Gynecologic Surgery Research Articles

Perioperative liberal drinking management promotes postoperative gastrointestinal function recovery after gynecological laparoscopic surgery: A randomized controlled trial

Study objectiveThis study aims to evaluate the effect of perioperative liberal drinking management, including preoperative carbohydrate loading (PCL) given 2 h before surgery and early oral feeding (EOF) at 6 h postoperatively, in enhancing postoperative gastrointestinal function and improving outcomes in gynecologic patients. The hypotheses are that the perioperative liberal drinking management accelerates the recovery of gastrointestinal function, enhances dietary tolerance throughout hospitalization, and ultimately reduces the length of hospitalization. DesignA prospective randomized controlled trial. SettingOperating room and gynecological ward in Wuhan Union Hospital. PatientsWe enrolled 210 patients undergoing elective gynecological laparoscopic surgery, and 157 patients were included in the final analysis. InterventionsPatients were randomly allocated in a 1:1:1 ratio into three groups, including the control, PCL, and PCL-EOF groups. The anesthetists and follow-up staff were blinded to group assignment. MeasurementsThe primary outcome was the postoperative Intake, Feeling nauseated, Emesis, Examination, and Duration of symptoms (I-FEED) score (range 0 to 14, higher scores worse). Secondary outcomes included the incidence of I-FEED scores >2, and other additional indicators to monitor postoperative gastrointestinal function, including time to first flatus, time to first defecation, time to feces Bristol grade 3–4, and time to tolerate diet. Additionally, we collected other ERAS recovery indicators, including the incidence of PONV, complications, postoperative pain score, satisfaction score, and the quality of postoperative functional recovery at discharge. Main resultsThe PCL-EOF exhibited significantly enhanced gastrointestinal function recovery compared to control group and PCL group (p < 0.05), with the lower I-FEED score (PCL: 0[0,1] vs. PCL-EOF: 0[0,0] vs. control: 1[0,2]) and the reduced incidence of I-FEED >2 (PCL:8% vs. PCL-EOF: 2% vs. control:21%). Compared to the control, the intervention of PCL-EOF protected patients from the incidence of I-FEED score > 2 [HR:0.09, 95%CI (0.01–0.72), p = 0.023], and was beneficial in promoting the patient's postoperative first flatus [PCL-EOF: HR:3.33, 95%CI (2.14–5.19),p < 0.001], first defecation [PCL-EOF: HR:2.76, 95%CI (1.83–4.16), p < 0.001], Bristol feces grade 3–4 [PCL-EOF: HR:3.65, 95%CI (2.36–5.63), p < 0.001], first fluid diet[PCL-EOF: HR:2.76, 95%CI (1.83–4.16), p < 0.001], and first normal diet[PCL-EOF: HR:6.63, 95%CI (4.18–10.50), p < 0.001]. Also, the length of postoperative hospital stay (PCL-EOF: 5d vs. PCL: 6d and control: 6d, p < 0.001), the total cost (PCL-EOF: 25052 ± 3650y vs. PCL: 27914 ± 4684y and control: 26799 ± 4775y, p = 0.005), and postoperative VAS pain score values [POD0 (PCL-EOF: 2 vs. control: 4 vs. PCL: 4, p < 0.001), POD1 (PCL-EOF: 1 vs. control: 3 vs. PCL: 2, p < 0.001), POD2 (PCL-EOF: 1 vs. control:2 vs. PCL: 1, p < 0.001), POD3 (PCL-EOF: 0 vs. control: 1 vs. PCL: 1, p < 0.001)] were significantly reduced in PCL-EOF group. ConclusionsOur primary endpoint, I-FEED score demonstrated significant reduction with perioperative liberal drinking, serving as a protective intervention against I-FEED>2. Gastrointestinal recovery metrics, such as time to first flatus and defecation, also showed substantial improvements. Furthermore, the intervention enhanced postoperative dietary tolerance and expedited early recovery.Trial registration: ChiCTR2300071047(https://www.chictr.org.cn/).

Retroperitoneal Leiomyoma as a Source of Pelvic Pain: A Case Report and Review of the Literature

Purpose: Leiomyomas are benign growths originating from the myometrium of the uterus and the most common pelvic tumor in women. They are frequently a source of abnormal uterine bleeding and pelvic pain, but occasionally occur outside of the uterus. Retroperitoneal leiomyomas are exceedingly rare with only about 100 cases noted in systematic reviews and literature searches. Given its rarity, preoperative diagnosis can be challenging. Our purpose is to raise awareness of this condition by reporting a case of retroperitoneal leiomyoma as an unexpected source of pelvic pain and (2) reviewing literature for commonly seen patient presentations, preoperative diagnostic challenges, and management of retroperitoneal leiomyomas. Case Report: Patient was a 34-year-old nulliparous woman who presented with pelvic cramping, rectal pressure, and dysmenorrhea and was found to have an adnexal mass of unclear origin on pelvic ultrasound and computed tomography. Follow-up magnetic resonance imaging (MRI) showed a heterogenous mass containing macroscopic fat next to the left ovary with possible “claw sign”, but also abutting the sigmoid colon. Ovarian mass was the preoperative suspected diagnosis based on imaging. Tumor markers were negative. Patient underwent a diagnostic laparoscopy and a 7-centimeter globular mass was noted retroperitoneally along the left pelvic side wall, completely separate from the uterus and adnexa. It did not appear to involve the ureter or sigmoid colon. Given clear visualization of surrounding structures, it was carefully resected from the pararectal space given likely source of pelvic pain. Pathology resulted as leiomyoma and endometriosis. An English language PUBMED, MEDLINE, CINAHL search for retroperitoneal leiomyomas yielded 34 case reports available for review. Five of the cases were in the United States and 29 were international. One systematic review was identified that spanned cases from 1941-2007. These case reports were then reviewed for patient characteristics, imaging findings, treatment, and follow-up to summarize common findings. Results: Pathophysiology of extrauterine fibroids - Retroperitoneal leiomyomas may originate as an unintended consequence of the power morcellation leading to seeding of cells sprayed during shredding. Extrauterine myomas in a patient without a history of morcellation is theorized to be a pedunculated fibroid that torses on itself, detaches from the uterus, attaches to other tissue, and then is sustained through neovascularization. They may also be of primary multifocal origin, rather than metastatic or parasitic. As with intrauterine leiomyomas, there is also a small risk (&lt;0.01%) that the fibroid may be a leiomyosarcoma. Patient characteristics - A systemic review of retroperitoneal leiomyoma case reports revealed a mean age of 46.27 years. Seventy percent of patients had never undergone gynecologic surgery, while 29% had a previous hysterectomy or myomectomy. Of patients that still had a uterus, 29% had concurrent uterine leiomyomas. If symptomatic, these masses can present as nonspecific or bulk symptoms depending on size and location. These include fatigue, discomfort, back and/or pelvic pain, constipation, and urinary incontinence. Around 25% of patients may be asymptomatic. Imaging findings - As in our above case, retroperitoneal leiomyomas can be difficult to diagnose on imaging. Imaging workup for pelvic pain with concern for a mass should begin with pelvic ultrasound. MRI can be useful as an imaging modality when ultrasound has poor delineation, rapid growth is noted, or malignancy is suspected. This can additionally be helpful for surgical planning if a diagnostic laparoscopy is planned for further evaluation. As in our patient, however, MRI can also be misleading. If encountered intraoperatively, extrauterine myoma should be part of the differential for a retroperitoneal mass. Treatment - Complete surgical excision of the mass is recommended. Depending on imaging and patient risk factors for malignancy, referral to a gynecology oncology specialist can be considered. Recurrence is rare, but long-term follow up is recommended for surveillance. As they have been shown to have estrogen and progesterone receptors, minimizing hormone usage can be beneficial. In the case of recurrence, long-term therapy with gonadotropin-releasing hormone agonists or aromatase inhibitors could be considered. Conclusion: Preoperative diagnosis of extrauterine leiomyoma can be extremely difficult. This case was unique in that adnexal mass was the preoperative diagnosis. MRI can be useful as an imaging modality when ultrasound has poor characterization or is concerning for malignancy. If encountered intraoperatively, extrauterine myoma should be part of the differential for a pelvic mass. Complete excision is the definitive treatment for retroperitoneal myomas. Post-excision surveillance is recommended to screen for the rare possibility of recurrence.

Retroperitoneal Leiomyoma as a Source of Pelvic Pain: A Case Report and Review of the Literature

Purpose: Leiomyomas are benign growths originating from the myometrium of the uterus and the most common pelvic tumor in women. They are frequently a source of abnormal uterine bleeding and pelvic pain, but occasionally occur outside of the uterus. Retroperitoneal leiomyomas are exceedingly rare with only about 100 cases noted in systematic reviews and literature searches. Given its rarity, preoperative diagnosis can be challenging. Our purpose is to raise awareness of this condition by reporting a case of retroperitoneal leiomyoma as an unexpected source of pelvic pain and (2) reviewing literature for commonly seen patient presentations, preoperative diagnostic challenges, and management of retroperitoneal leiomyomas. Case Report: Patient was a 34-year-old nulliparous woman who presented with pelvic cramping, rectal pressure, and dysmenorrhea and was found to have an adnexal mass of unclear origin on pelvic ultrasound and computed tomography. Follow-up magnetic resonance imaging (MRI) showed a heterogenous mass containing macroscopic fat next to the left ovary with possible “claw sign”, but also abutting the sigmoid colon. Ovarian mass was the preoperative suspected diagnosis based on imaging. Tumor markers were negative. Patient underwent a diagnostic laparoscopy and a 7-centimeter globular mass was noted retroperitoneally along the left pelvic side wall, completely separate from the uterus and adnexa. It did not appear to involve the ureter or sigmoid colon. Given clear visualization of surrounding structures, it was carefully resected from the pararectal space given likely source of pelvic pain. Pathology resulted as leiomyoma and endometriosis. An English language PUBMED, MEDLINE, CINAHL search for retroperitoneal leiomyomas yielded 34 case reports available for review. Five of the cases were in the United States and 29 were international. One systematic review was identified that spanned cases from 1941-2007. These case reports were then reviewed for patient characteristics, imaging findings, treatment, and follow-up to summarize common findings. Results: Pathophysiology of extrauterine fibroids - Retroperitoneal leiomyomas may originate as an unintended consequence of the power morcellation leading to seeding of cells sprayed during shredding. Extrauterine myomas in a patient without a history of morcellation is theorized to be a pedunculated fibroid that torses on itself, detaches from the uterus, attaches to other tissue, and then is sustained through neovascularization. They may also be of primary multifocal origin, rather than metastatic or parasitic. As with intrauterine leiomyomas, there is also a small risk (&lt;0.01%) that the fibroid may be a leiomyosarcoma. Patient characteristics - A systemic review of retroperitoneal leiomyoma case reports revealed a mean age of 46.27 years. Seventy percent of patients had never undergone gynecologic surgery, while 29% had a previous hysterectomy or myomectomy. Of patients that still had a uterus, 29% had concurrent uterine leiomyomas. If symptomatic, these masses can present as nonspecific or bulk symptoms depending on size and location. These include fatigue, discomfort, back and/or pelvic pain, constipation, and urinary incontinence. Around 25% of patients may be asymptomatic. Imaging findings - As in our above case, retroperitoneal leiomyomas can be difficult to diagnose on imaging. Imaging workup for pelvic pain with concern for a mass should begin with pelvic ultrasound. MRI can be useful as an imaging modality when ultrasound has poor delineation, rapid growth is noted, or malignancy is suspected. This can additionally be helpful for surgical planning if a diagnostic laparoscopy is planned for further evaluation. As in our patient, however, MRI can also be misleading. If encountered intraoperatively, extrauterine myoma should be part of the differential for a retroperitoneal mass. Treatment - Complete surgical excision of the mass is recommended. Depending on imaging and patient risk factors for malignancy, referral to a gynecology oncology specialist can be considered. Recurrence is rare, but long-term follow up is recommended for surveillance. As they have been shown to have estrogen and progesterone receptors, minimizing hormone usage can be beneficial. In the case of recurrence, long-term therapy with gonadotropin-releasing hormone agonists or aromatase inhibitors could be considered. Conclusion: Preoperative diagnosis of extrauterine leiomyoma can be extremely difficult. This case was unique in that adnexal mass was the preoperative diagnosis. MRI can be useful as an imaging modality when ultrasound has poor characterization or is concerning for malignancy. If encountered intraoperatively, extrauterine myoma should be part of the differential for a pelvic mass. Complete excision is the definitive treatment for retroperitoneal myomas. Post-excision surveillance is recommended to screen for the rare possibility of recurrence.

Evaluation of Various Indications of Total Abdominal Hysterectomy in Holy Family Red Crescent Medical College Hospital for Last 20 Months

Background: Total Abdominal Hysterectomy (TAH) is a common surgical procedure for treating various gynecological conditions. This study aims to evaluate the demographic characteristics, comorbidities, and clinical indications for TAH at Holy Family Red Crescent Medical College Hospital, Dhaka, Bangladesh. Methods: This retrospective study included all TAH cases performed from January 2018 to August 2019. Data on patient age, comorbidities (hypertension and diabetes), and indications for TAH were collected from hospital records. Descriptive statistics were used to analyze the data. Results: A total of 320 TAH cases were reviewed. The most common age group was 41-50 years (43.13%), followed by patients aged ≤40 years (31.56%). Hypertension was present in 36.25% of the patients, and diabetes was observed in 30.94%. The most frequent indication for TAH was fibroid uterus (55.63%), followed by adenomyosis (18.75%) and post-menopausal bleeding (14.38%). Other indications included ovarian cysts (5.63%), endometrial hyperplasia (5.00%), and pelvic mass (6.25%). Conclusion: The findings highlight uterine fibroids, adenomyosis, and post-menopausal bleeding as the primary indications for TAH, with a significant prevalence of hypertension and diabetes among the patients. Effective management strategies for these conditions and considerations of comorbidities are crucial in optimizing surgical outcomes. Further research into minimally invasive techniques may enhance patient care in gynecological surgery.

The Rendezvous Technique: A Minimally Invasive Non-Surgical Approach for the Management of Iatrogenic Ureteral Injuries.

Background/Objectives: The aim of our study is to evaluate the feasibility and efficacy of the rendezvous technique for the treatment of iatrogenic ureteral injuries. Methods: From 2014 to 2019, 29 patients treated with the rendezvous technique for mono- or bilateral iatrogenic ureteral injuries were enrolled in this retrospective study. All the leaks were previously assessed by CT-urography and antegrade pyelography. Ureteral continuity was restored by performing the rendezvous technique, combining antegrade trans-nephrostomic access and a retrograde trans-cystostomic approach. A double J stent was antegradely inserted, and a nephrostomy tube was kept in place at the end of the procedure. A post-procedure CT-urography and a 30-day nephrostogram follow-up were performed. In the absence of a contrast leak, the nephrostomy tube was removed. Patient follow-up was set with CT-urography at 3, 6, and 12 months and stent substitution every 4 months. The CT-urography was performed to confirm the restored integrity of the ureter before stent removal. Results: The rendezvous technique was successful in all cases with the resolution of the ureteral leak. No major complications were observed. In all the patients, the nephrostomy tube was removed after 30 days. After performing CT-urography, the stent was removed permanently after 12 months. Only three cases showed local post-treatment stenosis treated with surgical ureteral reimplantation. Conclusions: The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter, avoiding open surgery and providing valuable support for the management of complications after gynecological surgery.

When synchronous mucinous metaplasia and neoplasia of the female genital tract and peutz-jeghers syndrome meet: a case report and literature reviews

BackgroundPeutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous polyps in the gastrointestinal tract and mucocutaneous pigmentation on the lips, oral mucosa, nose, fingers, and toes. Synchronous mucinous metaplasia and neoplasia of the female genital tract (SMMN-FGT) refers to the occurrence of multifocal mucinous lesions in at least two sites, including the cervix, uterus, fallopian tubes, and ovaries, in the female genital tract. SMMN-FGT and PJS are rare diseases with a very low incidence, especially when occurring simultaneously.Case presentationWe report a case in which a woman with a large mass on the left ovary underwent a gynecological surgery and was diagnosed with cervical gastric-type adenocarcinoma and mucinous lesions in the endometrium, bilateral fallopian tubes, and ovary, i.e., SMMN-FGT, by postoperative paraffin pathology. The patient sought medical attention for abdominal distension and enlargement. A gynecological ultrasound revealed a multilocular cystic mass in the pelvis, while serum tumor markers were within normal limits, with mildly elevated carbohydrate antigen 199 and carbohydrate antigen 125 levels. Cervical thin-prep cytology test result was negative. The patient had a family history of PJS with black spots on her skin and mucous membranes since the age of 8 years. She underwent multiple partial small bowel resections and gastrointestinal polypectomy owing to intestinal obstruction and intussusception. She underwent left adnexectomy, hysterectomy, right salpingectomy, greater omental resection, appendectomy and right ovary biopsy, and received six courses of adjuvant chemotherapy with Lopressor plus Carboplatin. Genetic testing revealed a heterozygous serine threonine kinase 11 germline mutation and there were no signs of recurrence during the 18-month follow-up period after treatment.ConclusionsThis is a rare case in which PJS was complicated by SMMN-FGT. Owing to its extreme rarity, there are no guidelines, but reported cases appear to indicate a poor prognosis. We retrospectively reviewed all cases of collisions between PJS and SMMN-FGT and explored the clinical features, pathological characteristics, diagnosis, treatment methods, and prognosis when the two diseases coexisted. The aim is to deepen the clinicians’ understanding of this disease for early detection, diagnosis and treatment.

Case Report of Lipomyoma

Report: Uterine lipoleiomyoma are rare forms of leiomyomas that are often only described in literature as case reports. Lipoleiomyomas could increase in size despite menopause and most commonly occur in postmenopausal women with an incidence rate of 0.03% to 0.2% Clinical symptoms of lipoleiomyoma are very similar to leiomyoma. Radiologic imaging can aid in the diagnosis of lipoleiomyoma with smooth muscle confined to the tumor periphery. In our case, we describe a 53y/o G0P0 perimenopausal patient who complained of abnormal uterine bleeding with irregular menses, urinary retention and difficulty completely emptying her bladder due to the large mass compressing her bladder. She was diagnosed with a large 8.8 cm hyperechoic lesion with internal vascularity arising from the central uterus/ endometrium. Radiology recommended a pelvic MRI for further differentiation of mass. Office hysteroscopy with endometrial biopsy was performed. Pathology confirmed limited inactive endometrium, benign endometrial surface epithelium. The patient requested a hysterectomy through a minimally invasive gynecologic surgery approach. A pelvic MRI was performed that revealed a large, round, circumscribed mass measuring 7.3 X 7.2 X 7.5 cm favoring to represent an intramural lipoleiomyoma. The patient had a robotic assisted laparoscopic hysterectomy which was uncomplicated. Final histopathologic diagnosis was uterine lipomyoma. As benign masses, management for lipoleiomyoma are guided by symptoms, fertility preservation desires, and whether or not a patient is a candidate for surgical intervention. Given the rarity of these cases, the histogenesis is still relatively unknown although various theories exist such as differentiation of embryonic fat cells, metaplastic changes of existing cells into fat cells, and pluripotent cell migration. Although there was not evidence of malignancy in our case report, certain literature has suggested the presence of coexisting malignancies and in an even rarer occasion the presence of liposarcoma from a lipoleiomyoma. More information is needed on these rare cases in order to further lead management and any recommendations regarding cancer screening on top of age related recommendations already in place.

Innovations in Hybrid Laparoscopic Surgery: Integrating Advanced Technologies for Multidisciplinary Cases.

Combining conventional laparoscopic techniques with cutting-edge technologies, such as robotics, improved imaging, and flexible equipment, hybrid laparoscopic techniques represent a revolutionary advancement in minimally invasive surgery. These methods have several benefits, such as increased accuracy, quicker healing periods, and fewer complications, which makes them especially useful in complicated multidisciplinary situations. The historical evolution, uses, benefits, and drawbacks of hybrid laparoscopic procedures are examined in this narrative review, which also covers urological, gastrointestinal, cardiothoracic, and gynecological surgery. The review focuses on how these methods promote interdisciplinary cooperation and creativity by enabling more accurate and successful surgical operations. It also discusses the equipment needs, integration difficulties, and technical difficulties that need to be resolved to reach the full potential of hybrid laparoscopic surgery. For hybrid laparoscopic procedures to become more widely used and effective in the future, there is a need for specialized training programs, interdisciplinary research collaborations, and ongoing technological advancements.

Laboratory findings of postoperative venous thromboembolism (VTE) in Dr. Sardjito General Hospital, Yogyakarta

Venous thromboembolism (VTE) is a significant risk, especially for older individuals. Indonesian studies found 37.1% VTE incidence in bedridden patients over 40 and 2.1% in major surgeries. Surgery, like hip fractures, raises the risk temporarily. Diagnosis relies on tests like ultrasound with Doppler, Wells score, and neutrophil-to-lymphocyte ratio (NLR). This study aimed to evaluate the laboratory findings of postoperative VTE. A retrospective analysis was conducted in Dr. Sardjito General Hospital, Yogyakarta using medical record data of VTE patients who underwent major surgery. The laboratory data, including complete blood count characteristics for every month for three months after postsurgery and DVT presentation when it occurred on the diagnostic day were collected. In total of 27 patients involved in this study, VTE cases were more common in digestive (41.2%) and obstetric gynecology surgeries (29.4%) for females, and nervous (44.4%) and cardiovascular surgeries (22.2%) for males. Females had a higher prevalence of Well Score ≥3 (82.4% vs 40%; p=0.058) and longer VTE therapy durations (65.50 ± 46.51 vs 39.60 ± 41.04 d; p=0.172). Males had more unilateral VTE occurrences (90.9 vs 56.3%; p=0.070) and a higher proportion of total occlusion cases (60 vs 37.5%; p=0.422). NLR exhibited a significant decrease from the 1st to the 2nd month (10.52 vs 3.64; p=0.009), followed by an insignificant increase in the 3rd month (3.64 vs 3.98; p=0.878). Notably, NLR trended downward in the 2nd month examination. In conclusion, VTE occurs in 0.21% of postoperative patients, with the highest incidence observed in post-gynecological surgery patients. The NLR can serve as a diagnostic tool for VTE in extremities, as an elevated NLR indicates the presence of a more proximal thrombus.

TP53 somatic evolution in cervical liquid-based cytology and blood from individuals with and without ovarian cancer and BRCA1 or BRCA2 germline mutations.

Somatic TP53 mutations are prevalent in normal tissue but little is known about their association with cancer risk. Cervical liquid-based cytology (LBC), commonly known as Pap test, provides an accessible gynecological sample to test the value of TP53 somatic mutations as a biomarker for high-grade serous ovarian cancer (HGSC), a cancer type mostly driven by TP53 mutations. We used ultra-deep duplex sequencing to analyze TP53 mutations in LBC and blood samples from 70 individuals (30 with and 40 without HGSC) undergoing gynecologic surgery, 30 carrying BRCA1 or BRCA2 germline pathogenic variants (BRCApv). Only 30% of the tumor mutations were found in LBC samples. However, TP53 pathogenic mutations were identified in nearly all LBC and blood samples, with only 5.4% of mutations in LBC (20/368) also found in the corresponding blood sample. TP53 mutations were more abundant in LBC than in blood and increased with age in both sample types. BRCApv carriers with HGSC had more TP53 clonal expansions in LBC than BRCApv carriers without cancer. Our results show that, while not useful for direct cancer detection, LBC samples capture TP53 mutation burden in the gynecological tract, presenting potential value for cancer risk assessment in individuals at higher hereditary risk for ovarian cancer.

Fast-Track surgery protocol in perioperative care for gynecological laparoscopy.

This study aimed to compare fast-track surgery (FTS) and traditional perioperative care protocols in laparoscopic gynecological surgeries, assessing their impact on length of stay (LOS), recovery time, and postoperative complications. A case-control retrospective study was conducted at Suzhou Hospital of Integrated Chinese and Western Medicine, involving 167 patients undergoing laparoscopic gynecological surgery from June 2021 to June 2023. Of them, 81 patients underwent surgery based on the FTS protocol (FTS group) and 86 patients received a traditional perioperative management (control group). Patients in both groups underwent gynecologic laparoscopic procedures, including uterine, ovarian and tubal surgeries. Data were collected on general patients' characteristics, including age, BMI, surgery type and time, intestinal recovery and out-of-bed activity time, LOS, pain levels, and postoperative complications. Wilcoxon rank sum test with continuity correction was used to assess the difference in operative characteristics and postoperative pain levels. Fisher's exact test was used to assess the difference in overall frequency of postoperative complications between groups. Patients in the FTS group exhibited faster intestinal recovery, shorter mobilization time, and reduced LOS compared to the control group. Pain levels were significantly lower at one, six and twelve hours post-surgery in the FTS group. Overall, the proportion of postoperative complications was significantly lower in the FTS group than in the control group. Implementing the FTS protocol in laparoscopic gynecological surgeries for benign conditions can reduce LOS, accelerate recovery, and minimize pain without increasing postoperative complications. Further research with more diverse patient populations is warranted to validate these findings.

Evolving Referral Patterns and Management Following Implementation of a Multidisciplinary Fibroid Center: A Retrospective Cohort Study.

Background/Objectives: Our objective was to evaluate changes in the management of symptomatic fibroids after establishing a multidisciplinary fibroid center with minimally invasive gynecologic surgery (MIGS) and interventional radiology (IR). Methods: A retrospective cohort study was conducted at the fibroid center created in September 2020. Patients were offered same-day consults with both MIGS and IR providers. Data were collected for patients with initial consultations from January to June 2019 (pre-fibroid center) and from January to June 2021 (post-fibroid center). Results: Among 615 patients meeting inclusion criteria, 273 had consultations pre-center and 342 post-center. More patients seen post-center had previously attempted medical management (30.1% vs. 20.2%), with a significant proportion having no prior medical or surgical treatment (53.2% vs. 61.5%). Post-center, there were more MIGS consultations (65.5% vs. 53.1%) and a decrease in general gynecology (GYN) consultations (19.0% vs. 25.6%). More patients sought additional opinions post-center (83.6% vs. 67.0%), particularly with MIGS (58.8% vs. 37.0%). General GYNs referred to MIGS (79.3% vs. 73.1%) and IR specialists (16.0% vs. 13.0%) more often in 2021. In 2021, use of MRI increased (66.5% vs. 52.4%), and more patients underwent uterine artery embolization (UAE) within 1 year of consultation compared to the pre-center period (13.8% vs. 6.9%). Conclusions: Patients with symptomatic fibroids often seek the expertise of specialists to explore treatment options. A multidisciplinary fibroid center that integrates efforts of MIGS and IR enables thorough counseling and a rise in the utilization of minimally invasive procedures, including UAE.

Multidisciplinary Development and Implementation of a Trial of Void Algorithm to Standardize and Reduce Indwelling Urethral Catheter Use.

Prolonged indwelling catheter use is a known risk factor for catheter-associated UTIs (CAUTIs). We sought to reduce catheter use by creating and implementing a trial of void (TOV) algorithm to standardize indwelling Foley catheter removal in surgical patients. We partnered with the Departments of General Surgery and Nursing to develop an evidence-based TOV algorithm for a step-down unit at a large urban teaching hospital. Our cohort included patients treated with intra-abdominal, thoracic, vascular, urologic, and gynecologic surgeries. The primary outcome was mean cumulative indwelling urethral catheter patient-days. For example, if 2 patients had catheters for 3 and 7 days, respectively, then cumulative catheter days would be 10. We analyzed changes in catheter use 90 days before and after algorithm implementation. The mean number of hospitalized patient-days before and after algorithm introduction did not differ (32.2 vs 32.0, P = .60). After implementation, mean cumulative catheter patient-days decreased (14.8 vs 9.9, P < .01), as did mean daily number of patients with catheters on the unit (3.7 vs 3.1, P = .02). There was 1 CAUTI before and after algorithm implementation, the latter deemed associated with algorithm nonadherence. Catheter use in a surgical floor control group where the algorithm was not implemented did not differ for any outcome over the same time period (P > .05). A multidisciplinary approach to standardize catheter care with a TOV algorithm is feasible and effective in reducing catheter use. Further research is needed to determine its impact on CAUTI rate.

Foreign body cases in obstetrics and gynecology practice

The article presents cases that took place in obstetrics and gynecology practice, the detection of a foreign body after surgical operations, childbirth through the natural birth canal.Patient safety is one of the most pressing issues in healthcare. Promoting safety requires that all those involved in health care recognize that the potential for error exists and that teamwork and communication are essential to preventing errors.Retention of surgical objects such as a gauze pad, instrument, or needle after surgery or an invasive procedure is a rare but potentially serious phenomenon associated with significant morbidity and mortality.Gauze swabs and napkins are the most common finds, while surgical instruments and needles are rare.We will present cases of foreign bodies in the practice of obstetrician-gynecologists.In the first case, the foreign body was left in the anterior abdominal wall. Two cases of napkins being left in the abdominal cavity after gynecological and surgical operations. In the fourth case, a needle was left in the cervix after delivery through the natural birth canal and suturing of soft tissue tears in the birth canal. Moreover, the needle was not detected either after childbirth, or outside of pregnancy, or during pregnancy, but was detected during examination of the cervix in mirrors in the early postoperative period.The problem of finding a foreign body after surgery remains unsolved. According to statistics, one patient per year in each hospital suffers from a forgotten foreign body. A foreign body left behind can give rise to a lawsuit for damages against the surgeon and medical staff.Pre- and post-operative object counting is the most common foreign body screening method used in the world.Careful surgical technique should be routinely followed, which includes counting sponges, tampons, napkins, and instruments aimed at preventing postoperative foreign material in body cavities. A patient with significant gastrointestinal symptoms and a history of surgery should have a high index of suspicion for postoperative foreign body retention. Perioperative counting of equipment and materials is the most common method of foreign body screening.

Vesicovaginal Fistula Secondary to Left Ectopic Ureter in a 3-Year-Old Female with Left Ureter-Duplication in Tamale Teaching Hospital, Ghana: A Case Report

Purpose: Vesicovaginal fistula (VVF) is a pathological connection between the bladder and vagina, primarily caused by gynaecological surgery, obstructed labour, and cesarean section. VVF significantly impairs quality of life and is prevalent in developing countries, with Africa seeing up to 130,000 new cases annually. Surgical repair, especially transvaginal approaches, remains the primary treatment. Paediatric cases of VVF, often linked to congenital anomalies like ectopic ureter, are rare and complex to manage. Methodology: We report a case of a 3-year-old female with continuous urinary leakage since birth, initially flagged for renal anomalies via prenatal imaging. Clinical examination was normal with no distress or developmental issues. Diagnostic assessments, including abdominal ultrasound and micturating cystourethrogram (MCUG), revealed left hydronephrosis, hydroureter, and a definitive vesicovaginal fistula. A CT Urogram confirmed the diagnosis, showing contrast leakage into the vagina. Findings: Diagnostic cystoscopy revealed a normally positioned right ureteric orifice, while the left was aberrantly positioned near the bladder neck. Culposcopy identified a ureterocele in the posterior fornix of the vagina. During laparotomy, a dilated left distal ureter was observed entering the vagina, indicating true ureter duplication. The surgical intervention involved left ureteric reimplantation using the antireflux method, successfully resolving the anomaly. Post-operative recovery was smooth, with significant improvement in urinary symptoms and no recurrence or complications noted during follow-up. Unique contribution to theory, policy and practice: VVF secondary to ectopic ureter in paediatric patients is rare but manageable with early diagnosis and tailored surgical intervention. Our case underscores the importance of a multidisciplinary approach and the efficacy of ureteral reimplantation in treating complex congenital anomalies, leading to favourable outcomes and symptom resolution.

A comparative study on the effect of intrathecal nalbuphine and buprenorphine as an adjuvant to 0.5% hyperbaric bupivacaine in elective infraumbilical surgeries

: Subarachnoid blockade provides excellent operating conditions for lower abdominal, orthopedic, pelvic, urological, gynecological and lower extremity surgery. Most subarachnoid anesthetics are single shot injections and have a definite duration; hence opioids have been used along with local anesthetics in subarachnoid block to prolong its effect, duration, quality of analgesia and minimize the necessity of postoperative analgesics.: The primary objective of the study was to assess the onset and duration of sensory and motor blockade. The secondary objective of the study was to compare the hemodynamics, duration of postoperative analgesia and the complications encountered between the two groups.: A prospective randomized double-blinded study was done in 120 patients divided into two group with 60 in each group as group N and group B by computer generated random numbers. Group N received 0.5% Heavy Bupivacaine (3.2ml) + 0.6mg of Nalbuphine (0.3ml) to a total volume of 3.5 ml and Group B received 0.5% Heavy Bupivacaine (3.2ml) + 90µg of Buprenorphine (0.3 ml) to a total volume of 3.5 ml for spinal anesthesia. The differences between the groups were statistically analyzed with the Independent t test for continuous variables and Pearson’s chi-square test for categorical variables. Observations and results: The onset of sensory block (p=0.303) and motor block (p=0.510) was observed to be faster in group N when compared to group B with statistical insignificance, but the duration of both sensory block (p˂0.001) and motor block (p˂0.001) was more pronounced in group B when compared to group N with statistical significance. The duration of effective analgesia was more pronounced in group B (468.35±30.57 minutes) compared to group N (362.70±35.53 minutes).: The duration of the sensory and motor block with effective postoperative analgesia were more pronounced in buprenorphine compared to nalbuphine and hence intrathecal buprenorphine is a better alternative adjuvant to intrathecal nalbuphine in elective infraumbilical surgeries.

HSD34 Analysis of Changes in the Number of Cases of Gynecological Surgeries for Benign Indications in Hungary

HSD34 Analysis of Changes in the Number of Cases of Gynecological Surgeries for Benign Indications in Hungary

A delayed diagnosis of iatrogenic ureteral injury results in increased morbidity

This study aimed to register and analyse outcomes after iatrogenic ureteral injuries (IUI) with special emphasis on potential consequences of a delayed diagnosis, and further to analyse if the incidence of IUI has changed during the study period. 108 patients treated for an IUI during 2001–2021 were included. Injuries due to endourological procedures, planned tumour resection and traumatic injuries were excluded. All relevant information to answer the research questions were entered into a database. Chi-square and t-tests were used for categorical and continuous variables respectively. Regression analysis was used to evaluate potential change of incidence in IUIs over time. Our results showed that most IUIs (74, 69%) were caused by gynaecological surgery. 49 (45%) had a delayed diagnosis (not diagnosed intraoperatively). Younger age (mean 50 vs 62 years, p < 0.001) and benign indication for laparoscopic hysterectomy (OR 8.0, p < 0.001) predisposed for a delayed diagnosis. Patients with a delayed diagnosis had a higher number of secondary injury related procedures (mean 4.6 vs 1.7, p < 0.001), hospital admissions (mean 3.0 vs 0.8, p < 0.001) and longer hospital stays (mean 20.6 vs 3.9 days p < 0.001) compared to patients with an intraoperative diagnosis. There was complete recovery for 91% of the patients. We did not observe any changes in IUI incidence during the study period. In conclusion, our study underlines that IUI can cause major morbidity for the patient affected if not diagnosed intraoperatively. Benign indication and younger age are predictors for a delayed diagnosis. The prognosis is good, with 91% full recovery. No significant changes in incidence of IUIs were observed.

Gynecological Laparoscopic Surgeries under Spinal Anesthesia: Benefits and Challenges.

This prospective study investigated the feasibility of performing laparoscopic pelvic surgery under spinal anesthesia and analyzed the intraoperative side effects, like pain, nausea, and vomitus, of 915 patients. The implementation and performance of laparoscopic surgery under local anesthesia on 915 patients (out of a total of 3212 who underwent laparoscopic pelvic surgery under spinal anesthesia) were analyzed in relation to BMI (body mass index), obesity, pain during surgery, amount of intraperitoneal mmHg CO2 gas pressure, and surgical complications. BMI > 30, intra-abdominal adhesions, increased duration of the operation, bleeding, and increased intraperitoneal CO2 pressure were statistically significant as the main causes of pain during laparoscopic surgery under spinal anesthesia. Underweight patients, on the other hand, had less pain when intra-abdominal pressure increased compared to those of normal weight. The appearance of pain, nausea, and vomitus occurred in 10.3% of patients, and these events were easy to manage and treat. They did not affect the surgeon's work or the course of the operation. In light of these observations, we are proposing spinal anesthesia for laparoscopic surgery as the first choice in patients who have no contraindications. To the best of our knowledge, this clinical study constitutes the largest clinical observation and dataset concerning spinal anesthesia in laparoscopic pelvic surgery. ISRCTN38987, 10 December 2019.

Postoperative Cognitive Decline in Patients Undergoing Major Gynecologic Oncology Surgery: A Pilot Prospective Study

ObjectivesPostoperative cognitive decline (POCD) is characterised by deficits in attention, memory, executive function, and information processing that persist beyond the early postoperative period. Its incidence ranges from 10%–25% after noncardiac surgery. Limited literature exists on POCD after gynecologic oncology surgery. Our primary objective was to identify the incidence of POCD among patients 55 years or older undergoing major gynecologic oncology surgery. MethodsThis mixed-methods, prospective, observational cohort study followed patients 55 years or older who underwent surgery for gynecologic malignancies between February and July 2022. Semi-structured interviews and the Mini-Mental State Exam (MMSE) were administered before surgery as well as 1 and 3 months after. Assessments were delivered virtually and in-person in the context of the COVID-19 pandemic. POCD was defined as ≥2-point decline from baseline MMSE score. ResultsTwenty-four patients participated; 19 completed the 1-month follow-up, and 15 completed the 3-month follow-up. The average age was 64 (range: 56–90). The mean preoperative MMSE score was 16.6 out of 17 (virtual) and 12.9 out of 13 (in-person). Two patients had a 1-point decline in their 1-month MMSE score; both recovered by 3 months. One patient had a 1-point decline in their 3-month MMSE score. Semi-structured interviews revealed common themes of “brain fog” at the 1-month follow-up and mild, persistent attention and word-finding deficits at 3 months postoperatively. ConclusionsThis study’s qualitative component captured subtle subjective findings suggestive of potential POCD. Larger studies are required, and a more extensive neuropsychological test battery may be required to elicit subtle findings not clearly reflected by MMSE scores.