Uterine Isthmus Research Articles

Isthmocele‑an iatrogenic pathology: A prospective study in a tertiary unit.

Isthmocele, also known as uterine niche, refers to a myometrial defect of the anterior wall of the uterine isthmus, specifically at the site of the previous C-section scar. The prevalence of isthmocele has increased in tandem with the rise in deliveries by caesarean section. Risk factors include aspects related to the surgical procedure. The present study aimed to assess the relationship between various suture types and the development of a niche. The analysis of the present study is based on data collected from the evaluation of 52 patients, 6 weeks post C-section performed in 'Saint Pantelimon' Hospital in Bucharest, Romania. The parameters examined included patient age, the number of previous births by C-section, the type of suture used and uterine anatomy. Out of all the 52 patients, 42.3% developed an isthmocele. The results confirm a significant association between the presence of the niche and the type of suture of the first layer, proving that when non-locking continuous suture was used, the absence of niche was observed in most cases, while using the locking continuous suture was associated with more niches. Using the continuous locking suture for the first layer was associated with severe niches, while no severe niches were observed in patients with the other two types of sutures. There is a statistically significant association between the use of continuous locking sutures for uterine closure in the first layer and the development of a uterine niche. Furthermore, all instances of severe niches were linked to this type of suture, compared with continuous non-locking suture or interrupted suture. Given the escalating rate of C-sections, further research is crucial to identify the suture type that minimizes the risk of isthmocele formation. The present study's limitations revolve around its exclusive focus on a single institution and the relatively small sample size.

Uterine layers hypervascularization in atypical placentation: the comparison of magnetic resonance imaging with vascular pathomorphology

Rationale: One in five women worldwide delivers through cesarean section, which is associated to a high rate of placenta previa and abnormal placenta attachment to the uterine wall. The grade of placenta accreta spectrum (PAS) correlates with blood loss volume, which could be related to vascularization characteristics. Up to now, there have been no studies on the diagnostic value of magnetic resonance criteria for hypervascularization of the uterine wall and their correlation with an assumed grade of PAS according to the International Federation of Gynecology and Obstetrics (FIGO) classification. Also, abnormal vessels location and their wall structure have not been studied with state-of-the-art pathomorphological methods. Aim: To develop a classification for various types of the uterine wall hypervascularization depending on the depth of placental invasion assessed by magnetic resonance imaging (MRI). Methods: We retrospectively analyzed medical files of 66 patients aged 18 to 45 years, who were assumed to have PAS based on their sonography results. To clarify the extent and localization of the placental invasion, all patients had MRI performed at 24 to 32 weeks of gestation. In all patients, the PAS grade was verified pathologically; in 30 of them (45,5%), a detailed pathological examination was additionally performed. The PAS grades were classified according to Morbidly Adherent Placenta Imaging Reporting and Data System (MAPI-RADS). The MRI data were correlated with the PAS (FIGO) grade estimated from intraoperative data and with intraoperative blood loss. At the final study step, the MRI data was correlated with abnormal pathomorphology, with the assessment of the degree of vascularization and the visual picture of abnormal uteroplacental vasculature. Results: We have proposed a classification of MRI signs of hypervascularization in the lower uterine segment correlating with the depth of placenta accreta. Type 1. Single small vessels in the myometrium, medium caliber arteries in the projection of the uterine serosa (normal variation for the 3rd trimester of gestation). Type 2. Numerous small confluent vessels, mainly in the uteroplacental region, and retroplacental hematomas (typical for placenta accreta, or FIGO PAS 1). Type 3. Intrauterine hypervascularization with a deficient myometrium thickness, predominantly vessels of the middle layer (typical for placenta increta, or FIGO PAS 2). Type 4. Thinning of the lower uterine segment due to significant bulging of the placenta in the presence of curved anastomosing vessels of vast caliber over 4 mm (typical for placenta increta – FIGO PAS 2, as well as placenta percreta – FIGO PAS 3a). Type 5. Hypervascularization outside the uterus, over its surface and in the parametrial tissues: at the border with the bladder, uterine isthmus, including signs of fibrosis and growing into the posterior bladder wall (typical for various grades of placenta percreta – FIGO PAS 3b, 3c). Conclusion: The proposed classification of uterine wall hypervascularization in accordance with the grades of placenta accreta spectrum (FIGO PAS) could be useful for its practical implementation by radiologists.

Superb microvascular imaging for assessment of post‐cesarean myometrial blood flow from 1 to 4 weeks after operation: A preliminary study

AbstractPurposeTo evaluate superb microvascular imaging for measuring puerperal myometrial microvascular blood flows at incisional sites following cesarean delivery.MethodsTwenty postpartum women (singleton births) were studied: 10 with cesarean and 10 with transvaginal deliveries. All cesarean cases were first operational delivery with lower uterine incision, repaired with double‐layer suture. At 1 and 4 weeks postpartum, the uterus was delineated using transvaginal ultrasonography with superb microvascular imaging. Separate regions of interest were created for anterior myometrium of the isthmus and the body. The microvascular flow profile in three circular sampling points placed in a region of interest was quantified and expressed as vascular density. The vascular density ratio of the uterine isthmus to the body was compared between one and four weeks for both groups. Wilcoxon's signed‐rank test was used to assess statistical significance (set at p < 0.05).ResultsIn cesarean deliveries, the vascular density ratio of the uterine isthmus to the body increased from 1 (median: 0.51, range: 0.30–0.68) to 4 weeks (0.99, 0.85–1.60), whereas no changes were noted in transvaginal deliveries.ConclusionSuperb microvascular imaging can effectively measure myometrial microvascular blood flow recovery at cesarean incision sites, indicating its potential as a tool for monitoring postpartum wound healing.

Forceps-assisted delivery leads to the formation of a giant uterine isthmus diverticulum: A case report

The formation of uterine diverticula following forceps-assisted delivery is a rare complication characterized by irregular and prolonged postpartum menstruation. While ultrasound and MRI can assist in diagnosis, the identification of this condition often suffers from delayed recognition due to an absence of cesarean section history. Case Report: We present a case involving a 31-year-old woman who developed a uterine diverticulum as a result of forceps delivery and was misdiagnosed for four years. Conclusions: This case report highlights an uncommon complication associated with forceps-assisted delivery—uterine diverticula—and proposes strategies for the early identification and prevention of such conditions following these types of deliveries.

Uterine Niche: A Pathology to Consider

Uterine niche is a recess located in the anterior wall of the uterine isthmus, over the cesarean section scar. This condition is often asymptomatic, but it can be associated with symptoms such as abnormal uterine bleeding, pelvic pain and secondary infertility. Endovaginal ultrasound is the first-line diagnostic method. Treatment includes hormonal methods or surgery, and surgical treatment seems to be the most effective in resolving symptoms. We describe the case of a 37-year-old woman, with an obstetric history of a pregnancy with cesarean delivery, who complained of pelvic pain and menstrual irregularity. An endovaginal ultrasound was requested, which reported the presence of a “… echogenic oval formation with well-defined limits measuring 28x17 mm in the topography of the cesarean scar.” After a clinical discussion with a doctor specializing in Gynecology, the patient was referred to a hospital consultation in this specialty for investigation. The diagnosis of uterine niche was confirmed, and the treatment consisted of the placement of an intrauterine system.

The categorization of opaque pathologies outside of contrast media in hysterosalpingography which facilitate interpretation: A pictorial review.

Hysterosalpingography (HSG) is a practical and reliable imaging method to evaluate the cervical canal, uterine isthmus, uterine cavity, and fallopian tubes. Using HSG, opaque pathologies outside of contrast media can be detected as well as pathologies of uterus and fallopian tubes. We aim to present and categorize some uncommon and interesting abnormal findings that are located outside of the contrast areas in HSG. This is a pictorial review that depicts various types of HSG images that include opaque pathologies outside of the contrast areas. Images have been extracted from valuable archives collected over 50 yr by professor Shahrzad. A plain pelvic film contains soft tissues of the pelvis, bony structures, artifacts, or foreign bodies. Categorization might easily help the radiologist to interpret the HSG cliché. Opaque pathologies outside of contrast area in HSG can be categorized into 2 groups: "Pelvic Tissue Related" and "Foreign Bodies". Pelvic tissue abnormalities might have a gynecologic or non-gynecologic source. Foreign bodies can be located in the pelvis or outside of the body. HSG is a reliable and inexpensive procedure. Familiarity with the pathologies of pelvic tissues and the accurate interpretation of HSG images are important.

Clinical Efficacy of Laparoscopic Uterine Isthmus Cerclage in the Treatment of Cervical Insufficiency and Its Impact on Perinatal Outcomes

Objective: To investigate the efficacy of laparoscopic cervical isthmus cerclage and its impact on perinatal outcomes in patients with cervical insufficiency (CIC). Methods: A total of 120 patients with CIC admitted from July 2016 to July 2023 were randomly assigned to two groups. Group A underwent laparoscopic cervical isthmus cerclage, while Group B received vaginal cervical isthmus cerclage. Perinatal outcomes were compared. Results: Group A demonstrated shorter operation and hospitalization times compared to Group B (P < 0.05). Intraoperative blood loss was also significantly less in Group A (P < 0.05). The treatment success rate in Group A was higher than that in Group B (P < 0.05). During pregnancy, the cervical length in Group A was greater, and the perinatal body weight was higher compared to Group B (P < 0.05). Additionally, the postoperative complication rate was lower in Group A (P < 0.05), and the SF-36 score of CIC patients in Group A was higher than that in Group B (P < 0.05). Conclusion: Laparoscopic cervical isthmus cerclage demonstrates the potential to reduce the duration of the disease, increase perinatal body weight, improve treatment success rates, and enhance the quality of life for patients with CIC.

Anterior sacrospinous ligament fixation by the vaginal route in ten steps

Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs such as the vagina and uterus. While POP may not always cause symptoms, it can significantly impact a woman's quality of life. Diagnosis is typically made through clinical examination, and treatment options range from pelvic-floor physical therapy to surgery.Anterior sacrospinous ligament fixation (ASSLF) has emerged as a viable technique for treating apical prolapse vaginally. This procedure involves attaching the cervix or vaginal vault to the sacrospinous ligament, providing satisfactory results in the short term. Compared to the posterior approach, ASSLF shows similar efficacy, shorter operative time, and potentially fewer complications. Vaginal surgery offers advantages such as lower morbidity and cost, ability to address other pelvic conditions simultaneously, and suitability for managing recurrences.The presented case involves a 72-year-old woman with stage 3 cystocele, stage 3 hysterocele, stage 1 rectocele, and severe voiding dysfunction. After unsuccessful attempts with a pessary, surgical intervention becomes necessary. An instructive video article has been created to standardize the essential steps of ASSLF and facilitate resident education. The video demonstrates ten surgical steps, including installation/exposure, anterior vaginal wall infiltration, median anterior colpotomy, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture, cystocele correction, colpotomy and vaginal wall repair, uterine anterior isthmus suture and sacrospinous ligament fixation, and colporrhaphy final closure.In conclusion, POP is a prevalent condition that can be effectively managed through techniques like ASSLF. Vaginal surgery offers several advantages, and proper training and standardization of surgical steps contribute to successful outcomes and resident education.

EP27.18: Emergency cerclage of the uterine isthmus in a pregnant patient with history of trachelectomy

EP27.18: Emergency cerclage of the uterine isthmus in a pregnant patient with history of trachelectomy

Pelvic arteriovenous malformation involving the uterine and internal iliac vessels with concomitant true aneurysm of uterine artery diagnosed through color Doppler ultrasound

BACKGROUND: Pelvic arteriovenous malformations (AVMs) are rare but carries life-threatening consequences. CASE REPORT: A 47-year-old multipara who had previously undergone four cesarean sections came for re-evaluation of a malignant ovarian new growth. She was asymptomatic. Repeat ultrasound revealed normal ovaries, and a cystic structure at the left adnexa with abundant mixing of colors, turbulent flow and pulsative waveforms on spectral Doppler. It arises from serpentine tubular structures from the uterine isthmus. Uterine artery aneurysm was considered. Magnetic resonance angiography confirmed the findings of aneurysm and pelvic arteriovenous malformation. The patient underwent a hysterectomy with ligation and excision of aneurysm. Histopathologic findings showed pelvic AVM and a true aneurysm of the uterine artery. CONCLUSION: Ultrasound with color Doppler is a low-cost and readily available tool for gynecologists for the diagnosis and management of pelvic AVM.

Treatment of uterine scar cystoid diverticulum by hysteroscopy combined with laparoscopy

To report a patient with prolonged intermenstrual bleeding and a cystic mass at a cesarean scar treated with laparoscopic folding sutures and hysteroscopic canalization. A 4.0 cm-cystic mass formed at the uterine scar caused continuous menstrual blood outflow in the diverticulum and was treated with hysteroscopy combined with laparoscopy. University hospital. A 38-year-old woman of childbearing age who had undergone two cesarean sections and two abortions reported vaginal bleeding for 10 years, which began shortly after the second cesarean section. Curettage was performed, but no abnormality was found. The patient unsuccessfully tried to manage her symptoms with traditional Chinese medicine and hormone drugs. The muscular layer of the lower end of the anterior wall of the uterus was weak, and there were cystic masses on the right side. The bladder was stripped from the lower uterine segment under laparoscopy, and the surrounding tissue of the mass at the uterine scar was separated. The position of the cesarean scar defect was identified by hysteroscopy combined with laparoscopy, and the relationship between the uterine mass and surrounding tissues was analyzed. An electric cutting ring resection on both sides of the obstruction was performed to eliminate the valve effect. The active intima of the scar diverticulum was destroyed by electrocoagulation, followed by laparoscopic treatment of the uterine scar diverticulum mass. An intraoperative tumor incision revealed visible bloody fluid mixed with intimal material. The uterine scar diverticulum defect was repaired using 1-0 absorbable barbed continuous full-thickness mattress fold sutures. Finally, the bilateral round ligament length was adjusted so that the uterus tilted forward. Recovery of menstruation and anatomy of the uterine isthmus. The operation was successful, and the postoperative recovery was fast. There was no interphase bleeding at the 1-month follow-up, and the uterine scar diverticulum was repaired, with the thickness of the uterine scar muscle layer increasing to 0.91 cm. The simple, straightforward procedure to resolve the abnormal cystic, solid mass formed because of the continuous deposition of blood in the uterine scar diverticulum involved laparoscopic folding and docking sutures combined with hysteroscopic canal opening.

Real-time ultrasound demonstration of uterine isthmus contractions during pregnancy

Asymptomatic isthmic contractions are a frequent physiological phenomenon in pregnancy, sometimes triggered by bladder voiding. They can interfere with proper cervical length assessment and may lead to false images of placenta previa. However, there is limited research on the prevalence and characteristics of these contractions. This study aimed to determine the prevalence and characteristics of isthmic contractions after bladder voiding in the second trimester of pregnancy, to evaluate their effect on cervical length assessment, and to propose a new method for the objective assessment of the presence and intensity of isthmic contractions. In this prospective observational study, long videos of the uterine cervix were recorded in 30 singleton pregnancies during the second trimester of pregnancy after bladder voiding. Isthmic length and cervicoisthmic length changes were assessed over time. The isthmic length was measured using a new approach, which involved calculating the distance from the base of the cervix to the internal os, including the isthmus. Isthmic contractions were observed in 43% of pregnant women (95% confidence interval, 26%-62%) after bladder voiding. The median time for complete isthmus relaxation was 19.7 minutes (95% confidence interval, 15.0 to not available). No substantial differences in maternal characteristics were found between individuals with and without contractions. The proposed method for measuring isthmic length provided an objective assessment of the presence and intensity of isthmic contractions. A cutoff of 18 mm in isthmic length allowed for the distinction of pregnant women presenting a contraction. In addition, the study identified a characteristic undulatory pattern in the relaxation of the isthmus in half of the cases with contractions. Isthmic contractions are a common occurrence after bladder voiding in the second trimester of pregnancy and may interfere with proper cervical length assessment. We recommend performing cervical assessment at least 20 minutes after bladder voiding to reduce the risk of bias in cervical length measurement and to avoid false images of placenta previa. The new method for measuring isthmic length provides an objective way to assess the presence and intensity of isthmic contractions. Further research is needed to understand the role of isthmic contractions in the physiology of pregnancy and birth.

Successful Hysteroscopic Management of Cesarean Scar Defect Pregnancy

A 30-year-old multipara of 2 with history of 1 cesarean delivery, presented to the emergency department (ED) with one day of pelvic pain and vaginal bleeding. A positive β-human chorionic gonadotropin (β-hCG) blood test (215 mUI/mL) had been obtained 20 days prior. Upon admission, she was hemodynamically stable, and the physical exam showed no cervical changes or active bleeding. Transvaginal Ultrasound (TVUS) performed in the ED revealed a gestational sac (GS) implanted in the uterine isthmus, with a 6.7 mm embryo without cardiac activity. She was admitted for further evaluation. Formal TVUS (Figure 1) revealed an apparent cesarean scar defect (CSD) containing a 6 mm embryo without cardiac activity. Trophoblast tissue extended towards the defect, and the myometrial residual thickness (MRT) measured 1.4 mm. Adnexa appeared normal. Serial β-hCG levels were obtained, resulting on 2,177 on admission, 1,972 on the second, and 1,924 mUI/mL on the fourth day. Based on these findings, diagnosis of CSD pregnancy was made. Hysteroscopic management (Figure 2) was decided and successfully performed under regional anesthesia and continuous ultrasound guidance. Complete resection of the GS occupying the CSD was achieved using a bipolar resectoscope. Post-procedure, the patient received a prophylactic dose of Methotrexate (100 mg IM), an etonogestrel implant was inserted, and was discharged without incidents the day following surgery. The pathology report confirmed the diagnosis. On follow-up 12 days after surgery, patient was asymptomatic, β-hCG levels resulted 7.4 mIU/mL, and on a 6-month follow-up visit, was discharged to primary healthcare. Reasonable evidence supports hysteroscopic management of CSD pregnancy, with the benefit of direct visualization (1, 2, 3). Other techniques, like use of a double balloon catheter have been described (4). Hysteroscopy was chosen despite of the MRT (5), with staged laparoscopic repair due to an unclear fertility desire.

Differential diagnosis of paracervical vascular anomalies in pregnancy.

Table S1. Table summarizing the history of four patients with paracervical vascular anomalies, both UAP and varices. Videoclip S1. Video demonstrating the aspect of the same patient of figure 1. A whirlpool flow is seen inside the UAP, both at greyscale ultrasound and at Doppler assessment, even with a high PRF. The vascular mass is located on the left cervical side and seemed to be fed by left uterine artery as shown by the pulsed Doppler analysis. Videoclip S2. Video demonstrating the aspect of the UAP of case 2. A whirlpool flow is seen inside the UAP located on the right of the hysterotomic breech. The feeding vessel is clearly visible arising from the right uterine artery (arrow). Videoclip S3. Transvaginal ultrasound of case 3. Moving the probe laterally from the cervix, the varices are visible, with their tortuous course and their low-velocity intraluminal flow. At Power Doppler the left uterine artery is clearly visible across the vascular mass, without dilatation nor clear communicating feeding vessel, strengthening the hypothesis of the venous origin of the formation. Videoclip S4. Transvaginal ultrasound of case 4; the venous vascular formation is detectable by moving the probe on the right side of uterine isthmus. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

V12-12 ROBOT-ASSISTED CERCLAGE SACROHYSTEROPEXY

You have accessJournal of UrologyCME1 Apr 2023V12-12 ROBOT-ASSISTED CERCLAGE SACROHYSTEROPEXY Miranda Eubank, Hiroko Miyagi, Veronica Demtchouk, and Louis Moy Miranda EubankMiranda Eubank More articles by this author , Hiroko MiyagiHiroko Miyagi More articles by this author , Veronica DemtchoukVeronica Demtchouk More articles by this author , and Louis MoyLouis Moy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Laparoscopic cerclage sacrohysteropexy is a novel surgical technique first described and performed laparoscopically by Dr. Peter Rosenblatt. It is a uterine-sparing technique that requires less suturing and dissection compared to traditional sacrocervicopexy and alternative uterine-sparing methods. His team reports equivalent anatomic outcome with reduced intraoperative time when compared to traditional sacrocervicopexy. To our knowledge, cerclage sacrohysteropexy has not yet been demonstrated robotically. METHODS: We demonstrate the cerclage sacrohysteropexy using robot-assisted laparoscopy. To achieve uterine suspension the uterine isthmus was identified. Tissue windows were dissected laterally on each side of the isthmus. Polypropylene mesh was looped through the lateral windows, encircling the isthmus. The mesh tail was pulled cephalad and secured to the sacral promontory in standard fashion. RESULTS: The patient had good apical suspension and adequate vaginal caliber at the conclusion of the case. There were no intraoperative or postoperative complications. She was doing well upon 1 month follow-up. Physical exam at the time of follow up showed a c-point of –8. CONCLUSIONS: Robot-assisted cerclage sacrohysteropexy is a viable uterine-sparing option for treatment of apical pelvic organ prolapse. It requires less suturing and dissection than other uterine-sparing and non-uterine-sparing techniques. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1068 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Miranda Eubank More articles by this author Hiroko Miyagi More articles by this author Veronica Demtchouk More articles by this author Louis Moy More articles by this author Expand All Advertisement PDF downloadLoading ...

Ultrasound Guided Hysteroscopy in the Complex Uterine Isthmus

<h3>Study Objective</h3> To demonstrate clinical considerations, operative setup and techniques for a reproducible method of achieving safe hysteroscopic access to the endometrial cavity using multimodal imaging techniques to navigate the complex uterine isthmus. <h3>Design</h3> Educational and stepwise instructional narrated surgical video. <h3>Setting</h3> Community Gynecologic Surgery Referral Practice <h3>Patients or Participants</h3> A 31-year-old G1P1 patient with severe cervical stenosis and high-grade isthmocele is referred for assistance with cervical dilation prior to planned embryo transfer. <h3>Interventions</h3> The patient underwent combined simultaneous hysteroscopic and ultrasonographic visualization to safely access the endometrial cavity. <h3>Measurements and Main Results</h3> A reproducible procedural setup and workflow is described in depth including positioning of patient, assistants and technology as well as detailed stepwise procedure instructions to obtain endometrial access without perforation. <h3>Conclusion</h3> As recognition of isthmocele and other anatomic pathology increases alongside high rates of cesarean section, the gynecologic surgeon must command careful perioperative planning, multimodal imaging techniques and a firm grasp of instrumentation safety parameters as part of the advanced endoscopic skill set required to navigate this complex anatomic area.

Vaginal transisthmic myomectomy: a step by step video tutorial

To provide a video tutorial on vaginal transisthmic myomectomy in women with large submucosal fibroids. Stepwise demonstration of the technique, with a narrated video footage. Submucosal fibroids protrude into the uterine cavity and can cause numerous symptoms, including abnormal uterine bleeding, dysmenorrhea, subfertility, and obstetric complications. Over the last decades, hysteroscopic resection has become the preferred surgical approach for submucosal fibroids because it provides significant advantages regarding perioperative morbidity and postoperative recovery time when compared with laparotomy or laparoscopy with complete transection of the uterine wall. However, in large or multiple fibroids, longer surgery durations of hysteroscopic resection can lead to higher complication rates and incomplete resection. In some cases, hysteroscopic resection might even be impossible to perform. Furthermore, in many regions, special equipment for hysteroscopic myomectomy might not be available. Herein, we present a minimally invasive surgical alternative for approaching submucosal fibroids. A 26-year-old woman presenting with hypermenorrhea and dysmenorrhea (on a numeric rating scale from 0-10) caused by a recurrent International Federation of Gynaecology and Obstetrics (FIGO) type 0 fibroid measuring 5 cm in diameter. Vaginal transisthmic myomectomy performed with a longitudinal transection of the uterine cervix and isthmus, morcellation of the fibroid with a scalpel, and multilayer reconstruction. Vaginal transisthmic myomectomy is a fast and relatively simple, minimally invasive surgical technique suitable for large or multiple FIGO 0 and some FIGO 1 fibroids, necessitating the use of only basic surgical equipment. Vaginal transisthmic myomectomy provides an additional minimally invasive surgical approach for submucosal fibroids. This surgical option for selected patients may help prevent complications resulting from prolonged hysteroscopic surgery,repeated hysteroscopic procedures owing to incomplete resection, and the morbidity of transabdominal approaches for myomectomy.With this video, we aim to expedite the clinical learning curve of this technique, which should be investigated on a broader scale in the future.

Large cervical myoma originating from the uterine corpus

This case report aimed to present a case of large cervical myoma that obliterated the ureterovesical area and filled the entire cervix. A 33-year-old patient had a tumoral lesion of approximately 80x60 mm, compatible with myoma, that filled the cervical cavity. On vaginal examination, a barrel- shaped, immobile and large cervix was palpated. A preoperative bilateral double J catheter was applied to the patient. While the uterine cervix was barrel-shaped due to myoma and was palpable from Douglas, it was firmly fixed anteriorly to the bladder and corpus. During bladder dissection, approximately 4 cm defect was formed in the isthmus, and the uterine cavity was entered. A myoma with a diameter of approximately 9 cm, which filled the entire cervix from the uterine isthmus and had a stem attached to the fundus, was observed in the cavity, and the myoma was pulled out from the defect with a tenaculum and removed. Since the anterior cervix could not be reached and bladder dissection could not be achieved, a subtotal hysterectomy was performed. Although they are mainly treated surgically, there is no standard treatment for cervical myomas. Due to its proximity to vital organs, care should be taken against the risk of organ injury.

A combination of two novel ligation techniques for complicated laparoscopic intraligamental myomectomy

To perform laparoscopic myomectomy by combining two novel ligation techniques for a large lateral intraligamental myoma. A step-by-step explanation of the surgical procedure using a video with narration. University hospital. A 39-year-old woman (gravida 1, para 0) presented with an asymptomatic pelvic mass. Sonographic imaging revealed a 10-cm subserous myoma from the right lateral uterine isthmus wall. Laparoscopic exploration revealed a large myoma growing from the right lateral cervical isthmus wall toward the broad ligament. It was protruding into the pararectal space with duplicated ureters. For such a large lateral intraligamental myoma, any conventional approach has the potential to cause massive bleeding and accidental injuries. We devised and implemented a preventative strategy for intraoperative bleeding by combining two novel ligation techniques used in laparoscopic myomectomy. We made an incision at the posterior leaf of the broad ligament and exposed the myometrium enveloping the fibroid and the base of the fibroid. Then we performed an incision 2 cm away from the right lower edge of the fibroid base, opening the myometrium and pseudocapsule. We applied two novel ligation techniques that ligate the pedicle on the left of the fibroid and the pseudocapsule on the right of the fibroid. Enucleation and loop tightening were implemented simultaneously. The entire pseudocapsule and most of the myometrium enveloping the fibroid were ligated in the loop knot. Only a small portion of the myometrium on the right side was outside the loop knot, which required electrocoagulation. Loop ligation was performed twice more for reinforcement in the same location. The peritoneum was then closed. Laparoscopic myomectomy was completed successfully for a large lateral intraligamental myoma using our novel technique. The surgery lasted 110 min, and the volume of intraoperative blood loss was 150 mL. The patient had a normal postoperative course. Combining two novel ligation techniques in laparoscopic myomectomy is a safe and efficient surgical choice. This technique has obvious advantages in large, broad ligament myomas, reducing bleeding and avoiding unintentional injuries, even in duplicated ureters. Furthermore, this technique is not limited by the device and does not increase the cost of surgery.

Istmocele. Reporte de caso

Defects in cesarean scar results from a postoperative complication of the uterine isthmus, also known as an isthmocele. This is a reservoir-like pouch defect on the anterior wall of the uterine isthmus located at the site of a previous cesarean scar. The flow of menstrual blood through the cervix may be slowed by the presence of isthmocele, as the blood may accumulate in the niche and, together with the presence of fibrotic tissue, cause pelvic pain. The removal of the local inflamed tissue improves symptoms and restores fertility. We report the case of a 39-year-old with history of inter-menstrual bleeding, pelvic pain and dysmenorrhea. Images studies revealed a cesarean scar defect connected to a small cavity in the myometrium compatible with an isthmocele. After surgical excision, symptoms resolved. This case highlights the importance surrounding diagnosis, management and benefits of surgical repair of uterine scar defect after cesarean section.