Search

IMPORTANCE: Approximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms. OBJECTIVE: To achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition. DESIGN, SETTING, AND PARTICIPANTS: A consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022. MAIN OUTCOMES AND MEASURES: Definition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche. RESULTS: In total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis. CONCLUSIONS AND RELEVANCE: In this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.

Objective To assess the effects of multiple myomectomy at laparotomy on fertility potential of infertile women who are planning to undergo assisted reproductive technology (ART) treatment. Methods A retrospective single centre cohort study was conducted. Data of infertile women who were planning to undergo ART and underwent open myomectomy for multiple fibroids between January 2010 and December 2018 were reviewed. Data were collected on demographics, presenting symptoms, preoperative imaging findings, operative details, and postoperative and IVF outcomes. The primary outcome measure was the necessity for further hysteroscopic surgery prior to subsequent in vitro fertilisation (IVF) cycle. The secondary outcome measure was live birth rate. Results A total of 55 women were included in the analyses. The median number of fibroids removed was 12 (range, 3-51). Thirteen (26%) women required further surgery before embryo transfer. In women with a breached endometrial cavity, the likelihood of further hysteroscopic division of intrauterine adhesions was increased 18-fold (P=0.017). Thirty-two women underwent 45 IVF cycles, 16 of which resulted in live birth (50%). Conclusions Infertile women with large and multiple fibroids could have good fertility outcomes following open myomectomy. Special care must be taken not to damage the uterine cavity. The intraoperative breach of the endometrial cavity seems to increase the risk of intrauterine adhesions, which may further compromise ART treatment and outcomes. Hysteroscopy prior to any embryo transfer cycle may help to optimise the endometrial cavity and fertility outcome in women who underwent multiple myomectomy.

Background A recent Cochrane review concluded that cervical cerclage reduces preterm birth before 37, 34 and 28 weeks of gestation and also probably reduces the risk of perinatal death. Transabdominal cerclage was developed for a subgroup in whom transvaginal cerclage had failed or was not possible. This approach appeared more effective in improving foetal survival rates or obstetric outcomes. Most commonly transabdominal cervical cerclage is placed at laparotomy (open transabdominal cerclage), but with the advance of minimal access techniques, laparoscopic transabdominal cervical cerclage is replacing the traditional open operation. The objective of this prospective case series is to explore the outcomes of pre-conception laparoscopic transabdominal cerclage procedures. Method Data was prospectively collected from 54 women at high risk of second trimester miscarriage and preterm delivery due to cervical insufficiency undergoing pre-conception laparoscopic transabdominal cerclage by a single operator. This included demographics, obstetric and gynaecological history (including previous cervical cerclage procedures), surgical complication rates, conception and subsequent pregnancy outcomes. Results There were 36 pregnancies progressing beyond the first trimester with a “take home baby” rate of 89% (32/36), a live birth rate of 92% (33/36) and neonatal survival rate of 97% (32/33). The mid-trimester loss (MTL) rate was 8% (3/36) with delivery rates after 37 weeks of 75% (27/36) and between 34 -37 weeks of 8% (3/36) and 23-34 weeks of 8% (3/36). Conclusions Our prospective case series provides further evidence that laparoscopic transabdominal cerclage (TAC) is feasible, safe and effective when transvaginal cerclage fails or is not possible.

Background Surgery for deep endometriosis often requires input from urological surgeons. This study aims to determine pre-operative and intra-operative factors that influence the need for urological input in laparoscopic resection of rectovaginal endometriosis and to assess the usefulness of a scoring system to predict this. Methods We conducted a retrospective cohort study of 230 patients undergoing laparoscopic excision of deep endometriosis, at a tertiary referral centre for endometriosis in London UK, 2011 to 2015. Data from pre-operative assessment, surgery and post-operative follow up were analysed and patients were categorised according to their pre-operative and intra-operative risk factors. The primary outcome measure was the requirement of intra-operative input by urological surgeons. Results The median age was 35 years. In addition to the excision of endometriosis, 19.6% patients (45 patients) underwent hysterectomy, 14.8% (34 patients) required JJ stent placement, 6.1% (14 patients) had bowel resections and 2.6% (6 patients) required an ileostomy. 93.9% (216 patients) were considered normal-risk pre-operatively, of whom 89.4% (193/216) did not require any intra-operative urological input. 10.6% of this normal-risk group (23/216) required JJ stents, of whom 69.6% (16/23) also required a hysterectomy or bowel resection. Post operative complications occurred in 0.9% (2/216) of normal-risk patients, with none having required intra-operative urological reconstruction. Six percent (14 patients) were deemed to be increased-risk pre-operatively, of whom 78.6% (11/14) required JJ stent insertion. Thirty-six percent of increased-risk patients (5/14) had pre-operative renal dysfunction demonstrated on MAG3/DMSA and 80.0% of these (4/5) required intra-operative ureteric reconstruction. Conclusions Patients considered normal-risk pre-operatively, planned for excision, without hysterectomy or bowel resection, can be safely managed without specific urology input. Patients with risk-features are highly likely to require urological input, particularly for JJ stent insertion. Patients with pre-operative renal dysfunction, demonstrated on MAG3/DMSA, have a high chance of requiring intra-operative ureteric reconstruction and are best managed with pre-planned reconstructive urologist input.

Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy. This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library were searched up to February 2017 and evidence was collated and graded following the NICE-approved process. The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder disease and symptomatic benign adnexal tumours in pregnancy. The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the evidence stems from specialised centres.

In academic and intellectual discussions on how to achieve sustainable growth and development in the world, it is stated that it is not easy for countries to gain, develop and maintain competitiveness in the globalization environment and often noted that it will not be possible without Research and Development (R&D) and innovation activities. In this context, this study examines the relationship between R&D expenditures to GDP ratio and global innovation index in the scope of BRICS_T countries (Brazil, Russia, India, China, South Africa, and Turkey). For this, panel cointegration and causality analyses were applied based on data covering the period 2007-2019. First, horizontal cross-sectional dependence between series was analyzed by the LM CD test developed by Pesaran (2004) and LM adj. test whose deviation was corrected by Pesaran et al. (2008). After cointegration coefficients were determined as heterogeneous, 1st and 2nd generation unit root tests were implemented. 1st generation unit root tests Maddala & Wu (1999), Choi (2001), and Im, Pesaran & Shin (2003) were applied; stationarity was tested by CADF test, one of the 2nd generation unit root tests; Westerlund & Edgerton's (2007) LM Bootstrap Panel Cointegration test was utilized for detecting long-run relationship between variables. After long-run coefficient estimations were performed through FMOLS, Dumitrescu & Hurlin (2012) causality test was applied. Consequently, the statistically significant positive effect of R&D on global innovation index GII was determined. The highest effect was in China and Russia. Panel-wide, a 4.3% enhancing effect was determined. In addition, two-way causality was detected between the R&D and GII variables.