Screening and prevention of ovarian cancer.

Ovarian cancer remains the most lethal gynaecological malignancy with 314 000 cases and 207 000 deaths annually worldwide. Ovarian cancer cases and deaths are predicted to increase in Australia by 42% and 55% respectively by 2040. Earlier detection and significant downstaging of ovarian cancer have been demonstrated with multimodal screening in the largest randomised controlled trial of ovarian cancer screening in women at average population risk. However, none of the randomised trials have demonstrated a mortality benefit. Therefore, ovarian cancer screening is not currently recommended in women at average population risk. More frequent surveillance for ovarian cancer every three to four months in women at high risk has shown good performance characteristics and significant downstaging, but there is no available information on a survival benefit. Population testing offers an emerging novel strategy to identify women at high risk who can benefit from ovarian cancer prevention. Novel multicancer early detection biomarker, longitudinal multiple marker strategies, and new biomarkers are being investigated and evaluated for ovarian cancer screening. Risk-reducing salpingo-oophorectomy (RRSO) decreases ovarian cancer incidence and mortality and is recommended for women at over a 4-5% lifetime risk of ovarian cancer. Pre-menopausal women without contraindications to hormone replacement therapy (HRT) undergoing RRSO should be offered HRT until 51 years of age to minimise the detrimental consequences of premature menopause. Currently risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) should only be offered to women at increased risk of ovarian cancer within the context of a research trial. Pre-menopausal early salpingectomy is associated with fewer menopausal symptoms and better sexual function than bilateral salpingo-oophorectomy. A Sectioning and Extensively Examining the Fimbria (SEE-FIM) protocol should be used for histopathological assessment in women at high risk of ovarian cancer who are undergoing surgical prevention. Opportunistic salpingectomy may be offered at routine gynaecological surgery to all women who have completed their family. Long term prospective opportunistic salpingectomy studies are needed to determine the effect size of ovarian cancer risk reduction and the impact on menopause.

Contraception and sterilization selection at delivery among pregnant patients with malignancy.

INTRODUCTION: Since malignancy during pregnancy is uncommon, information regarding contraception selection or sterilization at delivery is limited. The objective of this study was to examine the type of long-acting reversible contraception or surgical sterilization procedure chosen by pregnant patients with malignancy at delivery. MATERIAL AND METHODS: This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample in the USA. The study population was vaginal and cesarean deliveries in a hospital setting from January 2017 to December 2020. Pregnant patients with breast cancer (n = 1605), leukemia (n = 1190), lymphoma (n = 1120), thyroid cancer (n = 715), cervical cancer (n = 425) and melanoma (n = 400) were compared with 14 265 319 pregnant patients without malignancy. The main outcome measures were utilization of long-acting reversible contraception (subdermal implant or intrauterine device) and performance of permanent surgical sterilization (bilateral tubal ligation or bilateral salpingectomy) during the index hospital admission for delivery, assessed with a multinomial regression model controlling for clinical, pregnancy and delivery characteristics. RESULTS: When compared with pregnant patients without malignancy, pregnant patients with breast cancer were more likely to proceed with bilateral salpingectomy (adjusted odds ratio [aOR] 2.30) or intrauterine device (aOR 1.91); none received the subdermal implant. Pregnant patients with leukemia were more likely to choose a subdermal implant (aOR 2.22), whereas those with lymphoma were more likely to proceed with bilateral salpingectomy (aOR 1.93) and bilateral tubal ligation (aOR 1.76). Pregnant patients with thyroid cancer were more likely to proceed with bilateral tubal ligation (aOR 2.21) and none received the subdermal implant. No patients in the cervical cancer group selected long-acting reversible contraception, and they were more likely to proceed with bilateral salpingectomy (aOR 2.08). None in the melanoma group chose long-acting reversible contraception. Among pregnant patients aged <30, the odds of proceeding with bilateral salpingectomy were increased in patients with breast cancer (aOR 3.01), cervical cancer (aOR 2.26) or lymphoma (aOR 2.08). The odds of proceeding with bilateral tubal ligation in pregnant patients aged <30 with melanoma (aOR 5.36) was also increased. CONCLUSIONS: The results of this nationwide assessment in the United States suggest that among pregnant patients with malignancy, the preferred contraceptive option or method of sterilization at time of hospital delivery differs by malignancy type.

Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery for Frozen Pelvis.

STUDY OBJECTIVE: To show feasibility and techniques used to perform a total hysterectomy, bilateral salpingectomy, endometriosis resection, and ovarian reconstruction in a patient with a frozen pelvis secondary to a history of ruptured tubo-ovarian abscess. DESIGN: Narrated step-by-step video demonstration. SETTING: Single academic institution. INTERVENTIONS: In patients with a history of multiple abdominal surgeries, abdominal mesh, or in the case of this patient, a history of a ruptured tubo-ovarian abscess, a vaginal approach may be safer. Immediate access to the uterine pedicles through the vagina bypasses the need for extensive enterolysis and adhesiolysis when compared to an abdominal approach. With the use of indocyanine green injected into bilateral ureters, we highlight the benefits of immediate identification of the ureters allowing for safer and more efficient dissection. We show rotational uterine maneuvers to aid in rectosigmoid-to- posterior-uterus dissection in a limited space due to dense pelvic adhesions. Lastly, we demonstrate ovarian reconstruction and oophoropexy for the purpose of easier ovarian identification in future surgeries to possibly reduce the risks of ovarian remnant syndrome. CONCLUSION: This video highlights the feasibility and strategies used to perform robot-assisted vaginal natural orifice transluminal endoscopic surgery on a patient with a frozen pelvis.

Hysteroscopic Transillumination as a Guide for Laparoscopic Excision of Rudimentary Uterine Horn: A Winning Duo.

STUDY OBJECTIVE: Anatomic anomalies of the female reproductive genital tract affect approximately 5.5% of women [1]. The hemiuterus or class U4 by the European Society of Human Reproduction and Embryology / European Society for Gynaecological Endoscopy 2013 classification is a rare congenital malformation defined as a unilateral uterine development, with a contralateral part that could be either incompletely formed or absent. This class is divided into 2 subclasses depending on the presence or not of a functional rudimentary cavity (U4a/U4b) [2]. This work aimed to share our experience performing an hysteroscopic and laparoscopic combined technique to surgically manage this uterine malformation exploiting the hysteroscopic transillumination. DESIGN: A step-by-step explanation of surgical technique with narrated video footage. SETTING: Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy. INTERVENTIONS: A 32-year-old woman with a symptomatic (severe dysmenorrhea and chronic pelvic pain) suspected U4a uterine malformation diagnosed at our center was scheduled for laparoscopic removal of the right uterine horn and ipsilateral salpingectomy exploiting the contemporary hysteroscopic transillumination guidance. We selected this approach to avoid possible complications owing to the anatomic anomalies that are very common in these cases [3,4]. After coagulation and section of the right round ligament at the uterine angle and opening of the right broad ligament, access to the retroperitoneum was obtained to directly visualize the entire course of ureter and the uterine artery. The right uterine artery was coagulated and sectioned at the uterus. Then, the hysteroscope was introduced to the uterine fundus and the light source brightness was increased up to 100% to allow an adequate transmural visualization of the uterine defect from the laparoscope. Once the defect edge was well highlighted, the right uterine horn was isolated and removed using a monopolar hook, taking care to preserve an adequate amount of myometrium. A double layer running suture with barbed absorbable thread (V-Loc) for reconstructive purposes was performed. The specimen was retrieved inside an endobag to allow a safe extraction. Right salpingectomy was then performed. CONCLUSION: Considering the great anatomic variability of this condition, this type of surgery is not always simple. Indeed, the borders between the uterus and the rudimentary uterine horn are often not perfectly recognizable; this can lead to accidental removal of healthy myometrium and increase the risk of perioperative bleeding [5]. In our experience, the combined hysteroscopic and laparoscopic combined technique allows the surgeon to better delimit the borders of the hemiuterus, providing a more conservative and safer surgery. Hysteroscopic transillumination offers the possibility to modulate the radicality in the resection of the rudimentary horn and in the final treatment of dysmorphism.

Bilateral salpingectomy as an option of permanent contraception at time of caesarean section: A survey of practice.

BACKGROUND: Opportunistic bilateral salpingectomy during benign gynaecologic surgery is advocated as a risk-reducing strategy due to the inverse association of epithelial ovarian cancers observed in epidemiological studies in a low-risk setting. Currently, no formal guidance exists for permanent surgical contraception at time of caesarean section in Australia. AIMS: Our aim was to survey Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) regarding bilateral salpingectomy compared to other procedures offered for permanent contraception at the time of caesarean section. MATERIALS AND METHODS: An online survey was utilised to collect clinician demographics, opinions, barriers, and justifications in regard to options of permanent surgical contraception at time of caesarean section. RESULTS: Bilateral salpingectomy was identified as the most effective method of permanent contraception at time of caesarean section. However, only 62% of respondents offer the procedure as a method of permanent contraception. The two most common reasons for clinicians to offer bilateral salpingectomy at time of caesarean section were evidence suggesting a link between the fallopian tube and gynaecological cancer (80%) and efficacy as a permanent form of contraception (16%). The primary barrier identified by 51% of respondents was perceived increased risk of surgical complications, followed by reasoning that it would not allow the possibility of future tubal reversal. CONCLUSION: This study identifies diverse opinions on surgical approach to permanent contraception at time of caesarean section and offered by clinicians of RANZCOG. Further research is required to establish safety profiles and short- and long-term risks of bilateral salpingectomy.

IFTT in children and adolescents-single-center experience and systematic review of literature.

PURPOSE: Isolated fallopian tube torsion (IFTT) is defined by rotation of the fallopian tube around itself without involving the ipsilateral ovary. It is a rare cause of acute lower abdominal pain in (adolescent) girls, but is commonly overlooked. Due to its rarity, literature is still scarce. Currently there is no generally accepted management and treatment. METHODS: A retrospective analysis of all IFTT cases treated in our institution was performed. In addition, a systematic literature research on pediatric IFTT was carried out on Medline/ PubMed database according to PRISMA principles using predefined search terms and inclusion criteria. Patient characteristics regarding age, clinical symptoms, diagnostic methods, treatment, and follow-up were analyzed. RESULTS: Three of our patients and fifty-nine reports totaling one hundred seventy girls were included in the analysis. Mean age was 13.0 years. Left tube was slightly more often affected (52.9%). Abdominal pain was present in 99.4% of cases accompanied with nausea in 57.1%. In only 16.4%, correct preoperative diagnosis was made. Salpingectomy was the most common treatment in 111 (66.9%) cases, 55 (33.1%) patients were treated with detorsion of the tube (organ-sparing management). Girls with symptoms longer than 1 day had a significant higher rate of salpingectomy (95% CI, P = 0.0323). CONCLUSION: When IFTT is suspected, emergency laparoscopy should be performed to possibly preserve future reproductive potential. In case of detorsion and reinstated blood supply, organ-preserving management should be performed with simultaneous addressment of concomitant pathology if possible. Sufficient long-term follow-up must be assured to get significant results to introduce guidelines for children and adolescents.

Isolated Fallopian Tube Torsion in Children With Hydrosalpinx: Is Conservative Management an Option?

BACKGROUND: Isolated fallopian tube torsion (IFTT) is very rare gynecological emergency in pediatric population. Our objective is to assess treatment options and discuss outcome of a cohort of IFTT with a focus on the association between IFTT and hydrosalpinx (HSX). METHODS: A retrospective review was conducted. Pediatric patients with IFTT operated in the same center were included. RESULTS: Seventeen girls (aged: 11-16 years) were managed for acute abdominal pain between 2008 and 2018, with intraoperative diagnosis of IFTT. All patients underwent laparoscopic exploration, with laparoscopically fallopian tube detorsion in all patients. Based on the association of IFTT with HSX after fallopian tube detorsion, patients were divided into 2 groups: group 1 (IFTT without HSX; 12 girls) and group 2 (IFTT with HSX; 5 girls). During the same surgery, complementary surgical procedures were done. In group 1: salpingectomies (4), partial salpingectomies (2) and cystectomies (6) were done. In group 2: salpingectomy (1), salpingotomy (1), and cyst ablation (1). The treatment was called conservative when the tube was preserved.Follow-up was uneventful in group 1. In group 2, for all patients with initial fallopian tube preservation, further surgical procedures were necessary (1-4 surgeries/patient), and, finally, another 3 patients required salpingectomy. CONCLUSIONS: Conservative treatment with tube preservation of IFTT without HSX appeared to be beneficial compared to those with HSX, with no recurrence of torsion or symptoms during the follow-up. However, the same conservative treatment was not sufficiently effective for IFTT with HSX and required further procedures due to recurrence of torsion. LEVEL OF EVIDENCE: IV.

Risk factors for tubal patency and their impact on pregnancy rate after partial salpingectomy and end-to-end anastomosis. / è¾“åµç®¡éƒ¨åˆ†åˆ‡é™¤æœ¯è”åˆç«¯ç«¯å»åˆæœ¯å½±å“æ‚£è€ è¾“åµç®¡é€šç• æ€§å’Œå¦Šå¨ çš„ç›¸å ³å› ç´ åˆ†æž.

OBJECTIVES: To explore the risk factors for tubal patency after partial salpingectomy and end-to-end anastomosis, and their impact on pregnancy outcomes. METHODS: A total of 300 patients with tubal pregnancy who underwent partial salpingectomy and end-to-end anastomosis in Zhengzhou Maternal and Child Health Hospital from January 2020 to April 2023 were enrolled in the study. Hysterosalpingography was performed after surgical treatment to examine the tubal patency. Lasso-Logistic regression was used to analyze the risk factors for postoperative tubal patency, and Spearman's correlation was used to analyze the impact of each risk factor on the pregnancy rate. RESULTS: Hysterosalpingography showed that the fallopian tube was not obstructed in 225 cases (unobstructed group), the tube was not completely patent (n=54) or blocked (n=21) (obstructed group). Univariate analysis showed that age, diameter of the tubal pregnancy sac, location of tubal pregnancy, timing of surgery, pelvic adhesion, anastomotic method, length of remaining tubal, history of pelvic surgery, number of intraoperative electrocoagulation, intraoperative blood loss, and experience of surgeons were factors affecting postoperative tubal patency (all P<0.01). Lasso regression analysis identified location of tubal pregnancy, pelvic adhesion, anastomotic method, length of remaining tubal, history of pelvic surgery, number of intraoperative electrocoagulation, and experience of surgeons as influencing factors. Multivariate Logistic regression analysis showed that tubal isthmus pregnancy, pelvic adhesion, open anastomosis surgery, history of pelvic surgery, and number of intraoperative electrocoagulation were independent risk factors for postoperative tubal patency, while length of remaining tubal and years of surgeon's work experience were independent protective factors for postoperative tubal patency (all P<0.01). A total of 295 patients were followed up for 1 year, 192 cases (65.08%) were pregnant, including 172 cases of intrauterine pregnancy (89.58%) and 20 cases of ectopic pregnancy (10.42%). Spearman correlation analysis showed that tubal isthmus pregnancy, pelvic adhesion, open abdominal anastomosis surgery, pelvic surgery history, and times of intraoperative electrocoagulation were negatively correlated with postoperative pregnancy, while the remaining tubal length and years of surgeon's working experience were positively correlated with postoperative pregnancy rate (all P<0.01). CONCLUSIONS: For tubal patency of patients after partial salpingectomy combined with end-to-end anastomosis, the history of tubal isthmus pregnancy, pelvic adhesion, open abdominal anastomosis, pelvic surgery, and the number of intraoperative electrocoagulation are independent risk factors, which are negatively correlated with postoperative pregnancy. The remaining tubal length and the years of surgeon's work experience are independent protective factors, which are positively correlated with postoperative pregnancy.

Opportunistic Salpingectomy at the Time of Laparoscopic Cholecystectomy for Ovarian Cancer Prevention: A Cost-effectiveness Analysis.

OBJECTIVE: To perform a cost-effectiveness analysis to examine the utility and effectiveness of OS performed at the time of elective cholecystectomy [laparoscopic cholecystectomy (LAP-CHOL)]. SUMMARY BACKGROUND DATA: OS has been adopted as a strategy to reduce the risk of ovarian cancer in women undergoing hysterectomy and tubal sterilization, although the procedure is rarely performed as a risk reducing strategy during other abdominopelvic procedures. METHODS: A decision model was created to examine women 40, 50, and 60 years of age undergoing LAP-CHOL with or without OS. The lifetime risk of ovarian cancer was assumed to be 1.17%, 1.09%, and 0.92% for women age 40, 50, and 60 years, respectively. OS was estimated to provide a 65% reduction in the risk of ovarian cancer and to require 30 additional minutes of operative time. We estimated the cost, quality-adjusted life-years, ovarian cancer cases and deaths prevented with OS. RESULTS: The additional cost of OS at LAP-CHOL ranged from $1898 to 1978. In a cohort of 5000 women, OS reduced the number of ovarian cancer cases by 39, 36, and 30 cases and deaths by 12, 14, and 16 in the age 40-, 50-, and 60-year-old cohorts, respectively. OS during LAP-CHOL was cost-effective, with incremental cost-effectiveness ratio of $11,162 to 26,463 in the 3 age models. In a probabilistic sensitivity analysis, incremental cost-effectiveness ratio for OS were less than $100,000 per quality-adjusted life-years in 90.5% or more of 1000 simulations. CONCLUSIONS: OS at the time of LAP-CHOL may be a cost-effective strategy to prevent ovarian cancer among average risk women.

Risk of ovarian cancer after salpingectomy and tubal ligation: Prospects on histology and time since the procedure.

OBJECTIVE: Recent theories propose that most epithelial ovarian cancer (EOC), depending on histological type, originate from other gynecological tissues and involve the ovary secondarily. According to these theories, any protective effect of salpingectomy and tubal ligation may vary by histological type. The study aim was to examine the association between salpingectomy and tubal ligation, respectively, and risk of EOC, with a focus on associations specific for histological types. METHODS: We identified EOC cases and matching controls in national registries and gathered information on surgical procedures and potential confounders. Conditional logistic regression was used to estimate odds ratio (OR) with 95% confidence interval (CI) of EOC related to salpingectomy and tubal ligation, respectively, overall and stratified by histological type. Furthermore, we investigated the association according to timing of the procedures. RESULTS: Our study comprised 16,822 EOC cases. Each case was matched with 40 controls. There was an overall EOC risk reduction after unilateral (OR = 0.73; 95% CI: 0.60-0.87) and bilateral salpingectomy (OR = 0.46; 95% CI: 0.31-0.67). A slight risk reduction was seen among women with previous tubal ligation (OR = 0.91; 95% CI: 0.83-0.99). For salpingectomy, the risk reduction increased with increasing time since the surgical procedure and was only present among women younger than 50 years at salpingectomy. Unilateral and bilateral salpingectomy was associated with a risk reduction for most histological types. CONCLUSION: The association between previous salpingectomy and reduced risk of several histological subtypes of EOC supports the suggested theories about the site of origin of EOC and may be of clinical importance.

Patient perspectives on risk-reducing salpingectomy with delayed oophorectomy for ovarian cancer risk-reduction: A systematic review of the literature.

OBJECTIVE: Increasing evidence suggests the fallopian tube as the site of origin of BRCA1/2-associated high-grade ovarian cancers. Several ongoing trials are evaluating salpingectomy with delayed oophorectomy (RRSDO) for ovarian cancer risk reduction and patients are beginning to ask their clinicians about this surgical option. This study sought to systematically review the available literature examining patient preferences regarding RRSDO and risk-reducing salpingo-oophorectomy (RRSO) to provide clinicians with an understanding of patient values, concerns, and priorities surrounding ovarian cancer risk-reducing surgery. METHODS: We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO No.: CRD42023400690). We searched key electronic databases to identify studies evaluating acceptance and surgical decision-making regarding RRSO and RRSDO among patients with an increased risk of ovarian cancer. RESULTS: The search yielded 239 results, among which six publications met the systematic review inclusion criteria. Acceptance of RRSDO was evaluated in all studies and ranged from 34% to 71%. Factors positively impacting patients' acceptance of RRSDO included: avoidance of surgical menopause, preservation of fertility, concerns about sexual dysfunction, family history of breast cancer, and avoidance of hormone replacement therapy. Factors limiting this acceptance reported by patients included concerns regarding oncologic safety, surgical timing, and surgical complications. CONCLUSION: To date, few studies have explored patient perspectives surrounding RRSDO. Collectively, the limited data available indicate a high level of acceptance among BRCA1/2 carriers, and provides insight regarding both facilitating and limiting factors associated with patient preferences to better equip clinicians in the counseling and support of their patients.

TUBectomy with delayed oophorectomy as an alternative to risk-reducing salpingo-oophorectomy in high-risk women to assess the safety of prevention: the TUBA-WISP II study protocol.

BACKGROUND: Risk-reducing salpingectomy with delayed oophorectomy has gained interest for individuals at high risk for tubo-ovarian cancer as there is compelling evidence that especially high-grade serous carcinoma originates in the fallopian tubes. Two studies have demonstrated a positive effect of salpingectomy on menopause-related quality of life and sexual health compared with standard risk-reducing salpingo-oophorectomy. PRIMARY OBJECTIVE: To investigate whether salpingectomy with delayed oophorectomy is non-inferior to the current standard salpingo-oophorectomy for the prevention of tubo-ovarian cancer among individuals at high inherited risk. STUDY HYPOTHESIS: We hypothesize that postponement of oophorectomy after salpingectomy, to the age of 40-45 (BRCA1) or 45-50 (BRCA2) years, compared with the current standard salpingo-oophorectomy at age 35-40 (BRCA1) or 40-45 (BRCA2) years, is non-inferior in regard to tubo-ovarian cancer risk. TRIAL DESIGN: In this international prospective preference trial, participants will choose between the novel salpingectomy with delayed oophorectomy and the current standard salpingo-oophorectomy. Salpingectomy can be performed after the completion of childbearing and between the age of 25 and 40 (BRCA1), 25 and 45 (BRCA2), or 25 and 50 (BRIP1, RAD51C, and RAD51D pathogenic variant carriers) years. Subsequent oophorectomy is recommended at a maximum delay of 5 years beyond the upper limit of the current guideline age for salpingo-oophorectomy. The current National Comprehensive Cancer Network (NCCN) guideline age, which is also the recommended age for salpingo-oophorectomy within the study, is 35-40 years for BRCA1, 40-45 years for BRCA2, and 45-50 years for BRIP1, RAD51C, and RAD51D pathogenic variant carriers. MAJOR INCLUSION/EXCLUSION CRITERIA: Premenopausal individuals with a documented class IV or V germline pathogenic variant in the BRCA1, BRCA2, BRIP1, RAD51C, or RAD51D gene who have completed childbearing are eligible for participation. Participants may have a personal history of a non-ovarian malignancy. PRIMARY ENDPOINT: The primary outcome is the cumulative tubo-ovarian cancer incidence at the target age: 46 years for BRCA1 and 51 years for BRCA2 pathogenic variant carriers. SAMPLE SIZE: The sample size to ensure sufficient power to test non-inferiority of salpingectomy with delayed oophorectomy compared with salpingo-oophorectomy requires 1500 BRCA1 and 1500 BRCA2 pathogenic variant carriers. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: Participant recruitment is expected to be completed at the end of 2026 (total recruitment period of 5 years). The primary outcome is expected to be available in 2036 (minimal follow-up period of 10 years). TRIAL REGISTRATION NUMBER: NCT04294927.

Interstitial Ectopic Pregnancy: Laparoscopic Cornuostomy.

STUDY OBJECTIVE: To demonstrate and discuss the technique of cornuostomy for surgical management of interstitial ectopic pregnancy. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Tertiary referral center in Manchester, United Kingdom. INTERVENTION: Interstitial ectopic pregnancies are rare but are associated with a higher mortality rate than other ectopic pregnancies [1,2]. It occurs when the fertilized embryo implants in the interstitial portion of the fallopian tube traversing the vascularized myometrium. When undiagnosed they present late in the second trimester associated with rupture and catastrophic bleeding, with a mortality rate of 2% to 2.5%.2 Diagnosis requires a degree of vigilance from the ultrasound operator because it is commonly misdiagnosed as intrauterine pregnancies. Surgical management options include laparoscopic cornual resection or cornuostomy. There is no consensus on the optimal surgical technique but cornuostomy is a more conservative approach associated with less disruption to uterine anatomy and loss of myometrium [3,4]. A 22-year-old gravida 4 woman presented at 7 weeks' gestation with right iliac fossa pain. Initial serum human chorionic gonadotropin was 18 136 IU/L. Transvaginal ultrasound scan showed an empty endometrial cavity and an echogenic "donut"-shaped mass within the right interstitial space, within the uterine serosa but outside the endometrial cavity (Supplemental Video 1). At laparoscopy the diagnosis of a right interstitial ectopic pregnancy was confirmed (Supplemental Video 2). Vasopressin 20 IU diluted in 80 mL of normal saline was injected around the base of the ectopic pregnancy. Monopolar diathermy was used to incise the overlying serosa followed by hydrodissection to separate the ectopic gestational sac from the myometrial attachment. The resulting defect was inspected and closed in 2 layers. Total operating time was 46 minutes. CONCLUSION: Although there is no clear evidence to guide the management of all interstitial ectopic pregnancies, an individualized approach taking into account the woman's previous history and future fertility plans and wishes is essential. In this case, given the woman's previous contralateral salpingectomy and her wishes for a conservative approach, a laparoscopic cornuostomy was likely the best option.

Clinical improvement after Essure® devices removal: a systematic review.

PURPOSE: Essure® implant is a permanently implanted minimally invasive birth control device for women (female sterilisation) widely used between 2002 and 2018. Many adverse events were reported by patients. Increasingly removal procedures have been performed in symptomatic patients. However, there is a lack of in-depth studies on clinical improvement after Essure® removal. We aimed to review all clinical studies about symptoms and quality of life (QoL) after removal procedures. MATERIALS AND METHODS: A review of literature in electronic search in Medline and Embase databases from January 2002 to January 2022 using the following keywords: Essure; Essure removal; quality of life; symptomatology improvement. RESULTS: Out of 764 articles in the initial database, 18 clinical studies were eligible for inclusion in our literature review. Overall clinical improvement rates after removal ranged from 21% to 98%. All symptoms were less frequent after Essure® removal, although with large discrepancies between studies. Lack of improvement was reported between 1% to 15% of patients. Rate of patients with improvement of QoL after removal ranged from 58 to 98%. The pain was reported as significantly reduced after the surgery. CONCLUSIONS: In the available literature, Essure® removal in symptomatic patients may improve symptoms and quality of life. This should be discussed in the benefits and risks ratio before deciding on the best option of management.

Essure® removal in symptomatic patients may improve symptoms and quality of life.

Forensic Analysis of Eighteen Tubal Pregnancy-Related Medical Damage.

OBJECTIVES: To analyze the cases of medical damage after misdiagnosis of tubal pregnancy, to explore the causes of medical damage, the causal relationship between medical malpractice and the damage consequences, as well as the causative potency, in order to provide evaluation ideas for forensic identification of such cases. METHODS: Eighteen cases of forensic identification of tubal pregnancy related medical damage were collected and retrospectively analyzed from the aspects of age, maternity history, fertility requirements, risk factors, diagnosis and treatment, medical malpractice, damage consequences, and causative potency. RESULTS: All 18 cases were tubal pregnancy, of which 17 cases had medical malpractice, resulting in 14 cases of affected tubal resection, 2 cases of hemorrhagic shock death, 1 case of intrauterine fetal death and affected tubal resection. The other case had the consequence of affected tubal resection, but there was no malpractice in the treatment. CONCLUSIONS: Correct diagnosis is helpful to make appropriate treatment plan, prevent disease progression and reduce serious adverse consequences and the occurrence of medical disputes. Scientific and reasonable analysis of the causal relationship between medical malpractice and damage consequences and the causative potency is of great significance to the successful settlement of medical disputes.

Racial and ethnic differences in the adoption of opportunistic salpingectomy for ovarian cancer prevention in the United States.

BACKGROUND: Clinicians in the United States have rapidly adopted opportunistic salpingectomy for ovarian cancer prevention. However, little is known about racial and ethnic differences in opportunistic salpingectomy adoption. Surgical innovations in gynecology may be adopted differentially across racial and ethnic groups, exacerbating current disparities in quality of care. OBJECTIVE: This study aimed to evaluate racial and ethnic differences in opportunistic salpingectomy adoption across inpatient and outpatient settings and assess the effect of national guidelines supporting opportunistic salpingectomy use on these differences. STUDY DESIGN: A sample of 650,905 women aged 18 to 50 years undergoing hysterectomy with ovarian conservation or surgical sterilization from 2011 to 2018 was identified using the Premier Healthcare Database, an all-payer hospital administrative database, including more than 700 hospitals across the United States. The association between race and ethnicity and opportunistic salpingectomy use was examined using multivariable-adjusted mixed-effects log-binomial regression models accounting for hospital-level clustering. Models included race and ethnicity by year of surgery (2011-2013 [before guideline] and 2014-2018 [after guideline]) interaction term to test whether racial and ethnic differences in opportunistic salpingectomy adoption changed with the release of national guidelines supporting opportunistic salpingectomy use. RESULTS: From 2011 to 2018, 82,792 women underwent hysterectomy and opportunistic salpingectomy (non-Hispanic White, 60.3%; non-Hispanic Black, 18.8%; Hispanic, 12.2%; non-Hispanic other race, 8.7%) and 23,398 women underwent opportunistic salpingectomy for sterilization (non-Hispanic White, 64.7%; non-Hispanic Black, 10.8%; Hispanic, 16.7%; non-Hispanic other race, 7.8%). The proportion of hysterectomy procedures involving an opportunistic salpingectomy increased from 6.3% in 2011 to 59.7% in 2018 (9.5-fold increase), and the proportion of sterilization procedures involving an opportunistic salpingectomy increased from 0.7% in 2011 to 19.4% in 2018 (27.7-fold increase). In multivariable-adjusted models, non-Hispanic Black (risk ratio, 0.94; 95% confidence interval, 0.92-0.97), Hispanic (risk ratio, 0.98; 95% confidence interval, 0.95-1.00), and non-Hispanic other race women (risk ratio, 0.93; 95% confidence interval, 0.90-0.96) were less likely to undergo hysterectomy and opportunistic salpingectomy than non-Hispanic White women. A significant interaction between race and ethnicity and year of surgery was noted in non-Hispanic Black compared with non-Hispanic White women (P<.001), with a reduction in differences in hysterectomy and opportunistic salpingectomy use after national guideline release (risk ratio2011-2013, 0.80 [95% confidence interval, 0.73-0.88]; risk ratio2014-2018, 0.98 [95% confidence interval, 0.95-1.01]). Moreover, non-Hispanic Black women were less likely to undergo an opportunistic salpingectomy for sterilization than non-Hispanic White women (risk ratio, 0.91; 95% confidence interval, 0.88-0.95), with no difference by year of surgery (P=.62). Stratified analyses by hysterectomy route and age at surgery revealed similar results. CONCLUSION: Although opportunistic salpingectomy for ovarian cancer prevention has been rapidly adopted in the United States, our findings suggested that its adoption has not been equitable across racial and ethnic groups. Non-Hispanic Black, Hispanic, and non-Hispanic other race women were less likely to undergo opportunistic salpingectomy than non-Hispanic White women even after adjusting for sociodemographic, clinical, procedural, hospital, and provider characteristics. These differences persisted after the release of national guidelines supporting opportunistic salpingectomy use. Future research should focus on understanding the reasons for these differences to inform interventions that promote equity in opportunistic salpingectomy use.

Female permanent contraception trends and updates.

Permanent contraception remains one of the most popular methods of contraception worldwide. This article has reviewed recent literature related to demographic characteristics of users, prevalence of use and trends over time, surgical techniques, and barriers to obtain the procedure. We have emphasized the patient's perspective as a key element of choosing permanent contraception. This review has incorporated sections on salpingectomy, hysteroscopy, unmet need, impact of policies at religiously affiliated institutions, and reproductive coercion.

Spontaneous Pregnancy after Total Bilateral Salpingectomy: A Systematic Review of Literature.

OBJECTIVE: To assess the occurrence of spontaneous pregnancy after a history of total bilateral salpingectomy (BS). DATA SOURCES: A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching MEDLINE, Embase, Google Scholar, PubMed, SCOPUS, and Web of Science from database inception to February 20, 2020. METHODS OF STUDY SELECTION: We included women with a history of total BS for any indication with subsequent spontaneous pregnancy. Excluded were women who had a history of incomplete/partial salpingectomy or tubal occlusion, who had pregnancy after assisted reproductive technology, and whose pregnancy was not appropriately confirmed via beta-subunit of human chorionic gonadotropin or ultrasound. TABULATION, INTEGRATION, AND RESULTS: The systematic search retrieved 1942 articles; 39 studies were potentially eligible, and their full texts were reviewed. A total of 4 case reports were included. Total BS had been performed for other indications than permanent contraception in all cases. Pain was the most common presenting symptom. All 4 pregnancies were intrauterine in location. Treatment was based on desire to continue pregnancy and hemodynamic stability. CONCLUSION: Spontaneous pregnancy after total BS is exceedingly rare. The present data suggest that it is reassuring to offer total BS as a form of permanent contraception. Prospective data are warranted to ascertain short- and long-term effects of total BS for permanent contraception including its efficacy.

Utility of Vaginal Natural Orifice Transluminal Endoscopic Surgery for Permanent Sterilization after Failed Attempt at Bilateral Tubal Ligation at the Time of Previous Cesarean Section.

STUDY OBJECTIVE: To demonstrate the utility of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for opportunistic bilateral salpingectomy for permanent sterilization after a failed attempt at bilateral tubal ligation at the time of previous cesarean section. DESIGN: Stepwise demonstration with narrated video footage. SETTING: There is evidence to support the statistically significant superiority of vNOTES compared with conventional laparoscopy (CL) in terms of patient satisfaction, postoperative pain, time to recovery, and cosmetic results in bilateral salpingectomies for permanent sterilization [1]. Limited studies demonstrate the ease and safety of access to the abdominal cavity in vNOTES while avoiding passage through the abdominal wall, port site complications (infection, hernia, etc.), and those associated with peritoneal adhesions during abdominal laparoscopy or laparotomy [2]. To the best of our knowledge, this would be the first published video of a vNOTES bilateral salpingectomy performed specifically in a patient whose previously attempted bilateral tubal ligation was unsuccessful owing to adhesive disease from 4 previous cesarean sections. INTERVENTIONS: Institutional review board approval was not required. We describe a case of a 31-year-old female, with a history of 4 previous cesarean deliveries and a cholecystectomy, who desired permanent sterilization 3 months after the previous cesarean section. During previous cesarean section, bilateral adnexa were unable to be accessed owing to dense adhesions from previous surgeries. The patient was counseled on various forms of reversible contraceptive methods; however, she desired permanent sterilization with a surgical procedure. She was counseled on the various routes for opportunistic salpingectomy. Risks, benefits, and alternatives of each surgical approach were discussed. The patient consented for vNOTES opportunistic salpingectomy and possible CL. She was aware that she had significant adhesive disease at the time of previous cesarean section, so may potentially require a laparotomy for the procedure. However, she refused a laparotomy if the surgery was unable to be performed minimally invasively. (1) Demonstrate setup of transvaginal access platform for vNOTES bilateral salpingectomy. (2) Abdominal survey and appreciation of severe adhesive disease through posterior cul-de-sac. (3) Bilateral salpingectomy through single-site vaginal natural orifice surgery. CONCLUSION: vNOTES bilateral salpingectomy can be considered as a reasonable alternative to CL in patients with severe abdominal adhesive disease from previous surgeries.

Laparoscopic salpingectomy in Papio hamadryas for birth control in captivity.

OBJECTIVE: To evaluate the feasibility of laparoscopic salpingectomy in baboons (Papio hamadryas). We hypothesized that laparoscopic salpingectomy could be performed in baboon species within a reasonable amount of surgical time, with minor complications occurring at low rates. STUDY DESIGN: Case series and technique description. ANIMALS: Sixteen baboons (n = 16). METHODS: The surgical procedures were performed using the 3-port technique, with 5 mm instruments and a telescope placed at the umbilical and hypogastric regions. A salpinx dissection was performed, using a radiofrequency bipolar vessel sealing device, from the fimbriae to the uterine attachments. We evaluated the surgical duration, learning curve, and intraoperative and early postoperative complications. RESULTS: Ten adult and 6 subadult baboons with a mean weight of 9.32 kg, a range of 4-14.2 kg, and a standard deviation (SD) of 3.09 kg were included in the study. The total duration of surgery was 28.75 min (range, 16-50 min; SD, 9.60 min). The installation phase was completed in a mean time of 7.68 min (range, 3-15 min; SD, 3.43 min), and the time to complete the salpingectomy of both salpinges was 9.68 min (range, 4-20 min; SD, 3.97 min). No complications were observed in the postoperative period. CONCLUSION: Laparoscopic salpingectomy in Papio hamadryas was feasible, with an acceptable surgical time, low invasiveness, and only minor technical perioperative complications. CLINICAL SIGNIFICANCE: Laparoscopic salpingectomy could be a viable and safe therapeutic option in nonhuman primate birth-control programs.