Search

ObjectiveTo establish validity evidence for the Essentials in Minimally Invasive Gynecology laparoscopic and hysteroscopic simulation systems.MethodsA prospective cohort study was IRB approved and conducted at 15 sites in the United States and Canada. The four participant cohorts based on training status were: 1) novice (postgraduate year [PGY]-1) residents, 2) mid-level (PGY-3) residents, 3) proficient (American Board of Obstetrics and Gynecology [ABOG]-certified specialists without subspecialty training); and 4) expert (ABOG-certified obstetrician-gynecologists who had completed a 2-year fellowship in minimally invasive gynecologic surgery). Qualified participants were oriented to both systems, followed by testing with five laparoscopic exercises (L-1, sleeve-peg transfer; L-2, pattern cut; L-3, extracorporeal tie; L-4, intracorporeal tie; L-5, running suture) and two hysteroscopic exercises (H-1, targeting; H-2, polyp removal). Measured outcomes included accuracy and exercise times, including incompletion rates.ResultsOf 227 participants, 77 were novice, 70 were mid-level, 33 were proficient, and 47 were experts. Exercise times, in seconds (±SD), for novice compared with mid-level participants for the seven exercises were as follows, and all were significant (P

Background: Proficiency in total laparoscopic hysterectomy (TLH) is now a requirement of all graduating Canadian Obstetrics and Gynecology (OBGYN) trainees, but despite this requirement, a recent survey discovered that residency graduates are not receiving adequate training in TLH. Educational videos have been shown to be effective in teaching procedures in other surgical disciplines. Objective: To create an educational video to effectively teach TLH to OBGYN trainees. Methods: This qualitative study was undertaken at three academic hospitals affiliated with the University of Toronto between 2016 and 2018. Seven surgical experts were interviewed and recorded performing TLH. Qualitative and thematic analysis was used to synthesize a teaching curriculum via the Delphi method. An educational video was created and shown to small groups of consenting OBGYN trainees at various levels (15). Participants completed identical pre- and post-tests to assess knowledge, and a paired t-test was used to compare qualitative scores. A detailed focus group discussion for quality improvement was conducted. Results: The difference between the mean knowledge test scores pre-intervention (51%) compared with post-intervention (88%) was an increase of 37% (statistically significant, p-value = 0.001, CI = 2.7–4.8). Residents felt the tool was highly effective in demonstrating anatomy, surgical techniques, and clinical pearls. All residents recommended including the video in the residency curriculum. Conclusion: A TLH teaching video was systematically created, incorporating techniques from multiple surgical experts, improving gynecology trainees' knowledge surrounding surgical technique and anatomy in a safe and convenient learning environment. Trainees would recommend this tool to their peers and recommend it be incorporated into the residency training curriculum. [ABSTRACT FROM AUTHOR]

We describe a complicated ruptured Streptococcus pyogenes tubo-ovarian abscess (TOA) and peritonitis in a 24-year-old woman, necessitating eventual hysterectomy and a prolonged intensive care unit (ICU) admission 3 years after successful tubal occlusion with Essure® (Conceptus, Inc., Mountain View, CA) microinsert devices. The patient is a 24-year-old gravida 3, para 2, aborta 1 (G3P2Ab1) who had a 1-day history of worsening right lower quadrant pain without associated fever or cervical motion tenderness. Patient's medical history was complicated by mitochondrial neurogastrointestinal encephalopathy (MNGIE). Upon her admission to the hospital, an exploratory laparoscopy was performed. Intraoperative findings revealed a ruptured right-sided TOA. S. pyogenes was isolated from the peritoneal fluid and cervicovaginal cultures. After the laparoscopy, the patient experienced initial improvement but abruptly worsened and on postoperative day 7 was returned to the operating room for a planned repeat exploration and total abdominal hysterectomy. Gross pathological examination of the uterus showed appropriate Essure insert placement. Based on this case, tubal occlusion by induced fibrosis may not be a sufficient obstacle in preventing ascending pelvic infections. [ABSTRACT FROM AUTHOR]

Molecular biology studies of uveal melanoma have resulted in the development of novel immunotherapy approaches including tebentafusp-a T cell-redirecting bispecific fusion protein. More biomarkers are currently being studied. As a result, combined immunotherapy is being developed as well as immunotherapy with bifunctional checkpoint inhibitory T cell engagers and natural killer cells. Current trials cover tumor-infiltrating lymphocytes (TIL), vaccination with IKKb-matured dendritic cells, or autologous dendritic cells loaded with autologous tumor RNA. Another potential approach to treat UM could be based on T cell receptor engineering rather than antibody modification. Immune-mobilizing monoclonal T cell receptors (TCR) against cancer, called ImmTAC TM molecules, represent such an approach. Moreover, nanomedicine, especially miRNA approaches, are promising for future trials. Finally, theranostic radiopharmaceuticals enabling diagnosis and therapy with the same molecule bring hope to this research.

Uveal melanoma is the most common primary intraocular malignancy in adults, characterized by an insidious onset and poor prognosis strongly associated with tumor size and the presence of distant metastases, most commonly in the liver. Contrary to most tumor identification, a biopsy followed by a pathological exam is used only in certain cases. Therefore, an early and noninvasive diagnosis is essential to enhance patients' chances for early treatment. We reviewed imaging modalities currently used in the diagnostics of uveal melanoma, including fundus imaging, ultrasonography (US), optical coherence tomography (OCT), single-photon emission computed tomography (SPECT), fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), fundus autofluorescence (FAF), as well as positron emission tomography/computed tomography (PET/CT) or magnetic resonance imaging (MRI). The principle of imaging techniques is briefly explained, along with their role in the diagnostic process and a summary of their advantages and limitations. Further, the experimental data and the advancements in imaging modalities are explained. We describe UM imaging innovations, show their current usage and development, and explain the possibilities of utilizing such modalities to diagnose uveal melanoma in the future.

Uveal melanoma is the most common intraocular malignancy and arises from melanocytes in the choroid, ciliary body, or iris. The current eye-sparing treatment options include surgical treatment, plaque brachytherapy, proton beam radiotherapy, stereotactic photon radiotherapy, or photodynamic therapy. However, the efficacy of these methods is still unsatisfactory. This article reviews several possible new treatment options and their potential advantages in treating localized uveal melanoma. These methods may be based on the physical destruction of the cancerous cells by applying ultrasounds. Two examples of such an approach are High-Intensity Focused Ultrasound (HIFU)-a promising technology of thermal destruction of solid tumors located deep under the skin and sonodynamic therapy (SDT) that induces reactive oxygen species. Another approach may be based on improving the penetration of anti-cancer agents into UM cells. The most promising technologies from this group are based on enhancing drug delivery by applying electric current. One such approach is called transcorneal iontophoresis and has already been shown to increase the local concentration of several different therapeutics. Another technique, electrically enhanced chemotherapy, may promote drug delivery from the intercellular space to cells. Finally, new advanced nanoparticles are developed to combine diagnostic imaging and therapy (i.e., theranostics). However, these methods are mostly at an early stage of development. More advanced and targeted preclinical studies and clinical trials would be needed to introduce some of these techniques to routine clinical practice.

Vaginal cuff dehiscence represents a serious, but infrequent complication after hysterectomy, with a reported increased incidence following a laparoscopic approach. Various risk factors have been proposed including laparoscopically placed suture, surgical experience, use of electrosurgery, surgical indication, and obesity. Technical aspects of the procedure itself have also been questioned such as the variable use of monopolar electrosurgery during colpotomy and the suture type or number of layers chosen to reapproximate the vaginal cuff. Nothwithstanding the tendency for cuff dehiscence to occur following laparoscopic approach, there remains a paucity of high-quality data that supports or refutes this finding or clearly defines the mechanism(s) by which this event occurs allowing for the proposal of objective guidelines for reducing risk. Various techniques have been proposed to decrease the risk of vaginal cuff dehiscence during endoscopic hysterectomy, including use of monopolar current on cutting mode, achievement of cuff hemostasis with sutures rather than electrocoagulation, use of a two-layer cuff closure with polydioxanone suture, and use of bidirectional barbed suture for cuff closure. The authors experience at three university-based minimally invasive gynecologic surgery programs showed a low rate of vaginal cuff dehiscence in their own practices. Large randomized controlled trials are needed to truly determine whether there is a difference in vaginal cuff dehiscence between surgical modalities for hysterectomy as well as to determine the true risk factors.