Fibroid vascularisation assessed with 3D Power Doppler as predictor for fibroid related symptoms and quality of life; a pilot study

Background: Uterine fibroids present differently, from well vascularised up to calcified, with some causing heavy menstrual bleeding (HMB). Objectives: To investigate the association between fibroid vascularisation and HMB, other fibroid related symptoms and quality of life (QOL). Materials and Methods: A single centre pilot study was carried out in the Netherlands. Women with a maximum of two fibroids who chose expectant management were included. 3D sonography including power doppler was performed at baseline and at 3, 6 and 12 months follow up. Women were asked to complete the Pictorial Blood Assessment Chart (PBAC) and Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaires at every visit. Main outcome measure: The association between fibroid vascularisation and HMB. Results: 53 women were included in the study. Baseline fibroid vascularisation, measured as vascular index (VI) is associated with PBAC score; a 1% higher VI at baseline leads to an 11 point increase in PBAC score over time (RC 10.99, p=0.05, 95% CI -0.15 – 22.12). After correction for the baseline variables ethnicity and fibroid type the association becomes stronger (P<0.05). Fibroid volume at baseline and HMB are also associated: a 1 cm3 larger fibroid leads to 0.6 points increase in PBAC score over time (RC 0.56, p=0.03, 95% CI 0.05 – 1.07). Conclusions: This study highlights that both fibroid vascularisation and fibroid volume may be associated with an increase in menstrual blood loss, other fibroid related symptoms and QOL over time. What is new? We used 3D power doppler to predict symptomatic fibroids.

What to choose and why to use – a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis

Background: Endometriosis is a common benign gynaecological disease that affects pelvic structures and causes adhesions. Endometriosis outside the pelvis exists but is rarer. Deep endometriosis may affect organs such as the urinary bladder, ureters, bowel and sacral roots. Adenomyosis (growth of endometrium in the myometrium, sometimes explained by disruption of the uterine junctional zone) frequently co-exists with deep endometriosis. Over the past decades, multiple attempts have been made to describe the anatomical extent of endometriosis. Out of approximately 20 classification systems suggested and published so far, three have gained widespread acceptance. These are the rASRM (American Society of Reproductive Medicine) classification, the Endometriosis Fertility Index (EFI) and the Enzian classification. Ideally, a classification system should be useful both for describing disease extent based on surgical findings and results of imaging methods (ultrasound, magnetic resonance imaging). Objectives: To highlight the advantages and disadvantages of the three classification systems. Methods: This is a narrative review based on selected publications and experience of the authors. We discuss the current literature on the use of the rASRM, EFI and Enzian classification systems for describing disease extent with imaging methods and for prediction of fertility, surgical complexity, and risk of surgical complications. We underline the need for one universally acceptable terminology to describe the extent of endometriosis. Conclusions: A useful classification system for endometriosis should describe the sites and extent of the disease, be related to surgical complexity and to disease-associated symptoms, including subfertility and should satisfy needs of both, imaging specialists for pre-operative classification and surgeons. The need for such a system is obvious and is provided by the #Enzian classification. Future research is necessary to test its validity.

Laparoscopic morphological aspects and tentative explanation of the aetiopathogenesis of isolated endometriosis of the sciatic nerve: a review based on 267 patients

Background: Endometriosis of the sciatic nerve (ESN) is considered a rare disease. How can endometriosis develop within the sciatic nerve; a structure which has nothing in common with the uterus either anatomically or functionally, and why it occurs in the absence of any retroperitoneal/parametric endometriosis, is unknown. A better understanding of the pathophysiology of this enigmatic disease may improve its diagnosis and therapy. Materials and Methods: From a pool of 452 patients operated for ESN, only patients with “isolated” endometriosis of the sciatic nerve” confirmed at laparoscopy were included in this study. Patients with suspicion of ESN by extension from a parametric, ovarian or other intraperitoneal deeply infiltrating endometriosis were excluded from this study. Main outcome measure: All information acquired during the preoperative patient’s medical history and clinical examination were collected and compared with the morphological aspects of the disease observed by the laparoscopic treatment. Patients were classified into three groups according to the time interval between the onset of sciatic pain and the time of surgery: less than 1 year (Group 1), between 1 and 3 years (Group 2), and more than 3 years (Group 3). Results: Two hundred sixty-seven consecutive patients were included in this study. In Group 1 (n=67), 76% of the patients presented with cyclical sciatica, without sensory or motor disorders of the lower limbs. Laparoscopic exploration found in the great majority of these patients only the presence of an isolated endometrioma in the nerve itself, the size of which was proportional to the time elapsed since the onset of pain. In Group 2 (n=83), pain had become constant in 91% of the patients with neurological disorders of the lower limb (foot drop, Trendelenburg gait, atrophied muscles) in about 30% of patients. Laparoscopic examination revealed, in addition to intraneural cystic lesions, a retroperitoneal fibrosis in more than 80% of the patients. In the third group (N=117), more than 80% of the patients presented with neurological disorders of the lower limb, with, on laparoscopic examination, massive retroperitoneal fibrosis with endometriomas in the nerve and adjacent pelvic wall muscles in all patients and an infiltration of the obturator nerve in 41% of patients. Conclusions: The different morphologic aspects of ESN do not correspond to different forms of the disease, but obviously to one single disease at different stages of its evolution. ENS starts first with the development of an endometrioma within the sciatic nerve, then develops in a second step a perineural fibrosis that expands into the whole retroperitoneal space and finally involves surrounding anatomical structures. The ESN is a very particular pathology because it induces a completely new aspect on the pathogenesis of endometriosis: all hypothesis of implanted endometrial cells following retrograde menstruation, angiogenic spread, lymphogenic spread or the metaplasia theory cannot explain the pathogenesis of this disease. ESN obviously does not develop from “genital metastatic cells”. A possible hypothesis for explanation the pathogenesis of ESN, could consist in the development of endometriosis of the nerve from progenitor stem cells present within the nerve, pluripotent cells which, for an as yet unknown reason (possibly in connection with iterative inflammations and micro-damages of the nerve itself), mutate and proliferate to form endometriosis.

The impact of the Covid-19 pandemic on care of women with ectopic pregnancy in a tertiary London hospital

Background: In response to the COVID-19 pandemic, a central London tertiary referral hospital’s nurse-led Early Pregnancy & Acute Gynaecology Unit (EPAGU) suspended its walk-in service in favour of a telephone triage system with scheduled appointments. Objective: To assess if the pandemic and this adaptation to clinical services had an impact on the presentation, management and complication rate of ectopic pregnancies. Materials and Methods: A retrospective review was performed of ectopic pregnancies diagnosed in the EPAGU between 5th of March 2020 – 15th of July 2020 (pandemic) and 5th of March 2019 – 15th of July 2019 (pre-pandemic). Main outcome measures: Ultrasound findings, patient demographics, serum hCG concentrations, operative findings and complications. Results: There was a 36% reduction in attendances to the unit during the pandemic. Allowing for this, there was no significant difference in the diagnosis rate between the two periods. There was no significant difference in the gestation at diagnosis, serum hCG concentration or volume of mass at presentation. There was also no significant difference in rate of surgical intervention or complications including rupture of fallopian tube, haemoperitoneum or need for blood transfusion. Conclusion: This study suggests this is a safe means of caring for women with ectopic pregnancies which does not limit management options nor lead to higher complication rates. What is new: Other EPAGUs may choose to adopt a telephone triage system with reassurance of its safety.

Laparoscopic sacral hysteropexy for pelvic organ prolapse in a patient affected by marfan syndrome: a case report

Background: Marfan Syndrome (MS) is a dominantly inherited connective tissue disorder with consequences on the strength and resilience of connective tissues that may predispose to Pelvic Organ Prolapse (POP). Literature lacks studies investigating POP surgery in patients affected by MS that might help surgical management decisions. Objective: The objective of this paper is to describe the surgical procedure of laparoscopic sacral hysteropexy (LSHP) in a 37 years old woman affected by MS with symptomatic POP. Materials and Methods and main outcome measures: We performed a nerve-sparing laparoscopic sacral hysteropexy without complications and looked for anatomical and subjective outcomes. The patient completed The Female Sexual Distress Scale (FSDS), Pelvic Floor Disability Index (PFDI-20), and Wexner questionnaires preoperatively and postoperatively. Results: The patient stated a complete resolution of all POP related symptoms and there was a total correction of the descensus. Furthermore, no perioperative and postoperative complications were noted. Conclusions: LSHP could be an effective and safe procedure for the treatment of POP in women affected by MS and this case report is the first to describe a reconstructive procedure in this category of patients. What is new? The literature lacks studies investigating POP surgery in women with MS, that might help surgeons, thus we present this case to describe surgical and functional outcomes in this patient category, underlying the higher risk of complications and relapses related to the weakness of connective tissue. This case report may represent the basis of future studies to confirm the safety, efficacy and feasibility of LSHP and sacral colpopexy in patients with MS.

Indirect and atypical imaging signals of endometriosis: A wide range of manifestations

Background: Whilst some imaging signs of endometriosis are common and widely accepted as ‘typical’, a range of ‘subtle’ signs could be present in imaging studies, presenting an opportunity to the radiologist and the surgeon to aid the diagnosis and facilitate preoperative surgical planning. Objective: To summarise and analyse the current information related to indirect and atypical signs of endometriosis by ultrasound (US) and magnetic resonance imaging (MRI). Methods: Through the use of PubMed and Google scholar, we conducted a comprehensive review of available articles related to the diagnosis of indirect signs in transvaginal US and MRI. All abstracts were assessed and the studies were finally selected by two authors. Results: Transvaginal US is a real time dynamic exploration, that can reach a sensitivity of 79-94% and specificity of 94%. It allows evaluation of normal sliding between structures in different compartments, searching for adhesions or fibrosis. MRI is an excellent tool that can reach a sensitivity of 94% and specificity of 77% and allows visualisation of the uterus, bowel loop deviation and peritoneal inclusion cysts. It also allows the categorisation and classification of ovarian cysts, rectovaginal and vesicovaginal septum obliteration, and small bowel endometriotic implants. Conclusion: The use of an adequate mapping protocol with systematic evaluation and the reporting of direct and indirect signs of endometriosis is crucial for detailed and safe surgical planning.

Laparoscopic management of a full-thickness uterine niche with subsequent pregnancy outcome

Background: Uterine niche is the consequence of impaired healing of the myometrium following a lower segment transverse caesarean section (CS). Although there is conflicting evidence on the management of these cases, laparoscopic repair is a commonly used surgical treatment modality. Objectives: To demonstrate the management and laparoscopic repair of the niche with subsequent pregnancy outcome. Materials and Methods: We report a case of a 33-year-old patient who had a significant haematoma in the niche. The haematoma resolved after conservative management however, she remained symptomatic. Therefore, she had a laparoscopic repair. The narrated surgical video article demonstrates the dissection of the uterovesical fold overlying the niche, followed by the excision of the scar tissue and its repair with laparoscopic suturing. Ultrasound and magnetic resonance imaging images of the uterus demonstrating the haematoma at the caesarean section site, the niche after resolution of the haematoma and post-repair imaging are also provided. Main outcome measures: Repair of the niche, symptomatic relief of abnormal uterine bleeding, spontaneous conception and live birth. Ultrasonographic images also demonstrate uterine wall continuity post laparoscopic repair. Results: The patient recovered uneventfully. Full-thickness of myometrium was demonstrated with post-operative imaging and confirmed at the subsequent caesarean section. Gynaecological symptoms resolved following the repair. The patient conceived spontaneously after surgery and delivered at term by caesarean section without any complications. Conclusion: Laparoscopic management of the niche should be considered where there is a complete myometrial defect or significant thinning of the myometrium, especially in symptomatic women who desire future pregnancy.

Diagnosis and treatment of uncommon ileal endometriosis: a case report and literature review

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It is a common finding in premenopausal women and commonly affects the gastrointestinal tract, especially the rectosigmoid tract. Small bowel involvement is rare and usually asymptomatic making diagnosis difficult. Here we report an uncommon case of exophytic ileal endometriosis surgically treated. Detailed pre-operative counselling on the risk of ileal surgery should always be considered in all cases with endometriosis requiring surgery. We also present a review of the literature regarding the clinical presentation, diagnosis, and treatment of this challenging condition.

Short stay laparoscopic hysterectomy: An evaluation of feasibility and patient satisfaction

Background: Short-stay total laparoscopic hysterectomy (TLH) could lead to reduced hospital costs and decrease complications associated with hospitalisation such as hospital acquired-infection and venous thromboembolism. Objective: To evaluate the feasibility, safety and patient satisfaction of a novel short ‘less than 23-hour’ stay TLH protocol. Material and Methods: Prospective cohort study, at Birmingham Women’s Hospital, United Kingdom including eligible women undergoing TLH for benign indications or early stage cervical/endometrial cancer. Main outcome measures: Feasibility of discharge within 23-hours following TLH. Surgical complications and readmission rates were collected within 30-days of hysterectomy and patient’s satisfaction was assessed at 6-weeks. Results: Of the 128 eligible women, 104/128 women (81%) were discharged within 23-hours of admission, of which 62/104 or 60% (48.4% of the whole cohort) were discharged on the same day. Adenomyosis/fibroids, and previous caesarean sections were associated with a greater likelihood of stay beyond 23-hours (P<0.05). The overall complications rate was 13/128 (10%) with two grade-3 Clavien-Dindo intraoperative complications; one serosal bowel injury oversewn and one ureteric injury requiring reimplantation. The readmissions rate was 5/128 (4%). 94% of patients were ‘happy’ or ‘very happy’ with the pathway, although satisfaction was higher in short-stay patients (RR 1.2; 95% CI 0.95–1.94). Conclusion: Hospital discharge within 23-hours of TLH appears to be safe, feasible and acceptable to patients where a standardised, multidisciplinary care protocol is used. What is new? Our study is the first prospective case series in the UK reporting the safety and acceptability for performing laparoscopic hysterectomy as a 23-hour day case procedure.