Two-Port Laparoscopic Removal of Large Ovarian Cystadenoma.

An ovarian mucinous cystadenoma is a common benign tumour of the ovary that tends to reach very large sizes. Although traditional morcellation in the abdominal cavity is largely avoided in gynaecologic surgery, several authors have proposed other systems and techniques for the removal of large masses without resorting to laparotomy. We proposed an extremely minimally invasive technique to remove a large mass with a very low suspicion of malignancy, and created a video demonstration of the procedure. In this short film we illustrate our novel technique using only 2 laparoscopic ports, which maximizes both cosmesis and speed of recovery. The technique is not a completely closed system, therefore the potential for spreading an undiagnosed malignancy still exists. Accordingly, the authors do not suggest this technique for masses with a high potential for malignancy. However, in properly consented patients where there is very little suspicion for malignancy, our technique may be a reasonable option to promote fast recovery and provide excellent cosmesis.

Complications of Laparoscopic and Transabdominal Cerclage in Patients with Cervical Insufficiency: A Systematic Review and Meta-analysis.

OBJECTIVE: Cervical insufficiency is a defect of the cervix that leads to failure to preserve a full-term intrauterine pregnancy. Laparoscopic cerclage and open transabdominal cerclage (TAC) are effective ways to manage patients with cervical insufficiency. We performed this systematic review and meta-analysis to investigate the complications of laparoscopic cerclage and open TAC in the management of cervical insufficiency. DATA SOURCES: We searched PubMed, Cochrane, Scopus, and Web of Science using our search strategy and screened the results for our criteria. We extracted the results reported and analyzed them using Open Meta-Analyst (OpenMeta[Analyst], Brown School of Public Health, Providence, RI) and Review Manager (Cochrane Collaboration, London, United Kingdom) software. METHODS OF STUDY SELECTION: We included all randomized controlled and observational trials performed on patients with cervical insufficiency undergoing open TAC or laparoscopic cerclage that matched our search strategy. We excluded letters to the editor, reviews, meetings/conference abstracts, non-English or nonhuman studies, and instances where the full text was not available. TABULATION, INTEGRATION, AND RESULTS: We included a total of 33 trials. Both interventions of laparoscopic cerclage and open TAC were associated with significantly less total fetal loss (laparoscopic cerclage, relative risk [RR] 0.03; 95% confidence interval [CI], 0.01-0.08; p <.001, and open TAC, RR 0.19; 95% CI, 0.07-0.51; p <.009). The overall blood loss in open TAC was 110.589 mL (95% CI, 93.737-127.44; p <.001), and in laparoscopic cerclage, it was 24.549 mL (95% CI, 9.892-39.205; p = .001). In addition, open TAC had a positive effect regarding incidence of hemorrhage >400 mL (RR 0.077; 95% CI, 0.033-0.122; p <.001). Preterm premature rupture of membranes was significant in the open TAC (RR 0.037; 95% CI, 0.019-0.055; p <.001) and laparoscopic cerclage groups (RR 0.031; 95% CI, 0.009-0.053; p = .006). CONCLUSION: Laparoscopic cerclage may be safer than open TAC in the management of cervical insufficiency because we found a statistically significant lower incidence of fetal loss, blood loss, and rate of hemorrhage in the laparoscopic cerclage group. Clinically, this evidence may help support favoring a laparoscopic approach over an open one in appropriate patients, although it is unclear whether this benefit is limited to cerclages placed either before pregnancy or placed in the first-trimester or both.

A Systematic Review and Meta-Analysis of the Effect of Intraoperative Bupivacaine in Gynaecologic Surgery After 24 Hours or 9 Half-Lives.

OBJECTIVE: To review all high quality available evidence regarding the effect of intraoperative bupivacaine 24 hours (or 8.9 half-lives) after intraoperative administration at time of gynaecologic surgery and to ascertain whether a second mechanism of action, beyond the initial prevention of sodium channel depolarization and blockade of nerve impulses, may be occurring. DATA SOURCES: We searched all major databases with an algorithm designed to include all randomized trials that used any form of local bupivacaine, regardless of dose or route of administration, at the time of any gynaecologic surgery and compared its use with saline placebo. RESULTS: As expected, we found that bupivacaine showed a significant improvement for all gynaecologic surgeries with respect to pain intensity at 6 hours after surgery when compared with a saline group (mean difference [MD] -1.28; 95% CI -1.96 to -0.61], P = 0.07). We also found a significant difference at 24 hours after surgery, giving evidence to the possibility of a second mechanism of action (MD -0.57; 95% CI -1.10 to -0.05], P = 0.01). Further subgroup analysis for pain levels at 24 hours showed significant decreases in pain for the laparoscopy (MD -0.74; 95% CI -0.93 to -0.54, P < 0.01) and laparotomy (MD -2.60; 95% CI -2.93 to -2.27, P < 0.01)) subgroups but not for the vaginal hysterectomy (MD 0.20; 95% CI -0.69 to 1.09, P = 0.66) or prolapse surgery (MD -0.11; 95% CI -0.41 to 0.19, P = 0.48) subgroups. There was no significant difference with respect to the length of hospital stay (MD -0.11; 95% CI -0.59 to 0.38, P = 0.67). CONCLUSION: As expected, bupivacaine significantly reduced visual analog pain scores when compared with placebo at 6 hours after surgery, but also showed a significant difference at 24 hours after surgery, giving evidence of a second mechanism of action following the initial sodium channel blockade.

Combination of Laparoscopic Salpingectomy and Endometrial Ablation: A Potentially Underused Procedure.

Despite the advantages of a decreased risk of epithelial-cell ovarian cancer and the extremely minimally invasive nature of the procedure, combined salpingectomy and endometrial ablation is a potentially underused procedure in the United States to treat abnormal uterine bleeding and desired sterilization. The lack of utilization of this combined procedure might be based on factors other than clinical considerations, including slow acceptance and adoption of Committee Opinions expressing the value of salpingectomy over sterilization. Committee Opinions and randomized clinical trials have demonstrated the benefit of salpingectomy for sterilization and epithelial-cancer risk reduction, and there could be an additional protection against postablation tubal sterilization syndrome. This Commentary discusses the advantages and rationale for consideration of expanding usage of the combined approach.

Comparison of Mechanical Characteristics of Commonly Used Vaginal Packing Materials.

INTRODUCTION: Clinically, vaginal packing provides the benefit of hemostasis and is designed to prevent the formation of postoperative hematomas. Despite the common use of vaginal packing in pelvic surgery, there is limited data to indicate which material has the ideal characteristics for vaginal packing. MATERIALS AND METHODS: Three packing materials were used: DeRoyal® Fluftex™ (DeRoyal Industries, Inc., Powell, Tennessee), NHP Surgi-Pak™ vaginal packing (NHP Industries, Inc., City of Industry, California), and Curad® Plain Packing Strips (Medline Industries, Inc., Northfield, Illinois). A fluid with similar viscosity to human blood, defibrinated sheep's blood (Remel Laboratories, Nenexa Kansas) was used to saturate the materials. The primary outcome was the amount of fluid absorbance of each product in both the handpacked and unpacked state. The number of drops used to saturate each material were counted and converted to mL/g. Each product was tested three times and the results were measured by counting the number of drops needed to saturate the material in each experiment. Experiment: Three materials were obtained and conducted into two different experiments to test absorbance. The packed trial consisted of 0.1g of material and was compacted in a 146mm standard Pasteur pipette (Sigma-Aldrich Corp., St. Louis, Missouri). Droplets of sheep's blood were dispensed until each material had reached its capacity, which was determined by counting the last sequential drop received onto the respective material before the first of the fluid fell from the material into the collecting container. Trials were conducted three times per material and an average of the three trials was calculated. The second experiment tested 1g of each material unpacked and folded into eight layers. Droplets of blood were placed onto the material until each material leaked, which was defined again as the first fluid to fall from the material into the collecting container that it was suspended above. The number of drops needed to produce this effect was recorded. All droplets were counted and converted to mL/g. Standard deviation was calculated for each material in both experiments and an analysis of variance (ANOVA) single factor test was done. RESULTS: Three trials were conducted per material and there was a difference in absorbance between each packing material (p=0.02 packed, p=0.001 unpacked). Additionally, the plain packing strip absorbed the least amount of blood product in the packed and unpacked state compared to DeRoyal® Fluftex™ and NHP Surgi-Pak™ vaginal packing. The average absorbance of the packed materials was 7.7mL/g for DeRoyal® Fluftex™, 9.8mL/g for NHP Surgi-Pak™ vaginal packing, and 7.5mL/g for the Curad® Plain Packing Strips. There was a standard deviation of 2.08 drops for DeRoyal® Fluftex™, 3.51 drops for NHP Surgi-Pak™ vaginal packing, and 1.73 drops for Curad® Plain Packing Strips. Absorbance for DeRoyal® Fluftex™ unpacked was 8.2mL/g, NHP Surgi-Pak™ vaginal packing unpacked was 7.00mL/g, and Curad® Plain Packing Strips was 4.8mL/g. The standard deviation for the unpacked experiment was 29.02 drops for DeRoyal® Fluftex™, 13.61 drops for NHP Surgi-Pak™ vaginal packing, and 15.59 drops for Curad® Plain Packing Strips. A p-value of less than .05 in a confidence interval of 95% was determined. CONCLUSION: Even though there are studies showing the clinical benefits of vaginal packing after a variety of gynecological surgeries, there is less known about the characteristics of the ideal material. Minimal foreign body reaction, decreased adherence to surgical scars, X-ray visualization, low cost, and easy availability are among the ideal characteristics of the presumed ideal material used for vaginal packing. In this study, we compared the absorbance between three commonly used materials and did not find any statistical differences. Further studies are needed to show the clinical benefits and mechanical characteristics of material used for vaginal packing. Due to the lack of a statistically significant difference in absorbance between the materials, evaluation of mechanical characteristics may be beneficial in determining an ideal vaginal packing product.

RSVpreF vaccination in pregnancy: a meta-analysis of maternal-fetal safety and infant efficacy.

In May 2023, The United States Food and Drug Administration (FDA) approved a Pfizer©-sponsored (COMPANY, CITY, STATE, COUNTRY) bivalent RSVpreF (respiratory syncytial virus prefusion F protein-based vaccine) RSV vaccine (AbrysvoTM [COMPANY, CITY, STATE, COUNTRY]) for use during pregnancy to prevent neonatal/infant RSV infection. In February of 2022, FDA trials sponsored by GSK© (COMPANY, CITY, STATE, COUNTRY) on a similar RSVpreF RSV vaccine were halted because of the identification of a safety signal related to preterm births. As these vaccines use nearly identical pre-fusion F-protein technology, we sought to synthesize and evaluate the existing high-quality literature on their effectiveness and safety. From inception until March 15, 2024, we searched for randomized controlled trials (RCTs) on this topic. We used Review Manager (RevMan 5.4.1) (COMPANY, CITY, STATE, COUNTRY) to perform the analysis with 95% confidence intervals and risk ratios (RR). Our search yielded three large RCTs. From a safety perspective, many maternal side effects were greater in the RSVpreF group, with an increased incidence of local reactions (RR, 5.98 [3.68, 6.83]; P=0.01; I2=0%), blood disorders (RR, 1.07 [0.69, 1.66]; P=0.78; I2=0%), fatigue (RR, 1.05 [1.00, 1.10]; P=0.07; I2=0%), joint pain (RR, 1.60, 1.39 [0.68, 2.86]; P=0.37; I2=59%), cardiac disorders (RR, 1.19 [0.80, 1.77]; P=0.38; I2=0%), headache (RR, 0.80 [0.30, 2.10]; P=0.65; I2=0%), fever (RR, 0.90 [0.20, 4.16]; P=0.89; I2=57%), gastrointestinal disorders (RR, 1.04 [0.70, 1.56]; P=0.83; I2=0%), and pregnancy complications (RR, 1.01 [0.65, 1.56]; P=0.97; I2=17%). The vaccinated group demonstrated significant reduction RSV-lower respiratory tract disease (LRTD) cases (RR, 0.44 [0.33, 0.57]; P=0.01), severe LRT illness (RR, 0.29 [0.19, 0.44]; P=0.01), and hospitalizations (RR, 0.40 [0.24, 0.67]; P=0.005). RSVpreF vaccination was associated with a higher incidence of preterm delivery (RR, 1.24 [1.08, 1.44]; P=0.03); however, no significant difference in neonatal deaths was observed (RR, 1.42 [0.70, 2.89]; P=0.34). RSVpreF vaccination results in systemic adverse events and an increase in preterm delivery. Vaccination appeared to have acceptable short-term safety for newborns, but did not produce a significant decrease in neonatal death.

First and second-generation endometrial ablation devices: A network meta-analysis.

OBJECTIVE: First-generation and second-generation endometrial ablation (EA) techniques, along with medical treatment and invasive surgery, are considered successful lines of management for abnormal uterine bleeding (AUB). We set out to determine the efficacy of first and second-generation ablation techniques compared with medical treatment, invasive surgery and different modalities of the EA techniques themselves. DESIGN: Systematic review and network meta-analysis using a frequentist network. DATA SOURCES: We searched Medline (Ovid), PubMed, ClinicalTrials.gov, Cochrane CENTRAL, Web of Science, EBSCO and Scopus for all published studies up to 1 March 2021 using relevant keywords. ELIGIBILITY CRITERIA: We included all randomised controlled trials (RCTs) that compared premenopausal women with AUB receiving the intervention of second-generation EA techniques. DATA EXTRACTION AND SYNTHESIS: 49 high-quality RCTs with 8038 women were included. We extracted and pooled the data and then analysed to estimate the network meta-analysis models within a frequentist framework. We used the random-effects model of the netmeta package in R (V.3.6.1) and the 'Meta-Insight' website. RESULTS: Our network meta-analysis showed many varying results according to specific outcomes. The uterine balloon ablation had significantly higher amenorrhoea rates than other techniques in both short (hydrothermal ablation (risk ratio (RR)=0.51, 95% CI 0.37; 0.72), microwave ablation (RR=0.43, 95% CI 0.31; 0.59), first-generation techniques (RR=0.44, 95% CI 0.33; 0.59), endometrial laser intrauterine therapy (RR=0.18, 95% CI 0.10; 0.32) and bipolar radio frequency treatments (RR=0.22, 95% CI 0.15; 0.31)) and long-term follow-up (microwave ablation (RR=0.11, 95% CI 0.01; 0.86), bipolar radio frequency ablation (RR=0.12, 95% CI 0.02; 0.90), first generation (RR=0.12, 95% CI 0.02; 0.90) and endometrial laser intrauterine thermal therapy (RR=0.04, 95% CI 0.01; 0.36)). When calculating efficacy based only on calculated bleeding scores, the highest scores were achieved by cryoablation systems (p-score=0.98). CONCLUSION: Most second-generation EA systems were superior to first-generation systems, and statistical superiority between devices depended on which characteristic was measured (secondary amenorrhoea rate, treatment of AUB, patient satisfaction or treatment of dysmenorrhoea). Although our study was limited by a paucity of data comparing large numbers of devices, we conclude that there is no evidence at this time that any one of the examined second-generation systems is clearly superior to all others.

Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery hysterectomy versus vaginal hysterectomy for benign indications.

Objective: As the second most common surgery performed on women in the United States, hysterectomy techniques are constantly examined for validity and superiority. The vaginal natural orifice transluminal endoscopic surgery (vNOTES) has increased in popularity since the first vNOTES hysterectomy was performed in 2012. We sought out to evaluate the safety and effectiveness of hysterectomy by vNOTES compared to conventional vaginal hysterectomy for various benign indications. Data sources: We searched Scopus, Medline, PubMed, ClinicalTrials.Gov, and the Cochrane Library. Our search included all studies from each respective database's inception until September 1, 2023. Study eligibility criteria: We included eligible studies that compare vNOTES hysterectomy versus conventional vaginal hysterectomy for various benign indications, and included at least one of our preselected outcomes. The main outcomes were estimated blood loss (mL), operation time (min), length of hospital stay (d), Visual Analogue Scale pain score at Day 1, intraoperative complications, and postoperative complications. Study appraisal and synthesis methods: We analyzed data of our continuous outcomes using RevMan 5.4.1. Continuous outcomes were analyzed using mean difference (MD) and 95% confidence intervals (CIs) under the inverse variance analysis method. We assessed the quality of the studies using the ROBINS-I assessment tool. Results: We found 4 eligible studies to include in our analysis. Surgeon declared estimated blood loss was found to be similar in both groups (MD=-44.70 [-99.97, 10.57]; P=.11). Also, the total length of hospital stay (in days) was found to be comparable in both groups (MD=-0.16 [-1.62, 1.30]; P=.83). We also found no other statistically significant difference between hysterectomy by vNOTES and vaginal hysterectomy in other studied outcomes, including the duration of the operation, the Visual Analogue Scale Pain score after 1 day, intraoperative complications, and postoperative complications. Conclusion: vNOTES seems to be associated with a nonsignificant lower surgeon declared estimated blood loss. We found no other significant differences in hospital stay, intraoperative, or postoperative outcomes. Further studies may clarify if other differences in safety or efficacy exist.

Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery vs laparoscopic hysterectomy.

OBJECTIVE: Because vaginal natural orifice transluminal endoscopic surgery and laparoscopic hysterectomy techniques both aim to decrease tissue injury and postoperative morbidity and mortality and to improve a patient's quality of life, we sought to evaluate the safety and effectiveness of a hysterectomy by vaginal natural orifice transluminal endoscopic surgery and compared that with conventional laparoscopic hysterectomy among women with benign gynecologic diseases. DATA SOURCES: We used Scopus, Medline, ClinicalTrials.Gov, PubMed, and the Cochrane Library and searched from database inception to September 1, 2023. STUDY ELIGIBILITY CRITERIA: We included all eligible articles that compared vaginal natural orifice transluminal endoscopic surgery hysterectomy with any conventional laparoscopic hysterectomy technique without robotic assistance for women with benign gynecologic pathology and that included at least 1 of our main outcomes. These outcomes included estimated blood loss (in mL), operation time (in minutes), length of hospital stay (in days), decrease in hemoglobin level (g/dL), visual analog scale pain score on postoperative day 1, opioid analgesic dose required, rate of conversion to another surgical technique, intraoperative complications, postoperative complications, and requirements for blood transfusion. We included randomized controlled trials and observational studies. Ultimately, 14 studies met our criteria. METHODS: The study quality of the randomized controlled trials was assessed using the Cochrane assessment tool, and the quality of the observational studies was assessed using the ROBINS-I tool. We analyzed data using RevMan 5.4.1. Continuous outcomes were analyzed using the mean difference and 95% confidence intervals under the inverse variance analysis method. Dichotomous outcomes were analyzed using OpenMeta[Analyst] and odds ratios and 95% confidence intervals were reported. RESULTS: The operative time and length of hospitalization were shorter in the vaginal natural orifice transluminal endoscopic surgery cohort. We also found lower visual analog scale pain scores, fewer postoperative complications, and fewer blood transfusions in the vaginal natural orifice transluminal endoscopic surgery group. We found no difference in the estimated blood loss, decrease in hemoglobin levels, analgesic usage, conversion rates, or intraoperative complications. CONCLUSION: When evaluating the latest data, it seems that vaginal natural orifice transluminal endoscopic surgery techniques may have some advantages over conventional laparoscopic hysterectomy techniques.

Response to Dr. Somovilla del Saz's letter to the editor regarding "Risk of all-cause and cardiac-related mortality after vaccination against COVID-19: A meta-analysis of self-controlled case series studies".

This is a response to Dr. Somovilla del Saz's letter to the editor regarding Marchand et al.'s article, "Risk of all-cause and cardiac-related mortality after vaccination against COVID-19: A meta-analysis of self-controlled case series studies." The response is on behalf of all authors clarifying misconceptions about the work.

Effect of the decision to perform hysteroscopy on asymptomatic patients before undergoing assisted reproduction technologies-a systematic review and meta-analysis.

OBJECTIVE: Routine hysteroscopic evaluation before assisted reproductive technology treatment is a novel approach with the potential to reduce assisted reproductive technology failure even in the absence of evidence of uterine pathology. Following the publication of several relatively high-quality trials on this topic, we sought to determine if this practice is beneficial. DATA SOURCES: We searched Web of Science, MEDLINE, PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov from each database's inception until May 31, 2022 with our search strategy, attempting to locate all randomized controlled trials assessing the use of hysteroscopy in otherwise asymptomatic women undergoing assisted reproductive technology. STUDY ELIGIBILITY CRITERIA: We included only randomized controlled trials that included at least one of our selected outcomes, and we excluded any studies with suspicion of pathology before the time of hysteroscopy, other than knowledge of the patient's infertility. We included all the aforementioned studies regardless of procedures or modifications performed as a result of hysteroscopic findings. Our initial search yielded 1802 results, which were reduced to 1421 after removal of duplicates. Ultimately, 11 studies were found to meet our criteria and were included in our quantitative synthesis. METHODS: We used ReviewManager software, version 5.4.1 to analyze the data, which we imported after manually gathering from the 11 studies. Continuous and dichotomous outcomes were imported as standard deviations. Pooled analysis was described as a mean difference, relative to 95 % confidence interval in cases of continuous data. Dichotomous outcomes were analyzed using risk ratios and 95% confidence intervals. In homogeneous outcomes, we used a fixed-effects model, and in heterogeneous outcomes we used a random-effects model. RESULTS: Our results showed that hysteroscopy was associated with significant improvement in the clinical pregnancy rate (risk ratio, 1.27 [1.11-1.45]; P<.001). We found no differences between the hysteroscopy group and the control group in live birth rate (risk ratio, 1.26 [0.99-1.59]; P=.06), miscarriage rate (risk ratio, 0.99 [0.81-1.19]; P=.88), fertilization rate (risk ratio, 1.01 [0.93-1.09]; P=.88), incidence of multiple gestations (risk ratio, 1.29 [0.98-1.71]; P=.07), number of embryos transferred (mean difference, 0.04 [-0.18 to 0.26]; P=.73), chemical pregnancy rate (risk ratio, 1.01 [0.86-1.17]; P=.93), and number of oocytes retrieved (mean difference, 0.44 [-0.11 to 0.98]; P=.11). CONCLUSION: We observed an improvement in the clinical pregnancy rate, but no significant improvement in the live birth rate with routine hysteroscopy before assisted reproductive technology treatment. We believe this does not represent sufficient evidence to recommend routine hysteroscopy for otherwise asymptomatic patients before assisted reproductive technology treatment at this time.

Effect of a 20% intravenous fat emulsion therapy on pregnancy outcomes in women with RPL or RIF undergoing IVF/ICSI: a systematic review and meta-analysis.

Background and Aim: The aim of this study was to evaluate the efficacy a 20% intravenous fat emulsion therapy in women suffering from recurrent pregnancy loss or recurrent implantation failure (RPL/RIF) who are undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Materials and Methods: We searched Cochrane Library, ISI Web of Science, MEDLINE, ClinicalTrials.gov, PubMed, and Scopus using relevant keywords during February 2020 for randomized controlled trials (RCTs) comparing the therapy versus placebo or no intervention in women suffering from RPL/RIF and undergoing IVF/ICSI. Results: We included five RCTs with 840 patients. The intravenous fat emulsion therapy was significantly effective in increasing clinical pregnancy rates compared to the control group (risk ratios [RR] = 1.48, 95% confidence intervals [CI] [1.23, 1.79], P < 0.001). Furthermore, ongoing pregnancy and live birth rates were significantly higher with 20% intravenous fat emulsion therapy RR = 1.71, 95% CI [1.27, 2.32], P = 0.005 and RR = 1.85, 95% CI [1.44, 2.38], P < 0.001. Despite the statistically significant differences, the quality of evidence was only considered moderate, and this was primarily due to high risk of bias in the included RCTs. Conclusion: Our review provides a moderate level of evidence that intravenous fat emulsion therapy is effective in improving reproductive outcomes among women with RPL/RIF performing IVF/ICSI techniques. Further, investigation is required to ascertain optimal dosage and timing of administration. Relevance for Patients: Women suffering from RPL or RIF may wish to consider discussing with their reproductive endocrinologist the addition of a 20% fat emulsion therapy to planned IVF or ICSI cycles, which may improve outcomes.

Adnexal masses suspected to be benign treated with laparoscopy.

OBJECTIVE: Guidelines for referring women with pelvic masses suspicious for ovarian cancer to gynecologic oncologists have been developed by the American College of Obstetrician Gynecologists (ACOG). We set out to evaluate the negative predictive value of these guidelines and to assess a modified algorithm involving minimally invasive surgery in the treatment of women with masses suspected to be benign. METHODS: 257 consecutive patients with adnexal masses of 8cm to 13cm on preoperative ultrasound examination meeting Triage Criteria set forth in ACOG Committee Opinion 280. Patients meeting the selection criteria were scheduled for operative laparoscopy, washings, adnexectomy, bagging, and colpotomy. A total of 240 patients successfully completed intended treatment (93.38%), and 234 of these did not require admission (97.5%). There was a low incidence of significant complications: 97.50% of women were successfully treated as outpatients, 97.92% of surgeries lasted <136 minutes, and <97.08% had blood loss <200mL. The negative predictive value of ACOG Committee Opinion 280 Triage Criteria as a deselector for having invasive ovarian malignancy in our population was 95.57% for premenopausal and 90.91% for postmenopausal women. CONCLUSIONS: Laparoscopic adnexectomy, bagging, and colpotomy is a desirable goal for patients with ovarian masses in the 8cm to 13cm range meeting selection criteria affording a minimally invasive approach with attendant benefits including outpatient treatment (97.5%), few complications, low likelihood of iatrogenic rupture of the ovarian capsule (1.25%), and low necessity for reoperation after final pathology is evaluated (6.03%). Negative predictive value of ACOG Committee Opinion 280 is confirmed in a community gynecology practice and is recommended to form the basis of a new treatment algorithm for women with adnexal masses.

Treatment of Cesarean Scar Ectopic Pregnancy in China with Uterine Artery Embolization-A Systematic Review and Meta-Analysis.

Cesarean scar ectopic pregnancy (CSP) is a rare form of ectopic pregnancy, and treatment of CSP with uterine artery embolization (UAE) is a novel approach. With increasing numbers of cesarean sections being performed annually, the incidence of this condition is likely to increase. The authors became aware of an unusually high number of published studies originating in mainland China regarding this unusual treatment and sought to perform a meta-analysis to provide comprehensive evidence on this novel practice. METHODS: We performed a thorough search and included all forms of quality studies on this topic that reported UAE as a part of first-line management of CSP. We included only studies originating in China. Ultimately, 37 studies were included for qualitative and quantitative synthesis of evidence. After screening retrieved records and extracting data from eligible studies, we pooled continuous data as a mean estimate and 95% confidence interval (CI), and dichotomous data as proportion and 95% CI. RESULTS: CSP patients treated with protocols including UAE had a mean time of 30 days for serum ß-hCG normalization, 95% CI [26.816, 33.881]. They had a mean estimated intraprocedural blood loss of 4.19 ± 3.76 mL, a mean hospital stay of nine days, 95%CI [7.914, 9.876], and a success rate of 93.4%, 95%CI [0.918, 0.951]. The severe complication rate was 1.2%, 95%CI [0.008, 0.017]. CONCLUSION: UAE, in combination with other procedures is being used effectively for the treatment of CSP in China. Protocols including UAE have a success rate of approximately 93.4%, and a severe complication rate of approximately 1.2%. This data's utility is limited by vast differences in the studied protocols and questionable feasibility outside of China.

Systematic review and meta-analysis of Veress needle entry versus direct trocar entry in gynecologic surgery.

Objective: Although many studies have been performed, no consensus exists as to the ideal entry for laparoscopic gynecologic surgery. We sought out to compare the safety of direct trocar insertion with that of the Veress needle entry technique in gynecologic laparoscopic surgery. Design: Systematic review with meta-analysis. Setting: We searched Medline, ClinicalTrials.Gov, PubMed, Cochrane CENTRAL, SCOPUS, and Web of Science from their inception through 31 July 2021 for relevant studies. We included only controlled trials and ultimately seven trials were included in our meta-analysis. Participants: Inclusion criteria included women undergoing gynecological laparoscopic surgery. Intervention: The intervention of direct trocar insertion technique compared with Veress needle entry technique. Main outcome measures: We compared five different outcomes associated with the efficacy and complications of laparoscopic entry. Results: The pooled analysis showed that Veress needle entry was associated with a significant increase in the incidences of extraperitoneal insufflation (RR=0.177, 95% Cl (0.094 to 0.333), p<0.001), omental injury (RR=0.418, 95% Cl (0.195 to 0.896), p<0.001), failed entry (RR=0.173, 95% Cl (0.102 to 0.292), p<0.001), and trocar site infection (RR=0.404, 95% Cl (0.180 to 0.909), p<0.029). There was no significant difference between the two groups regarding the visceral injury (RR=0.562, 95% Cl (0.047 to 6.676), p<0.648). Conclusions: When excluding all data apart from gynecologic surgery, the Veress needle entry technique may have an increased incidence of some, but not all complications of laparoscopic entry. It may also have a higher incidence of failed entry compared with direct entry techniques. Care should be taken in extrapolating these general results to specific surgeon experience levels. Trial registration number: CRD42021273726.

Salpingectomy, tubal ligation and hysteroscopic occlusion for sterilization.

INTRODUCTION: Sterilization of females is considered one of the most prevalent contraceptive techniques among women in the United States. There are many surgical sterilization procedures including salpingectomy, tubal ligation, and hysteroscopic occlusion of the fallopian tubes. We provide an overview of these methods from the clinical data and latest studies available on this topic. EVIDENCE ACQUISITION: In order to review the latest literature on the topic, we searched electronic databases including PubMed, Web of Science, Scopus, and Cochrane library for all eligible studies from May 1st 2018 until May 1st 2022 using the following strategy: ("fallopian tube removal" OR Salpingectomy OR "fallopian tube excision" OR "tubal sterilization") AND ("tubal ligation" OR "bipolar coagulation" OR "tubal clip" OR "tubal ring" OR fimbriectomy). We reviewed every study that met our criteria and subjectively considered their results and methodology into this narrative review. EVIDENCE SYNTHESIS: In addition to reviewing major guidelines in the United States, 19 recent studies met our eligibility criteria and were included in this review. We grouped the findings under the following headings: anatomical and physiological considerations, sterilization, salpingectomy, tubal ligation, and hysteroscopic tubal occlusion. CONCLUSIONS: Bilateral salpingectomy and techniques of tubal ligation or occlusion continue to be effective procedures with good safety profiles. All techniques have similar surgical outcomes and long-term success rates. As salpingectomy has the advantage of reducing the risk of occurrence of ovarian cancer, this is preferential when feasible. Hysteroscopic occlusion techniques may be more minimally invasive but have the disadvantages of delayed efficacy, the need for a second invasive diagnostic procedure, and limited availability.

Efficacy of hyoscine in pain management during hysteroscopy: a systematic review and meta-analysis

We conducted a systematic review and meta-analysis of relevant clinical trials from full-text, scientific journal archives to assess the efficacy of hyoscine for the management of pain during in-office hysteroscopy (OH) procedures. Cochrane CENTRAL, ClinicalTrials.Gov, MEDLINE, PubMed, SCOPUS and the Web of Science were searched for all clinical trials that matched our search criteria. A full assessment of bias was made using the Cochrane Group tool-set. The following outcomes were included: visual analogue scale (VAS) score for postoperative pain, postoperative need for analgesia, and procedure time. In the case of homogeneous data, the analysis was performed using a fixed effects system, and the random effects system was used with heterogeneous data. Inclusion criteria included only randomized clinical trials, and interventions that included patients receiving hyoscine-N-Butyl Bromide during OH, regardless of dose or mode of administration, and compared this with placebo. Three clinical trials were included. The actual mean difference (MD) of the VAS pain score showed no significant difference between hyoscine or placebo [MD: -0.28 (-1.08, 0.52), (p=0.49)]. For postoperative analgesia, the overall MD showed no significant difference between hyoscine or placebo [MD: 0.43 (0.16, 1.14), (p=0.09)]. For procedure time, the combined effect estimate failed to show any significant difference between hyoscine and placebo [MD: -0.66 (-2.77, 1.44) (p=0.54)]. Contrary to previously published data, our meta-analysis using the latest available RCTs fails to show hyoscine as being effective in reducing pain or the need for other forms of anesthesia in OH.

Case Report of a Rare Nonpuerperal Uterine Inversion Managed with Uterosacral Ligament Hysteropexy.

Nonpuerperal uterine inversions are rare. Typically occurring in older women, they are most commonly due to transcervical mass expulsion. Diagnosis is often difficult because of vague symptomatology, presentation, and unknown course of the pathology. Surgical correction is often necessary in the presence of active bleeding or prolapse severity causing urinary retention. This case of nonpuerperal inversion presented to the emergency department with vaginal bleeding and mass protrusion. The examination was consistent with POPQ stage IV prolapse and uterine inversion secondary to cervical expulsion of multiple uterine fibroids. Because of full cervical dilation and concerns of ureteral injury with an extirpative procedure, vaginal myomectomy was performed with concomitant robotic uterosacral ligament hysteropexy. The operative procedure and postoperative course were uncomplicated, and discharge occurred on post-op day 1. She remained asymptomatic at the 6-month follow-up encounter. Though uterine preservation has been performed in cases of uterine inversion to maintain fertility, there are no reported cases of concomitant hysteropexy being completed for correction of POPQ stage IV prolapse simultaneously encountered. Additionally, the novel robotic approach has not been documented. This case illustrates the short-term success of robotic uterosacral hysteropexy as an additional option of care with potentially less morbidity when compared to hysterectomy for advanced stage uterine prolapse with nonpuerperal uterine inversion.

Feasibility of Risk Reducing Salpingo-Oophorectomy at the Time of Abdominal Surgery for Correction of Pelvic Organ Prolapse and Urinary Incontinence.

OBJECTIVE: The objective of this study is to assess the perioperative outcomes when prophylactic bilateral salpingo-oophorectomy (BSO) is performed concomitantly with surgery to repair pelvic organ prolapse (POP) or stress urinary incontinence (SUI). MATERIALS AND METHODS: This is a retrospective case-control study of patients who underwent abdominal surgery for the correction of POP and/or SUI with or without concomitant BSO at a tertiary care center. The primary outcome measures were postsurgery length of hospitalization, estimated blood loss, and 30-day readmission rate. The secondary outcome measure was detection of ovarian cancer precursor lesions. RESULTS: We identified 734 patients who had surgery for POP and/or SUI. The control group contained 385 patients, and the BSO group contained 349 patients. There was no difference between the control and BSO groups in the postsurgery length of stay (LOS) (35.2 h vs. 34.1 h; P = 0.49), and all-cause 30-day readmission rate (14.2% vs. 11.6%; P = 0.3085). However, there was decreased blood loss (40.8 ml vs. 67.2 ml, P < 0.0001) in the BSO group compared to the control group. Sub-analysis of primary outcomes in postmenopausal women (age > 55) showed decreased postsurgery LOS (33.4 h vs. 37.4 h; P = 0.0208) and decreased blood loss (35.9 ml vs. 82.7 ml; P < 0.0001) in the BSO group compared to control. CONCLUSION: Secondary to the lack of additional complications, we recommend surgeons give more consideration to finding appropriate candidates for a risk reducing BSO at time of abdominal surgery to repair POP or SUI.

Systematic review of the effect of implementing enhanced recovery after surgery on selected attributes of surgical recovery in gynecology

This study aimed to systematically review the available literature on enhanced recovery after surgery (ERAS) following gynecologic procedures performed either as an open surgery or as a minimally invasive gynecological surgery (MIGS) in terms of outcomes. This review revealed the results of published literature and assessed the benefits and diverse outcomes of ERAS implementation in patients undergoing MIGS or other gynecologic surgeries. In this review, we sought to examine the efficacy of entire ERAS protocols, faithfully performed, to determine whether they were successful in improving individual attributes of surgical recovery. Electronic databases of PubMed, Cochrane, Web of Science, Scopus, MEDLINE, and ClinicalTrials.gov were systematically searched in January 2021 for relevant studies. Data were extracted from eligible studies including LOS, change in the quality-of-life and recovery over time, postoperative complications including nausea and vomiting, opioid or anesthesia use, hospital cost, patient satisfaction, postoperative pain, and readmission rate as outcomes. Many of the included studies reported a significant reduction in the LOS as well as in readmission rates, hospital cost, and occurrence of nausea and vomiting postoperatively. Moreover, a clinically significant increase was noted in patient satisfaction in studies that have used tools that measure patient satisfaction. No studies have reported a significant increase in the overall quality of recovery using appropriately validated tools. Following ERAS implementation, patients' postoperative rehabilitation, including postoperative discomfort, readmission rates, and satisfaction, showed a clinically significant improvement.