Current Women's Health Reviews - Volume 14, Issue 1, 2018

Background: Important innovations in laparoscopy have come in the form of technological advances and improvements in best practice for patients in need of minimally invasive gynecologic surgery. Objective: To review recent advancements in laparoscopic instrumentation and emerging best practices around gynecologic laparoscopy. Results: New instrumentation reviewed include sub-5 mm instruments, three-dimensional imaging, narrow band imaging (NBI), and articulated instruments. Smaller (mini-laparoscopy and percutaneous) instruments can provide equivalent outcomes for certain operations with less abdominal wall trauma. Three-dimensional imaging may be particularly helpful for learners in the laparoscopic environment. NBI may pick up more endometriosis lesions but the clinical impact the small increase in sensitivity appears to be negligible over conventional white light laparoscopy. Adding articulation to certain advanced energy devices may facilitate division of vascular pedicles difficult to reach with standard straight instruments. Evidence suggests that mechanical bowel preparation before gynecologic laparoscopy and the routine use of adhesion barriers in myomectomy have doubtful value and can likely be abandoned. Preventative salpingectomy at the time of hysterectomy does not afford additional complications but likely has a role in prevention of some ovarian cancers. Good fetal outcomes are seen with laparoscopic cerclage, equivalent to outcomes seen with the traditional abdominal approach. Achieving hemostasis with electrosurgical energy is more detrimental to ovarian function than other methods, such as suturing. Excision may be superior to ablation of endometriosis lesions, and excision of bowel and bladder disease may be aided with the use of transanal staplers and barbed suture. Pretreatment with Gonadotropin Releasing-Hormone Analogues may have a role in laparoscopic myomectomy for large fibroids. The risk of uterine rupture after laparoscopic myomectomy appears to be low when proper technique is used. Conclusion: Gynecologic laparoscopists should consider available new technology in instrumentation and practice as the field continues to evolve.

Simulation in minimally invasive surgery has quickly evolved from early box trainers to high tech computer-based virtual reality systems that allow trainees to practice complete surgical procedures. Simulation provides a safe introduction to advanced laparoscopic and robotic skills in an age of decreasing surgical numbers and work hours. This article reviews the evidence in support of simulation, reviews simulators available for both laparoscopic and robotic surgery, and discusses creation of a simulation program for gynecology residents.

Background: Robotic-assisted laparoscopy can be safely utilized to surgically treat multiple gynecological conditions. Few studies have evaluated its role in performing adnexal surgeries. Objective: To identify which adnexal surgeries are more commonly being performed robotically and review safety and efficacy outcomes. Method: A literature search was performed using electronic databases using keywords robotic, adnexal surgery, ovarian, tubal, endometriosis, infertility, and pediatrics. Results: A limited number of studies were identified that evaluated the role of robotic technology in adnexal surgeries such as oophorectomy or cystectomy for benign adnexal masses, removal of ovarian remnant, tubal reanastomosis, adnexal surgeries performed during pregnancy, and in the pediatric population for ovarian pathology. The results of these studies are based largely on a small number of retrospective data. These studies suggest similar perioperative complication rates for robotic surgery and conventional laparoscopy for the treatment of these conditions. Conclusion: Robotic assisted laparoscopy has been demonstrated to treat adnexal pathology with favorable outcomes. However, the benefit of this technology compared to conventional laparoscopy for these procedures is undetermined and larger prospective studies are necessary to better understand its advantages and disadvantages.

Objective: The objective of this article is to review the current literature on laparo-endoscopic single-site (LESS) surgery in gynecology, discuss recent developments, and what is on the horizon for LESS surgery. Design: Appraisal of articles published on the use of laparo-endoscopic single-site surgery in gynecology from 2008 to the present. PubMed, Medline, and the Cochrane Central Register of Controlled Trials were systematically searched using the terms “laparo-endoscopic single-site”, “single-site laparoscopy”, “single port laparoscopy”, “SPA”, “SILS”, “LESS”, “robotic single-site surgery”, and “R-LESS” between January 1, 2016 and February 15, 2016. Publication date restrictions were all publications 2008 and later. Non-English language was excluded. Results: LESS and R-LESS is safe, feasible, and equivalent to traditional multiport laparoscopy and robotic surgery. Cosmesis is potentially the most obvious advantage associated with LESS surgery. Instrument crowding with associated external instrument space conflicts is a major problem since all the instruments are inserted through a single point on the abdomen. For the experienced laparoscopist, the learning curve for LESS is shorter and associated with less morbidity when compared to the learning curve of multiport laparoscopy. Conclusion: LESS surgery is another option of approach to minimally invasive gynecologic surgery. There is a clear body of literature demonstrating that LESS is feasible, safe, and equivalent to traditional multiport and robotic surgery. There is growing literature regarding improved cosmesis, improved pain control, quicker recovery, and shorter hospitalizations but these studies, even when combined, are underpowered. Both traditional and robotic laparoendoscopic single site surgeries are still in the early development and diffusion.

Objective: The minimally invasive surgical treatment options for many chronic pelvic pain disorders are reviewed, including treatments for endometriosis, ovarian remnant syndrome, pelvic congestion, post-ablation pain, pelvic adhesions, and uterine retroversion. Design: A systematic review of the literature referring to surgical treatments of chronic pelvic pain, with emphasis on articles published after 1990. Data Sources: Medline searches for terms including the specific chronic pain syndromes and “surgery,” “treatment,” or “management.” Eligibility Criteria: Trials, prospective and observational studies, and reviews assessing the treatment efficacy of surgical modalities employed in the treatment of chronic pelvic pain conditions were considered. Only English-language articles were included. Results: The indications, efficacy, risks, and benefits of minimally invasive treatments for each chronic pelvic pain condition are discussed. Conclusion: There are well-defined minimally invasive surgical treatment options for each chronic pelvic pain condition reviewed. There are limitations of available literature, both in level of evidence and quantity. Most studies are confounded by the multifactorial nature of chronic pelvic pain.

Background: In an effort to mitigate the risks associated with power morcellation, gynecologic surgeons have developed alternative methods for tissue extraction and the surgical treatment of uterine fibroids. Containment systems have allowed surgeons to continue performing minimally invasive myomectomies while minimizing the risk of intraperitoneal dissemination of tissue. In order to properly synthesize the available data on contained tissue extraction techniques, a PubMed search was performed using the key words: laparoscopy, uterine fibroids, and contained tissue extraction. Objective: In this article, we will review the current status of minimally invasive surgical techniques utilized in the treatment of fibroids.

Background: Ovulation induction plays an important role in the pregnancy outcome of assisted reproduction. Individualized controlled ovarian hyper-stimulation (COH) based on the prediction of the ovarian response for each individual is regarded as the treatment of choice. Objective: This review summarizes the various protocols available at present and then examines the use of COH protocols for different causes of infertility. Results: The advantage and efficacy of mild stimulation are proposed as suitable for poor responders and women of advanced age. For women with endometriosis or adenomyosis, the reproductive outcomes of assisted reproduction benefit from prolonged downregulation with a gonadotropinreleasing hormone (GnRH) agonist before the start of ovarian stimulation. For high responders, a GnRH antagonist protocol facilitates a GnRH agonist trigger and the segmentation of in vitro fertilization cycle to avoid ovarian hyperstimulation syndrome. The efficacy of various adjuvant therapies, including growth hormone, estrogen, levothyroxine, vitamin D, melatonin and myo-inositol is also reviewed.

Background: Premenstrual Dysphoric Disorder (PMDD) is a newly recognized diagnostic entity in the DSM-5, characterized by intense mood and cognitive fluctuations accompanied by distressing physical symptoms. PMDD symptoms typically arise after ovulation and gradually resolve after the onset of menstruation. With an estimated prevalence of 3-8% in the general female population, PMDD is a chronic and impairing disorder that affects significantly women's quality of life and everyday functioning. Objective: The aim of this article is to review the existing literature on biological, genetic and psychological etiological factors in PMDD and to discuss corresponding treatment considerations. Results: Fluctuations in the functions of sex hormones, serotonin and GABA neurotransmitters, as well as personality traits related to stress and vulnerability to negative effect are implicated in the development of PMDD. Available evidence-based treatments include a number of hormonal therapies and antidepressant medications, while there is accumulating evidence for the clinical utility of psychotherapeutic interventions. Controversies in the diagnostic validity of PMDD mainly concern the asserted social constructiveness of the disorder and the difficulty to validly distinguish PMDD from other mood disorders with similar symptomatology. Conclusion: Controversies pertaining to the clinical nature and taxonomy of PMDD are highlighted and recommendations are offered, focusing on the need to identify biomarkers for PMDD and to investigate possible efficacy of non-pharmacological, psychotherapeutic interventions to address PMDD.

Background: Primary ovarian insufficiency (POI) or premature ovarian failure (POF) is defined by spontaneous amenorrhea with elevated serum gonadotropin levels and reduced estradiol level. POI frequently leads to reduced fertility and a number of clinical symptoms or signs related to premature menopause. The etiologies of POI include genetic or chromosomal defects, autoimmune factors, environmental factors, and idiopathic causes. However, the pathogenesis of POI is difficult to study due to a lack of suitable disease models. Recent evidence suggests that pluripotent stem cells (PSCs), including embryonic stem (ES) cells and induced pluripotent stem (iPS) cells, can be induced into germ cells and granulosa cells. Specifically, mouse PSCs can be directed to functional sperm and oocytes that lead to viable and fertile offspring. However, in humans, only early germ cells have been derived, including female primordial germ cells and immature haploid male germ cells with meiotic potential. Some evidence also suggests defective differentiation potential into germ cells and granulosa cells from POI patient-specific iPS cells (by reprogramming somatic cells from POI patients). Objective and Results: This report reviews current studies, advances, and future prospects in the derivation of POI patient-specific iPS cells, the efficiency of differentiating iPS cells into functional and mature germ cells and granulosa cells, and the potential to use the entire process as a disease model to screen drugs, toxicants and toxins. Conclusion: It is concluded that current data have provided good evidence to support the use of POI patient-specific iPS cells to model human POI and potentially other reproductive disorders.

Background: Hypersensitivity to human seminal fluid is a rare condition that mainly affects younger women although reports have also demonstrated it occurring in postmenopausal women. The clinical features of this condition may occur soon after intercourse or at a later stage and vary from weak local reactions to life threatening anaphylactic reactions. Objective: The main objective of this article to share our experience in managing a case with seminal fluid hypersensitivity. We also wanted to outline the management strategy we used to manage this difficult clinical scenario and compare with what has been done in the past. Result: In our case, successful intravaginal desensitisation was carried out using diluted fresh seminal fluid at increasing concentrations. The couple were subsequently advised to have regular unprotected intercourse and to try to conceive naturally. The patient, however, was asked to continue taking antihistamines before sexual intercourse. Conclusion: Human seminal fluid allergy is an uncommon condition. Diagnosis of the condition can be challenging and as a result this disorder can be underdiagnosed, especially in mild cases with local vaginal symptoms. As in our case, treatment of this clinical condition can be particularly challenging especially in the context of fertility.