Transvaginal Insertion Research Articles

Clinical outcomes using a 3D printed tandem-needle-template and the EMBRACE-II planning aims for image guided adaptive brachytherapy in locally advanced cervical cancer

Background Extensive local disease or narrow vagina may compromise brachytherapy (BT) in patients with cervical cancer. This is the first study to analyze long-term outcomes of using 3D printed vaginal tandem-needle templates (3DP TNT) for transvaginal insertion of needles in parallel (P) or parallel and oblique (P&O) direction to the tandem. Material and methods All patients treated with BT using 3DP TNT from 2015-2020 were included. Decision to use a 3DP TNT and preplanning were made after 4-5 weeks of external beam radiotherapy, based on gynecological examination and MRI with a tandem-ring applicator in situ. The TNT was 3D-printed in house consisting of a circular template with P&O holes for guidance of plastic needles and a shaft fitting the uterine tandem. Thus, the radioactive source was never in direct contact with the 3DP TNT. The TNT was 3D printed in a standard or personalized configuration. Planning aims were based on the Embrace II protocol. Results 101 patients (median age of 63 years) were included: 49 with P needles only and 52 with P&O needles. Personalized TNT was used in 19 patients in the P&O group. Performance status (WHO) was > 0 in 48%. FIGO2018 stage III-IV was present in 77%. T-score at diagnosis and BT was 9.1 and 6.3 respectively, with a significantly higher T-score in the P&O compared to P group. The mean high-risk CTV D90 was 93 Gy with no significant difference between the two groups. Three-year local control rates were 85%, 95%, 75% for the overall, P- and P&O group respectively and 68%, 80% and 56% for cancer specific survival. Grade ≥3 treatment related complications were observed in 10 (10%) patients. Conclusions 3DP TNT for BT in cervical cancer provides successful management of very extensive local disease and/or unfavorable anatomy with the possibility for treatment individualization.

Pure vNOTES Contained Power Morcellation: First Report

Study Objective To demonstrate a new technique of pure vaginal natural orifice transluminal endoscopic surgery (vNOTES) contained power morcellation of a transversely enlarged uterus in an endobag. Design Stepwise description of the technique with a narrated video. Setting Minimally invasive gynecological surgery department with experience in vNOTES at a tertiary care private hospital. Patients or Participants A 45-year-old female with a large fibroid uterus resulting in severe menorrhagia. Interventions The surgery is performed in the following manner and sequence- 1. Vaginally assisted NOTES hysterectomy for a large fibroid uterus. 2. Transvaginal insertion of VNMor Endobag (Veol Medical Technologies, Koparkhairane, Navi Mumbai- 400705, India) and bagging the specimen. 3. Application of vNOTES port to the VNMor Endobag followed by power morcellation of large uterus in bag using the Versator NOTES morcellator (Veol Medical Technologies, Koparkhairane, Navi Mumbai- 400705, India). Measurements and Main Results The duration of hysterectomy was 43 mins, the duration of power morcellation was 14.5 mins, and the duration of other steps was 17 mins. Blood loss was about 75 ml. The weight of the retrieved specimen was 906 grams. There was no conversion to laparoscopy or laparotomy. There were no intraoperative and postoperative complications. The patient was discharged on day 2. Conclusion Pure vNOTES contained power morcellation is a feasible new technique using new modified instrumentation. This technique can possibly reduce the time required for specimen retrieval through a narrow vagina. It has the potential to retrieve large uteri or masses transvaginally. However, this should be evaluated in further studies. To demonstrate a new technique of pure vaginal natural orifice transluminal endoscopic surgery (vNOTES) contained power morcellation of a transversely enlarged uterus in an endobag. Stepwise description of the technique with a narrated video. Minimally invasive gynecological surgery department with experience in vNOTES at a tertiary care private hospital. A 45-year-old female with a large fibroid uterus resulting in severe menorrhagia. The surgery is performed in the following manner and sequence- 1. Vaginally assisted NOTES hysterectomy for a large fibroid uterus. 2. Transvaginal insertion of VNMor Endobag (Veol Medical Technologies, Koparkhairane, Navi Mumbai- 400705, India) and bagging the specimen. 3. Application of vNOTES port to the VNMor Endobag followed by power morcellation of large uterus in bag using the Versator NOTES morcellator (Veol Medical Technologies, Koparkhairane, Navi Mumbai- 400705, India). The duration of hysterectomy was 43 mins, the duration of power morcellation was 14.5 mins, and the duration of other steps was 17 mins. Blood loss was about 75 ml. The weight of the retrieved specimen was 906 grams. There was no conversion to laparoscopy or laparotomy. There were no intraoperative and postoperative complications. The patient was discharged on day 2. Pure vNOTES contained power morcellation is a feasible new technique using new modified instrumentation. This technique can possibly reduce the time required for specimen retrieval through a narrow vagina. It has the potential to retrieve large uteri or masses transvaginally. However, this should be evaluated in further studies.

Clinical advantage and outcomes of computed tomography-based transvaginal hybrid brachytherapy performed only by sedation without general or saddle block anesthesia.

Three-dimensional image-guided brachytherapy is the standard of care in cervical cancer radiotherapy. In addition, the usefulness of the so-called "hybrid brachytherapy (HBT)" has been reported, which involves the addition of needle applicators to conventional intracavitary brachytherapy for interstitial irradiation. To evaluate the clinical outcomes of CT-based HBT consisting of transvaginal insertion of needle applicators (CT-based transvaginal HBT) and only intravenous sedation without general or saddle block anesthesia. This is a retrospective chart review of patients who received definitive radiotherapy, including CT-based transvaginal HBT, between February 2012 and July 2019. The inclusion criteria were as follows: (i) histologically diagnosed disease, (ii) untreated cervical cancer, (iii) International Federation of Gynecology and Obstetrics (FIGO) stage IB1-IVA disease in the 2008 FIGO staging system, and (iv) patients who underwent CT-based transvaginal HBT at least once in a series of intracavitary brachytherapy. Overall, 54 patients fulfilled the eligibility criteria in the present study. The median follow-up period was 32 (IQR, 19-44) months. No patient complained of symptoms such as persistent bleeding or abdominal pain after the treatment. The 3-year local control (LC), disease-free survival, and overall survival rates for all 54 patients were 86.6%, 60.3%, and 90.7% (95% CI [81.3%-100.0%]), respectively. The 3-year LC rate was 87.7% in patients with FIGO III-IVA and 90.4% in tumor size >6.0cm. The incidence rate of late adverse events, grade ≥3, in the rectum and bladder was 0% and 1.8%, respectively. In the dose-volume histogram analyses, transvaginal HBT increased the dose of HR-CTVD90 by ~7.5% without significantly increasing the dose of organs at risk. Considering the favorable clinical outcomes, CT-based transvaginal HBT may be a good option for treating cervical cancer.

Prevalence of Complications after Interval Postpartum Intrauterine Device Insertion

Background and Aim: Postpartum intrauterine device (PPIUD) is a reversible, long-term and effective technique of contraception. The intrauterine device (IUD) is inserted within 48 hours of delivery. The immediate insertion of an intrauterine device causes certain complications. The present study aimed to assess the prevalence of complications after Interval Postpartum Intrauterine Device Insertion. Materials and Methods: This cross-sectional study was carried out on 147 women who underwent postpartum IUD (PPIUD) insertions during from January 2021 to June 2021 at Gynecology department, Mufti Mehmood Memorial Teaching Hospital (MMMTH), Dera Ismail Khan and Muhammad Teaching Hospital Peshawar. All the women who delivered and showed willingness for PPIUCD insertion were enrolled and continuously follow-up for 4 to 6 weeks after delivery. Demographic, obstetric, and clinical parameters were recorded on pre-designed medical proforma. PPIUCD insertion after 6 weeks of delivery were followed-up for the evaluation of complications. Uterine infection, medical removal of IUD, IUD expulsion, perforation, and method discontinuation were the outcome variables. SPSS version 20 was used for data analysis. Results: Of the total deliveries, 147 women inserted the postpartum intrauterine contraceptive device (PPIUCD). Of the total, about 122 (83%) women returned for follow-up after 6 weeks. All the women underwent transvaginal insertion of intrauterine contraceptive devices. The PPIUCD insertion related complications with prevalence were uterine infection 26 (21.3%), overall method suspension 17 (13.9%), perforation 20 (16.4%), interceptive uterine device expulsions 25 (20.5%), and intrauterine device removal 32 (26.2%). The severe uterine infection was in 2 (1.7%) cases who were hospitalized. Conclusion: The postpartum intrauterine device cumulative expulsion rate was higher among women compared to the expulsion rate of insertions. The longer duration of bloody lochia flow and delivery intrauterine device insertions were the key risk factors for expulsion of PPIUCD. Women can safely utilize intrauterine contraceptive devices with low complications beyond four week. Keywords: Postpartum intrauterine device; Complications; Intrauterine device expulsion

Value of tube combined with real-time ultrasound-guided accurate interstitial high-dose-rate brachytherapy for post-operative pelvic side-wall recurrences of cervical cancer.

PurposeTreatment of post-operative pelvic side-wall relapses of cervical cancer has always been a therapeutic challenge for radiation oncologists. Radiation dose boost to recurrent tumor by brachytherapy is necessary, but difficult to achieve. Our treatment center has successfully achieved precise transvaginal insertion of a pelvic side-wall mass, using a metal tube with real-time ultrasound guidance. This study investigates the efficacy and safety of image-guided high-dose-rate (HDR) interstitial brachytherapy (IBT) for patients with post-operative pelvic side-wall relapses.Material and methodsBetween 2018 and 2020, 36 post-operative pelvic side-wall relapses of cervical cancer patients receiving external beam radiotherapy (EBRT) combined with HDR-IBT were analyzed retrospectively. Doses per fraction ranged from 6.0 to 7.0 Gy, whereas cumulative equivalent doses in 2 Gy fractions ranged from 80 to 100 Gy. Effects of prognostic factors on local control (LC) and progression-free survival (PFS) were analyzed, and late toxicity data were evaluated.ResultsA total of thirty-six patients were included, with a median follow-up of 19.3 months. The tumor response was obtained for all patients, with radiological complete remission in 20 (55.6%) patients. Two-years LC and PFS rates were 72.2% and 47.2%, respectively. Grade II rectal toxicity was observed in 5 patients (13.9%). Multivariate analyses for LC and PFS using proportional regression model were performed, in which shape of exophytic tumor was associated with a significantly better prognosis for both LC and PFS (HR = 0.071, 0.128, p = 0.005, 0.002). Clinical target volume (CTV) D90 remained associated with a significantly better prognosis for PFS (HR = 0.056, p = 0.000).ConclusionsA metal tube placed in the vagina, under the guidance of real-time ultrasound in transvaginal IBT for pelvis masses can be accurately achieved. The shape of exophytic tumor and CTV D90 were associated with a significantly better prognosis for PFS, and the shape of exophytic tumor was also associated with a better prognosis for LC. Therefore, radiation dose boost using IBT can improve the prognosis of patients with post-operative pelvic side-wall recurrences of cervical cancer.

Technique Description and Outcomes of Robotic Transvaginal-Assisted Living Donor Kidney Transplantation

Objective: The aim of the study was to describe the surgical technique of totally robotic kidney transplantation with transvaginal insertion and to assess its safety and feasibility. Methods: It is a prospective analysis of the first 5 cases of robotic kidney transplantation with transvaginal insertion. Robotic-assisted kidney transplantation was performed after transvaginal insertion of a living donor kidney graft. Donor’s and recipient’s characteristics, intraoperative variables, postoperative complications, and surgical outcomes were assessed. Results: The median operative time was 220 min. Mean rewarming ischemia time of 53 min, with immediate diuresis. No intraoperative complications were observed. Mean hospitalization period was 9 days, with mean Cr of 1.5 mg/dL at discharge. Conclusions: Robotic kidney transplantation with transvaginal insertion is feasible and safe. A greater number of procedures are required to confirm the results of this new technique.

MP52-16 ROBOTIC TRANSVAGINAL ASSISTED LIVING DONOR KIDNEY TRANSPLANTATION

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery II (MP52)1 Apr 2020MP52-16 ROBOTIC TRANSVAGINAL ASSISTED LIVING DONOR KIDNEY TRANSPLANTATION Tarek Ajami*, Mireia Musquera, Lluis Peri, Maurizio D'Anna, and Antonio Alcaraz Tarek Ajami*Tarek Ajami* More articles by this author , Mireia MusqueraMireia Musquera More articles by this author , Lluis PeriLluis Peri More articles by this author , Maurizio D'AnnaMaurizio D'Anna More articles by this author , and Antonio AlcarazAntonio Alcaraz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000914.016AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Kidney transplantation is the treatment of choice for end stage renal disease (ESRD), for its better survival and quality of life in comparison with dialysis. Surgery has evolved over the past years towards minimally invasive techniques to improve cosmetic results and reduce morbidity. To this end, the vagina has been used for organ extraction and insertion. Also, the introduction of robotics has opened up the possibility of safe intracorporeal kidney transplantation. The objective is to describe the surgical technique of totally robotic kidney transplantation with transvaginal insertion and to assess its safety and feasibility. METHODS: It is a prospective analysis of the first 5 cases of robotic kidney transplantation with transvaginal insertion. Robotic assisted kidney transplantation was performed after transvaginal insertion of a living donor kidney graft. Donor’s and recipient’s characteristics, intraoperative variables, postoperative complications, and surgical outcomes were assessed. RESULTS: The median operative time was 220 min. Mean rewarming ischemia time of 53 minutes, with immediate diuresis. No intraoperative complications were observed. Mean hospitalization period was 9 days, with mean creatinine of 1.5 mg/dl at discharge time. CONCLUSIONS: Robotic kidney transplantation with transvaginal insertion is feasible. A greater number of procedures are required to confirm the safety of this new technique. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e778-e778 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tarek Ajami* More articles by this author Mireia Musquera More articles by this author Lluis Peri More articles by this author Maurizio D'Anna More articles by this author Antonio Alcaraz More articles by this author Expand All Advertisement PDF downloadLoading ...

Anterior and middle pelvic organ prolapse repair using a six tension-free strap low weight transvaginal mesh: long-term retrospective monocentric study of 311 patients

IntroductionTreatment of pelvic organ prolapse is an important public health issue due to the ageing population. The Food and Drug Administration, in 2011, issued a warning on complications after transvaginal insertion of high weight mesh. We evaluated a 6 tension-free straps, light prosthesis made from polypropylene monofilaments. Materials and methodsThis monocentric, retrospective study included patients undergoing anterior or apical prolapse repair surgery by placement of a six tension-free strap low weight vaginal mesh between 2008 and 2017. The surgical history, concomitant surgery, clinical examination results, pre and postoperative results of the Urinary Symptom Profile questionnaire, and intraoperative and postoperative complications were collected from patients’ medical records. Results311 patients were included (median follow-up: 33 months). The majority (93%) had stage ≥ III cystocele and 26% had stage ≥ III hysterocele. Postoperatively, there were nine cases (2.9%) of asymptomatic cystocele recurrence and 11 (3.5%) cases of hysterocele recurrence, among them six underwent reoperation. Vaginal comfort was significantly improved in 92% vs. 17% before surgery (p < 0,0001); two (1,76%) patients had de novo dyspareunia. Preoperatively, 104 patients had stress urinary incontinence (SUI), 45,2% of them were cured postoperatively. There were 62 (30%) cases of de novo SUI. A significant improvement of dysuria (p < 0,0001) and overactive bladder (OAB) was found for all severity stages (p < 0,0001). Severe complications included haematoma (7,4%), mesh exposure (1.3%), retraction (0.6%), bladder injury (0.6%) and chronic pain (0.6%). ConclusionTreatment of anterior and/or mid-segment prolapse by transvaginal insertion of a six-strap low-weight mesh is long-term effective, with acceptable morbidity.

V36 - Laparoscopic kidney transplantation with transvaginal insertion of allograft kidney

V36 - Laparoscopic kidney transplantation with transvaginal insertion of allograft kidney

Towards rebuilding vaginal support utilizing an extracellular matrix bioscaffold.

Pelvic organ prolapse is a common condition related to failure of the supportive soft tissues of the vagina; particularly at the apex and mid-vagina. Few studies have investigated methods to regenerate these failed structures. The overall goal of the study was to determine the feasibility of utilizing a regenerative bioscaffold in prolapse applications to restore apical (level I) and lateral (level II) support to the vagina without negatively impacting vaginal structure and function. The significance of our findings is two fold: 1. Implantation of properly constructed extracellular matrix grafts promoted rebuilding of level I and level II support to the vagina and did not negatively impact the overall functional, morphological and biochemical properties of the vagina. 2. The presence of vaginal incisions in the transvaginal insertion of bioscaffolds may compromise vaginal structural integrity in the short term.

Transvaginal insertion of kidney and robotic kidney transplantation: First 19 cases

Transvaginal insertion of kidney and robotic kidney transplantation: First 19 cases

V54 Robotic kidney transplantation with transvaginal graft insertion

V54 Robotic kidney transplantation with transvaginal graft insertion

Laparoscopic Transplantation Following Transvaginal Insertion of the Kidney: Description of Technique and Outcome

Laparoscopic kidney transplantation (LKT) is well accepted modality of treatment for ESRD patients at our center. Usually, the kidney is inserted through small Pfannenstiel incision. With the permission of the Internal Review Board, we carried out LKT in eight female recipients following insertion of the kidney through the vagina. The kidney was procured by the retroperitoneoscopic approach. Antibiotic prophylaxis was given. All cases were carried out successfully with immediate graft function and 100% graft and patient survival at 1 year of follow-up. Estimated glomerular filtration rate at 1 month and 1 year was similar to eight randomly selected female recipients who underwent open kidney transplantation (OKT). No analgesia was required in seven out of eight patients after the 3rd postoperative day. In summary, vaginal insertion of kidney and LKT is safe and feasible in a selected group of patients. It is associated with better analgesia and has similar allograft function as compare to OKT.

Improvements in robotic natural orifice surgery with a novel material handling system

Natural orifice translumenal endoscopic surgery (NOTES) has many potential advantages over other minimally invasive surgical techniques, but it presents a number of challenges introduced by the restrictive natural access points. Fully insertable dexterous in vivo robots have been developed that eliminate the spatial restrictions of the entry point, but they also are isolated within the abdomen. A material handling system (MHS) developed to bridge the gap between the in vivo robots and the surgical team promises a number of improvements over other current technologies. The MHS was implemented with two different nonsurvival swine models to validate the utility and benefits of the system. The first procedure was attempted transgastrically but proved too difficult because the geometry of the esophagus was prohibitively small. The system was instead inserted via a 50-mm GelPort and tested for robustness. The second procedure used a transvaginal insertion via a custom 25-mm trocar. Throughout both procedures, the practitioners were asked for qualitative feedback regarding the effectiveness of the device and its long-term efficiencies. The MHS was able to deliver a standard surgical staple securely to the peritoneal cavity. The practitioner was able to use the laparoscopic grasper both to insert and to remove the staple from the MHS. The system also proved capable of maintaining insufflation pressure throughout a procedure. It was cycled a total of five times in both the insertion and the retraction directions. Visualization from the MHS camera was poor at times because the lighting on the system was somewhat inadequate. No excessive bleeding or collateral damage to surrounding tissues was observed during the procedure. This study demonstrated that the MHS is fully capable of achieving payload transport during a NOTES operation. The system is intuitive and easy to use. It dramatically decreases collateral trauma in the natural access point and can advantageously reduce the overall duration of a procedure.

Les prothèses synthétiques dans la cure de prolapsus génitaux par la voie vaginale : bilan en 2005

Since 1996, prosthetic meshes have become increasingly popular for transvaginal surgical cure of genital prolapse. In light of the growing number of proposed techniques and materials we reviewed the experience of the pioneers in order to provide surgeons with the most objective information available. We reviewed the literature indexed in Meline/PubMed and Current Contents retaining all work concerning resorbable and non-resorbable meshes. For the larger class of non-resorbable meshes we also reviewed articles by category of material, each type of mesh being carefully defined: different compositions of polypropylene, polyester, composite meshes and also insertion kits. Resorbable meshes were evaluated in two randomized studies which did not demonstrate better results than with simple folding known to have a high rate of recurrence. For polypropylene meshes, Marlex was studied in six trials which demonstrated a high rate of cure at one year but also a high rate of erosion which reached 25%. Use of Atrium was mentioned in three studies with a 6 to 12% recurrence rate and an erosion rate nearly reaching 20%. The majority of studies used Prolene and Gynemesh. Seventeen authors reported their experience, generally reviewing retrospective series, with recurrence rates of less than 10% for follow-up periods rarely greater than two years. A large variety of forms and sizes have been used, hindering comparisons. The rate of erosion was also quite variable, as high as 45%, demonstrating the need for a precise definition of erosion. Only recently have authors shown interest in the impact of prosthetic meshes on quality of life and sexual activity. An improvement is generally noted for defecation but the rate of dyspareunia has reached as high as 60%. Here again grades of prosthetic retraction should be better defined. Proposed to improve these phenomena, soft Prolene recently used by several authors does not appear to fulfil expectations. Since 2005, several precut polypropylene meshes have been proposed with an insertion kit. The Prolift kit has been followed prospectively in 100 patients undergoing regular surveillance. Surgipro has been used sporadically in small series but follow-up is still too short for proper assessment. Polyester meshes (Mersilene and Paritex) have been presented by three authors who have found them useful but reports have been vague concerning results and complications. Polytetrafluoroethylene has not been evaluated for transvaginal surgery, probably because of the poor tolerance of suburetral bands. For composite meshes, Vypro has been used by four authors who noted about 10% erosion but with a short follow-up insufficient to draw conclusions about the functional and anatomic outcome. Surfaced meshes, advocated for transvaginal treatments, have been studied in only two reports. Plevitex is a polypropylene mesh coated with collagen; another polyester composite with polyglactin 910. The rate of dyspareunia varied from 14 to 24%. Other composites with antiadherents or antiseptics are also proposed for transvaginal insertion but have not been studied. This work demonstrated the lack of sufficient evidence from prospective randomized trials and the lack of standardized techniques to draw any definite conclusions. While evidence is being accumulated on the lower rate of recurrence for anterior compartment prolapse, the lack of data on the rate of complications and patient quality of life is unacceptable for this functional surgery. We still have reservations about widespread use of synthetic meshes. A special chapter is detailed in appendix on post-operative complications. These new specific complications call to a new semiology, with a classification in 4 types and under-types, proposed by authors. Type 1: defects of healing. Type 2: the infection of the graft. Type 3: the shrinkage of the mesh. Type 4: erosions. Authors detail the symptoms of these 4 types as well as the prevention and the treatment of these complications.

Transvaginal Drainage of Ascites as an Alternative to Abdominal Paracentesis in Patients with Severe Ovarian Hyperstimulation Syndrome, Obesity, and Generalized Edema

Objective: To describe an alternative technique for transvaginal drainage of ascites in a case of severe ovarian hyperstimulation syndrome (OHSS), generalized edema, and obesity. Design: Case report. Setting: A university-based hospital IVF and Reproductive Medicine Unit. Patient(s): A patient hospitalized with severe OHSS after IVF-ET in whom drainage of large amounts of ascitic fluid was necessary. Intervention(s): Ultrasonographic transvaginal insertion of a wire guide through a standard IVF needle into the Douglas pouch. Placement of a “peel-away” set on the wire, which was replaced with a “pigtail” indwelling catheter. Main Outcome Measure(s): Amount of drained ascitic fluid. Result(s): Ascitic fluid was drained efficiently, leading to improvement of the patient’s condition. Conclusion(s): Transvaginal ultrasonography-guided insertion of a pigtail catheter through the Douglas pouch is an efficacious procedure when the abdominal approach for decompression of ascites is difficult.

Uterine perforation: A complication of continuous fetal monitoring

A case of intrapartum perforation of the uterus secondary to transvaginal insertion of an intrauterine catheter for continuous fetal monitoring is reported. The perforation resulted in an intraperitoneal abscess. A new, soft, Teflon cannula is described as a possible safer method of introducing the intrauterine catheter.