The use of intra-operative ultrasound in gynecological surgery: a review

Association between hospital procedure volume, socioeconomic status, comorbidities, and adverse events related to surgical abortion: a nationwide population-based cohort study

BACKGROUND

Limited evidence exists on the influence of hospital procedure volume, socioeconomic status, and comorbidities on surgical abortion outcomes.

OBJECTIVE

Our study aimed to assess the association between hospital procedure volume, individual and neighborhood deprivation, comorbidities, and abortion-related adverse events.

STUDY DESIGN

A nationwide population-based cohort study of all women hospitalized for surgical abortion was conducted from January 1, 2018 to December 31, 2019 in France. Annual hospital procedure volume was categorized into 4 levels based on spline function visualization: very low (<80), low ([80-300]), high ([300-650]), and very high-volume (≥650) centers. The primary outcome was the occurrence of at least one surgical-related adverse event, including hemorrhage, retained products of conception, genital tract and pelvic infection, transfusion, fistulas and neighboring lesions, local hematoma, failure of abortion, and admission to an intensive care unit or death. These events were monitored during the index stay and during a subsequent hospitalization up to 90 days. The secondary outcome encompassed general adverse events not directly linked to surgery.

RESULTS

Of the 112,842 hospital stays, 4951 (4.39%) had surgical-related adverse events and 256 (0.23%) had general adverse events. The multivariate analysis showed a volume-outcome relationship, with lower rates of surgical-related adverse events in very high-volume (2.25%, aOR=0.34, 95% CI [0.29-0.39], P<.001), high-volume (4.24%, aOR=0.61, 95% CI [0.55-0.69], P<.001), and low-volume (4.69%, aOR=0.81, 95% CI [0.75-0.88], P<.001) wh en compared to very low-volume centers (6.65%). Individual socioeconomic status (aOR=1.69, 95% CI [1.47-1.94], P<.001), neighborhood deprivation (aOR=1.31, 95% CI [1.22-1.39], P<.001), and comorbidities (aOR=1.79, 95% CI [1.35-2.38], P<.001) were associated with surgical-related adverse events. Conversely, the multivariate analysis of general adverse events did not reveal any volume-outcome relationship.

CONCLUSION

The presence of a volume-outcome relationship underscores the need for enhanced safety standards in low-volume centers to ensure equity in women's safety during surgical abortions. However, our findings also highlight the complexity of this safety concern which involves multiple other factors including socioeconomic status and comorbidities that policymakers must consider.

Enhancing precision in hysteroscopic surgery: The role of intraoperative ultrasound

Hysteroscopy stands as the gold-standard approach for managing intrauterine pathology. However, in complex clinical cases, hysteroscopic evaluation alone may prove insufficient for the safest and successful patient management. Intraoperative ultrasound (IOUS) has emerged as a valuable adjunct to hysteroscopic surgery, offering real-time visualization of endometrial cavity, uterine walls and instruments within the uterine cavity, enabling precise delineation of anatomical structures, and helping to assess the extent of pathology during intricate interventions. This review aims to comprehensively assess the applications, efficacy and utility of IOUS in hysteroscopic surgery. Available evidence indicates that in hysteroscopic myomectomy, IOUS significantly reduces the risk of uterine perforation, particularly in submucosal FIGO 2 myomas, and enhances the likelihood of a single-step procedure. During hysteroscopic metroplasty, ultrasound guidance decreases the chance of incomplete uterine septum resection. In the hysteroscopic management of severe Asherman syndrome, IOUS reduces the risk of uterine perforation or false passage. For cesarean scar pregnancy (CSP), ultrasound is crucial in defining the most appropriate surgical approach and is effective in guiding the hysteroscopic treatment of endogenic CSP. The use of IOUS in hysteroscopy proves valuable in complex cases where the risk of uterine perforation or incomplete procedure is increased.

Role of Hysteroscopy in the Management of Uterine Vascular Malformations with a Focus on Enhanced Myometrial Vascularity - A Review of Diagnosis and Treatment with the Suggested Algorithm

Postpregnancy bleeding is common after failed pregnancy, termination of pregnancy, and postnatally after both vaginal and cesarean delivery. Pelvic ultrasound (US) is usually the initial imaging modality of choice to ascertain the cause when the bleeding is heavy or prolonged. When used in combination with Doppler studies, US can help differentiate retained products of conception (RPOC) from rarer uterine vascular malformations (UVM), including true arterial vascular malformations and areas of enhanced endometrial vascularity (EMV), which may themselves be associated with any RPOC present. While the management of RPOC is well established and has evolved from an almost universal surgical approach to increasingly more medical or expectant alternatives, clinical decisions over the management of a concurrent UVM are less clear and treatment options need to be individualized depending on features of the lesion and the clinical situation with hysteroscopy featured as an important modality, especially when dealing with EMV's. In this review, we discuss the role of hysteroscopy in the treatment of enhanced myometrial vascularity with and without associated RPOC and propose a management algorithm.

PERSONIFICATION OF VISUAL DIAGNOSTIC METHODS IN WOMEN WITH SUBMUCOSAL UTERINE FIBROIDS: A RETROSPECTIVE CLINICAL ANALYSIS

OBJECTIVE

The aim: To determine the parameters of perioperative application of radiographic methods for visual diagnosis in women with submucous uterine fibroids.

PATIENTS AND METHODS

Materials and methods: We conducted a retrospective analysis of the data from 200 medical records of women with submucous uterine fibroids (SUF).

RESULTS

Results: Preoperatively, nodes were diagnosed by ultrasound as follows: solitary nodes - SM0 type - 65 (46%) near the fundus; SMІ - 41 (29%) on the anterior or posterior wall; SMІІ - 35 (25%) on the lateral walls of the uterus and in the cornual areas of the fallopian tubes; multiple in combinations: О3-4 / SMІ - 16 (27.0%) and О3-6 / SMІІ - 14 (24.0%); with localization: О3-4 / SM0 - mainly in the fundus - 49%, О3-4 / SMІ and О3-4 / SMІІ on the posterior and lateral - 25.0%, 28.0%; О5-6 / SM0 - posterior and fundus - 38.0%, 49.0%; О5-6 / SMІ and О5-6 / SMІІ - posterior and lateral - 45.0% and 37.5%. The maximum average diameter was 20-30 mm, with a quantity of ≤ 3 per individual. When comparing ultrasound and MRI data, discrepancies in the number and localization of nodes were observed in cases of isolated SMІ / SMІІ (on the lateral walls and in the cornual areas of the uterus) at 29.0%; as well as in cases involving combinations of nodes of types О 3-4 / SMІ at 39.0% and О 3-4 / SMІІ at 23.0% (p<0.05). During hysteroscopy, in the group without intraoperative sonography, there were 30% more conversions from hysteroscopic to laparoscopic myomectomy, and 25% more combinations of hysteroscopic myomectomy with laparoscopic monitoring.

CONCLUSION

Conclusions: Hysteroscopic myomectomy with intraoperative sonography is an effective method of treatment for isolated and multiple fibroids of types SMІ/ SMІІ and О3-4/SMІ as well as О3-4/SMІІ.

Study protocol for a randomised controlled trial on the use of intraoperative ultrasound-guided laparoscopic ovarian cystectomy (UGLOC) as a method of fertility preservation in the management of benign ovarian cysts

INTRODUCTION

The lifetime risk of women undergoing surgery for the presence of benign ovarian pathology in the UK is 5%-10%. Despite minimally invasive surgical techniques, evidence suggests a number of healthy ovarian follicles and tissues are resected intraoperatively, resulting in subsequent decline of ovarian reserve. As such, there is an increasing demand for the implementation of fertility preservation surgery (FPS). This study will evaluate the effect on ovarian reserve following two different surgical interventions for the management of benign ovarian cysts.

METHODS AND ANALYSIS

We will conduct a two-armed randomised controlled trial comparing laparoscopic ovarian cystectomy, considered gold standard treatment as per the Royal College of Obstetricians and Gynaecologists (RCOG) Green Top guidelines for the management of benign ovarian cysts, with ultrasound-guided laparoscopic ovarian cystectomy (UGLOC), a novel method of FPS. The study commencement date was October 2021, with a completion date aimed for October 2024. The primary outcome will be the difference in anti-Müllerian hormone (AMH) (pmol/L) and antral follicle count (AFC) measured 3 and 6 months postoperatively from the preoperative baseline. Secondary outcomes include assessment of various surgical and histopathological findings, including duration of hospital stay (days), duration of surgery (minutes), presence of intraoperative cyst rupture (yes/no), presence of ovarian tissue within the resected specimen (yes/no) and the grade of follicles excised within the specimen (grade 0-4). We aim to randomise 94 patients over 3 years to achieve power of 80% at an alpha level of 0.05.

ETHICS AND DISSEMINATION

Findings will be published in peer-reviewed journals and presented at national and international conferences and scientific meetings. The Chelsea NHS Research and Ethics Committee have awarded ethical approval of the study (21/LO/036).

TRIAL REGISTRATION NUMBER

NCT05032846.

Paraaortic Lymphadenectomy in Gynecologic Oncology—Significance of Vessels Variations

Lymphadenectomy has been an essential part of the surgical treatment in surgical oncology, as the lymphatic channels and nodes are the main dissemination pathway for most of the gynecological cancers. Pelvic and paraaortic lymphadenectomy are frequent surgical procedures in gynecologic oncology. Paraaortic lymph node dissection facilitates staging, prognosis, surgical and postoperative management of patients. It is one of the most challenging retroperitoneal surgeries. A comprehensive knowledge of the paraaortic region is mandatory. Intraoperative bleeding is the most common complication during lymphadenectomy due to direct vascular injury, poor tissue handling, exuberant retraction and possible anatomical variations of the vessels in the paraaortic region. Approximately, one-third of women will have at least one anatomic variation in the paraaortic region. It must be stressed that anomalous vessels may be encountered in every woman who will undergo surgery. Consequently, detailed knowledge of anatomical vessels variations is required in order to prevent iatrogenic vessel injury. The importance of these variations is well described in urology, vascular and general surgery. Conversely, in oncogynecological surgery, there are few articles, which described some of the vessels variations in the paraaortic region. The present article aims to propose a surgical classification and to describe the majority of vessels variation, which could be encountered during paraaortic lymphadenectomy in gynecologic oncology. Moreover, surgical considerations in order to prevent anomalous vessels injury are well described.