Effectiveness of ovarian suspension in preventing post-operative ovarian adhesions in women with pelvic endometriosis: A randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>Endometriosis is a common benign condition, which is characterized by the growth of endometrial-like tissue in ectopic sites outside the uterus. Laparoscopic excision of the disease is frequently carried out for the treatment of severe endometriosis. Pelvic adhesions often develop following surgery and they can compromise the success of treatment. Ovarian suspension (elevating both ovaries to the anterior abdominal wall using a Prolene suture) is a simple procedure which has been used to facilitate ovarian retraction during surgery for severe pelvic endometriosis. The study aims to assess the effect of temporary ovarian suspension following laparoscopic surgery for severe pelvic endometriosis on the prevalence of post-operative ovarian adhesions.</p> <p>Methods</p> <p>A prospective double blind randomised controlled trial for patients with severe pelvic endometriosis requiring extensive laparoscopic dissection with preservation of the uterus and ovaries. Severity of the disease and eligibility for inclusion will be confirmed at surgery. Patients unable to provide written consent, inability to tolerate a transvaginal ultrasound scan, unsuccessful surgeries or suffer complications leading to oophorectomies, bowel injuries or open surgery will be excluded.</p> <p>Both ovaries are routinely suspended to the anterior abdominal wall during surgery. At the end of the operation, each participant will be randomised to having only one ovary suspended post-operatively. A new transabdominal suture will be reinserted to act as a placebo. Both sutures will be cut 36 to 48 hours after surgery before the woman is discharged home. Three months after surgery, all randomised patients will have a transvaginal ultrasound scan to assess for ovarian mobility. Both the patients and the person performing the scan will be blinded to the randomisation process.</p> <p>The primary outcome is the prevalence of ovarian adhesions on ultrasound examination. Secondary outcomes are the presence, intensity and site of post-operative pain.</p> <p>Discussion</p> <p>This controlled trial will provide evidence as to whether temporary ovarian suspension should be included into the routine surgical treatment of women with severe pelvic endometriosis.</p> <p>Trial registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN24242218">ISRCTN24242218</a></p

Trocar-guided total tension-free vaginal mesh repair of post-hysterectomy vaginal vault prolapse

Contains fulltext : 81076.pdf (publisher's version ) (Closed access)INTRODUCTION AND HYPOTHESIS: The objective of this study was to report 1 year anatomical and functional outcomes of trocar-guided total tension-free vaginal mesh (Prolift) repair for post-hysterectomy vaginal vault prolapse with one continuous piece of polypropylene mesh. METHODS: We conducted a prospective observational cohort study of 46 patients. A minimum sample size of 35 patients was needed to detect a recurrence rate of less than 20% at 12 months. Instruments of measurement used were pelvic organ prolapse quantification and validated questionnaires. RESULTS: Overall anatomical success was 91% (95% confidence interval 83-99), with significant improvement in experienced bother and quality of life. Mesh exposure occurred in seven patients (15%). No adverse effects on sexual function could be detected. CONCLUSIONS: Trocar-guided total tension-free vaginal mesh (Prolift) repair with one continuous piece of mesh for post-hysterectomy vaginal vault prolapse is well tolerated and anatomically and functionally highly effective. Results of controlled trials will determine its position in the operative armamentarium

Mourning and melancholia revisited: correspondences between principles of Freudian metapsychology and empirical findings in neuropsychiatry

Freud began his career as a neurologist studying the anatomy and physiology of the nervous system, but it was his later work in psychology that would secure his place in history. This paper draws attention to consistencies between physiological processes identified by modern clinical research and psychological processes described by Freud, with a special emphasis on his famous paper on depression entitled 'Mourning and melancholia'. Inspired by neuroimaging findings in depression and deep brain stimulation for treatment resistant depression, some preliminary physiological correlates are proposed for a number of key psychoanalytic processes. Specifically, activation of the subgenual cingulate is discussed in relation to repression and the default mode network is discussed in relation to the ego. If these correlates are found to be reliable, this may have implications for the manner in which psychoanalysis is viewed by the wider psychological and psychiatric communities

Clinical approach for the classification of congenital uterine malformations

A more objective, accurate and non-invasive estimation of uterine morphology is nowadays feasible based on the use of modern imaging techniques. The validity of the current classification systems in effective categorization of the female genital malformations has been already challenged. A new clinical approach for the classification of uterine anomalies is proposed. Deviation from normal uterine anatomy is the basic characteristic used in analogy to the American Fertility Society classification. The embryological origin of the anomalies is used as a secondary parameter. Uterine anomalies are classified into the following classes: 0, normal uterus; I, dysmorphic uterus; II, septate uterus (absorption defect); III, dysfused uterus (fusion defect); IV, unilateral formed uterus (formation defect); V, aplastic or dysplastic uterus (formation defect); VI, for still unclassified cases. A subdivision of these main classes to further anatomical varieties with clinical significance is also presented. The new proposal has been designed taking into account the experience gained from the use of the currently available classification systems and intending to be as simple as possible, clear enough and accurate as well as open for further development. This proposal could be used as a starting point for a working group of experts in the field

Laparoscopic management of high transverse vaginal septae: a case report

Transverse vaginal septae are a rare cause of haematocolpos secondary to obstructed menstruation. Low transverse vaginal septae are usually resected vaginally, however, medium/high septae are often more complex requiring a laparotomy. Two adolescent girls presented with obstructed menstruation due to high transverse vaginal septae. We describe the laparoscopic technique for the management of high transverse vaginal septae as an alternative to the traditional approach of abdomino-perineal resection via laparotomy. A laparoscopic approach enabled resection of the transverse septae in both cases with the restoration of normal menstruation. Laparoscopic resection of high transverse vaginal septae is a feasible alternative to laparotomy. © 2013 Springer-Verlag Berlin Heidelberg

Laparoscopic Sacrocolpopexy to Treat Prolapse of the Neovagina Created by Vaginal Dilation in Rokitansky Syndrome

BACKGROUND: Vaginal dilation is the first choice of treatment for women with a short vagina due to Rokitansky syndrome. Although the neovagina lacks pelvic support, prolapse of the neovagina is a surprisingly rare complication of treatment. Laparoscopic sacrocolpopexy is recommended in the treatment of posthysterectomy vault prolapse in younger women but has not been used to treat neovaginal prolapse. CASE: A 23-year-old woman with Rokitansky syndrome presented with a symptomatic prolapse of the neovagina. This was successfully treated with a laparoscopic sacrocolpopexy. SUMMARY AND CONCLUSIONS: Laparosopic sacrocolpopexy appears to be an effective treatment in the unusual situation of vaginal prolapse after dilation

Hemoperitoneum as a precursor of deep pelvic endometriosis: a cohort study

OBJECTIVE: To determine whether significant hemoperitoneum could be a precursor of deep pelvic endometriosis METHODS: This was a prospective observational cohort study which was carried out in a dedicated gynecological diagnostic unit over a period of 18 months. We included consecutive pre-menopausal, non-pregnant women who attended with severe acute lower abdominal pain and underwent a pelvic ultrasound examination. Women were triaged for surgical or conservative management depending on the cause of pain and severity of their symptoms. Those who were selected for conservative management were invited for follow up ultrasound scans. The main outcome measure was evidence of newly developed deep endometriosis at follow up. RESULTS: One hundred and eighteen non-pregnant women attended with severe acute lower abdominal pain, 20 of whom had emergency surgery. Seventeen women with past history of endometriosis or evidence of endometriosis on the initial scan were excluded from the study. Conservative management was employed in 81 women, eight of whom had evidence of significant hemoperitoneum at presentation. A total of 35 women attended for all their follow up ultrasound scans. At the completion of follow up 4/6 (67%, 95% CI 22-96)] women who initially presented with significant intra-abdominal bleeding had developed new evidence of DE compared to 1/29 (3%, 95% CI 0-18) of those without hemoperitoneum. (RR 19.3 (95% CI 3-144) (p=<0.001). CONCLUSION: In some women, the presence of significant hemoperitoneum that is managed conservatively precedes the development of deep endometriosis (DE)