecessary treatments and their complications.


Assuntos
Gonadotropina Coriônica Humana Subunidade beta/análise , Reações Falso-Positivas , Gonadotropina Coriônica , Humanos , Procedimentos Desnecessários
20.
Rambam Maimonides Med J ; 8(2)2017 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-28467761

RESUMO

The authors present a systematic review of randomized and observational, retrospective and prospective studies to compare between robotic surgery as opposed to laparoscopic, abdominal, and vaginal surgery for the treatment of both benign and malignant gynecologic indications. The comparison focuses on operative times, surgical outcomes, and surgical complications associated with the various surgical techniques. PubMed was the main search engine utilized in search of study data. The review included studies of various designs that included at least 25 women who had undergone robotic gynecologic surgery. Fifty-five studies (42 comparative and 13 non-comparative) met eligibility criteria. After careful analysis, we found that robotic surgery was consistently connected to shorter post-surgical hospitalization when compared to open surgery, a difference less significant when compared to laparoscopic surgery. Also, it seems that robotic surgery is highly feasible in gynecology. There are quite a few inconsistencies regarding operative times and estimated blood loss between the different approaches, though in the majority of studies estimated blood loss was lower in the robotic surgery group. The high variance in operative times resulted from the difference in surgeon's experience. The decision whether robotic surgery should become mainstream in gynecological surgery or remain another surgical technique in the gynecological surgeon's toolbox requires quite a few more randomized controlled clinical trials. In any case, in order to bring robotic surgery down to the front row of surgery, training surgeons is by far the most important goal for the next few years.

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