Managing couples with recurrent miscarriage: A narrative review and practice recommendations

There is significant variation in practice when managing couples with recurrent miscarriage (RM), with guidelines differing on the definition of RM, recommended investigations, and treatment options. In the absence of evidence-based guidance, and following on from a paper by the authors-FIGO Good Practice Recommendations on the use of progesterone in the management of recurrent first-trimester miscarriage-this narrative review aims to propose a global holistic approach. We present graded recommendations based on best available evidence.

Thrombophilia screening in women with recurrent first trimester miscarriage: is it time to stop testing? - a cohort study and systematic review of the literature

OBJECTIVE

There are numerous studies reporting a disproportionally high prevalence of thrombophilia in women with a history of recurrent miscarriage (RM), which has led to overdiagnosis and treatment without an improvement in clinical outcomes. The objective of our study was to assess the prevalence of inherited and acquired thrombophilia in a large cohort of women with a history of early RM using internationally agreed diagnostic criteria and inclusion parameters and compare it to the meta-analysis results of existing literature.

METHODS

DESIGN: Retrospective cohort study and systematic review of literature.

SETTING

This is a retrospective cohort study set-up in two dedicated tertiary centres for women with RM in Southwest London and Surrey. We reviewed all the available literature related to causes of RMs. We ascertained the prevalence of thrombophilia in the study population and compared it with historical and published prevalence in the general population.

PARTICIPANTS

1155 women between 2012 and 2017. All patients had three or more first trimester miscarriages and a full thrombophilia screen.

RESULTS

The overall prevalence of thrombophilia in our study population is 9.2% (106/1155) with 8.1% (94/1155) of cases positive for inherited thrombophilia, which is similar to the general population; Factor V Leiden (4.9%; 57/1155) and prothrombin gene mutation (2.9%; 34/1155) were the most common inherited thrombophilias, while only 1% (12/1155) tested positive for acquired thrombophilia. Persistent positive lupus anticoagulant (LA) was found in 0.5% (6/1155) and persistent positive anticardiolipin (ACL) antibodies with a value ≥40 U/mL was found in 0.5% (6/1155) of patients. Tests for LA/ACL were performed a minimum of 12 weeks apart thus meeting the revised Sapporo criteria for a diagnosis of antiphospholipid syndrome.

CONCLUSION

The findings of our study demonstrate that the prevalence of inherited thrombophilia is similar in women with RM to that in the general population. Similarly, the prevalence of acquired thrombophilia, using the revised Sapporo criteria, in the cohort of RMs is similar to that in the general population. Therefore, we do not recommend investigation or treatment of inherited or acquired thrombophilia in women with RM.

PROSPERO REGISTRATION NUMBER

CRD42020223554.

A systematic review highlighting poor-quality of evidence for Content Validity of Quality of Life (QoL) Instruments in Female Chronic Pelvic Pain (CPP)

OBJECTIVES

To evaluate the content validity of 19 Patient Reported Outcome Measures (PROMs) used to measure QoL in women with CPP DESIGN AND SETTING: We searched EMBASE, MEDLINE, PsycINFO databases and Google Scholar from inception to August 2020. We included records describing the development or studies assessing content validity of PROMs. Two reviewers independently assessed the methodological quality of PROMs using the COSMIN checklist. Evidence was synthesised for relevance, comprehensiveness and comprehensibility. Quality of evidence was rated using a modified GRADE approach.

MAIN RESULTS

PROM development was inadequate for all instruments included in this review. No high-quality evidence ratings were found for relevance, comprehensiveness and comprehensibility. QoL was measured using generic instruments (68.42%, 13/19) rather than those specific to chronic pain (21.04%, 4/19) or pelvic pain (10.53%, 2/19). Quality of concept elicitation was inadequate for 90% of PROMs. Half of PROMs did not include patients in their development and only 40% were devised using a sample representative of the target population for which the PROM was developed. Cognitive interviews were conducted in one-fifth of PROMs and were mostly of inadequate/doubtful quality.

CONCLUSION

There is poor-quality of evidence for content validity of PROMs used to measure QoL in women with CPP.

Maternal and perinatal outcomes of dichorionic diamniotic twins in women after spontaneous and assisted conception

OBJECTIVE

Twin pregnancies have been shown to be associated with numerous maternal and perinatal complications. Published data shows conflicting reports on whether assisted conception influences these risks. The purpose of this study was to assess the impact of mode of conception on maternal and perinatal outcomes of dichorionic diamniotic twin pregnancies.

STUDY DESIGN

This was a large retrospective study of 497 women with dichorionic diamniotic twins that were conceived spontaneously or with assisted conception in a single centre over a 10-year period.

RESULTS

This study showed no significant difference in mode of delivery (OR 1.40 95% CI 0.88 - 2.24), need for admission to neonatal unit (OR 1.56 95% CI 0.88-2.77), or preterm births between dichorionic twin pregnancies conceived following assisted conception when compared to spontaneously conceived dichorionic twin pregnancies. Women who conceived twins by assisted conception that did not have an elective caesarean section were more likely to go into spontaneous labour than have an induction of labour (OR 0.54 95% CI 0.3 - 0.99). They also had a higher chance of having an estimated blood loss of more than 1L than women who conceived naturally (OR 1.70 95% CI 1.06 - 2.73).

CONCLUSIONS

In the case of dichorionic twins, this study showed that assisted conception does not seem to be associated with adverse obstetric and perinatal outcomes when compared with spontaneous conception. These results should be considered reassuring to women undergoing assisted conception, and may assist clinicians when counselling patients for assisted conception treatment. Further research is needed to assess the impact of assisted conception on postpartum blood loss.

A meta-synthesis of qualitative literature on female chronic pelvic pain for the development of a core outcome set: a systematic review

INTRODUCTION AND HYPOTHESIS

Qualitative research has an increasing role in the development of core outcome sets (COS) adding patient perspectives to the considerations of core outcomes. We aimed to identify priorities of women with experience of chronic pelvic pain (CPP).

METHODS

The search strategy was a systematic review of qualitative studies identified from Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, MEDLINE and PsycInfo databases. Selection criteria were qualitative studies exploring the experience of women with CPP. Two independent researchers extracted data and summarized findings using thematic analysis. A CERQual assessment was performed to assess the confidence of review findings.

RESULTS

We identified pertinent issues affecting women with CPP including the lack of holistic care, influence of psychosocial factors and the impact of pain on quality of life. Five meta-themes central to delivering a patient-centred approach were highlighted: acceptance of pain, quality of life, management of CPP, communication and support. Management of CPP was the most commonly reported meta-theme across seven studies and half of studies reported quality of life, management, communication and support. Quality appraisal of included studies identified only a single study that met all CASP (Critical Appraisal Skills Programme) criteria. There was high confidence in the evidence for acceptance of pain, quality of life and communication meta-themes.

CONCLUSION

Meta-themes revealed by this review should be considered as a priority and reflected in outcomes reported by future studies evaluating interventions for CPP. In addition, these themes should be considered by clinicians managing women with CPP.

A systematic review on reported outcomes and outcome measures in female idiopathic chronic pelvic pain for the development of a core outcome set

BACKGROUND

A core outcome set (COS) is required to address inconsistencies in outcome reporting in chronic pelvic pain (CPP) trials.

OBJECTIVES

Evaluation of reported outcomes and selected outcome measures in CPP trials by producing a comprehensive inventory to inform a COS.

SEARCH STRATEGY

Systematic review of randomised controlled trials (RCTs) identified from Cochrane Central Register of Controlled Trials (CENTRAL), Embase and MEDLINE databases.

SELECTION CRITERIA

RCTs assessing efficacy and safety of medical, surgical and psychological interventions for women with idiopathic CPP.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted outcomes and outcome measures. Similar outcomes were grouped and classified into domains to produce a structured inventory.

MAIN RESULTS

Twenty-four trials were identified including 136 reported outcomes and outcome measures. Rates of reporting outcomes varied (4-100%) and pelvic pain was the most frequently reported outcome (100%). All trials reported the pain domain; however, only half reported quality of life, clinical effectiveness and adverse events. No differences in outcome reporting were observed in five high-quality trials (21%). Univariate analysis demonstrated an association between quality of outcome reporting and methodological quality of studies (r_s  = 0.407, P = 0.048).

CONCLUSION

There is wide variation in reported outcomes and applied outcome measures in CPP trials. While a COS is being developed and implemented, we propose the interim use of commonly reported outcomes in each domain: pain (pelvic pain, dyspareunia, dysmenorrhoea), life impact (quality of life, emotional functioning, physical functioning), clinical effectiveness (efficacy, satisfaction, cost effectiveness, return to daily activities) and adverse events (surgical, perioperative observations, nonsurgical).

TWEETABLE ABSTRACT

There is significant variation in outcome reporting in CPP trials. Our systematic review forms the basis for the development of a core outcome set.

A national survey: Evaluating current practice and risk assessment in morcellation amongst gynaecologists in the United Kingdom

OBJECTIVE

To evaluate current practice and adherence to AAGL and BSGE power morcellation guidelines.

STUDY DESIGN

Cross-sectional survey.

SETTING

United Kingdom.

PATIENTS/POPULATION

157 National Health Service (NHS) hospital trusts (organisation comprising of one or more hospitals) offering gynaecological services.

INTERVENTION

A questionnaire was emailed between March-July 2018 and completed by Lead/ Directors of Gynaecology within each organisation. Descriptive statistics were used to present results from this study.

MEASUREMENTS/RESULTS

We assessed power morcellation practice patterns, informed consent processes and outcomes over the last 12 months. We received 136 responses (87 % response rate). Power morcellation was performed by a third (59, 37.6 %) of all UK hospitals. The median number of gynecologists performing morcellation per organisation was 2 (Q1-Q3: 2-4). A median of 7 morcellators (Q1-Q3: 0-17) were purchased and 7 morcellators (Q1-Q3: 1.25-15.75) used per annum. A median of 10 (Q1-Q3: 2.0-15.0) laparoscopic hysterectomies and 5 (Q1-Q3: 0.5-9.0) myomectomies requiring morcellation were performed per annum. Almost, a third of hospitals did not perform an endometrial biopsy or MRI. 79.7 % (47) of trusts consented for power morcellation and 76 %, (46) explained risk of inadvertent leiomyosarcoma. 83.3 %, (50) had no patient literature and almost half had no audit process 45 %, (27).

CONCLUSION

Current UK practice does not reflect recommendations from the AAGL or BSGE. Deficiencies were identified in pre-operative evaluation, local governance procedures, and consenting practices regarding use of a power morcellator and risk of occult leiomyosarcoma.

Diagnostic delay for superficial and deep endometriosis in the United Kingdom

A Cross-sectional study was undertaken at a specialist centre in the United Kingdom investigating duration and causes of delay in the diagnosis of endometriosis. One hundred and one women completed a self-reported questionnaire containing 20 items about their psychosocial, symptoms and experiences. The statistical analysis included a Mann-Whitney U test. A p value of .05 was considered statistically significant. The Spearman's rank correlation was also calculated. Overall, there was a median delay of 8 years (Q1-Q3: 3-14) from the onset of symptoms to a diagnosis of endometriosis. Factors such as menstrual cramps in adolescence, presence of rectovaginal endometriosis, normalisation of pain and the attitudes of health professionals contributed to a delayed diagnosis (p values<.05). There was a negative correlation indicating the earlier the onset of symptoms, the greater the delay to diagnosis (Spearman's Rank Correlation Coefficient -0.63, p<.01). The results of this study highlight a considerable diagnostic delay associated with endometriosis and the need for clinician education and public awareness.Impact statementWhat is already known on this subject? The diagnostic delay of 7-9 years with endometriosis has been reported globally. In an effort to standardise surgical treatment, improve outcomes, and shorten delays specialist endometriosis centres were introduced in 2011. There has been no recent quality improvement assessment since the establishment of such centres.What do the results of this study add? This is the most recent evaluation in the United Kingdom since the introduction of specialist endometriosis centres. There is a considerable diagnostic delay associated endometriosis in the United Kingdom with a median of 8 years. The delays seem not to have improved over the last two decades. We have identified medical and psychosocial factors that may contribute to such delays. These include factors such as menstrual cramps in adolescence, presence of rectovaginal endometriosis, normalisation of pain and attitudes of health professionals contribute to a delayed diagnosis.What are the implications of these findings for clinical practice and/or further research? The results of this study, highlight the need for clinician education and public awareness to decrease the long term-morbidity and complications that result from untreated endometriosis.

Identifying Preoperative Factors Associated with Nonresponders in Women Undergoing Comprehensive Surgical Treatment for Endometriosis

STUDY OBJECTIVE

To examine whether existing quality of health outcome measures can be used to predict or have an association with nonresponse surgery for endometriosis.

DESIGN

Retrospective cohort study.

SETTINGS

Single endometriosis referral center.

PATIENTS

Women (n = 198) undergoing surgery for endometriosis.

INTERVENTIONS

Validated health questionnaires and visual analogue scales.

MEASUREMENTS AND MAIN RESULTS

Patients were given validated health questionnaires, including Endometriosis Health Profile 30, Gastrointestinal Quality of Life Index, EuroQol-5, Hospital Anxiety and Depression Scale, preoperatively and at 12 months after full surgical excision of endometriosis. Visual analogue scales were also used that measured dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain. Surgical management was dependent on severity of disease. Superficial disease was treated by laparoscopic peritoneal excision or laser ablation. Deep infiltrating disease involving the bowel was excised completely together with laparoscopic bowel surgery (shave, disc, or segmental resection) with/without concomitant total hysterectomy and bilateral salpingo-oophorectomy. Nonresponders were defined as women who failed to demonstrate an improvement in pain scores 12 months postoperatively. We examined preoperative and postoperative questionnaires, visual analogue scores, and other variables such as age at onset of symptoms, type of surgery, and the presence of postoperative complications comparing responder and nonresponder women to identify the factors associated with nonresponse. Of 102 women treated for superficial endometriosis, 25 (24.51%) were nonresponders. No factors were associated with nonresponse at 12 months. Of 96 women treated for severe endometriosis involving the bowel, 10 (10.41%) were nonresponders. Nonresponders had significantly less preoperative pain (p = .031) and feeling of control (p = .015) than responders. There was no association between nonresponders and women who underwent a hysterectomy with bilateral salpingo-oophorectomy or those with complications. Radical bowel surgery (resection) was associated with nonresponders.

CONCLUSION

Minimal preoperative factors are associated with nonresponse for women having surgery for endometriosis. The severity of pain experienced by women with endometriosis may be used to predict their response to surgery.

A Stepwise Approach to Laparoscopic Excision of a Noncommunicating Rudimentary Horn

STUDY OBJECTIVE

To demonstrate our approach to laparoscopic excision of a noncommunicating rudimentary horn (AmericanSociety for Reproductive Medicine classification II(b), European Society of Human Reproduction and Embryology/European Society of Gynaecological Endoscop classification class U4a).

DESIGN

Technical video (Canadian Task Force classification level III).

SETTING

University Hospital.

PATIENT

A 25-year-old women with a left-sided pelvic mass.

INTERVENTION

Laparoscopic excision of noncommunicating rudimentary horn with hysteroscopy and cystoscopy. Institutional Review Board/Ethics Committee ruled that approval was not required for this study.

MEASUREMENTS AND MAIN RESULTS

Noncommunicating rudimentary horns are present in 20% to 25% of women with a unicornuate uterus [1]. Noncommunicating rudimentary horns may be associated with dysmenorrhea, pelvic pain, subfertility, and poor obstetric outcomes. Laparoscopic excision of rudimentary horns can be challenging and complex. Factors to consider in relation to the rudimentary horn are attachment to the uterus, presence and course of the ureter, and vascular supply. In this video we demonstrate our approach to laparoscopic excision of a rudimentary horn including preoperative imaging to plan surgical care. A 25-year-old women presented with pelvic pain and underwent a laparotomy for a left-sided pelvic mass. Intraoperatively, a rudimentary horn was suspected, and she was started on a gonadotropin-releasing hormone analogue pending diagnostic imaging and definitive surgery. Computed tomography demonstrated an absent left kidney and ureter. Intraoperatively, we began with a cystoscopy to identify and confirm an efflux from ureteral openings. A real-time hysteroscopy was performed to identify the unicornuate uterus from the rudimentary horn and to exclude vaginal or cervical anomalies. Through hysteroscopic transillumination the plane of dissection was identified between the rudimentary horn and uterus [2,3]. This technique is especially useful when the rudimentary horn is densely fused to the unicornuate uterus. Retroperitoneal dissection was performed ipsilateral to the rudimentary horn. A lateral approach was used to coagulate the uterine artery at its origin. The bladder was reflected from the horn to allow excision. A Thunderbeat device (Olympus Medical Systems, Tokyo, Japan) was used to excise the rudimentary horn, keeping very close to the specimen to ensure no penetration of the unicornuate uterus. Hemostasis was achieved, and no additional sutures were required. The specimen was removed using in-bag morcellation.

CONCLUSION

A stepwise hysteroscopic and laparoscopic approach can be used to safely resect a rudimentary horn as demonstrated by this case.

Laparoscopic Colposuspension for Recurrent Stress Incontinence after Tension-free Vaginal Tape

STUDY OBJECTIVE

To demonstrate laparoscopic colposuspension for recurrent stress incontinence after failed tension-free vaginal tape (TVT).

DESIGN

A technical video showing laparoscopic colposuspension for previously surgically treated stress incontinence (Canadian Task Force classification III).

SETTING

A university hospital.

PATIENT

A 58-year-old woman with previous TVT presents with recurrent stress urinary incontinence.

MEASUREMENTS AND MAIN RESULTS

Midurethral slings have equivalent cure rates to the more invasive colposuspension. They are preferentially used for stress urinary incontinence despite a mesh erosion rate of 3.5% with 2.5% requiring further surgery, sling removal, or revision over 9 years [1,2]. Recent negative publicity concerning synthetic mesh tape has led to a resurgence of interest in mesh-free alternatives, including urethral bulking agents, rectus fascia slings, and colposuspension. Laparoscopic colposuspension is a well-established minimally invasive surgery that avoids synthetic mesh, with a quicker recovery, less scarring, and equivalent success to an open approach [3]. Bladder neck mobility is an important marker during selection of this technique. In this video, we demonstrate our transperitoneal technique of colposuspension in the case of failed TVT. This technique allows clear visualization of the operating field and is faster and less bloody than a full dissection. Because complications can ensue from extensive excision and extraction, unless the previous TVT has caused problems such as pain, we normally leave it in situ. Careful dissection is undertaken into the Retzius space to the paravaginal tissues where the iliopectineal ligament is located. On each side, we apply 2 extracorporeally tied nonabsorbable Ethibond (Johnson and Johnson Medical NV, Bruxelles, Belgium) sutures as recommended [4], caudal and lateral to the TVT, lifting the paravaginal tissues to the ligament. The knot is placed on the ligament side to minimize erosion risk. The peritoneal defect is closed with a Vicryl 2.0 (Johnson and Johnson Medical NV) suture. This technique offers a viable mesh-free option for the treatment of recurrent stress incontinence in women who have had failed TVT.

A Stepwise Approach to Laparoscopic Enucleation and Excision of Retroperitoneal Cysts

STUDY OBJECTIVE

To show a step-by-step approach to laparoscopic enucleation and excision of retroperitoneal cysts using a technical video.

DESIGN

A technical video (Canadian Task Force classification III).

SETTING

A benign gynecology department at a university hospital.

INTERVENTION

Laparoscopic enucleation and excision of retroperitoneal cysts.

CONCLUSION

Retroperitoneal cysts are rare lesions associated with numerous complications including compression on neighboring organs, infection, rupture, and malignant transformation. Excision of retroperitoneal cysts can be challenging, and dissection of the retroperitoneal space is associated with bowel and vascular injury [1]. Laparoscopic drainage and fenestration have been promoted to prevent visceral injury [2]. Such approaches are ineffective, with increased recurrences and fluid accumulation requiring repeat surgical procedures [3,4]. Successful laparoscopic excision of retroperitoneal cysts has been reported although there are no published videos of the technique [5]. In this video, we use 2 separate cases to show our step-by-step laparoscopic approach to enucleate and excise retroperitoneal cysts. Various methods to safely enter retroperitoneal spaces to avoid inadvertent damage to surrounding structures are detailed. A combination of careful blunt and sharp dissection is used to find specific planes to separate the cyst from the overlying peritoneum and underlying pelvic sidewall structures such as the ureter, vasculature, and nerves. We minimize energy use, and, when it is used, we are mindful regarding active blade positioning of the ultrasonic dissector to prevent inadvertent cyst rupture and injury to the surrounding structures. Keeping the cysts intact aids in leverage and prevents inadvertent spillage of potentially malignant contents. The cysts are retrieved laparoscopically by contained bag decompression.

Laparoscopic Resection of Post-Cesarean Section Scar Uterine Cyst

STUDY OBJECTIVE

To demonstrate a technique of performing laparoscopic resection of a post-cesarean section scar uterine cyst.

DESIGN

Technical video (Canadian Task Force classification III).

SETTING

University Hospital.

PATIENT

A 38-year old woman.

INTERVENTION

Laparoscopic excision of a uterine cyst within a cesarean section scar.

MEASUREMENTS AND MAIN RESULTS

A 38-year-old woman presented with secondary subfertility requesting removal of a cesarean section scar defect to prepare the uterine cavity for in vitro fertilization. Preoperative ultrasound demonstrated a 17.7 × 12.2 mm scar defect. At rigid hysteroscopy the anterior uterine wall cyst was observed and noted to be narrowing the uterine cavity. A laparoscopic approach was used to excise the uterine cyst. We carefully mobilized the bladder from its adhesions at the site of the previous cesarean section scar. The uterine cyst was located and margins of the defect identified. An ultrasonic-energy device was used to enucleate and excise the cyst. A uterine manipulator helped to identify the cervical canal and protect the posterior wall from inadvertent suture placement. The defect was closed with 1 vicryl interrupted sutures, being careful to incorporate the full thickness of the uterine wall to an able maximal opposition. An adhesion barrier was applied to the area. Transvaginal ultrasound scanning performed 6 weeks postoperatively demonstrated full healing with no residual defect.

CONCLUSION

Niches are recognized complications of cesarean sections resulting from incomplete healing of the scar and more likely in single-layer closures [1]. They can be associated with postmenstrual spotting, dysmenorrhea, chronic pain, subfertility, and poorer reproductive and obstetric outcomes [1-5]. Laparoscopic resection of niches is well established, showing symptomatic relief and an increase in residual myometrium [6]. Although cesarean section scar defects have been described as niches, we presented a further variety of defect that has not been previously described, a uterine cyst.

Simplified Laparoscopic Sacrohysteropexy

STUDY OBJECTIVE

To demonstrate a simplified technique of performing laparoscopic sacrohysteropexy for uterine prolapse.

DESIGN

A technical video demonstrating a simplified method of laparoscopic sacrohysteropexy (Canadian Task force classification level III).

SETTING

The benign gynecology department at a university hospital.

INTERVENTIONS

A 38-year old woman with grade 3 uterine descent presented requesting surgical management for symptomatic prolapse.

CONCLUSION

Laparoscopic sacrohysteropexy is becoming an increasingly popular alternative to hysterectomy to treat uterine prolapse in women. We present a novel approach of performing laparoscopic sacrohysteropexy that differs from previously described methods [1,2]; it is shorter, simpler, and reduces possible complications. Key differences include the mesh type, site of attachment, and dissection of the peritoneum while creating the possibility of future vaginal delivery after pregnancy. Our simplified technique uses a polyvinylidene fluoride mesh woven with a square weave secured to the posterior aspect of the cervix under a layer of visceral peritoneum. Because there is no longitudinal give of the mesh, unlike polypropylene meshes with a diamond weave, a wrap method [2] is not required. No dissection of the broad ligament and bladder is needed, eliminating the risk of bladder perforation and anterior mesh erosion with fewer adhesions and simplifying hysterectomy if required in the future. We also uniquely "tunnel" the peritoneum, reducing the size of defect for suture closure, and reperitonize the mesh. Previous methods restrict cervical dilatation and require women to have cesarean sections. The method described in the video allows women to deliver vaginally and, in the event of late miscarriage, avoid the need for hysterotomy. We have performed 25 cases with 1 mild cystocoele recurrence requiring no surgery, 1 reoperation for posterior compartment repair, and 1 case of cervical elongation requiring Manchester repair. No cases of recurrent uterine prolapse have occurred.

Mesh-Free Laparoscopic High Uterosacral Ligament Suspension during Total Laparoscopic Hysterectomy for Uterine Prolapse

STUDY OBJECTIVE

To demonstrate a mesh-free approach for uterine prolapse during a hysterectomy.

DESIGN

Technical video (Canadian Task Force classification III).

SETTING

Benign gynecology department at a university hospital.

PATIENT

A 50-year-old woman.

INTERVENTION

Laparoscopic high uterosacral ligament suspension technique.

MEASUREMENTS AND MAIN RESULTS

A 50-year-old woman presented with irregular vaginal bleeding and grade 3 uterine prolapse. The patient was concerned regarding the use of mesh and erosion. After counseling the patient agreed to a mesh-free single procedure. The use of mesh for the treatment of pelvic organ prolapse has become the subject of controversy and litigation. Complications of mesh erosion have resulted in the US Food and Drug Administration reclassifying transvaginal meshes as high-risk devices in 2016 [1]. Mesh erosion risk is up to 23% with hysterectomy and concomitant laparoscopic sacrocolpopexy [2] and 3% with sacrohysteropexy [3]. We present an alternative laparoscopic approach of treating uterine prolapse with high uterosacral suspension during laparoscopic hysterectomy. Our method avoids the use of mesh, sacrocervicopexy and morcellation, or an interval sacrocolpopexy. Although high uterosacral ligament suspension can be performed vaginally, it carries up to an 11% risk of ureteric injury [4].

CONCLUSION

In this video a bilateral ureterolysis is performed, before hysterectomy, isolating the uterosacral ligaments. These are then suspended to the vaginal vault in a purse-string fashion using Vicryl 0 (polyglactin 910) and intracorporeal knot-tying. Postprocedure the vault is well supported with a vaginal length of 12 cm.

Technical video: modified laparoscopic colposuspension

BACKGROUND

Laparoscopic colposuspension has been shown in some studies to have equivocal results as open colposuspension, and in addition to treating stress incontinence can also reduce anterior vaginal wall compartment prolapse, as described by Burch in 1961 [1].

STUDY OBJECTIVE

To demonstrate a novel modified technique for laparoscopic colposuspension.

DESIGN

Narrated step-by-step video demonstration of the modified laparoscopic colposuspension technique.

SETTING

Department of Obstetrics and Gynecology, Royal Surrey County Hospital.

INTERVENTION

Initially, 180 mL methylene blue with saline solution is instilled into the bladder for clear identification. Incision and dissection bilaterally, directly onto the ileopectineal ligament (Cooper's ligament) are performed. By using the Kent dissecting knotter, dissection down the space of Retzius to the paravaginal tissues is easily performed. Two 0 Ethibond sutures (Ethicon, Inc., Somerville, NJ) are then placed on each side, between the Cooper's ligament and the paravaginal tissues. These are tied via an extracorporeal knot using the other end of the Kent dissecting knotter. The peritoneal defects are then closed sequentially using 2/0 polyglactin 910 sutures (Vicryl; Ethicon) in a figure-of-eight intracorporeal surgical slip knot technique.

MAIN RESULTS

The patient had second-degree anterior wall prolapse with proved stress incontinence and descent of the bladder neck observed on video urodynamics. At 8 months after surgery she has no symptomatic or measurable prolapse and no stress incontinence.

CONCLUSION

This modified laparoscopic colposuspension procedure can be used in most cases because it is a transperitoneal technique. It requires substantially less dissection than the traditional techniques do, which results in a markedly reduced operative time.

The birth of forceps

Operative vaginal delivery has been described since the Middle Ages. During this time, however, labour would be sustained over several days and intrapartum death almost inevitable. In these circumstances, intervention involving the use of surgical instruments or even kitchen utensils would serve purely as an attempt to avoid maternal mortality. The establishment of forceps-assisted delivery as a means of avoiding both maternal and neonatal morbidity was initiated in the 16th century by the Chamberlen family and later developed over several centuries by leading obstetricians of the time including Simpson, Barnes and Keilland. The evolution of forceps is a fascinating story which is rich in history. Despite the development of Ventouse and the increasing use of Caesarean section for difficult delivery, forceps remain an integral part of obstetric practice. The striking resemblance of modern day forceps to the original instruments used by the Chamberlens is a testament to both the family's ingenuity and enterprise as well as the subsequent pioneering obstetricians who followed in their footsteps.

Rapid in vivo testing of drug response in multiple myeloma made possible by xenograft to turkey embryos

Background:

The best current xenograft model of multiple myeloma (MM) in immune-deficient non-obese diabetic/severe-combined immunodeficient mice is costly, animal maintenance is complex and several weeks are required to establish engraftment and study drug efficacy. More practical in vivo models may reduce time and drug development cost. We recently described a rapid low-cost xenograft model of human blood malignancies in pre-immune turkey. Here, we report application of this system for studying MM growth and the preclinical assessment of anticancer therapies.

Methods:

Cell lines and MM patient cells were injected intravenously into embryonic veins on embryonic day 11 (E11). Engraftment of human cells in haematopoietic organs was detected by quantitative real-time polymerase chain reaction, immunohistochemistry, flow cytometry and circulating free light chain.

Results:

Engraftment was detected after 1 week in all embryos injected with cell lines and in 50% of those injected with patient cells. Injection of bortezomib or lenalinomide 48 h after cell injection at therapeutic levels that were not toxic to the bone marrow dramatically reduced MM engraftment.

Conclusion:

The turkey embryo provides a practical, xenograft system to study MM and demonstrates the utility of this model for rapid and affordable testing therapeutics in vivo. With further development, this model may enable rapid, inexpensive personalised drug screening.

Common CCR 5 polymorphism in stroke: the CCR 5 delta32 polymorphism differentiates cardioembolism from other aetiologies of ischaemic cerebrovascular diseases

Inflammation is involved in the development of atherosclerosis. The CC chemokine receptor 5 (CCR5) initiates chemotaxis and modulates the inflammation secondary to atherosclerosis and related vascular diseases. The CCR5 Delta32 polymorphism influences the expression of CCR5 on the cell surface. The purpose of this study was to examine the effect of the Delta32 polymorphism in ischaemic cerebrovascular disease (ICVD). The CCR5 Delta32 polymorphism was genotyped in 1462 individuals: 562 ischaemic stroke (IS), 97 transient ischaemic attack (TIA) and in 803 healthy controls. All 659 ICVD patients were categorized according to the Trial of Org 10172 in Acute Stroke Treatment aetiological classification. The investigated subtypes were large artery atherosclerosis (LAA), cardioembolism (CE), small artery occlusion (SAO) and cryptogenic disease (CRYPT). Genotyping was performed with the TaqMan polymerase chain reaction. The Delta32 allele was less frequent in CE patients compared with LAA (OR, 0.4; 95% CI, 0.24-0.79; P = 0.008), SAO (OR, 0.5; 95% CI, 0.29-0.84; P = 0.01), CRYPT (OR, 0.5; 95% CI, 0.28-0.82; P = 0.008) and controls (OR, 0.5; 95% CI, 0.36-0.82; P = 0.002). Multiple logistic regression analysis showed that the Delta32 allele is associated with a lower risk for cardioembolic ICVD (OR 0.5; 95% CI, 0.28-0.75; P = 0.002) when compared with ICVD of other causes. The Delta32 polymorphism of CCR5 may differentiate cardioembolism from the remaining causes of ICVD.

The tibialis tendon as a valuable anterior cruciate ligament allograft substitute: biomechanical properties

The study evaluates the biomechanical properties of single-strand and single-loop tibialis (anterior and posterior) tendon allografts. A comparison was made with bone-patellar tendon-bone (BPTB) allografts. Sixty-four tendon allografts were evaluated in this study. Sixteen of these were single-strand tibialis anterior (TA) and 16 single-strand tibialis posterior (TP) tendons. Sixteen single-loop TA and TP tendons were also tested. The fourth group was composed of 16 BPTB allografts. The biomechanical properties determined were maximal load, stiffness, cross-sectional area and elongation. The results of this study showed that the maximal load of the single-loop tibialis tendons (1,553 +/- 62 N) was greater than of the BPTB (1,139 +/- 99 N), TA (776 +/- 43 N) and TP (888 +/- 64 N) tendons. The stiffness of the single-loop tibialis tendons (236 +/- 10 N/mm) was also greater than of the BPTB (168 +/- 13 N/mm), TA (60 +/- 2 N/mm) and TP (73 +/- 5 N/mm) tendons. The cross-sectional area of the BPTB tendons was 67 +/- 5 mm(2), of the single-loop tibialis tendons 36 +/- 2 mm(2), of the TA tendons 20 +/- 1 mm(2), and of the TP tendons 23 +/- 1 mm(2). The elongation of the single-loop tibialis tendons and of the BPTB tendons was almost similar (7 +/- 0.4 mm). The same applied to the TA and TP tendons (14 +/- 0.6 mm). The results of this in vitro mechanical study suggest that fresh-frozen single-loop TA and TP tendons, and BPTB allografts are an acceptable substitute for hamstrings in anterior cruciate ligament reconstruction.

Tositumomab and Iodine I 131 Tositumomab for Recurrent Indolent and Transformed B-Cell Non-Hodgkin’s Lymphoma

Purpose

An open-label phase II study was conducted at two centers to establish the efficacy and safety of tositumomab and iodine I 131 tositumomab at first or second recurrence of indolent or transformed indolent B-cell lymphoma.

Patients and Methods

A single dosimetric dose was followed at 7 to 14 days by the patient-specific administered radioactivity required to deliver a total body dose of 0.75 Gy (reduced to 0.65 Gy for patients with platelets counts of 100 to 149 × 109/L). Forty of 41 patients received both infusions.

Results

Thirty-one of 41 patients (76%) responded, with 20 patients (49%) achieving either a complete (CR) or unconfirmed complete remission [CR(u)] and 11 patients (27%) achieving a partial remission. Response rates were similar in both indolent (76%) and transformed disease (71%). The overall median duration of remission was 1.3 years. The median duration of remission has not yet been reached for those patients who achieved a CR or CR(u). Eleven patients continue in CR or CR(u) between 2.6+ and 5.2+ years after therapy. Therapy was well tolerated; hematologic toxicity was the principal adverse event. Grade 3 or 4 anemia, neutropenia, and thrombocytopenia were observed in 5%, 45%, and 32% of patients, respectively. Secondary myelodysplasia has occurred in one patient. Four patients developed human antimouse antibodies after therapy. Five of 38 assessable patients have developed an elevated thyroid-stimulating hormone; treatment with thyroxine has been initiated in one patient.

Conclusion

High overall and CR rates were observed after a single dose of tositumomab and iodine I 131 tositumomab in this patient group. Toxicity was modest and easily managed.

Radioimmunoscintigraphy with Tc-99m-labelled SM3 in differentiating malignant from benign adnexal masses

OBJECTIVE

Ultrasound scanning, serum CA125 and menopausal status have previously been combined in a risk of malignancy index for the differential diagnosis of adnexal masses. Although this approach has greater accuracy than either individual tests or clinical assessment, it has a significant false positive and false negative rate. Efforts have been directed at refining differential diagnosis and this study assessed the role of radioimmunoscintigraphy using the stripped mucin 3 (SM3) antibody that has a 17-fold greater uptake in malignant than benign ovarian tumours in vitro.

DESIGN

Prospective study of patients with a pelvic mass using radioimmunoscintigraphy.

SETTING

Department of Nuclear Medicine of St Bartholomew's Hospital in collaboration with Cancer Network.

POPULATION

A total of 93 patients with pelvic masses were recruited for this study of which 32 had ovarian cancer and 61 had benign lesions.

METHODS

Radioimmunoscintigraphy was performed with Tc-99m-labelled SM3 (600 MBq), anterior and posterior pelvis imaged at 10 minutes and at 4 and 24 hours and evaluated with change detection analysis and probability mapping.

MAIN OUTCOME MEASURES

Sensitivity and specificity of radioimmunoscintigraphy for ovarian cancer.

RESULTS

Radioimmunoscintigraphy had a sensitivity for ovarian cancer of 84% (27 true positive and 5 false negatives) and a specificity of 87% (53 true negatives and 8 false positives) giving a negative predictive value of 91%.

CONCLUSION

These results suggest that radioimmunoscintigraphy could be used to reduce the number of false positive findings in a strategy to refine differential diagnosis of the pelvic mass.

Neuro-otological findings in Pendred syndrome

Pendred syndrome is an autosomal recessive inherited disorder characterized by profound hearing impairment and inappropriate iodine release by the thyroid on perchlorate challenge. Thirty-three cases comprising members of 13 families and eight isolated cases were studied, with detailed audiological and vestibular investigation and computerized tomography. A uniform, profound, symmetrical sensorineural hearing loss was identified in all cases. Approximately one-third of the group reported progressive hearing impairment, in childhood or adolescence, associated with head injury, infection, or delayed secondary hydrops. Ninety per cent of the cases scanned showed dilated vestibular aqueducts, and all cases with progression of the hearing impairment demonstrated this structural abnormality. Approximately one-third of the cases had normal vestibular function, but a further third demonstrated a unilateral peripheral deficit, while the remaining third showed bilateral vestibular hypofunction. There was no intra-familial concordance of vestibular findings, and no correlation between vestibular abnormality and presence or absence of a dilated vestibular aqueduct, with or without a Mondini malformation. In older children and adults, Pendred syndrome was associated with a profound, symmetrical, sensorineural auditory impairment, and a variety of vestibular abnormalities, which are not uniform within families, or correlated with structural labyrinthine deformities.

Effects of turn residues in directing the formation of the beta-sheet and in the stability of the beta-sheet

The designed peptide (denoted 20-mer, sequence VFITS(D)PGKTYTEV(D)PGOKILQ) has been shown to form a three-strand antiparallel beta-sheet. It is generally believed that the (D)Pro-Gly segment has the propensity to adopt a type II' beta-turn, thereby promoting the formation of this beta-sheet. Here, we replaced (D)Pro-Gly with Asp-Gly, which should favor a type I' turn, to examine the influence of different type of turns on the stability of the beta-sheet. Contrary to our expectation, the mutant peptide, denoted P6D, forms a five-residue type I turn plus a beta-bulge between the first two strands due to a one amino-acid frameshift in the hydrogen bonding network and side-chain inversion of the first beta-strand. In contrast, the same kind of substitution at (D)Pro-14 in the double mutant, denoted P6DP14D, does not yield the same effect. These observations suggest that the SDGK sequence disfavors the type I' conformation while the VDGO sequence favors a type I' turn, and that the frameshift in the first strand provides a way for the peptide to accommodate a disfavored turn sequence by protruding a bulge in the formation of the beta-hairpin. Thus, different types of turns can affect the stability of a beta-structure.