Andreas Chrysostomou - Academia.edu (original) (raw)

Papers by Andreas Chrysostomou

International Journal of Gynecology & Obstetrics, 2009

Journal of Gynecology and Obstetrics

Research and Reports in Gynecology and Obstetrics, 2017

Results: Fourteen patients with cutaneous (scar) and umbilical endometriosis attended the clinic ... more Results: Fourteen patients with cutaneous (scar) and umbilical endometriosis attended the clinic during the study period. Out of these, only eight cases (47.2%) met the inclusion criteria of scar endometriosis clinically and underwent diagnostic laparoscopy. The mean age was 35.6 years (29-47) and mean parity was 1.5 (0-3), with a history of previous pelvic surgery or caesarean sections. Biopsy of the lesion confirmed the presence of endometrial tissue (gland and stroma) and haemorrhage. Diagnostic laparoscopy, after the excision of umbilical or scar endometriosis, revealed no pelvic endometriosis. Conclusion: A laparoscopy to exclude pelvic endometriosis should not be undertaken in patients who present with scar endometriosis, as there is a potential risk of introducing endometriosis into the pelvic cavity.

South African Journal of Obstetrics and Gynaecology, 2020

Hysterectomy is one of the most common operative procedures for benign gynaecological diseases. [... more Hysterectomy is one of the most common operative procedures for benign gynaecological diseases. [1] It can be performed abdominally, vaginally or laparoscopically, with or without robotic assistance. At present, total abdominal hysterectomy (TAH) constitutes the most common approach, despite the fact that vaginal hysterectomy (VH) or laparoscopic hysterectomy (LH) should be the preferred route based on their well-documented benefits. [2] It is estimated that ~20% of women living in England and Wales will have undergone a hysterectomy before the age of 55 years. Most surgeons perform up to 80% of these procedures via the abdominal route. [3,4] The reason for this can be explained, in part, by personal preference, but is mainly due to a lack of training and experience, thus resulting in the surgeon's reluctance to perform VH. This is the case particularly in nulliparous woman in the presence of uterine enlargement, in women with previous gynaecological surgery or women who have undergone a previous caesarean section (CS). The above factors should not be considered as contraindications to performing VH. [5-7] In the USA, one in three women undergoes hysterectomy by the age of 60 years. Of these women, 22% have undergone VH. The introduction of LH increased the number of VH (if the uterus is removed by that route) to 33%; however, the additional 11% were exclusively performed laparoscopically and not without that assistance. [8] Despite the introduction of LH, 66.1% of the hysterectomies performed in the USA are open abdominal hysterectomies. [8] The benefits of VH are similar to those of LH, with minimal postoperative discomfort, less need for analgesics, shorter hospital stay and quicker return to normal daily activity compared with AH. There are also fewer postoperative complications and reduced hospital costs in VH than AH and even LH. [9-11] Objectives To explore the potential provider-related obstacles to offering less invasive hysterectomies, evaluate provider attitudes toward mode of access and inquire about provider-perceived contraindications to performing VH or LH. Methods The study was based upon a two-page, anonymous, electronic survey that was designed to explore practising gynaecologists' preferences regarding the optimal hysterectomy procedure for benign uterine conditions and the perceived barriers towards MIH. The survey included questions on demographic characteristics, preferred approach to hysterectomy, the approximate number of surgical cases per year and potential barriers or contraindications for performing VH or LH. A question enquiring whether surgeons have any intention of changing their approach to hysterectomy in the future was also included. Background. Hysterectomy remains one of the most common operative procedures for benign uterine diseases. Total abdominal hysterectomy (TAH) constitutes the most common approach despite the advantages of minimally invasive hysterectomy (MIH). Objectives. To explore the current opinion on hysterectomy choices amongst members of the South African Society of Obstetricians and Gynaecologists (SASOG), as well as the perceptions and potential barriers that may inhibit gynaecologists from offering MIH to their patients. Methodology. An anonymous survey designed to explore the preferences of practising obstetrician gynaecologists regarding the optimal hysterectomy procedure, and perceived barriers towards MIH. Results. The average age of the respondents (N=152) was 45.7 years, with 88.2% having >5 years' experience in private practice. When asked about the preferred route of hysterectomy for themselves or their relatives, 46.2% chose vaginal hysterectomy (VH), 25.4% chose total laparoscopic hysterectomy (TLH), 15% chose laparoscopic assisted vaginal hysterectomy (LAVH) and 8.5% chose TAH. However, the most commonly performed hysterectomy procedure undertaken by the respondents in the last year was TAH. Only half of the respondents wished to increase their rate of VH and a lesser number to extend their laparoscopic hysterectomy rates. Conclusion. Although the majority of the respondents preferred the minimally-invasive VH or TLH for themselves or their relatives, TAH remains the most common hysterectomy method among SA gynaecologists. This difference could present an ethical dilemma for the gynaecologist. The desire of a minority to change their approach to VH indicates the difficulty in changing attitudes and the need to promote VH as a technique within SASOG.

European Journal of Obstetrics & Gynecology and Reproductive Biology, 2021

OBJECTIVES This study was undertaken at the Department of Obstetrics and Gynaecology of the Charl... more OBJECTIVES This study was undertaken at the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital to determine if the use of formal guidelines and a standardised surgical technique would increase the rate of vaginal hysterectomy (VH) and result in an overall decline in open abdominal hysterectomy (AH). STUDY DESIGN All women admitted between July 2001 and December 2014 for hysterectomy due to benign conditions, meeting the guidelines criteria (vaginally accessible uterus, uterus ≤ 12 weeks size or ≤ 280 g on ultrasound examination and pathology confined to the uterus) were included. The surgical route was determined using the Unit surgical decision tree algorithm. In cases where the pathology was not confined to the uterus or success in VH was uncertain, laparoscopic assisted vaginal hysterectomy (LAVH) was performed. The VH procedures were performed by the residents in training, under the supervision of specialists with large experience in vaginal surgery. In addition to the patient characteristics and surgical approach to hysterectomy, length of hospital stay, intra-operative and immediate post-operative complications were also recorded and analysed. RESULTS A year before the initiation of the study, the percentage of all VHs undertaken in the Department was 9.8 % (mainly performed for utero-vaginal prolapse). During the study period, 1143 vaginal procedures (1017 VHs and 126 LAVHs) were performed. The most common indications were cervical dysplasia, uterine fibroids, dysmenorrhoea or abnormal uterine bleeding, adenomyosis, endometrial hyperplasia and chronic pelvic pain. Introducing a formal clinical decision tree algorithm and a standardised surgical technique resulted in an increase in the rate of VH to 48.4 % and overall decline in open AH from 91.2%-51.6%. Thus, the VH/AH ratio increased from 1/9 at the beginning of the study (July 2001) to 1/1 by its end (December 2014). In all cases, VH was performed without the need to convert the vaginal to the abdominal route. CONCLUSION The use of institutional guidelines for determining the hysterectomy route and a standardised VH technique resulted in an increased number of performed VHs. This provided an essential opportunity for residents to acquire, improve and maintain the skills required to safely perform VH.

European Journal of Obstetrics & Gynecology and Reproductive Biology, 2020

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised some importa... more The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised some important interrogations on minimally invasive gynaecological surgery. The International Society of gynaecological Endoscopists (ISGE) has taken upon itself the task of providing guidance and best practice policies for all practicing gynaecological endoscopists. Factors affecting decision making processes in minimal invasive surgery (MIS) vary depending on factors such as the phase of the pandemic, policies on control and prevention, expertise and existing infrastructure. Our responsibility remains ensuring the safety of all health care providers, ancillary staff and patients during this unusual period. We reviewed the current literature related to gynecological and endoscopic surgery during the Coronavirus Disease 19 (COVID-19) crisis. Regarding elective surgery, universal testing for SARS-CoV-2 infection should be carried out wherever possible 40 h prior to surgery. In case of confirmed positive case of SARS-CoV-2, surgery should be delayed. Priority should be given to relatively urgent cases such as malignancies. ISGE supports medical optimization and delaying surgery for benign non-life-threatening surgeries. When possible, we recommend to perform cases by laparoscopy and to allow early discharges. Any procedure with risk of bowel involvement should be performed by open surgery as studies have found a high amount of viral RNA (ribonucleic acid) in stool. Regarding urgent surgery, each unit should create a risk assessment flow chart based on capacity. Patients should be screened for symptoms and symptomatic patients must be tested. In the event that a confirmed case of SARS-CoV-2 is found, every attempt should be made to optimize medical management and defer surgery until the patient has recovered and only emergency or life-threatening surgery should be performed in these cases. We recommend to avoid intubation and ventilation in SARS-CoV-2 positive patients and if at all possible local or regional anesthesia should be utilized. Patients who screen or test negative may have general anesthesia and laparoscopic surgery while strict protocols of infection control are upheld. Surgery in screen-positive as well as SARS-CoV-2 positive patients that cannot be safely postponed should be undertaken with full PPE with ensuring that only essential personnel are exposed. If available, negative pressure theatres should be used for patients who are positive or screen high risk. During open and vaginal procedures, suction can be used to minimize droplet and bioaerosol spread. In a patient who screens low risk or tests negative, although carrier and false negatives cannot be excluded, laparoscopy should be strongly considered. We recommend, during minimal access surgeries, to use strategies to reduce production of bioaerosols (such as minimal use of energy, experienced surgeon), to reduce leakage of smoke aerosols (for example, minimizing the number of ports used and size of incisions, as well as reducing the operating pressures) and to promote safe elimination of smoke during surgery and during the ports’ closure (such as using gas filters and smoke evacuation systems). During the post-peak period of pandemic, debriefing and mental health screening for staff is recommended. Psychological support should be provided as needed. In conclusion, based on the existent evidence, ISGE largely supports the current international trends favoring laparoscopy over laparotomy on a case by case risk evaluation basis, recognizing the different levels of skill and access to minimally invasive procedures across various countries.

South African Journal of Obstetrics and Gynaecology, 2017

Background. Primary umbilical endometriosis (PUE) is a rare condition affecting 0.5-1% of all cas... more Background. Primary umbilical endometriosis (PUE) is a rare condition affecting 0.5-1% of all cases of extragenital endometriosis. The method of using routine laparoscopic inspection of the pelvis to exclude pelvic endometriosis has been applied extensively over the years. It has been demonstrated that even patients who have had no previous pelvic surgery or caesarean section, and have no symptoms of pelvic endometriosis or history of infertility, have presented with this condition. Objective. To investigate whether patients with PUE should always undergo a laparoscopy to exclude pelvic endometriosis. Methods. The study included women presenting with a history of painful umbilical nodules or bleeding from the umbilical nodule during or after menstruation in the absence of previous surgery either for gynecological disorders or caesarean section. The study began in January 2010 and ended in December 2016. All patients underwent umbilical biopsy confirming the presence of umbilical endometriosis before the diagnostic laparoscopy took place. Results. Fourteen patients with cutaneous (scar) and umbilical endometriosis attended the clinic during the study period. Of these, only six cases (42.8%) met the inclusion criteria of PUE clinically, and underwent diagnostic laparoscopy. Their mean age was 31.1 years (range 23-48), and the mean parity was 1.1 (range 0-3), with no history of previous pelvic surgery or caesarean section. Biopsies of the lesions confirmed the presence of endometrial tissue (gland and stroma) and haemorrhage. Diagnostic laparoscopy that took place immediately after the excision of umbilical endometriosis revealed no pelvic endometriosis. Conclusion. A laparoscopy to exclude pelvic endometriosis should not be undertaken in patients who present with PUE, as there is a potential risk of introducing endometriosis into the pelvic cavity. Additionally, there is a risk of exposing the patient to unnecessary intervention and possible complications associated with the procedure.

European Journal of Obstetrics & Gynecology and Reproductive Biology, 2018

This project was established by the International Society for Gynecologic Endoscopy (ISGE) to pro... more This project was established by the International Society for Gynecologic Endoscopy (ISGE) to provide evidence-based recommendations on the selection of women in whom vaginal hysterectomy can be safely performed. Study design: The ISGE Task Force for vaginal hysterectomy for non-prolapsed uterus defined key clinical questions that led the literature search and formulation of recommendations. The search included Medline/PubMed and Cochrane Database. English language articles were reviewed from January 2003 to January 2018, in conjunction with reviews published by the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL). The bibliographies of selected works were also checked to acquire additional data where relevant. The available information was graded by the level of evidence using the approach developed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group. For each clinical question, the ISGE recommendations were defined in accordance with the evidence quality. Results: Six recommendations on patient selection for vaginal hysterectomy, including two grade 1B and four grade 2B recommendations were established. Conclusion: Vaginal hysterectomy for non-prolapsed uterus is the treatment of choice for many gynaecological patients in whom hysterectomy is indicated. It may be safely executed, and thus, should be offered to a large group of appropriately selected women, who today are operated in the main by the abdominal or laparoscopic approach. All efforts should be directed towards teaching the technique of vaginal hysterectomy during residency.

South African Medical Journal, 2008

Objectives: 1) to compare short term clinical results with standard abdominal hysterectomy (AH); ... more Objectives: 1) to compare short term clinical results with standard abdominal hysterectomy (AH); 2) to investigate the feasibility of registrar training in VH by laparoscopic assistance; 3) to investigate the impact of laparoscopy in changing the route of hysterectomy in women assessed as being unsuitable for VH on clinical examination. Methods: 104 women scheduled for AH for benign uterine conditions were enrolled in this study, meeting the following criteria: uterine size ≤14-week pregnancy, width ≤9cm and length ≤14cm. Clinical ovarian pathology and uterine prolapse were exclusion criteria. Patients were divided in 2 groups matched with respect to age, parity, previous pelvic surgery and indications for hysterectomy. Prior to VH laparoscopic assessment of pelvic organs was performed for 58 of the 104 patients in this study, 46 of these patients had abdominal hysterectomies without laparoscopic assessment. Results: All cases allocated to have VH facilitated by laparoscopic assessm...

South African Journal of Obstetrics and Gynaecology, 2019

Swyer syndrome, or pure 46,XY gonadal dysgenesis, is a rare disorder of sex development, characte... more Swyer syndrome, or pure 46,XY gonadal dysgenesis, is a rare disorder of sex development, characterised by the failure of sex gland development (ovaries or testes) in a phenotypic female patient. A 24-year-old woman with this syndrome presented at a tertiary academic hospital in South Africa, complaining of primary amenorrhoea and infertility. After gonadectomy and fertility treatment, a rare successful pregnancy outcome was achieved. A patient with Swyer syndrome, in a specialist fertility programme, can maintain a normal pregnancy and delivery.

European Journal of Obstetrics & Gynecology and Reproductive Biology

South African Journal of Obstetrics and Gynaecology

Simple 46,XY gonadal dwysgenesis, also called Swyer syndrome, is a very rare condition, estimated... more Simple 46,XY gonadal dwysgenesis, also called Swyer syndrome, is a very rare condition, estimated to occur in approximately 1/100 000 people. The condition first becomes apparent in adolescence, with delayed puberty and primary amenorrhoea. This is a case study of a patient who presented with primary amenorrhoea and primary infertility. She was a 24-year-old phenotypically female patient with a delayed diagnosis of Swyer syndrome.