Uterine Manipulator Research Articles

8809 Laparoscopic Cornual Resection after Ectopic Pregnancy in Fallopian tube Remnant

<h3>Study Objective</h3> To review ectopic pregnancies after salpingectomies. To demonstrate a safe and feasible approach to a laparoscopic cornual resection after an ectopic in a fallopian tube remnant. <h3>Design</h3> A single person case report with a stepwise demonstration of surgical techniques with narrated video footage. <h3>Setting</h3> Tertiary-care academic center. <h3>Patients or Participants</h3> A 31-year-old has a history a history of a right salpingo-oophorectomy in childhood and a left salpingectomy after a history of two ectopic pregnancies. She presented with a right fallopian tube remnant ectopic pregnancy, which was treated with methotrexate. Prior to embryo transfer, it was recommended for her to have this right tubal remnant removed. <h3>Interventions</h3> Vasopressin was administered into the uterus for bleeding prevention into the right cornua. A uterine manipulator was placed, and methylene blue was injected to delineate the tubal ostia and thus the area of resection. A small wedge resection of the cornua was performed and the uterus closed in 2 layers with a 2-0 V-loc suture. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Ectopic pregnancies after bilateral salpingectomies are rare. In patients who desired invitro fertilization after a history of an ectopic pregnancy in a fallopian tube remnant, may safely undergo a resection of the uterine cornua, by a trained gynecologic surgeon.

Strategies to Minimize Blood Loss during Laparoscopic Hysterectomy for Management of Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> Demonstrate techniques to minimize blood loss during laparoscopic hysterectomy for management of cesarean scar ectopic pregnancy. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> 33-year-old G5P4004 with one prior cesarean delivery presented to the ER with abdominal pain and vaginal spotting in early pregnancy. Her vital signs were normal with a Hemoglobin of 8.9. Ultrasound revealed a ∼6-week cesarean scar ectopic pregnancy. She was counseled on management options including laparoscopic resection of the ectopic with repair of uterine defect or laparoscopic hysterectomy. The patient was satisfied with her parity and opted for hysterectomy. <h3>Interventions</h3> The patient underwent total laparoscopic hysterectomy, bilateral pelvic wall dissection, bilateral salpingectomy, and cystoscopy. Various considerations and techniques were used intraoperatively to minimize blood loss. 1. Major vasculature (uterine and utero-ovarian arteries) was interrupted before placement of uterine manipulator 2. Uterine manipulator was placed under laparoscopic guidance in a retroverted fashion to avoid disruption of pregnancy 3. The correct plane was identified during dissection between the bladder and pregnancy to avoid injury or bleeding 4. Additional bleeding was anticipated and encountered even after major blood supply was interrupted, likely related to collateral vasculature to the pregnancy <h3>Measurements and Main Results</h3> Successful management of cesarean scar ectopic pregnancy was performed via laparoscopic hysterectomy. Estimated blood loss was 100cc and the surgery was uncomplicated. <h3>Conclusion</h3> Cesarean scar ectopic pregnancy is more common with the rising rate of cesarean deliveries. Risk of hemorrhage in this scenario is higher due to possible trophoblastic involvement up to level of uterine arteries. However, various techniques may be used to decrease blood loss during definitive surgical treatment.

Laparoscopic Excision of Parametrium Endometriosis

<h3>Study Objective</h3> To present a case of parametrium and bladder endometriosis. <h3>Design</h3> Case report illustrated with video. <h3>Setting</h3> Patient placed in semi-gynecological position, legs in stirrups and Trendelenburg tilt. A minimally invasive laparoscopic surgery was performed helped by a uterine manipulator. <h3>Patients or Participants</h3> We present the case of a 29-year-old woman complaining of chronic pelvic pain, severe dysmenorrhea radiating to lumbar region and coccyx, and intense deep dyspareunia. At the pelvic examination, she had a 4 cm painful nodule affecting the left parametrium, extending to the paravaginal aspect and ipsilateral uterosacral ligament. The complementary investigation with pelvic ultrasound evidenced a uterus with 83cc volume, a 1.5cm leiomyoma, a 1cm infiltrating vesical nodule, a 2 cm nodule in the right round ligament, and a 4 cm retrocervical nodule affecting left parametrium and vaginal wall. <h3>Interventions</h3> Laparoscopic surgical removal of all endometriotic lesions. <h3>Measurements and Main Results</h3> Patient was discharged in the 1^st post-operative day and maintained the use of foley catheter up to the 14th day. She had a negative post-void residual test, no urinary impairment and complete remission of symptoms. The final pathological report confirmed endometriosis and leiomyoma. <h3>Conclusion</h3> Parametrium endometriosis can affect around 17% of women with deep endometriosis, and the surgical treatment can cause voiding disfunctions due to inferior hypogastric nerve and plexus proximity. We should always perform a nerve-sparing surgery when possible.

8901 Strategies for a Successful Minilaparotomy Myomectomy

<h3>Study Objective</h3> To provide a unique video highlighting techniques to promote a successful minilaparotomy myomectomy of large uterine fibroids. <h3>Design</h3> Video presentation. <h3>Setting</h3> Academic tertiary care hospital. <h3>Patients or Participants</h3> A nulliparous 37-year-old presented for fertility sparing surgical management of symptomatic uterine fibroids via a minilaparotomy incision. Pre-operative planning included a pelvic MRI notable for two large FIGO 7 fibroids, one of which was an 11 cm pedunculated myoma that was noted to have torsed along with the fallopian tube. <h3>Interventions</h3> This video highlights techniques of mitigating blood loss including the pre-operative tranexamic acid and rectal misoprostol. Moreover, a handheld vessel sealer was specifically chosen for this procedure to ensure efficiency of dissection and hemostasis. Unique to our video is the use of a tourniquet to mitigate bleeding from a large myoma stalk. Additionally, a cell-saver was utilized to minimize the risk of a blood transfusion. In order to promote visualization and uterine mobility, a self-containing circumferential retractor was utilized, and the patient was placed in dorsal lithotomy with a uterine manipulator. Highlighted in this video is the importance of the core/wedge technique, which facilitated the decompression and evacuation of 689g of fibroids from a 6 cm minilaparotomy incision. <h3>Measurements and Main Results</h3> Our hemostatic efforts were successful in minimizing blood loss, which was estimated to be 350cc, below the threshold for cell saver autologous transfusion. The entire procedure was successfully performed with a minilaparotomy incision, and the patient met criteria for same day discharge. <h3>Conclusion</h3> Strategies for a successful myomectomy include the use of pre-procedure tranexamic acid and misoprostol, cell saver for possible autologous transfusion, a self-containing retractor, handheld vessel sealer/tourniquet, and efficiency with the core/wedge morcellation technique.

Robotic-Assisted vs Conventional Laparoscopic Transabdominal Cerclage Placement

<h3>Study Objective</h3> To compare and contrast robotic-assisted versus laparoscopic transabdominal cerclage placement. <h3>Design</h3> Video. <h3>Setting</h3> Tertiary academic medical center with two minimally-invasive gynecologists. <h3>Patients or Participants</h3> Two patients at approximately 13 weeks gestation with cervical insufficiency. <h3>Interventions</h3> Transabdominal cerclage. <h3>Measurements and Main Results</h3> It is important to know useful tools in placement of minimally invasive transabdominal cerclage. These include the 30-degree laparoscope, sacrocolpopexy cup, uterine manipulators, and laparoscopic paddle retractor. Consider use of a suprapubic port for laparoscopic cerclage placement for more ideal angle for dissection of the avascular tunnel and passage of the Mersilene tape. Tying the Mersilene tape anteriorly laparoscopically can be helpful so that no additional port is used for manipulation of the uterus. <h3>Conclusion</h3> Transabdominal cerclage may be placed safely in a minimally invasive fashion both with robotic-assisted and conventional laparoscopic approach.

Laparoscopic Abdominal Cerclage after Prior Radical Trachelectomy

<h3>Study Objective</h3> To present a case and surgical video of laparoscopic abdominal cerclage placement after prior radical trachelectomy and demonstrate techniques in overcoming challenging dissections and an alternative surgical technique in placement of cerclage. <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> In the operating room with a patient in dorsal lithotomy position with both arms tucked. A 10mm port was placed at the umbilicus and 3 additional 5mm ports were placed in the right and left lower quadrant and suprapubic region. A uterine manipulator, flexible laparoscopic, and bipolar sealing device were used. <h3>Patients or Participants</h3> One patient. <h3>Interventions</h3> A 34yo P2 with prior surgical history of exploratory laparotomy, radical trachelectomy, sentinel lymph node mapping, pelvic lymphadenectomy for stage 1B1 cervical squamous cell cancer. She had been disease free for two years and she had erosion of her vaginal cerclage that had been placed at the time of her original surgery. She had two prior cesarean deliveries prior to her cervical cancer diagnosis and desired future fertility. She underwent a laparoscopic abdominal cerclage with cystoscopy and ureteral catheter placement. <h3>Measurements and Main Results</h3> Laparoscopic placement of abdominal cerclage was successful. Surgical techniques in navigating difficult dissections are reviewed in the video. In the absence of a cervicouterine junction, placement a 5mm Mersilene tape cerclage at the neo-cervical region was successful. There were no intra or post-operative complications. Patient had a good surgical recovery. <h3>Conclusion</h3> This video demonstrates challenges in placement of an abdominal cerclage following a radical trachelectomy due to distortion of anatomy and dense post-surgical adhesions. The video demonstrates that laparoscopic placement at the neo-cervical junction can be accomplished successfully and safely.

Laparoscopic Myomectomy for a Large Incarcerated Posterior Myoma

<h3>Study Objective</h3> To demonstrate a technique for laparoscopic myomectomy with a large posterior fibroid and incarcerated uterus. <h3>Design</h3> We present a stepwise narrated demonstration of our technique for posterior myomectomy. <h3>Setting</h3> Referral Center in Upstate NY. <h3>Patients or Participants</h3> A 35-year-old with large posterior fibroid desiring fertility sparing treatment. <h3>Interventions</h3> Bilateral retroperitoneal dissections are performed, demonstrating both lateral and anterior approaches for isolation of uterine blood supply. Hemostatic control is achieved with the use of rectal misoprostol, intrauterine vasopressin and temporary occlusion of the uterine blood supply. A high hysterotomy is made and the fibroid is dissected away from the pseudocapsule, eventually allowing displacement of the uterus out of the posterior cul-de-sac with a vaginal hand as the dissection continues, demonstrating an approach to hysterotomy when the ideal location is inaccessible. On completion of the myomectomy, a uterine manipulator is placed, and excess serosa is trimmed. The myometrium is repaired with a 3-layer closure followed by a single layer on the uterine serosa. <h3>Measurements and Main Results</h3> Successful laparoscopic myomectomy for a 669-gram fibroid with estimated blood loss of 100ml and benign pathology. Patient discharged home postoperative day one. Normal appearing uterus on 3-month follow-up ultrasound. <h3>Conclusion</h3> Laparoscopic myomectomies can be safely performed on large posterior uterine fibroids even in the setting of an incarcerated uterus. The above techniques can improve hemostasis, access to the fibroid and repair of atypical hysterotomy.

Retropubic Leiomyoma Causing Urinary Retention: A Case Report

<h3>Study Objective</h3> To present a rare case and the surgical treatment of a retropubic leiomyoma. <h3>Design</h3> Case report illustrated with video. <h3>Setting</h3> We used the da Vinci Si platform in a side docking fashion, with four robotic arms and a laparoscopic 11mm trocar. Uterine manipulator and foley catheter were placed. <h3>Patients or Participants</h3> We present the case of a 39-year-old woman complaining of voiding difficulty, recurrent urinary tract infections and dyspareunia. At the pelvic examination, she had a 4 cm nodule in the anterior vaginal wall, occupying the retropubic space. The complementary investigation with pelvic MRI evidenced an infravesical solid nodular image with lobulated and well-defined contours, located anteriorly to the urethra, with a plane of contact with its anterior wall. It is manifested by intermediate signal on T1 and T2, absence of restriction to the water molecules diffusion and enhancement by contrast medium similar to the myometrium, measuring 3.0 × 3.6 × 3.1 cm. The patient was seen by a urologist which suggested a transvaginal biopsy to exclude malignancy. The biopsy result was leiomyoma. <h3>Interventions</h3> Patient was eligible for a robotic-assisted laparoscopic excision of a retropubic (FIGO 8) leiomyoma. The access to retropubic space was made through the urachus until the pubic bone. The fibroid was easily identified behind the pubic symphysis. Lateral dissection was carried out to identify landmarks and the fibroid was excised using gentle movements. There was no urethral or vesical lesion. The defect was closed with a double layer suture. <h3>Measurements and Main Results</h3> The foley catheter was removed in the first postoperative day and the patient had complete remission of symptoms. The final histopathological report confirmed leiomyoma. <h3>Conclusion</h3> Although being extremely rare, leiomyomas in the Retzius space should be considered in the differential diagnosis of voiding dysfunctions.

Cervical Fibroids - Key Surgical Steps

<h3>Study Objective</h3> To review critical steps during robotic assisted total laparoscopic hysterectomy in patients with large cervical fibroids, focusing on tips for safely performing ureterolysis, isolation of uterine vasculature, and colpotomy. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> Surgery is the primary therapy for cervical leiomyomas, which account for 0.6-2% of uterine fibroids. Cervical fibroids significantly alter anatomy, making a minimally invasive approach prohibitive to many providers. The size and location of the fibroid can cause alterations in ureter course and uterine vasculature, inability to use a uterine manipulator, and deformation of the colpotomy. <h3>Patients or Participants</h3> The first case depicts a patient with a 7.9-cm, midline, cervical fibroid. She received preoperative Leuprolide twice, resulting in a decrease in maximum diameter to 5.5 cm intra-operatively. The second case demonstrates a patient with a 13-cm cervical fibroid on imaging, noted to be at least 15 cm intra-operatively, causing bilateral hydroureters and hydronephrosis. <h3>Interventions</h3> This video demonstrates how to navigate the main challenges afforded by cervical fibroids when performing robotic hysterectomy. It includes how to create the space needed for ureterolysis and demonstrates using the ureter as a tool for navigation in the altered retroperitoneum. It highlights the importance of ligating the uterine arteries at their origin and reflecting the uterine arteries from medial to lateral. Finally, it reviews tips for completing a colpotomy using an end-to-end anastomosis (EEA) sizer as a guide and dynamic tool. <h3>Measurements and Main Results</h3> Both patients did well postoperatively with resolution of their symptoms. The second case had complete resolution of hydroureters and hydronephrosis. <h3>Conclusion</h3> Surgery is the primary therapy for cervical leiomyomas. A minimally invasive approach has proven benefits over open surgery but poses challenges due to distortion of normal anatomy. In the appropriate patient with a large cervical fibroid, robotic and laparoscopic hysterectomy can safely be performed by a skilled minimally invasive surgeon.

8535 Troubleshooting Less Is More: Three Simple Tricks Every Gynecologist Should Know

<h3>Study Objective</h3> To describe three simple techniques every Gynecologist should know for troubleshooting in the operating room. <h3>Design</h3> This is an educational video. <h3>Setting</h3> Intra-operative video recordings from various patient encounters. <h3>Patients or Participants</h3> Patients were undergoing minimally invasive gynecologic surgery at a tertiary care center. <h3>Interventions</h3> Three interventions are demonstrated: 1) simplified steps to culdotomy without a uterine manipulator 2) use of a Bovie to activate a laparoscopic instrument 3) steps to backfilling the bladder and performing a bladder survey with a 30-degree laparoscope. <h3>Measurements and Main Results</h3> Safe and efficient care of patients. <h3>Conclusion</h3> These simple techniques are helpful when encountering an unexpected situation, they allow the surgeon to move forward safely and efficiently.

8802 GYN 101: Introduction to Uterine Manipulators

<h3>Study Objective</h3> To understand the insertion techniques and use of various types of uterine manipulators. <h3>Design</h3> This video highlights the importance behind the use of manipulators during laparoscopy and identifies unique aspects of various types of manipulators. Additionally, we review how to properly insert and use manipulators. <h3>Setting</h3> The patient is placed in dorsal lithotomy for the video. <h3>Patients or Participants</h3> One patient is filmed to demonstrate the placement of a Fornisee manipulator for a robotic assisted total laparoscopic hysterectomy. A combination of simulation models and photographs were also utilized to review educational topics. <h3>Interventions</h3> The utility of manipulators during laparoscopy, various types of manipulators, and proper insertion techniques are reviewed. <h3>Measurements and Main Results</h3> We review how uterine manipulators assist with visualization, elevate the uterine vessels farther away from the ureters and bladder, and delineate the cervicovaginal junction assisting with colpotomy. Many manipulators have unique aspects that make them favored for specific clinical situations. This video demonstrates how extracorporeal hand movements position the uterus in an opposite fashion intra-abdominally. <h3>Conclusion</h3> It is important to know different manipulator types to tailor their use to specific clinical scenarios. Safe and accurate placement and proper movements are crucial in assisting the surgeon, especially during important dissection steps.

Building a Hysteroscopic Simulation Model

<h3>Study Objective</h3> Demonstrate the construction and implementation of a low-fidelity simulation model for hysteroscopy training to Obstetrics and Gynecology (OB/Gyn) residents. <h3>Design</h3> OB/Gyn residency training program. <h3>Setting</h3> Community-based hospital program. <h3>Patients or Participants</h3> PGY1 through PGY4 OB/Gyne residents from a community-based program. <h3>Interventions</h3> A hysteroscopic simulation model was constructed using low-cost, reusable, and readily accessible materials and supplies. This hysteroscopic model is used to assess residents' identification of a normal cervical canal, junction of the cervical canal and lower uterine segment, and both fallopian tube ostia. The residents should also be able to identify normal intrauterine anatomy and pathology. Learners are taught basic instrument use with proper scope rotation to minimize uterine manipulation and torque. <h3>Measurements and Main Results</h3> The "bell pepper" model is typically used as part of basic hysteroscopy simulation. There are some deficiencies of that model with its inability to accurately simulate proper cervical entry and identify normal intrauterine anatomy. This hysteroscopic simulation model better demonstrates proper insertion technique with angled lens resulting in improved visualization of lateral structures without angling the scope. It also provides training of proper scope rotation using the light post as a guide. <h3>Conclusion</h3> Low fidelity simulation models can be easily implemented into an OB/Gyn residency curriculum to enhance residents' procedural knowledge and skill development. Building this hysteroscopic simulation model provides a useful, practical, and low-cost training tool for teaching basic hysteroscopy techniques.

Double Trouble: Tips for Colpotomy and Vaginal Cuff Closure with Uterine Bicollis and Longitudinal Vaginal Septum

<h3>Study Objective</h3> To describe the laparoscopic technique for colpotomy, approach for laparoscopic excision of longitudinal vaginal septum, laparoscopic cuff closure with and without intact vaginal septum and considerations for uterine manipulation in patients with uterine bicollis and longitudinal vaginal septum. <h3>Design</h3> Two case reports. <h3>Setting</h3> Two laparoscopic cases at a single tertiary care center in the United States. <h3>Patients or Participants</h3> Two patients undergoing total laparoscopic hysterectomy (TLH) with uterine bicollis and longitudinal vaginal septa, one with a bicornuate uterus and one with uterine didelphys. <h3>Interventions</h3> The first patient with bicornuate uterus underwent TLH using a manipulator with small colpotomizer cup to accommodate the small caliber of the hemivagina and cervices. Colpotomy was performed by placing the manipulator first in the right cervix, then the left. Her vaginal septum left in situ as it was not bothersome. The septum was successfully integrated into the vaginal cuff. The second patient with uterine didelphys underwent TLH using a manipulator without a cup. The colpotomy was completed in a similar manner. Her septum was excised laparoscopically as it caused dyspareunia. The vaginal defect was repaired laparoscopically and cuff closed in the usual fashion. <h3>Measurements and Main Results</h3> Options for manipulation include a small manipulator cup, a manipulator without cup, vaginal devices such as sponge stick, vaginal/rectal probe or Briesky-Navratil retractor. Vaginal septa can be successfully incorporated into the vaginal cuff from a laparoscopic closure or excised laparoscopically. <h3>Conclusion</h3> Alternative means for uterine manipulation are often necessary in patients with uterine bicollis and longitudinal vaginal septa. Longitudinal vaginal septa can be successfully incorporated into the vaginal cuff for laparoscopic closure or excised and repaired laparoscopically.

8238 Approach to Dense Anterior and Posterior Adhesions during Laparoscopic Hysterectomy

<h3>Study Objective</h3> This video demonstrates surgical techniques for dense anterior and posterior adhesions during laparoscopic hysterectomy. <h3>Design</h3> Case report. <h3>Setting</h3> Academic hospital. <h3>Patients or Participants</h3> Two patients with dense uterine adhesions. Patient #1 had dense anterior uterine adhesions from a history of 3 prior cesareans. Patient #2 had dense posterior uterine adhesions from deep infiltrating endometriosis of the anterior rectosigmoid colon. <h3>Interventions</h3> A total laparoscopic hysterectomy was completed for both patients utilizing specific techniques to lyse dense adhesions to the uterine corpus. Techniques included 1) starting the dissection on the side of the uterine corpus opposite of the dense adhesions, 2) identifying the uterine manipulator colpotomy cup between the adhesions and the uterine vessels, 3) tunneling behind the adhesions along the colpotomy cup, and 4) completing the dissection medially and cephalad. <h3>Measurements and Main Results</h3> Total laparoscopic hysterectomies were completed in the setting of dense adhesions without unintended injury to surrounding structures. <h3>Conclusion</h3> This video demonstrates surgical techniques including four key steps that can be utilized during laparoscopic hysterectomy for both anterior and posterior adhesions to the uterine corpus.

Laparoscopic Myomectomy in the Retzius Space

<h3>Study Objective</h3> To illustrate a laparoscopic approach for the excision of the rare fibroid found within the Retzius space, to showcase relevant anatomy of the paravesical and Retzius space as well as to review the retroperitoneal vascular anatomy of the female pelvis. <h3>Design</h3> Elective Laparoscopic Myomectomy. <h3>Setting</h3> After verification of informed consent, the patient was taken to the operating room where a safety surgical briefing was performed. The patient was given a general anesthetic. They were then prepped and draped in the dorsal lithotomy position. 2g of Ancef was given. A foley catheter was inserted under sterile conditions and a Mengeshkar uterine manipulator was placed. <h3>Patients or Participants</h3> Previously healthy 36-year-old G1P1 who presented with a growing abdominal mass, she was otherwise asymptomatic. She was consented for laparoscopic myomectomy and underwent GnRH agonist treatment for 3 months prior to surgery. <h3>Interventions</h3> Laparoscopic Surgery. <h3>Measurements and Main Results</h3> Estimated blood loss was 400cc. The patient had no postoperative complications and was discharged home on post-operative day 1. The final specimen pathology was leiomyoma with a specimen weight of 556g. <h3>Conclusion</h3> Leiomyomas within the Retzius space are rare and can be safely excised using a laparoscopic approach. Bladder insufflation along with recognition of pelvic anatomical landmarks optimizes surgical navigation. Awareness of vascular structures present within Retzius space is instrumental for safe dissection.

8402 Two-Port Total Laparoscopic Hysterectomy and Excision of Simple Endometriosis in a Transgender Male Patient.

<h3>Study Objective</h3> To provide an overview of a two-port total laparoscopic hysterectomy with bilateral salpingo-oophorectomy in a transgender male patient and to demonstrate the feasibility of excision of simple endometriosis by this approach. <h3>Design</h3> Surgical video. The American College of Obstetricians and Gynecologists recommends vaginal approach to hysterectomy, whenever feasible; however, in the transgender male patient, the vaginal approach to hysterectomy may pose technical challenges due to limited vaginal access: vaginal atrophy (when on testosterone therapy), lack of uterine descensus due to nulliparity that is common, and often times infrequent or no vaginal intercourse. Moreover, the frequent desire for salpingo-oophorectomy in this population can make the vaginal approach a challenging one. When patients have history of dysmenorrhea and/or pelvic pain, laparoscopy offers an adequate intrabdominal survey to diagnose and treat endometriosis, which is precluded with vaginal access alone. <h3>Setting</h3> Academic hospital with a referral-based practice for the transgender male patient who desire gender affirming surgery. <h3>Patients or Participants</h3> 35-year-old nulligravid trans male with gender dysphoria and history of severe dysmenorrhea prior to beginning testosterone therapy, who desires gender affirming surgery by hysterectomy and bilateral salpingo-oophorectomy. <h3>Interventions</h3> A 5 mm umbilical trocar is used for a 30-degree camera to maximize visualization. A 5 mm suprapubic trocar for the single operative instrument is placed above the level of the uterus fundus. Success of a two-port hysterectomy is achieved by having excellent uterine manipulation to generate appropriate counter traction on the uterus. The hysterectomy is completed in the standard fashion, and the excision of simple endometriosis is completed with a single instrument by using blunt and sharp dissection. The vaginal cuff is closed vaginally. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> A two-port laparoscopic approach avoids placement of ancillary trocars on the appropriate patient. This technique can be also used in the appropriate cis-gendered patients. Excision of simple endometriosis can be feasible with the two-port approach.

Effect of Echogenic Catheter Usage During Embryo Transfer on Implantation in the in vitro Fertilization Program

Background: In vitro fertilization is the final option for treating infertile couples. The main determinants of the success of an in vitro fertilization (IFV) program are embryo quality, endometrial receptivity, and embryo transfer technic. When performing an embryo transfer, try to use a soft catheter and easily visible in the uterus with ultrasonography (USG) monitoring. One solution to this is soft echogenic catheter, as the echogenicity is shown and seen with USG will be able to reduce trauma and excessive uterine manipulation, and increase embryo implantation in the uterine wall. Objective: To determine the effectivity of echogenic catheter during embryo transfer in increasing implantation success. Materials and Methods: This study was a clinical trial conducted at the IVF unit at Bali Royal Hospital Denpasar from August 2018 to December 2019. All participants who took part in the IFV program, who met the requirements, were split into two groups. The case group was echogenic catheter group and the non-echogenic/standard catheter group, which served as the control group. The outcomes of both groups were then identified and compared. The results of this study were statistically tested using SPSS 13 method. Results: For this study, 38 samples were collected and split into two groups. Each case and control groups had 19 samples. There was no significant difference between two groups of all the confounding variables, except for the antral follicle with a mean of 5.58 ± 2.219 in the echogenic catheter group compared to 7.58 ± 2.893 in the non-echogenic catheter group. While the implantation outcome was 3 times greater in the echogenic catheter group, with 6 (31.6%) samples compared to 2 (10.5%) samples in the non-echogenic catheter group, the difference was not statistically significant (p &gt; 0.05). Conclusion: There is no significant difference between the outcome of echogenic catheter group and non-echogenic catheter group.

Early Cervical Cancer and Recurrence after Minimally Invasive Surgery without Uterine Manipulator

Objective: Worldwide cervical cancer is the fourth most common cancer and is also the fourth leading cause of death among women, after breast cancer, colorectal cancer, and lung cancer. The aim of this study is to investigate the long-term oncological safety of laparoscopic treatment without the use of a uterine manipulator for patients with early stage cervical cancer. Materials and methods: A single-center retrospective study was conducted at the Department of Obstetrics and Gynecology of ARNAS Garibaldi Nesima on patients surgically treated for early cervical cancer from 2014 to 2017. Inclusion criteria included squamous or adenosquamous histotype, FIGO stage from Ia1 to Ib2, cancer size &lt; 4 cm, ECOG status 0–1, and negative serum beta-HCG. The patients were divided into two groups: treatment with and without an intra-uterine manipulator. Results: Seventy patients were identified, but only thirty-one met the inclusion criteria and were enrolled. All patients underwent surgery: three patients with the uterine manipulator, twenty-eight without. Among the thirty-one patients enrolled, twelve women had cancer in situ (IA1), nineteen had an early stage cervical cancer, in particular two cases of cervical cancer stage IA2, ten cases of cervical cancer stage IB1, and seven cases of cervical cancer stage IB2, according to the FIGO classification. At follow-up, three cases of recurrence occurred, but the uterine manipulator was not used. Conclusion: After five years of follow-up, recurrence rates in patients treated with minimally invasive surgery are about 10%, but the use of a uterine manipulator is not related to a higher level of recurrence rates.

Establishment of a useful in vitro decidual induction model using eCG-primed nonpregnant mouse endometrial stromal cells†.

Uterine endometrial differentiation is essential for developmental continuity and female health. A convenient in vitro model mimicking the physiological status is needed to effectively evaluate implantation and uterine response mechanisms. Thus, we developed a promising in vitro model, the FSS (FSH mimic-stimulated synchronized) model, by using primary mouse uterine stromal cells (mUSCs) obtained from equine chorionic gonadotropin (eCG)-primed mice. These mUSCs could be differentiated into decidualized cells with 17 beta-estradiol (E2) and progesterone (P4). The pregnancy day 4 (PD4) model, in which mUSCs are obtained at day 4 of pregnancy, was used as a control. The cell shape index and polyploidy rates were similar between the two models. The staining intensities of lipids and glycogen were significantly higher in the induced groups in both models but stronger in the FSS model than in the PD4 model. The expression levels of AP-TNAP, cathepsin L, Prl8a2, Gja1, Cebpb, and Igfbp1 were increased at 24h after decidual induction. PR-alpha and PR-beta levels were also increased at 24h after decidual induction in both models. These results indicate that the FSS model provides a convenient method for obtaining USCs that are usable for various experimental approaches due to their physiological competence and flexibility for triggering induction. This may serve as a model system for the study of pathogeneses originating from the endometrium or communication with other tissues and lead to a better understanding of embryo implantation mechanisms. Furthermore, the results of this study will be integral for further refinements of 3D uterine culture manipulation techniques.

Does Vaginal Cuff Creation and Avoidance of a Uterine Manipulator Improve the Prognosis of Total Laparoscopic Radical Hysterectomy for Early Cervical Cancer? A Retrospective Multicenter Study.

Simple SummaryWe aimed to investigate the relationship between the collapse of the vaginal cuff and the prognosis of TLRH. In this retrospective multicenter analysis, 94 early cervical cancer patients who underwent O-RH or TLRH in six hospitals in Japan between September 2016 and July 2020 were included; 36 patients underwent TLRH. PFS and OS were not significantly different between O-RH and TLRH groups. Tumor spillage was prevented by creating a vaginal cuff to avoid using a uterine manipulator. Therefore, TLRH might be considered efficient.Our goal was to compare the treatment outcomes of open-abdominal radical hysterectomy (O-RH) and total laparoscopic hysterectomy (TLRH) with vaginal cuff creation and without using a uterine manipulator in stage IB1-B2 (tumor size < 4 cm) cervical cancer cases. In this retrospective multicenter analysis, 94 cervical cancer stage IB1-B2 patients who underwent O-RH or TLRH in six hospitals in Japan between September 2016 and July 2020 were included; 36 patients underwent TLRH. Propensity score matching was performed because the tumor diameter was large, and positive cases of lymph node metastases were included in the O-RH group due to selection bias. The primary endpoint was progression-free survival (PFS) and recurrence sites of TLRH and O-RH. PFS and OS (overall survival) were not significant in both the TLRH (n = 27) and O-RH (n = 27) groups; none required conversion to laparotomy. The maximum tumor size was <2 and ≥2 cm in 12 (44.4%) and 15 (55.6%) patients, respectively, in both groups. Reportedly, the TLRH group had lesser bleeding than the O-RH group (p < 0.001). Median follow-up was 33.5 (2–65) and 41.5 (6–75) months in the TLRH and O-RH groups, respectively. PFS and OS were not significantly different between the two groups (TLRH: 92.6%, O-RH: 92.6%; log-rank p = 0.985 and 97.2%, 100%; p = 0.317, respectively). The prognosis of early cervical cancer was not significantly different between TLRH and O-RH. Tumor spillage was prevented by creating a vaginal cuff and avoiding the use of a uterine manipulator. Therefore, TLRH might be considered efficient.