Pelvic Hematoma Research Articles

Early surgical outcomes of 550 consecutive patients treated for benign gynecological conditions by transvaginal natural orifice transluminal endoscopic surgery.

Evidence about intra- and postoperative complication rates related to transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynecological conditions is still limited. We report and analyze data from a large cohort of patients operated in a single institution during 3.5 years. To evaluate the safety and feasibility of vNOTES for benign gynecological indications, we performed a single-center observational study reporting and analyzing perioperative outcomes of 550 consecutive patients operated between 2020 and 2024. Of the 550 included patients, 365 (66.4%) underwent a vNOTES hysterectomy, 167 (30.4%) a procedure limited to the adnexa, and 18 (3.3%) other interventions, including myomectomy, pelvic adhesiolysis, post-hysterectomy pelvic hematoma drainage, pelvic organ prolapse repair, and appendectomy. The mean age was 49.4 ± 12.2 years, and the mean BMI was 26.2 ± 5.8 kg/m2. The total complication rate was 6.5% (36 cases), of which 2.7% (15 cases) were intraoperative complications and 4.0% (22 cases) were postoperative complications. Patients presented postoperative complications classified as Clavien-Dindo (CD) grade I in 4 cases (0.7%), grade II in 10 cases (1.8%), and grade III in 8 cases (1.5%). We observed no CD grade IV and V complications. Three patients (0.5%) were rehospitalized for postoperative complications management. The conversion rate was 1.6%, with nine cases of conversion to conventional laparoscopy and none to laparotomy. The application of vNOTES appears safe and feasible for most benign gynecological surgeries. Our study focused on surgical complications and demonstrated a profile similar to those reported in previous studies.

261.10: Prolonged static cold storage results in significant pelvic hematomas during normothermic machine perfusion of porcine kidney grafts.

261.10: Prolonged static cold storage results in significant pelvic hematomas during normothermic machine perfusion of porcine kidney grafts.

Clinical and radiographic predictors for angiography in pelvic trauma: An analysis of 1703 patients

IntroductionPatients who present with hemorrhage from pelvic fractures have an increased risk of mortality with prolonged time to intervention. Identifying risk factors associated with hemorrhage can expedite treatment. In this study we explore clinical and radiographic predictors for angiography in trauma patients with pelvic fractures. MethodRetrospective, single-center review between 2009 and 2019 at a level 1 trauma center of all trauma patients with pelvic fractures. We excluded patients who died prior to arrival or in the trauma bay who did not undergo computed tomography (“CT”). Finalized attending descriptions of CT findings were reviewed, including size of hematomas, and presence of extravasation. Chi-square, Mann-Whitney U and multi-variate regressions were performed. ResultsWe analyzed 1,703 trauma patients with pelvic fractures. Most common mechanisms of injury included MVC (45 %), fall (27 %) and motorcycle accident (12 %). 48 % (819/1703) of patients had pelvic hematomas on CT scan. 17 %(138/819) of patients with a hematoma also had evidence of extravasation. Significant predictors for extravasation on CT included large hematoma on CT, AIS extremity ≥2, binder placement, increased ISS, HR, and decreased GCS and SBP (p < 0.005). Significant predictors for angiography were similar, including AIS extremity ≥2, binder placement, presence of moderate and large hematoma and active extravasation on CT (p < 0.01). Stepwise logistic regression model incorporated ISS, HR, AIS extremity score, binder placement, and contrast extravasation with an AUC = 0.9345. ConclusionIn this large retrospective review of traumatic pelvic fractures, specific clinical and radiographic factors were significantly associated with pelvic hematomas, extravasation and/or need for angiography. Future collaborative work with orthopedics and interventional radiology is planned to better triage pelvic fracture patients and identify those at risk for bleeding that require earlier intervention.

Extravasated Pudendal Artery Pseudoaneurysm Presenting as a Large Vaginal Hematoma Following Uncomplicated Delivery

Body of Abstract: (1) To report a case of an extravasated pudendal pseudoaneurysm presenting as vaginal hematoma following an uncomplicated delivery. (2) To discuss alternatives of management of vulvar hematomas. Introduction: Postpartum hemorrhage is a leading cause of maternal mortality and can infrequently (1/300-1/1500 deliveries) be caused by vulvar hematomas. Vulvar hematomas are typically small and resolve with conservative treatment. Rarely, they can develop rapidly, posing a significant risk to the patient. Risks for vulvar hematomas include a prolonged second stage of labor, multiple gestation, operative vaginal delivery, episiotomy, and vaginal laceration. Extravasation from a pseudoaneurysm in the pelvic arteries is a rare cause of vulvar hematomas (&lt; 5% of cases) with &gt;75% involving the uterine artery. Pseudoaneurysms typically result from damage to vasculature during a traumatic delivery. Spread into the retroperitoneal space can lead to shock and eventual demise if improperly managed. This case illustrates the exceptionally rare occurrence of a pudendal artery pseudoaneurysm with rapidly expanding potentially catastrophic hematoma formation. Case Summary: Presented is a 21-year-old G2P1011 patient at 39w5d with a large vaginal hematoma diagnosed shortly following spontaneous vaginal delivery. The case initially presented to the hospital one hour after spontaneous rupture of membranes with an unremarkable pregnancy. Normal labor ensued and stage II of labor lasted one hour with an uncomplicated nonoperative vaginal delivery. Postpartum a significant increase in fundal height was noted. Cytotec was given and bladder catheterization removed 800 ml urine. Abdominal pain increased. Vital signs were normal. Exam revealed a large posterior vaginal wall swelling extending upward, but without active bleeding. A computerized tomography (CT) scan of the abdomen/pelvis revealed a 9.7 X 10.5 X 13.2 cm pelvic hematoma arising from the posterior vaginal wall with extension cephalad into the perirectal space and right adnexa. Evidence of active bleeding and bilateral hydronephrosis were reported. Hemoglobin was 10.1, down from admission 12.5. Symptoms included worsening abdominal pain and dizziness. Based on the active bleeding noted on CT scan and the progressive symptoms, the patient was transferred to a tertiary care center. Upon tertiary center admission the patient was tachycardic and hypotensive (P 153 and BP 101/61). Hemoglobin was 9.3. Physical exam was unchanged. Interventional radiology recommended and patient underwent embolization of bilateral uterine arteries for treatment of a diagnosed pseudoaneurysm with extravasation of the right pudendal artery. Postpartum day 1, mild right lower quadrant pain was felt to be consistent with the embolization. Hemoglobin decreased to 6.5, and the patient received one unit of packed red blood cells (PRBCs). Clinically, ambulation was tolerated, but tachycardia and hypotension remained and there was decreased swelling. Hemoglobin remained low at 6.8, and another unit of PRBCs was given. Hospital course thereafter was uneventful and discharge was on day 3. Discussion: This case describes a vaginal hematoma and pudendal artery pseudoaneurysm as a very rare but potentially life-threatening postpartum hemorrhage following vaginal delivery. Association with an uncomplicated pregnancy and delivery, involvement of the pudendal artery with an expanding large hematoma dissecting the retroperitoneal space creating a hemodynamically unstable situation are only rarely seen concurrently. Hematoma treatment starts conservatively, utilizing ice, rest, and pain control if patient is hemodynamically stable and the hematoma is small. When large, rapidly expanding, or the patient is hemodynamically unstable, surgical intervention or artery embolization should be considered when imaging identifies the source of bleeding. Imaging may include ultrasound, CT, CT angiography, and magnetic resonance imaging as options for localization of hematoma. No superior mode of evaluation is identified. Pseudoaneurysms following delivery have most commonly been described in the uterine arteries with only a handful of case reports documenting other sources including the obturator, labial, vaginal, and internal pudendal arteries. Our case demonstrates that extravasated pelvic artery pseudoaneurysms can present in benign appearing nonoperative deliveries and should be considered in the differential diagnosis as a source of post-partum hemorrhage. Recently, pseudo-aneurysms have more commonly been treated with IR artery embolization as it is a less invasive and better tolerated procedure by patients. Tsumagari et al suggested an algorithm proposing vulvovaginal hematomas should be observed versus surgically evacuated, whereas upper vaginal hematomas should undergo CT angiography for assessment for selective arterial embolization. Conclusion: Pseudoaneurysms of the pudendal artery with hematoma formation occurring in an uncomplicated delivery are an extremely rare cause of potentially life-threatening hemorrhage as reported in only a handful of cases. Because of their potential for catastrophic sequelae, they should be considered in the differential diagnosis of expanding upper vaginal hematomas. This case depicts the importance and success of rapid identification and embolization of pudendal artery pseudoaneurysm to prevent mortality.

Short-term outcomes of single port robotic hysterectomy with concomitant sacrocolpopexy.

The Da Vinci single port® (SP) robotic platform heralds a new era of minimally invasive surgery (MIS). The primary objective of this study was to assess short-term outcomes in patients undergoing SP robotic hysterectomy with concomitant sacrocolpopexy for pelvic organ prolapse (POP). We performed a retrospective case series at two tertiary care centers between January 2021 and August 2023. Patients with POP electing to undergo SP robotic hysterectomy with concomitant sacrocolpopexy were included. Chart abstraction was used to collect patient demographics and clinical outcomes. Recurrent POP was defined as new bothersome vaginal bulge symptoms and evidence of POP beyond the hymen on postoperative examination. 69 patients were included. Median operative time was 209min (135-312) and estimated blood loss was 100mL (20-2000). 1 (1.4%) patient sustained a major vascular injury resulting in laparotomy. Median pain score and morphine equivalents administered in PACU were low at 3 (0-7) and 3.2 (0-27) respectively. At 3months, 60 (86.9%) patients were seen either in person or via telemedicine for their follow up appointment. 59/60 (98.3%) reported no vaginal bulge symptoms and 50/51 (98.0%) had stage 0 or 1 prolapse on exam. One (1.4%) patient had recurrent prolapse and underwent an additional repair. Postoperative complications included 2 (2.9%) cases of ileus/small bowel obstruction, 1 (1.4%) pelvic hematoma requiring a blood transfusion, and 1 (1.4%) umbilical hernia. The SP robotic platform is a safe and feasible platform for MIS hysterectomy and sacrocolpopexy with good short term anatomic and symptomatic outcomes.

Role of the nurse in post cesarean section patient with hellp syndrome in the obstetrics and gynecology service of a National Hospital

Pregnancy with hellp syndrome is life-threatening, it appears in 5-9 out of every 1000 pregnancies and in 10-20% of cases with severe preeclampsia, it causes the breakdown of red blood cells, causing liver problems , bleeding and blood pressure. The objective of this study is to manage nursing care for a patient with síndrome of hellp and hemoperitoneum with pelvic hematoma in the obstetrics-gynecology service. The present study is a research with a qualitative approach, clinical case type, study subject female, 21 years old. The nursing care process was used as a method, the assessment guide of Marjorie Gordon's 11 functional patterns was applied, by which altered patterns were found, formulating the nursing diagnoses: Decreased cardiac output, Acute Pain and CP: Shock hypovolemic. The activities were executed in a timely manner, the evaluation was through the difference in baseline and final scores of the indicators. We can conclude that hellp syndrome is a hypertensive disorder of pregnancy, however, the complication of this post-cesarean patient is hemoperitoneum with pelvic hematoma, timely nursing care against this was the main axis in the patient's restoration. It is concluded that, according to the problems identified in the patient, the nursing care process was managed in its five stages, improving the patient's health status, but the survival and success of the treatment provided depends on the timely identification of the problems and appropriate choice of treatment

IJCM_384A: Sudden death due to a ruptured ectopic: An Autopsy case

Background: An Ectopic pregnancy occurs when fertilized ovum is implanted outside the uterine cavity. Typically, the site of this ectopic pregnancy is the Fallopian tube in about 93-97% of ectopic pregnancies. Only 50% of patients present with the classic clinical triad of ectopic pregnancy i.e., pain, amenorrhea, and vaginal bleeding. It is extremely important to diagnose a case of ectopic pregnancy to prevent rupture and internal bleeding Case Report: A 35-year-old Female, was brought to a hospital, gasping, complaining of pain abdomen, and abdominal distension. Pulses could not be felt, GCS was 3/15, blood pressure was not recordable. She was shifted to the Intensive Care Unit and intubated. Fluid correction was attempted and ionotopes were started. USG abdomen showed a hemoperitoneum, pelvic hematoma, and ruptured right adnexa. The patient was taken up for an emergency laprotomy and had a cardiac arrest on table, but could not be resuscitated. Following an Medicolegal case the body was subjected for postmortem examination, the relevant findings at autopsy will be discussed.

Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes.

Management of scrotal hernias presents as a common challenge, with operative interventions to address these hernias associated with higher rates of morbidity compared to those of less-complex pathology. Surgeons have advocated for the use of techniques such as primary abandonment of the distal sac as a potential means to reduce complications for operative intervention, with preliminary findings demonstrating feasibility. We sought to assess outcomes related to primary sac abandonment among patients undergoing minimally invasive (MIS) repair of scrotal hernias. A review of prospectively maintained databases among two academic hernia centers was conducted to identify patients who underwent MIS inguinal hernia repairs with primary sac abandonment. Patient demographics, hernia risk factors, intraoperative factors, and postoperative outcomes were evaluated. Short-term outcomes related to patient-reported experiences and surgical-site occurrences requiring procedural intervention were queried. Sixty-seven male patients [median age: 51.6years; interquartile range (IQR): 45-65years] underwent inguinal hernia repair with primary sac abandonment. Anatomic polypropylene mesh was used in 98.5% cases. Rates of postoperative complications were low and included postoperative urinary retention (6%), clinically identified or patient-reported seromas/hematomas within a 30-day follow-up period (23.9%), deep venous thrombosis (1.5%), and pelvic hematoma (1.5%). No seromas or hematomas necessitated procedural interventions, with resolution of symptoms within three months of their operation date. We report a multi-center experience of patients managed with primary abandonment of the sac technique during repair of inguinoscrotal hernias. Utilization of this technique appears to be safe and reproducible with a low burden of short-term complications.

Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery (RvNOTES) With Total Hysterectomy for Management of Stage IV Endometriosis With/Without Complete Cul-de-Sac Obliteration: 23-Case Pilot Feasibility Study

Study ObjectiveTo show feasibility and short-term outcomes of robot-assisted vaginal NOTES (RvNOTES) for the treatment of stage IV endometriosis during total hysterectomy with/without complete cul-de-sac obliteration. DesignRetrospective case series. SettingSingle academic tertiary care hospital in Houston, Texas, USA. PatientsTwenty-three adult women with stage IV endometriosis. InterventionsRvNOTES with total hysterectomy for excision of severe endometriosis. Measurements and Main ResultsPatients were assessed for various metrics including total operative time, robot dock time, robot console time, hysterectomy time, estimated blood loss, perioperative pain using the Visual Analogue Scale (VAS), and complications. The mean total operative time was 224.3 minutes. The study also found that patients with complete cul-de-sac obliteration had significantly longer operative times and higher estimated blood loss compared to those with partial or no obliteration. Postoperative VAS pain scores showed a significant reduction over a 6-week period. Complications included one case of complete ureteral transection, pelvic hematoma with infection, vaginal abscess, urinary tract infection, and pneumonia. ConclusionOur findings suggest that RvNOTES may be a feasible surgical approach in expert hands for treating stage IV endometriosis, even in cases with complete obliteration of the cul-de-sac.

Endovascular Management of Pelvic Trauma: The Interventional Radiology Point of View

Background: Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. Active bleeding is the most common cause of death among those patients. Due to limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management.Objective: The present article aims to discuss the available endovascular treatment modalities, and common angiographic treatment strategies and techniques.Conclusion: Interventional radiologists plays a key role in the management of patients with pelvic trauma. New standardized protocols are needed to minimize the time spent on deciding the correct treatment for each patient.

Pediatric scurvy case report: a novel presentation with deep vein thrombosis secondary to large bilateral spontaneous iliac subperiosteal hematomas

BackgroundScurvy is an uncommon disease in developed countries caused by deficiency of vitamin C. We present a case of scurvy in a 14-year-old male with autism with both novel presentation and imaging findings. This case had the novel presentation of lower limb deep vein thrombosis (DVT) secondary to compression of the external iliac vein from large bilateral iliac wing subperiosteal hematomas. Subperiosteal hematoma is a well-recognised feature of scurvy but large and bilateral pelvic subperiosteal hematoma causing DVT has not previously been described.Case presentationA 14 year old Caucasian male with background of autism and severe dietary restriction presented with lower limb swelling and immobility. He was diagnosed with lower limb DVT. Further investigation revealed an iron deficiency anaemia, and he was found on MRI to have large bilateral subperiosteal iliac hematomata causing compression of the iliac vessels. He improved following treatment with vitamin C replacement and follow-up imaging demonstrated resolution of the DVT and hematoma.ConclusionDVT is rare in children and when diagnosed should prompt investigation as to the underlying cause. This case demonstrates an unusual cause of DVT and as an unusual presentation of paediatric scurvy.

Short-Term Outcomes of First 100 Laparoscopic Colorectal Surgeries at a Newly Developed Surgical Setup at Peshawar.

The incidence of colorectal cancer (CRC) has risen steadily, necessitating innovative strategies for diagnosis and treatment. Minimally invasive surgery, exemplified by laparoscopic techniques, has emerged as a transformative approach in colorectal surgical practices. Laparoscopy offers advantages such as improved aesthetic outcomes, reduced post-operative pain, early patient mobilization, and shorter hospital stays. This study aims to present the short-term surgical outcomes of the first 100 elective laparoscopic CRC resections performed at a newly established tertiary care cancer center in Peshawar, Pakistan. Data were prospectively collected for CRC resections performed between April 2021 and February 2022. The study included patients above 18 years of age with biopsy-proven CRC. Surgical procedures were performed by two dedicated colorectal surgeons trained in minimally invasive surgery. Patient demographics, pre-operative factors, intraoperative parameters, and post-operative outcomes were systematically recorded and analyzed. Among the 100 cases included in the study, laparoscopic colorectal surgeries were successfully performed without any conversions to open surgery. The mean age of the study population was 52.5 years, with a male-to-female ratio of 2:1. The majority of cases were colon (48%) and anorectal cancers (52%). The mean lymph node yield was 18.29 (range 6-49). Only one patient required a re-look laparoscopy for a pelvic hematoma, and overall mortality was reported at 1%. Laparoscopic colorectal surgery is a safe and effective treatment option for elective colorectal operations with minimal post-operative complications and favorable short-term outcomes.

A comparative analysis of perioperative complications and biochemical recurrence between standard and extended pelvic lymph node dissection in prostate cancer patients undergoing radical prostatectomy: a systematic review and meta-analysis.

Pelvic lymph node dissection (PLND) is commonly performed during radical prostatectomy (RP) for prostate cancer staging. This study aimed to comprehensively analyze existing evidence compare perioperative complications associated with standard (sPLND) versus extended PLND templates (ePLND) in RP patients. A meta-analysis of prospective studies on PLND complications was conducted. Systematic searches were performed on Web of Science, Pubmed, Embase, and the Cochrane Library until May 2023. Risk ratios (RRs) were estimated using random-effects models in the meta-analysis. The statistical analysis of the data was carried out using Review Manager software. Nine studies, including three randomized clinical trial and six prospective studies, with a total of 4962 patients were analyzed. The meta-analysis revealed that patients undergoing ePLND had a higher risk of partial perioperative complications, such as lymphedema ( I2 =28%; RR 0.05; 95% CI: 0.01-0.27; P <0.001) and urinary retention ( I2 =0%; RR 0.30; 95% CI: 0.09-0.94; P =0.04) compared to those undergoing sPLND. However, there were no significant difference was observed in pelvic hematoma ( I2 =0%; RR 1.65; 95% CI: 0.44-6.17; P =0.46), thromboembolic ( I2 =57%; RR 0.91; 95% CI: 0.35-2.38; P =0.85), ureteral injury ( I2 =33%; RR 0.28; 95% CI: 0.05-1.52; P =0.14), intraoperative bowel injury ( I2 =0%; RR 0.87; 95% CI: 0.14-5.27; P =0.88), and lymphocele ( I2 =0%; RR 1.58; 95% CI: 0.54-4.60; P =0.40) between sPLND and ePLND. Additionally, no significant difference was observed in overall perioperative complications ( I2 =85%; RR 0.68; 95% CI: 0.40-1.16; P =0.16). Furthermore, ePLND did not significantly reduce biochemical recurrence ( I2 =68%; RR 0.59; 95% CI: 0.28-1.24; P =0.16) of prostate cancer. This analysis found no significant differences in overall perioperative complications or biochemical recurrence between sPLND and ePLND, but ePLND may offer enhanced diagnostic advantages by increasing the detection rate of lymph node metastasis.

Intrapelvic Hematoma Following Low-Energy Osteoporotic Pubic Ramus Fracutre: A Rare Case Report

Osteoporotic pelvic fractures are common in the elderly and most often treated with pain management and mobilization. Pelvic hemorrhage rarely occurs but can prove life-threatening. An 86-year-old woman was admitted in the emergency department due to a fall from own height and sustained a displaced fracture of the superior ramus of the pubic bone. The patient presented with decreasing low blood pressure and tachycardia, and a CT-scan revealed an intraperitoneal bleed and pelvic hematoma. She was treated with intravenous fluids, fibrinolytic inhibitors and monitoring in the intensive care unit. A renewed CT-scan showed no active bleeding.

A vendor-agnostic, PACS integrated, and DICOM-compatible software-server pipeline for testing segmentation algorithms within the clinical radiology workflow.

Reproducible approaches are needed to bring AI/ML for medical image analysis closer to the bedside. Investigators wishing to shadow test cross-sectional medical imaging segmentation algorithms on new studies in real-time will benefit from simple tools that integrate PACS with on-premises image processing, allowing visualization of DICOM-compatible segmentation results and volumetric data at the radiology workstation. In this work, we develop and release a simple containerized and easily deployable pipeline for shadow testing of segmentation algorithms within the clinical workflow. Our end-to-end automated pipeline has two major components- 1. A router/listener and anonymizer and an OHIF web viewer backstopped by a DCM4CHEE DICOM query/retrieve archive deployed in the virtual infrastructure of our secure hospital intranet, and 2. An on-premises single GPU workstation host for DICOM/NIfTI conversion steps, and image processing. DICOM images are visualized in OHIF along with their segmentation masks and associated volumetry measurements (in mL) using DICOM SEG and structured report (SR) elements. Since nnU-net has emerged as a widely-used out-of-the-box method for training segmentation models with state-of-the-art performance, feasibility of our pipleine is demonstrated by recording clock times for a traumatic pelvic hematoma nnU-net model. Mean total clock time from PACS send by user to completion of transfer to the DCM4CHEE query/retrieve archive was 5 min 32 s (± SD of 1 min 26 s). This compares favorably to the report turnaround times for whole-body CT exams, which often exceed 30 min, and illustrates feasibility in the clinical setting where quantitative results would be expected prior to report sign-off. Inference times accounted for most of the total clock time, ranging from 2 min 41 s to 8 min 27 s. All other virtual and on-premises host steps combined ranged from a minimum of 34 s to a maximum of 48 s. The software worked seamlessly with an existing PACS and could be used for deployment of DL models within the radiology workflow for prospective testing on newly scanned patients. Once configured, the pipeline is executed through one command using a single shell script. The code is made publicly available through an open-source license at "https://github.com/vastc/," and includes a readme file providing pipeline config instructions for host names, series filter, other parameters, and citation instructions for this work.

Giant Right Common Iliac Artery Aneurysm with Right Common Iliac Vein Fistula, Masquerading as Deep-Vein Thrombosis

Abstract Iliac artery aneurysm is rarely known to rupture into iliac vein, leading to features of aneurysm and in particular, right ventricular volume overload, and pulmonary artery hypertension, due to the extracardiac left to right shunt. Herein, we report the case of a 67-year-old gentleman who presented with massively swollen right lower limb, leading to pain and inability to walk without support for 1 month. He was diagnosed to have and treatment for deep vein thrombosis with Vitamin K antagonist for 2 years. Contrast computed tomography angiogram of the abdomen revealed giant right iliac artery aneurysm above its bifurcation with iliac vein fistula. He underwent open repair of aneurysm and transaneurysmal suture closure of the iliac fistula. However, for transient renal dysfunction and reexploration for pelvic hematoma, his recovery, including normalized right lower limb, was smooth.

Huge Retroperitoneal and Pelvic Hematoma Following VBAC (TOLAC): A Case Report

Huge Retroperitoneal and Pelvic Hematoma Following VBAC (TOLAC): A Case Report

Effect and safety of Lasso suture hook in transvaginal sacrospinous ligament fixation

To investigate the feasibility and safety of the Lasso suture hook in transvaginal sacrospinous ligament fixation, a total of 38 patients with vaginal vault prolapse at or above stage Ⅱ, and aged 46-75(62.7±12.5)years, who underwent transvaginal sacrospinous ligament fixation at the Second Affiliated Hospital of Soochow University from January 2018 to January 2021 were retrospectively analyzed. After complete exposure of the right sacrospinous ligament, the cervical/uterosacral ligament was sutured to the sacrospinous ligament using Lasso hook and polypropylene sutures. The completion rate of the operation, intraoperative complications, operation time, blood loss, and postoperative situations were observed, and the objective cure rate and subjective satisfaction were followed up. Transvaginal sacrospinous ligament fixation was successfully performed in all 38 patients using Lasso suture hooks. There were no bladder or rectum injuries during the operations, and no pelvic hematoma occurred. The operation time was 15-40 (24±9.5) min; the intraoperative bleeding was 20-60 (40±12.5) ml; the visual analogue scale(VAS)score was 3-5 (3.2±1.4) points on the first day of postoperative, and 2-4 (2.2±1.8) points on the third day of postoperative. No numbness or pain in buttocks and lower limbs after the operation. The 3-month follow-up results showed that the objective surgical success rate of the postoperative pelvic organ prolapse quantitation (POP-Q) score was 100% (38/38). The 1-year follow-up results showed that the objective surgical cure rate of postoperative POP-Q score was 92.1% (35/38). The score of Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20)was 42-180(120.4±44.9)before operation and 8-75 (28.0±14.3) after operation(t=15.90, P<0.001); The score of Pelvic Floor Function Impact Questionnaire-Short Form7 (PFIQ-7) was 52-214(112.8±44.5)before operation and 5-29 (14.3±6.0) after operation (t=14.40, P<0.001), and the subjective satisfaction rate is 89.5% (34/38) conducted by Patient Global Impression of Improvement (PGI-I). Transvaginal sacrospinous ligament fixation with Lasso suture hook is simple, safe, and feasible.

Robot-assisted oncologic pelvic surgery with Hugo™ robot-assisted surgery system: A single-center experience

ObjectiveTo report the outcomes of intra- and extra-peritoneal robot-assisted radical prostatectomy (RARP) and robot-assisted radical cystectomy (RARC) with Hugo™ robot-assisted surgery (RAS) system (Medtronic, Minneapolis, MN, USA). MethodsData of twenty patients who underwent RARP and one RARC at our institution between February 2022 and January 2023 were reported. The primary endpoint of the study was to report the surgical setting of Hugo™ RAS system to perform RARP and RARC. The secondary endpoint was to assess the feasibility of RARP and RARC with this novel robotic platform and report the outcomes. ResultsSeventeen patients underwent RARP with a transperitoneal approach, and three with an extraperitoneal approach; and one patient underwent RARC with intracorporeal ileal conduit. No intraoperative complications occurred. Median docking and console time were 12 (interquartile range [IQR] 7–16) min and 185 (IQR 177–192) min for transperitoneal RARP, 15 (IQR 12–17) min and 170 (IQR 162–185) min for extraperitoneal RARP. No intraoperative complications occurred. One patient submitted to extraperitoneal RARP had a urinary tract infection in the postoperative period that required an antibiotic treatment (Clavien-Dindo Grade 2). In case of transperitoneal RARP, two minor complications occurred (one pelvic hematoma and one urinary tract infection; both Clavien-Dindo Grade 2). ConclusionHugo™ RAS system is a novel promising robotic platform that allows to perform major oncological pelvic surgery. We showed the feasibility of RARP both intra- and extra-peritoneally and RARC with intracorporeal ileal conduit with this novel platform.

Safety and feasibility of right colectomy via a transvaginal approach: early experience from a single center

Objective: To investigate the safety and feasibility of performing right colectomy via a transvaginal approach. Methods: This was a retrospeltive cohort study. Data of 30 patients who had undergone transvaginal laparoscopic right colectomy (transvaginal group) and 23 women who had undergone laparoscopic right colectomy (laparoscopic group) from January 2019 to March 2022 in the Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital were collected retrospectively. The inclusion criteria for the transvaginal group were as follows: (1) post-menopausal woman; (2) transverse diameter of the tumor < 6 cm; and (3) diagnosis of benign polyps that were unresectable by endoscopy, mucinous tumors of the appendix, or confirmed right colon cancer not requiring D3 lymphadenectomy. The inclusion criteria for the laparoscopic group were as follows: (1) pathologically confirmed adenocarcinoma or high-grade intraepithelial neoplasia; (2) lesion located from the cecum to the right third of the transverse colon; and (3) clinically stage T1-4NanyM0. The exclusion criteria for the laparoscopic group were as follows: (1) distant metastasis discovered during surgical exploration; (2) multiple organ resection required or R0 resection not possible; or (3) conversion to open surgery required. Safety was evaluated on the basis of intra- and post-operative complications. Feasibility was assessed by postoperative recovery and quality of operative specimen. The body mass index was lower in the transvaginal than the laparoscopic group (22.0±3.1 kg/m2 vs. 24.1±2.6 kg/m2, t=2.617, P=0.012). Results: Among the 30 transvaginal laparoscopic right colectomies, 26 were pure transvaginal surgeries, three required laparoscopic assistance because of difficulties with anastomosis (n=2) or abdominal adhesions (n=1), and one required conversion to laparoscopic surgery because of vascular injury. Compared with the laparoscopic group, the transvaginal group had a longer surgery time (175.0 [147.5, 216.3] minutes vs. 120.0 [100.0, 120.0] minutes, U=63.000, P<0.001) and more blood loss (30.0 [10.0, 50.0] ml vs. 23.0 [10.0, 20.0] ml, U=208.000, P=0.011). The incidence of intraoperative complications (16.7% [5/30) vs. 0, P=0.061] was comparable between the two groups. In the transvaginal group, the sites of intraoperative injuries were bladder (n=3), ileocecal artery (n=1), and right uterine artery (n=1). The incidence of postoperative complications (20.0% [6/30] vs. 17.4% [4/23], χ2<0.001,P>0.999) was also comparable between the two groups. Clavien-Dindo grade III postoperative complications occurred in two patients in the transvaginal group (one patient had a pelvic hematoma that required embolization; the other had a vesico-vaginal fistula that required surgery). Postoperative visual analogue scale scores were significantly lower (P<0.001) in the transvaginal group. Times to first flatus, ambulation, and first intake and duration of postoperative hospital stay were comparable between the two groups (P>0.05). The proportion of specimens of moderate quality was 83.3% (25/30) in the transvaginal group and 100% (23/23) in the laparoscopic group; this difference is not significant (P=0.061). Among patients who underwent D2 lymph node dissection, the number of lymph nodes examined was comparable between the transvaginal (n=23) and laparoscopic groups (n=7) (18 [15, 27] vs. 20 [16, 29], U=69.500, P=0.589). Conclusion: Transvaginal right colon surgery is associated with less postoperative pain than laparoscopic surgery, but is not yet the preferred alternative because of the incidence of surgical complications.