Quantitative assessment of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse using support vector machines

INTRODUCTION AND HYPOTHESIS

The objective of this study was to quantitatively assess the ability of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse. New measurements representing pelvic structural characteristics are proposed and analyzed using support vector machines (SVM).

METHODS

This retrospective study used data from 207 women with different types and stages of prolapse. Their demographic information, clinical history, and dynamic MRI data were obtained from the database. New MRI measurements were extracted and analyzed based on these reference lines: pubococcygeal line (PCL), mid-pubic line (MPL), true conjugate line (TCL), obstetric conjugate line (OCL), and diagonal conjugate line (DCL). A classification model using SVM was designed to assess the impact of the features (variables) in classifying prolapse into low or high stage.

RESULTS

The classification model using SVM can accurately identified anterior prolapse with very high accuracy (>0.90), and apical and posterior prolapse with good accuracy (0.80 - 0.90). Two newly proposed MRI-based features were found to be significant in the identification of anterior and posterior prolapse: the angle between TCL and MPL for anterior prolapse, and the angle between DCL and PCL for posterior prolapse. The overall accuracy of posterior prolapse identification increased from 47% to 80% when the newly proposed MRI-based features were taken into consideration.

CONCLUSIONS

The proposed MRI-based measurements are effective in differentiating low and high stages of pelvic organ prolapse, particularly for posterior prolapse.

Total laparoscopic hysterectomy in the obese patient

Obesity is a challenging health problem that affects surgical decision-making. Obesity has also been associated with an increase in the perioperative complication rate in open abdominal hysterectomy and can increase the level of difficulty in performing a vaginal hysterectomy. Total laparoscopic hysterectomy (TLH) is a route that can offer advantages in obese patients including smaller incisions that are less likely to become infected as well as less post-operative pain and good visualization. With appropriate perioperative planning and techniques, excellent outcomes can be achieved.

Effect of a disposable automated suturing device on cost and operating room time in benign total laparoscopic hysterectomy procedures

Use of disposable automated laparoscopic suturing device was more cost-effective than the da Vinci surgical system or traditional laparoscopic suturing techniques for performance of total laparoscopic hysterectomy for benign disease.

Background and Objectives:

To determine the effect of a disposable automated laparoscopic suturing device, the Endo Stitch (ES) (Covidien, Mansfield, MA, USA), on hospital cost and surgical time in patients undergoing a benign total laparoscopic hysterectomy procedure compared with the use of the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) or traditional laparoscopic suturing technique.

Methods:

The Premier Perspective Database (Premier, Charlotte, NC, USA) was used to identify all inpatient hospital discharges with the primary procedure of a total laparoscopic hysterectomy (International Classification of Diseases, Ninth Revision, Clinical Modification code 68.41) for benign conditions between January 1, 2009, and June 30, 2011. Patients were further categorized into 3 groups: (1) those for whom the ES was used during the laparoscopic hysterectomy procedure, (2) those for whom robotic assistance (RA) was used, and (3) those for whom neither ES nor RA (NER) was used. Multivariate analysis was performed to examine the association among the ES, RA, and NER groups with respect to hospital cost, length of stay, and surgery time. The multivariate analysis controlled for the patient's age, race, severity of illness, and comorbid conditions, as well as hospital characteristics, such as bed size, region, and teaching status.

Results:

A total of 9308 patients undergoing an inpatient total laparoscopic hysterectomy procedure between January 1, 2009, and June 30, 2011, were eligible for the study. The ES was used in 974 of the patients (10%), RA was used in 3971 (43%), and neither technique was used in 4363 (47%). After adjusting for confounding variables, the mean hospital cost was $1769 (P = .0332) lower, with a 42-minute (P < .001) surgery time savings, for the ES group compared with the RA group. The mean hospitalization cost for the ES group was also $634 (P < .0879) less expensive, with a 21-minute (P = .0131) surgery time savings, compared with the NER group.

Conclusion:

Use of a disposable automated laparoscopic suturing device, the ES, is significantly more cost-effective than the use of the da Vinci surgical system or traditional laparoscopic suturing techniques for the performance of a total laparoscopic hysterectomy procedure for benign conditions.

Laparoscopic port closure

Formation of a post-operative trocar site hernia (TSH) is a serious complication of laparoscopic surgery with an incidence of 1.5%-1.8%, and may necessitate emergent surgical correction in the case of bowel strangulation. Many contributing factors increase the risk of this complication, and various surgical devices have been developed to help prevent post-operative TSH formation. Bladeless trocars with radially expanding technology have been shown to decrease the incidence of post-operative TSH. Various port site closure devices are also available on the market, which assist in closing the fascia, thus decreasing the risk of this complication. In this article, we will review the use of these devices and their potential to reduce post-operative TSH formation.

Assessment of a semiautomated pelvic floor measurement model for evaluating pelvic organ prolapse on MRI

INTRODUCTION AND HYPOTHESIS

The objective of this study was to assess the performance of a semiautomated pelvic floor measurement algorithmic model on dynamic magnetic resonance imaging (MRI) images compared with manual pelvic floor measurements for pelvic organ prolapse (POP) evaluation.

METHODS

We examined 15 MRIs along the midsagittal view. Five reference points used for pelvic floor measurements were identified both manually and using our semiautomated measurement model. The two processes were compared in terms of accuracy and precision.

RESULTS

The semiautomated pelvic floor measurement model provided highly consistent and accurate locations for all reference points on MRI. Results also showed that the model can identify the reference points faster than the manual-point identification process.

CONCLUSION

The semiautomated pelvic floor measurement model can be used to facilitate and improve the process of pelvic floor measurements on MRI. This will enable high throughput analysis of MRI data to improve the correlation analysis with clinical outcomes and potentially improve POP assessment.

Fully automated localization of multiple pelvic bone structures on MRI

In this paper, we present a fully automated localization method for multiple pelvic bone structures on magnetic resonance images (MRI). Pelvic bone structures are currently identified manually on MRI to identify reference points for measurement and evaluation of pelvic organ prolapse (POP). Given that this is a time-consuming and subjective procedure, there is a need to localize pelvic bone structures without any user interaction. However, bone structures are not easily differentiable from soft tissue on MRI as their pixel intensities tend to be very similar. In this research, we present a model that automatically identifies the bounding boxes of the bone structures on MRI using support vector machines (SVM) based classification and non-linear regression model that captures global and local information. Based on the relative locations of pelvic bones and organs, and local information such as texture features, the model identifies the location of the pelvic bone structures by establishing the association between their locations. Results show that the proposed method is able to locate the bone structures of interest accurately. The pubic bone, sacral promontory, and coccyx were correctly detected (DSI > 0.75) in 92%, 90%, and 88% of the testing images. This research aims to enable accurate, consistent and fully automated identification of pelvic bone structures on MRI to facilitate and improve the diagnosis of female pelvic organ prolapse.

The benefits of using barbed sutures with automated suturing devices in gynecologic endoscopic surgeries

Laparoscopic suturing and knot tying are some of the most difficult surgical skills to acquire, and are often times regarded as a rate-limiting step in the performance of advanced gynecologic endoscopic procedures. Automated suturing devices can significantly decrease the steep learning curve of this task but still require laparoscopic knot tying. Barbed sutures offer several advantages including rapid, consistent wound closure with even distribution of tension across the wound, the suture holds tension on its own, the need for knot tying with associated issues related to suture tensile strength and knot security is eliminated, and suturing time is decreased. Use of a barbed suture with an automated suturing device can offer many advantages to both the novice and the experienced surgeon, including increased efficiency, more uniform wound closure, and the ability to perform a laparoscopic continuous running stitch without the need for intracorporeal knot tying.

The gynecologist's role in preventing overdiagnosis of ectopic molar pregnancy: a case report

BACKGROUND

Ectopic hydatidiform mole is a rare, yet overdiagnosed, entity. A diagnosis of ectopic molar pregnancy requires close follow-up, has implications on future fertility, and may require chemotherapy. Patients diagnosed with a hydropic abortus do not require hormone surveillance or abstinence from pregnancy for the extended time period generally recommended for patients diagnosed with a complete or partial hydatidiform mole. The correct classification of products of conception is clinically important because each of the three diagnoses has a different potential for malignant transformation.

CASE

A 29-year-old woman, G5P2104, with ectopic pregnancy and without clinical or laboratory data suspicious for molar pregnancy required ancillary histopathologic testing for accurate diagnosis.

CONCLUSION

This case illustrates the vital role of the gynecologist in assimilating information to prevent over-diagnosis of ectopic molar pregnancy. General gynecologists must therefore understand the histopathologic options available for differentiating hydropic products of conception, partial hydatidiform mole and complete hydatidiform mole.

Third sacral foramina morphometry for sacral neuromodulation

OBJECTIVE

This study is aimed to define the geometry and location of the human S3 foramen, with respect to bony landmarks visible on ultrasound.

METHODS

Computed tomographic (CT) image data from an institutional review board-approved database of de-identified pelvic CT images were analyzed. Points along the S3 foramina and bony sacrum were tagged, and their locations saved. The saved points were mathematically analyzed to determine the geometry and relative location of the S3 foramina with respect to other bony landmarks, specifically the sacral hiatus, and the sacral spinous processes, and the caudad aspect of the bilateral SI joints ("SI line"). Descriptive statistics were used to describe the geometry and aggregate location of the S3 foramina bilaterally. CT data sets were excluded if they had evidence of pelvic bone injury, prior bony fixation, severe osteoporosis, or other deformity.

RESULTS

One hundred thirty-three data sets met the inclusion criteria. The SI line was superior to the sacral hiatus for reliable S3 localization. The entire circumference of approximately 14% of the S3 foramina is located cephalad to the SI line. The sagittal angle of trajectory for S3 was approximately 70 degrees relative to the dorsal surface of the sacrum.

CONCLUSIONS

Clinical localization of the S3 foramen for sacral neuromodulator needle placement is best obtained when the needle tip is positioned 15 to 25 mm lateral to the sacral spinous processes and 0.0 cm to 25 mm caudad to the SI line, at the level of the dorsal sacrum surface. The findings presented in this study may be applied to improve the efficacy and accuracy of neuromodulator lead placement into the S3 foramen. This study provides rationale for the effectiveness of the crosshair placement technique and demonstrates the best location for needle repositioning when this technique is not initially successful.

The benefits of automated suturing devices in gynecologic endoscopic surgeries: the Endo Stitch and SILS Stitch

Traditional laparoscopic suturing and knot tying requires a steep learning curve and is often the rate-limiting step in performing advanced laparoscopic gynecologic surgical procedures. It is particularly challenging due to difficulties with tissue handling and needle control while performing the procedure on a two-dimensional screen, oftentimes at unfavorable suturing angles. Automated suturing devices have greatly simplified the process and allow less-experienced surgeons to safely and efficiently perform laparoscopic suturing and knot tying. The Endo Stitch (Covidien, Mansfield, MA) is a 10-mm single-use suturing device that allows placement of multiple suture types during laparoscopic surgery, and simplifies the process of laparoscopic knot tying. The SILS Stitch (Covidien, Mansfield, MA) is based on the same technology as the Endo Stitch with the added advantage of articulation up to 75 degrees and rotation up to 360 degrees. This enables surgeons to operate in tight spaces during advanced laparoscopic procedures, and to reach tissues in their natural anatomical position rather than pulling or manipulating tissue into the suturing device. Newer technologies in laparoscopic surgery, such as the Endo Stitch and SILS Stitch, may allow gynecologic surgeons to expand their surgical repertoire of advanced laparoscopic procedures.