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Background Treatment of retained products of conception (RPOC) can be expectant, medical or operative. Surgical removal of RPOC may lead to intrauterine adhesions (IUA) and Asherman’s syndrome. Objective To evaluate how treatment options for RPOC affect future fertility by means of a systematic review. Search strategy MEDLINE, EMBASE, The Cochrane Library, and clinical trial registers were searched, and reference lists were scanned. Selection criteria Randomised controlled trials (RCT) comparing different treatment options for RPOC (conservative, medical or surgical treatment, including curettage and/or hysteroscopic techniques, with or without application of anti-adhesion therapy), in women of reproductive age, were eligible for inclusion. Data collection and analysis Reviewers independently performed data extraction and quality of evidence assessment. For dichotomous variables, results were presented as risk ratio (RR) with 95% CI. Main results Two studies were included. Nonsignificant differences were observed between the use of an anti-adhesion barrier gel versus no treatment after operative hysteroscopy in IUAs (RR 0.32, 95% CI 0.04 to 2.80, P value = 0.30) and clinical pregnancy (RR 2.22, 95% CI 0.67 to 7.42, P value = 0.19), and between hysteroscopic morcellation versus loop resection in IUAs (RR 0.86, 95% CI 0.06 to 13.12, P value = 0.91). Conclusion There is insufficient evidence on how different treatment options for RPOC affect future reproductive outcomes. Results from ongoing RCTs are needed to guide clinicians towards choosing the best treatment.

Fibroids may give rise to specific obstetrical complications such as pain due to degeneration, fetal malpresentation, or placenta previa. For all these reasons, surgical resection of the fibroid may be indicated before a pregnancy is pursued. The occurrence of a uterine rupture is a rare but severe complication of myomectomy. This study seeks to review the risk of uterine rupture during pregnancy and/or labor after laparoscopic myomectomy in comparison with laparotomic myomectomy. A systematic search of the literature through search strategies in MEDLINE (PubMed) and Embase (Embase.com) from January 1970 up to March 2013 was performed. We used the following MeSH terms and free text words: gynecologic surgical procedures, gynecologic surgery, leiomyoma, fibromyoma, fibroids, myoma, uterine tumors, and pregnancy complication. Our data show that the risk of uterine rupture during labor and delivery is low (0.75 %). Compared with traditional open myomectomy, the risk of uterine rupture during pregnancy is not significantly higher after a laparoscopic approach (P=0.119). More elective cesarean sections are performed after laparoscopic myomectomy compared with the conventional open technique (P=0.001). Our conclusions are supported by statistical pooling of observational studies of generally low methodological quality. The risk of uterine rupture after myomectomy is low (0.75 %). The available evidence in the literature does no allow discouraging attempts for childbirth per viam naturalem after previous myomectomy, regardless of the technique used. Randomized studies are needed before definitive evidence-based recommendations can be given. © 2014 Springer-Verlag. ispartof: Gynecological Surgery vol:11 issue:3 pages:197-206 status: published

While surgery is gaining in efficiency it is equally getting more and more complex. Meanwhile patients are getting more and more demanding. In the past decades, safety and quality have become prominent criteria by which surgical care is evaluated. Several important factors can be identified which are influencing the quality of surgical care, in our view these factors can be classified into four major groups: the team of caretakers, the patient, the material, and the procedure. For all of these factors, a high level of knowledge and optimal communication is crucial to guarantee a high standard of care and minimize the chance of complications. Different quality assessment tools are currently used in surgery. Databases of surgical procedures have the potential to offer an enormous amount of information on the quality of care. However, the implementation of comprehensive databases is difficult and expensive, while its value is overshadowed by possible underreporting. Introducing surgical checklists is a cheap yet efficient way to increase both the safety and the quality of surgical care. Nevertheless, its implementation is sometimes opposed since they slow down the patient flow. The risk of complications tends to increase when a new technique is introduced. Therefore, quality assurance (QA) programs have to be implemented. Surgical simulation training is rapidly becoming a necessary adjunct to traditional patient-based training models. Finally, key performance indicators (KPI) can be used for measuring the success of medical interventions such as surgery. For the near future, the introduction of one comprehensive medical file per patient could be a major step in increasing the safety and efficiency of our medical deeds. In parallel, a nationwide prospective registry for surgical interventions should be introduced. Postgraduate surgical training should be organized by the national professional groups and should be adapted to the local needs. A system of accreditation for specific interventions should be introduced guaranteeing their state-of-the-art application. ispartof: Gynecological Surgery vol:11 issue:2 pages:89-95 status: published

We review the current evidence about the treatment modalities of intrauterine adhesions (IUA) or Asherman’s Syndrome (AS). Systematic approach, audit and well-structured research is mandatory in order to establish the best treatment for the individual needs of patients. The clinical practice changed significantly over the last 20 years with technological advances in hysteroscopy and imaging techniques. Hysteroscopic treatment seems effective and safe. IUA or AS is a rather uncommon finding in general gynaecological practice. The referral to a tertiary centre will help to centralise the most difficult cases and create the opportunity to study more in detail the efficacy of each treatment modality and to compare the different treatment techniques.

The use of robot-assisted surgery (RAS) has gained popularity in the field of gynaecology, including pelvic floor surgery. To assess the benefits of RAS, we conducted a systematic review of randomized controlled trials comparing laparoscopic and robotic-assisted sacrocolpopexy. The Cochrane Library (1970–January 2015), MEDLINE (1966 to January 2015), and EMBASE (1974 to January 2015) were searched, as well as ClinicalTrials.gov and the International Clinical Trials Registry Platform. We identified two randomized trials (n = 78) comparing laparoscopic with robotic sacrocolpopexy. The Paraiso 2011 study showed that laparoscopic was faster than robotic sacrocolpopexy (199 ± 46 vs. 265 ± 50 min; p p = .110). Costs for using the robot were significantly higher in both studies, however, in the ACCESS trial, only when purchase and maintenance of the robot was included (LSC US$11,573 ± 3191 vs. RASC US$19,616 ± 3135; p p = 0.008). Pain was reportedly higher after RASC, although at different time points after the operation. There were no differences in anatomical outcomes, pelvic floor function, and quality of life. The experience with RASC was tenfold lower than that with LSC in both studies. The heterogeneity between the two studies precluded a meta-analysis. Based on small randomized studies, with surgeons less experienced in RAS than in laparoscopic surgery, robotic surgery significantly increases the cost of a laparoscopic sacrocolpopexy. RASC would be more sustainable if its costs would be lower. Though RASC may have other benefits, such as reduction of the learning curve and increased ergonomics or dexterity, these remain to be demonstrated.