Prediction of unsuccessful endometrial ablation: random forest vs logistic regression

Background Five percent of pre-menopausal women experience abnormal uterine bleeding. Endometrial ablation (EA) is one of the treatment options for this common problem. However, this technique shows a decrease in patient satisfaction and treatment efficacy on the long term. Study objective To develop a prediction model to predict surgical re-intervention (for example re-ablation or hysterectomy) within 2 years after endometrial ablation (EA) by using machine learning (ML). The performance of the developed prediction model was compared with a previously published multivariate logistic regression model (LR). Design This retrospective cohort study, with a minimal follow-up time of 2 years, included 446 pre-menopausal women (18+) that underwent an EA for complaints of heavy menstrual bleeding. The performance of the ML and the LR model was compared using the area under the receiving operating characteristic (ROC) curve. Results We found out that the ML model (AUC of 0.65 (95% CI 0.56–0.74)) is not superior compared to the LR model (AUC of 0.71 (95% CI 0.64–0.78)) in predicting the outcome of surgical re-intervention within 2 years after EA. Based on the ML model, dysmenorrhea and duration of menstruation have the highest impact on the surgical re-intervention rate. Conclusion Although machine learning techniques are gaining popularity in development of clinical prediction tools, this study shows that ML is not necessarily superior to the traditional statistical LR techniques. Both techniques should be considered when developing a clinical prediction model. Both models can identify the clinical predictors to surgical re-intervention and contribute to the shared decision-making process in the clinical practice.

Defining the limits of caesarean scar niche repair: new anatomical landmarks

Background Caesarean scar niche is increasingly being seen due to the rise in the number of caesarean sections worldwide. Indications and the ideal route for niche repair are still being researched. If the residual myometrium is less than 3 mm thick and potential fertility is needed, laparoscopy is the ideal surgical method for caesarean scar niche repair. The aim of this video presentation is to demonstrate techniques of identifying new anatomical landmarks during laparoscopic uterine niche repair. Results As seen in the video, Caesarean scar niche repair can be done in a step-by-step manner, with lateral bands serving as anatomical landmarks. Conclusions Lateral bands are a consistent anatomical landmark which identify the level and width of the uterine niche and thus simplify the laparoscopic repair making this a reproducible technique.

A novel approach to minimally invasive hysterectomy without the use of a uterine manipulator: Kamran’s TLH

Background Hysterectomy remains one of the most common major gynaecological procedures, with total laparoscopic hysterectomy (TLH) now established as the technique of choice over conventional open approaches. This approach depends on the use of a uterine manipulator to facilitate uterine retraction and colpotomy. This study describes a novel approach in performing total laparoscopic hysterectomy without the use of uterine manipulator or vaginal tubes and reports the intra- and postoperative outcome of this technique. Methods A single-centre retrospective analysis of patients who underwent TLH without uterine manipulator or vaginal tube “Kamran’s TLH” for benign conditions was performed from January 2017 to October 2019. Data collected included patients’ demographics, intraoperative finding and postoperative course. Results A total of eighty-six hysterectomies were performed utilizing the Kamran’s TLH (KTLH) approach. Mean age was 52.2 (± 11) years old and BMI was 28.2 (± 7). TLH with bilateral salpingo-oophorectomy was performed in 63 (73.3%) patients and TLH with preservation of ovaries in 23 (26.7%) patients. Mean operative time was 64.7 (± 27.9) min and estimated bloods loss was 46.2 (± 54.6) ml. No intraoperative complications were recorded and there was no conversion to open surgery. Only one patient required readmission and surgery for vaginal vault dehiscence during their postoperative course. Conclusion Uterine manipulator is a key component in performing laparoscopic hysterectomy. However, our approach demonstrated that TLH can be safely performed without the use of any uterine or vaginal manipulation.

Laparoscopic uterosacral ligament suspension versus sacrospinous ligament fixation for apical prolapse: perioperative outcomes

Background Pelvic organ prolapse can be repaired vaginally or laparoscopically. Studies comparing vaginal repair with sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (V-USLS) have found no difference in functional or adverse outcomes. Laparoscopic USLS (L-USLS) is becoming a popular treatment for pelvic organ prolapse because it has a low rate of ureteral compromise. To date, no studies have compared perioperative outcomes between L-USLS and SSLF. The objective of this study is to compare the rates of perioperative complications between these two methods. Methods This was a retrospective chart review of 243 consecutive patients who underwent L-USLS or SSLF at one institution between March 2017 and August 2019 for apical pelvic organ prolapse. Descriptive data was analyzed as appropriate with Student’s t tests and chi-square. Univariable logistic regression analysis was performed to assess predictors of perioperative complications. Results Preoperative Pelvic Organ Prolapse Quantification Stage (POP-Q) was similar between the two cohorts (p = 0.23). After adjusting for confounding factors, L-USLS was associated with a longer operative time (118 vs 142 min, p < 0.01) and shorter length of hospitalization (0.68 vs 1.06 days, p < 0.01). The estimated blood loss between the procedures was not statistically significant after adjusting for confounding factors. There was no difference in perioperative complication rates between L-USLS and SSLF (5% vs 7%, p = 0.55). No clinical risk factors were significantly associated with perioperative complications. Conclusion We did not find a difference in complications between L-USLS and SSLF.

Is it possible to estimate the need for surgical management in patients with a tubo-ovarian abscess at admission? A retrospective long-term analysis

Background This study aimed to determine the possible prognostic factors correlated with the treatment modalities of tubo-ovarian abscesses (TOAs) and thus to assess whether the need for surgery was predictable at the time of initial admission. Materials and methods Between January 2012 and December 2019, patients who were hospitalized with a TOA in our clinic were retrospectively recruited. The age of the patients, clinical and sonographic presentation, pelvic inflammatory risk factors, antibiotic therapy, applied surgical treatment, laboratory infection parameters, and length of hospital stay were recorded. Results The records of 115 patients hospitalized with a prediagnosis of TOA were reviewed for the current study. After hospitalization, TOA was ruled out in 19 patients, and data regarding 96 patients was included for analysis. Twenty-eight (29.2%) patients underwent surgical treatment due to failed antibiotic therapy. Sixty-eight (70.8%) were successfully treated with parenteral antibiotics. Medical treatment failure and need for surgery were more common in patients with a large abscess (volume, > 40 cm3, or diameter, > 5 cm). The group treated by surgical intervention was statistically older than the patients receiving medical treatment (p < 0.05). Conclusions Although the treatment in TOA may vary according to clinical, sonographic, and laboratory findings; age of patients, the abscess size, and volume were seen as the major factors affecting medical treatment failure. Moreover, TOA treatment should be planned on a more individual basis.

Medical and surgical interventions to improve the quality of life for endometriosis patients: a systematic review

Endometriosis impairs the quality of life (QoL) of many women, including their social relationships, daily activity, productivity at work, and family planning. The aim of this review was to determine the instruments used to examine QoL in previous clinical studies of endometriosis and to evaluate the effect of medical and surgical interventions for endometriosis on QoL. We conducted a systematic search and review of studies published between January 2010 and December 2020 using MEDLINE. Search terms included “endometriosis” and “quality of life.” We only selected studies that used a standardized questionnaire to evaluate QoL before and after medical or surgical interventions. Only articles in the English language were examined. The initial search identified 720 results. After excluding duplicates and applying inclusion criteria, 37 studies were selected for analysis. We found that the two scales most frequently used to measure QoL were the Short Form-36 health survey questionnaire (SF-36) and the Endometriosis Health Profile-30 (EHP-30). Many medical and surgical treatments demonstrated comparable benefits in pain control and QoL improvement. There is no clear answer as to what is the best treatment for improving QoL because each therapy must be personalized for the patient and depends on the woman’s goals. In conclusion, women must be informed about endometriosis and given easily accessible information to improve treatment adherence and their QoL.

Does hysteroscopy in women with persistent gestational trophoblastic disease reduce the need for chemotherapy? A prospective, single-arm, clinical trial pilot study

Background This study aimed to describe the efficacy of hysteroscopy in the management of women with the persistent gestational trophoblastic disease (PGTD)/GTN to reduce the need for chemotherapy. Materials and methods This prospective, single-arm, clinical trial study was recruited in an educational referral hospital between September 2018 and September 2019. Totally, 30 participants with a history of hydatidiform mole that was managed by uterine evacuation and developed low risk persistent gestational trophoblastic disease were recruited. Hysteroscopy was performed for removal of persisted trophoblastic tissue. Serum beta-hCG titer was measured before and 7 days after the procedure. Results The mean ± SD age of the participants was 31.4 ± 4.6 years. There was a significant difference (p = 0.06) between that mean ± SD of beta-hCG titer before (8168.4 ± 1758) and after (2648.8 ± 5888) hysteroscopy. Only two (6.6%) cases underwent chemotherapy due to no drop in the beta-hCG titer. Conclusion Hysteroscopy may play a significant role in the management of GTN, although it requires validation in larger prospective randomized studies and longer follow-up.

The use of hysteroscopic metroplasty with diode laser to increase endometrial volume in women with septate uterus: preliminary results

Background Septate uterus is a common Mullerian ducts anomaly. The aim of our pilot study was the evaluation of diode laser hysteroscopic metroplasty efficacy to increase endometrial volume in women with septate uterus. Results We prospectively enrolled 10 consecutive patients with septate uterus undergoing office hysteroscopic metroplasty with diode laser between February and November 2019. Endometrial volume was evaluated before and 3 months after surgery using 3D transvaginal ultrasound. The surgical procedure was uncomplicated in all patients, the endometrial volume increased at 3 months follow-up (the median increase was 1.9 cm3 (range 1.7–2.1), and there was a complete removal of septum with no intrauterine synechiae at follow-up hysteroscopy. Conclusions Office hysteroscopic metroplasty with diode laser is a safe procedure and has preliminary showed to increase endometrial volume. The increase in endometrial volume by 3D-TV US could be used as a prognostic factor for the reproductive outcomes.

Applied anatomy knowledge in gynaecology and obstetrics: the trainees’ perception

Background Medical education has recognised the importance of anatomy teaching. Limitations in applied anatomy knowledge exist among obstetrics and gynaecology (O&G) trainees. This study aims to evaluate the knowledge of O&G trainees in applied anatomy and study-associated factors. Materials and methods The questionnaire-based study involved O&G trainees between 1/8/2019 and 1/12/2019. Data collected included age, gender, evaluation of medical school anatomy course, attendance at applied anatomy workshops, operating theatre workload, and senior colleagues’ demonstration of anatomy during operating sessions. Results There were 271 trainees recruited with a mean age of 29.3 years, and 80.1% rated the value of medical school anatomy courses as average or above average. Furthermore, 90.8% never attended applied anatomy workshops. In addition, 9.6% and 62% of first- and fifth-year trainees rated their knowledge as either good or very good, and 41.7% reported that anatomy demonstrations by senior doctors happened sometimes. The overall score of applied anatomy knowledge was significantly higher in higher training years, with attendance at applied anatomy lectures, with more operating workloads, and when senior doctors demonstrate anatomy more often during operating sessions. Conclusions Deficiencies in knowledge existed. Factors which may improve knowledge include more applied undergraduate anatomy courses, more frequent operating sessions, attending anatomy workshops, and more senior colleagues’ demonstration of anatomy during surgeries.

Laparoscopy approach to sigmoid colon perforation secondary to intrauterine device migration

Currently, the intrauterine device (IUD) is one of the most used contraceptive methods worldwide, since it has shown to be effective and reversible. One of its complications is the migration of the device, which can affect close organs by perforating them. We present the case of a patient who presented a colouterine fistula secondary to an IUD migration.