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Wei G, Harley F, O’Callaghan M, Adshead J, Hennessey D, Kinnear N. Systematic review of urological injury during caesarean section and hysterectomy. Int Urogynecol J 2023; 34:371-389. [PMID: 36251061 PMCID: PMC9870963 DOI: 10.1007/s00192-022-05339-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/05/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION AND HYPOTHESIS We aim to review iatrogenic bladder and ureteric injuries sustained during caesarean section and hysterectomy. METHODS A search of Cochrane, Embase, Medline and grey literature was performed using methods pre-published on PROSPERO. Eligible studies described iatrogenic bladder or ureter injury rates during caesarean section or hysterectomy. The 15 largest studies were included for each procedure sub-type and meta-analyses performed. The primary outcome was injury incidence. Secondary outcomes were risk factors and preventative measures. RESULTS Ninety-six eligible studies were identified, representing 1,741,894 women. Amongst women undergoing caesarean section, weighted pooled rates of bladder or ureteric injury per 100,000 procedures were 267 or 9 events respectively. Injury rates during hysterectomy varied by approach and pathological condition. Weighted pooled mean rates for bladder injury were 212-997 events per 100,000 procedures for all approaches (open, vaginal, laparoscopic, laparoscopically assisted vaginal and robot assisted) and all pathological conditions (benign, malignant, any), except for open peripartum hysterectomy (6,279 events) and laparoscopic hysterectomy for malignancy (1,553 events). Similarly, weighted pooled mean rates for ureteric injury were 9-577 events per 100,000 procedures for all hysterectomy approaches and pathologies, except for open peripartum hysterectomy (666 events) and laparoscopic hysterectomy for malignancy (814 events). Surgeon inexperience was the prime risk factor for injury, and improved anatomical knowledge the leading preventative strategy. CONCLUSIONS Caesarean section and most types of hysterectomy carry low rates of urological injury. Obstetricians and gynaecologists should counsel the patient for her individual risk of injury, prospectively establish risk factors and implement preventative strategies.
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Affiliation(s)
- Gavin Wei
- grid.410678.c0000 0000 9374 3516Department of Urology, Austin Health, Melbourne, Australia
| | - Frances Harley
- grid.417072.70000 0004 0645 2884Department of Urology, Western Health, Melbourne, Australia
| | - Michael O’Callaghan
- grid.1010.00000 0004 1936 7304Adelaide Medical School, University of Adelaide, Adelaide, Australia ,grid.414925.f0000 0000 9685 0624Urology Unit, Flinders Medical Centre, Bedford Park, Adelaide, Australia ,grid.1014.40000 0004 0367 2697Flinders University, Adelaide, Australia
| | - James Adshead
- grid.415953.f0000 0004 0400 1537Lister Hospital, Stevenage, UK
| | - Derek Hennessey
- grid.411785.e0000 0004 0575 9497Department of Urology, Mercy University Hospital, Cork, Ireland
| | - Ned Kinnear
- grid.410678.c0000 0000 9374 3516Department of Urology, Austin Health, Melbourne, Australia ,grid.1010.00000 0004 1936 7304Adelaide Medical School, University of Adelaide, Adelaide, Australia
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King NR, Lin E, Yeh C, Wong JMK, Friedman J, Traylor J, Tsai S, Chaudhari A, Milad MP. Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review. Obstet Gynecol 2021; 137:434-442. [PMID: 33543898 DOI: 10.1097/aog.0000000000004280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications. DATA SOURCES A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted. METHODS OF STUDY SELECTION One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts. TABULATION, INTEGRATION, AND RESULTS Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08-0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03-0.05), comprising 48% (95% CI 40-55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76-89), and the remainder occurred during surgical dissection (18%, 95% CI 11-24). Most injuries were recognized intraoperatively (93%, 95% CI 87-100), and approximately half (55%, 95% CI 46-63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000-0.004). CONCLUSION The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.
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Affiliation(s)
- Nathan R King
- Department of Obstetrics and Gynecology and the Division of Biostatistics, Department of Preventive Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois; and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Macciò A, Sanna E, Lavra F, Calò P, Madeddu C. Novel technique of extracorporeal intrauterine morcellation after total laparoscopic hysterectomy: Three emblematic case reports. World J Clin Cases 2021; 9:5655-5660. [PMID: 34307621 PMCID: PMC8281410 DOI: 10.12998/wjcc.v9.i20.5655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/10/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the presence of a large uterus, total laparoscopic hysterectomy (TLH), always requires morcellation to allow removal of the tissues from the abdominal cavity. However, uncontained morcellation has been scrutinized because of the possible spread of occult leiomyosarcoma. Therefore, in-bag extracorporeal morcellation has been developed. However, tissue containment and extraction are extremely challenging, especially when considering the increasing uterine size to be removed through minimally invasive surgery.
CASE SUMMARY Herein, we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri with suspected occult leiomyosarcoma after TLH. The study enrolled patients who were planned for TLH for large uteri (weight > 500 g). TLH was performed following the procedure reported in our previous studies. The novel technique has been described step-by-step in a video, which representatively describes the preoperative imaging and morcellation procedure of three very large uteri weighing 1500 g, 1700 g, and 3700 g, respectively. The procedures were performed without any complications. The patients had an uneventful postoperative course, and in all cases, the pathology was benign leiomyoma.
CONCLUSION Extracorporeal intrauterine morcellation using the uterus outmost layer as a bag was found to be a feasible technique that allows a careful diagnosis and safe removal of suspected occult malignancies. The technique herein presented may be adopted in surgical practice, by adding it to the other available techniques of contained morcellation. It may represent a valid and feasible alternative, especially useful in cases of very large uteri exceeding the capacity of specimen retrieval bags.
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Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, Businco Hospital, ARNAS G. Brotzu, Cagliari 09100, Italy
| | - Elisabetta Sanna
- Department of Gynecologic Oncology, Businco Hospital, ARNAS G. Brotzu, Cagliari 09100, Italy
| | - Fabrizio Lavra
- Department of Gynecologic Oncology, Businco Hospital, ARNAS G. Brotzu, Cagliari 09100, Italy
| | - Piergiorgio Calò
- Department of Surgical Sciences, University of Cagliari, Cagliari 09100, Italy
| | - Clelia Madeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari 09100, Italy
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Feasibility and safety of total laparoscopic hysterectomy for uteri weighing from 1.5 kg to 11.000 kg. Arch Gynecol Obstet 2020; 303:169-179. [PMID: 32949285 DOI: 10.1007/s00404-020-05799-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE To assess the feasibility and safety of total laparoscopic hysterectomy (TLH) for uteri ≥ 1.5 kg. METHODS We prospectively evaluated all elective TLHs (with or without adnexectomy) performed for fibromatous uteri between August 2009 and August 2019 in the Department of Obstetrics and Gynecology, Sirai Hospital, Carbonia, and the Department of Gynecologic Oncology, Businco Hospital, Azienda Ospedaliera Brotzu, Cagliari. Patients with large myomatous uteri (uterine weight ≥ 1.5 kg on pathology reports) were included in the analysis. We examined all procedures and collected data about intra- and post-operative short-term and long-term complications, intraoperative blood loss, operative time, hospital stay, and time to achieve well-being. RESULTS Seventy-eight patients were included. The median weight was 2,000 g (range 1,500-11,000 g), estimated blood loss was 100 mL (range 10-700 mL), operating time was 135 min (range 60-300 min), and hospital stay was 2 days (range 2-5 days). Conversion to laparotomy occurred in 4 patients (5.1%) with uterine weight ranging from 3 to 5.5 kg, due to severe adherence syndrome or inadequate visualization. As for intraoperative complications, 1 patient (who had the largest removed uterus weighing 11,000 g) experienced an intraoperative ureteral injury (grade III). No major postoperative complications occurred. CONCLUSIONS This study provides the largest case series of TLH for fibromatous uteri > 1.5 kg and includes some of the largest uteri reported to date in the literature (weighing 5,320, 5,720, and 11,000 g, respectively). The study reaffirms the feasibility and safety of a minimally invasive hysterectomy even in the case of abnormally large uteri.
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Yabumoto K, Ito F, Matsushima H, Mori T, Kusuki I, Kitawaki J. Massive prolapsed submucous fibroid treated with laparoscopic surgery: A case report. J Obstet Gynaecol Res 2019; 45:942-946. [PMID: 30681230 DOI: 10.1111/jog.13901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 12/14/2018] [Indexed: 11/30/2022]
Abstract
Prolapsed uterine fibroids are pedunculated submucous fibroids that prolapse through the cervical canal. Herein, we describe the laparoscopic treatment of massive prolapsed submucous fibroids. A 47-year-old woman had experienced frequent urination and abnormal vaginal bleeding for 7 years. She presented with persistent lower abdominal pain. The uterine fundus was palpable at 3 cm above the umbilicus. Vaginal examination revealed a dark purple and easily bleeding mass in her vagina. Pelvic magnetic resonance imaging revealed a large mass prolapsing from the uterine endometrium, which occupied the cervical canal and vagina, without evidence of malignancy. Under a preoperative diagnosis of uterine fibroids with edematous degeneration, we performed laparoscopic uterine artery cutting, transvaginal removal of the fibroid by twisting, and total laparoscopic hysterectomy. Histopathological examination revealed leiomyoma with partial ischemia. Six days postoperatively, the patient was discharged without complications. This approach may be appropriate for the treatment of massive prolapsed submucous fibroids.
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Affiliation(s)
- Kazuya Yabumoto
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Fumitake Ito
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Hiroshi Matsushima
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Taisuke Mori
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Izumi Kusuki
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Jo Kitawaki
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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Factors for a Successful Laparoscopic Hysterectomy in Very Large Uteri. Case Rep Med 2017; 2017:1637472. [PMID: 29056970 PMCID: PMC5606097 DOI: 10.1155/2017/1637472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/09/2017] [Accepted: 08/02/2017] [Indexed: 11/17/2022] Open
Abstract
Minimally invasive hysterectomy is a standard procedure. Different approaches, as laparoscopically assisted vaginal hysterectomy, vaginal hysterectomy, and subtotal and total laparoscopic hysterectomy, have been described and evaluated by various investigations as safe and cost-effective methods. In particular, in comparison to abdominal hysterectomy, the minimally invasive methods have undoubted advantages for the patients. The main reason for a primary abdominal hysterectomy or conversion to abdominal hysterectomy during a minimal invasive approach is the uterine size. We describe our course of action in the retrospective analysis of five cases of total minimal-access hysterectomy, combining the laparoscopic subtotal hysterectomy and the vaginal extirpation of the cervix in uterine myomatosis with a uterine weight of more than 1000 grams, and discuss the factors that limit the use of laparoscopy in the treatment of big uteri. Trail Registration. The case report is registered in Research Registry under the UIN researchregistry743.
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An evaluation of laparoscopic hysterectomy alone versus in combination with laparoscopic myomectomy for patients with uterine fibroids. Eur J Obstet Gynecol Reprod Biol 2017; 210:132-138. [DOI: 10.1016/j.ejogrb.2016.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/02/2016] [Accepted: 12/04/2016] [Indexed: 12/16/2022]
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Driessen SRC, Sandberg EM, la Chapelle CF, Twijnstra ARH, Rhemrev JPT, Jansen FW. Case-Mix Variables and Predictors for Outcomes of Laparoscopic Hysterectomy: A Systematic Review. J Minim Invasive Gynecol 2015; 23:317-30. [PMID: 26611613 DOI: 10.1016/j.jmig.2015.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 12/14/2022]
Abstract
The assessment of surgical quality is complex, and an adequate case-mix correction is missing in currently applied quality indicators. The purpose of this study is to give an overview of all studies mentioning statistically significant associations between patient characteristics and surgical outcomes for laparoscopic hysterectomy (LH). Additionally, we identified a set of potential case-mix characteristics for LH. This systematic review was conducted according to the Meta-Analysis of Observational Studies in Epidemiology guidelines. We searched PubMed and EMBASE from January 1, 2000 to August 1, 2015. All articles describing statistically significant associations between patient characteristics and adverse outcomes of LH for benign indications were included. Primary outcomes were blood loss, operative time, conversion, and complications. The methodologic quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. The included articles were summed per predictor and surgical outcome. Three sets of case-mix characteristics were determined, stratified by different levels of evidence. Eighty-five of 1549 identified studies were considered eligible. Uterine weight and body mass index (BMI) were the most mentioned predictors (described, respectively, 83 and 45 times) in high quality studies. For longer operative time and higher blood loss, uterine weight ≥ 250 to 300 g and ≥500 g and BMI ≥ 30 kg/m(2) dominated as predictors. Previous operations, adhesions, and higher age were also considered as predictors for longer operative time. For complications and conversions, the patient characteristics varied widely, and uterine weight, BMI, previous operations, adhesions, and age predominated. Studies of high methodologic quality indicated uterine weight and BMI as relevant case-mix characteristics for all surgical outcomes. For future development of quality indicators of LH and to compare surgical outcomes adequately, a case-mix correction is suggested for at least uterine weight and BMI. A potential case-mix correction for adhesions and previous operations can be considered. For both surgeons and patients it is valuable to be aware of potential factors predicting adverse outcomes and to anticipate this. Finally, to benchmark clinical outcomes at an international level, it is of the utmost importance to introduce uniform outcome definitions.
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Affiliation(s)
- Sara R C Driessen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Evelien M Sandberg
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Claire F la Chapelle
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andries R H Twijnstra
- Department of Obstetrics and Gynecology, Bronovo Hospital, The Hague, The Netherlands
| | - Johann P T Rhemrev
- Department of Obstetrics and Gynecology, Bronovo Hospital, The Hague, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands; Department BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands.
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Urinary Tract Injuries in Laparoscopic Hysterectomy: A Systematic Review. J Minim Invasive Gynecol 2014; 21:558-66. [DOI: 10.1016/j.jmig.2014.01.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 12/28/2013] [Accepted: 01/06/2014] [Indexed: 11/23/2022]
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Does medical debulking with gonadotrophin-releasing hormone agonist facilitate vaginal hysterectomy with a moderate enlarged uterus? A randomized control study. Eur J Obstet Gynecol Reprod Biol 2013; 169:326-30. [DOI: 10.1016/j.ejogrb.2013.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 01/27/2013] [Accepted: 03/06/2013] [Indexed: 11/22/2022]
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Song T, Lee Y, Kim ML, Yoon BS, Joo WD, Seong SJ, Kim IH. Single-port access total laparoscopic hysterectomy for large uterus. Gynecol Obstet Invest 2012. [PMID: 23207276 DOI: 10.1159/000341141] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS To evaluate the feasibility and safety of single-port access total laparoscopic hysterectomy (SPA-TLH) for large uterus (>500 g). METHODS A prospective data collection was performed in 21 consecutive patients in March 2010 and August 2011. Surgical outcome including operative time (OT) and estimated blood loss (EBL) were analyzed. RESULTS SPA-TLH procedures were successfully performed in 16 cases (76.2%). Of the 5 failed cases, 4 were converted to multiport TLH because of distorted uterine contours and pelvic adhesions and 1 was converted to laparotomy for bleeding control. The median OT, uterine weight, and EBL were 110 (65-165) min, 600 (502-980) g, and 200 (100-800) ml, respectively. Spearman's correlation analysis demonstrated that OT and blood loss increased with increasing uterine weight (p = 0.003 and p = 0.033, respectively). No operative complications were observed during the hospital stay and 3-month follow-up following discharge. CONCLUSION SPA-TLH for large uterus is a feasible and safe technique.
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Affiliation(s)
- Taejong Song
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
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Current world literature. Curr Opin Obstet Gynecol 2010; 22:354-9. [PMID: 20611001 DOI: 10.1097/gco.0b013e32833d582e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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