Unexpected uterine sarcomas in 4478 patients with electric power morcellation for leiomyomas

Diagnosis and treatment of disseminated peritoneal leiomyomatosis implanted in the trocar site of a previous laparoscopic surgery

Laparoscopy combined with retrieval bag is an effective method for disseminated peritoneal leiomyomatosis that can prevent the spreading of tumor fragments.

Incidence and Predictors of Unexpected Malignancy in Benign Myomectomy or Hysterectomy

Introduction Detection of gynecological cancers preoperatively is imperative for practitioners for optimal patient management and outcome. This study aimed to estimate the incidence of unexpected malignancy (UM) in patients who underwent hysterectomy or myomectomy for presumed benign indications and to detect the predictive factors of UM. Methods A retrospective analytical study that included patients who underwent hysterectomy or myomectomy for benign indications from January 1st, 2016, to December 31st, 2020, was conducted at the Department of Obstetrics and Gynecology at Salmaniya Medical Complex, Bahrain. The main outcome was the overall incidence of UM and the incidence of each malignancy. Characteristics of UM were compared with benign pathologies. Fisher's exact and Pearson's chi-square tests were used to compare categorical variables and the Mann-Whitney U test or student's t-test for continuous variables. Binary logistic regression was used to identify the predictors of occurrence of UM. Confidence interval (CI) was set at 95%. A probability value (p-value) less than 0.05 was considered statistically significant. Results Out of 513 patients who underwent hysterectomy or myomectomy, 379 (73.9%) fulfilled the inclusion criteria, 314 (82.8%) hysterectomies and 65 (17.2%) myomectomies. The overall incidence of UM was 1.3% (n=5/379), 1.3% (n=4/314) among hysterectomies and 1.5% (n=1/65) among myomectomies. Three (0.8%) pre-malignant pathologies were identified: one (0.26%) smooth muscle tumor of unknown malignant potential, leiomyoma with bizarre nuclei, and mucinous borderline tumor of endocervical type of ovary each. The types of UM were sarcomas in three (0.26%) patients (two (0.5%) leiomyosarcoma and one (0.26%) endometrial stromal sarcoma) and endometrial adenocarcinoma and ovarian cancer in one (0.26%) patient each. No significant difference was found between the characteristics of UM and benign pathologies. Conclusion Although this study demonstrated a low incidence of UM among both hysterectomies and myomectomies, the age at the diagnosis of our patients with UM was as young as 34 years of age, and sarcomas were the most common type of UM. Disconcertingly, none of the studied independent variables had significantly predicted the occurrence of UM.

Contained Power Morcellation in Laparoscopic Uterine Myoma Surgeries: A Brief Review

Uterine fibromas are the most common benign uterine tumors. Although the majority of leiomyomas remain asymptomatic, they can cause serious clinical problems, including abnormal uterine bleeding, pelvic pain, and infertility, which require effective gynecological intervention. Depending on the symptoms as well as patients' preferences, various treatment options are available, such as medical therapy, non-invasive procedures, and surgical methods. Regardless of the extent of the surgery, the preferred option is the laparoscopic approach. To reduce the risk of spreading occult malignancy and myometrial cells associated with fragmentation of the specimen before its removal from the peritoneal cavity, special systems for laparoscopic contained morcellation have been developed. The aim of this review is to present the state-of-the-art contained morcellation. Different types of available retrieval bags are demonstrated. The advantages and difficulties associated with contained morcellation are described. The impact of retrieval bag usage on the course of surgery, as well as the effects of the learning curve, are discussed. The role of contained morcellation in the overall strategy to optimize patient safety is highlighted.

Application of single-port procedure and ERAS management in the laparoscopic myomectomy

OBJECTIVE

Advances in surgical techniques and perioperative management are the two major contributing factors to improved surgical outcomes. The purpose of the current study was to compare the efficacy of single-port surgery and perioperative enhanced recovery after surgery (ERAS) management in laparoscopic myomectomy.

METHODS

The present study included 120 patients undergoing laparoscopic myomectomy in the Gynecological Ward of Quzhou Affiliated Hospital of Wenzhou Medical University. According to the traditional perioperative management mode and ERAS management, multi-port and single-port procedures, all patients were assigned to the Conventional-SPLS (Single-Port Laparoscopic Surgery with conventional perioperative care) group (n = 34), Conventional-Multi (multi-port laparoscopic surgery with conventional perioperative care) group (n = 47), and ERAS (multi-port laparoscopic surgery with ERAS perioperative care) group (n = 39). The surgical outcomes of the three groups were compared operation time, intraoperative blood loss, variations in postoperative hemoglobin, postoperative walking time, postoperative flatus expelling time, postoperative hospital stay, and visual analog scale (VAS) scores at 6 and 12 h following surgery.

RESULTS

The ERAS group recovered the quickest in terms of postoperative walking time and flatus expelling duration. The ERAS group also recovered the shortest postoperative hospital stay (3.85 ± 1.14 days), which differed significantly from that in the Conventional-Multi group, but not significantly from that in the Conventional-SPLS group. In terms of VAS scores at 6 and 12 h after surgery, the ERAS group had the lowest pain intensity, which differed significantly from that of the other two groups. The effect of surgical procedures or postoperative care on hospital stay was assessed using multiple regression analysis. The results demonstrated that ERAS was an important independent contributor to reducing postoperative hospital stay (β = 0.270, p = 0.002), while single-port surgery did not affect this index (β = 0.107, p = 0.278).

CONCLUSION

In laparoscopic myomectomy, perioperative ERAS management could control postoperative pain and shorten hospital stay. Single-port surgery could speed up the recovery of gastrointestinal function and postoperative walking time, but it did not affect postoperative pain management or the length of hospital stay. Thus, the most effective approach to improving postoperative outcomes in laparoscopic myomectomy was the application of perioperative ERAS management.

Recurrence of Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: A Systematic Review of the Literature

Background: This study aimed to systematically review the existing literature on uterine smooth muscle tumor of uncertain malignant potential (STUMP) to provide information about characteristics and outcomes of patients and the risk factors for recurrence over a period of 60 years (1960−2021). Methods: According to PRISMA guidelines, we searched for "uterine smooth muscle tumor of uncertain malignant potential" in PubMed (all fields) and Scopus (Title/Abstract/Keywords) databases (accessed on 1 January 2022). Relevant articles were obtained in full-text format and screened for additional references. The only filter used was the English language. Studies including full case description of patients with histopathological diagnosis of STUMP in accordance with Stanford criteria were included. Results: Thirty-four studies, including 189 cases, were included. The median age was 43 years, and in 21.5% of cases there was a recurrence of the disease. Bivariate analysis showed a significant association between use of morcellation without bag and risk of recurrence (p = 0.001). Unprotected morcellation during demolitive or conservative surgery was independently associated with a higher risk of disease recurrence with a relative risk of 2.94 (p < 0.001). A significant progressive decrease in the recurrence rate was observed over time (r = −0.671, p = 0.008). The percentage of patients who underwent surgery followed by in-bag protected morcellation significantly increased after the publication of the U.S. Food and Drug Administration alert about the risk linked to this procedure (p = 0.01). Conclusions: Unprotected morcellation of the lesion is associated with the relapse of the disease. However, this clinical condition showed a drastic decrease over time. This could likely be due to the increased awareness by surgeons of the importance of customizing surgical treatment.

Differentiation of uterine low-grade endometrial stromal sarcoma from rare leiomyoma variants by magnetic resonance imaging

The purpose of this study is to evaluate utility of MRI in differentiation of uterine low-grade endometrial stromal sarcoma (LGESS) from rare leiomyoma variants. This multi-center retrospective study included consecutive 25 patients with uterine LGESS and 42 patients with rare leiomyoma variants who had pretreatment MRI. Two radiologists (R1/R2) independently evaluated MRI features, which were analyzed statistically using Fisher's exact test or Student's t-test. Subsequently, using a five-point Likert scale, the two radiologists evaluated the diagnostic performance of a pre-defined MRI system using features reported as characteristics of LGESS in previous case series: uterine tumor with high signal intensity (SI) on diffusion-weighted images and with either worm-like nodular extension, intra-tumoral low SI bands, or low SI rim on T2-weighted images. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of the two readers' Likert scales were analyzed. Intra-tumoral low SI bands (p < 0.001), cystic/necrotic change (p ≤ 0.02), absence of speckled appearance (p < 0.001) on T2-weighted images, and a low apparent diffusion coefficient value (p ≤ 0.02) were significantly associated with LGESS. The pre-defined MRI system showed very good diagnostic performance: AUC 0.86/0.89, sensitivity 0.95/0.95, and specificity 0.67/0.69 for R1/R2. MRI can be useful to differentiate uterine LGESS from rare leiomyoma variants.

A national survey: Evaluating current practice and risk assessment in morcellation amongst gynaecologists in the United Kingdom

OBJECTIVE

To evaluate current practice and adherence to AAGL and BSGE power morcellation guidelines.

STUDY DESIGN

Cross-sectional survey.

SETTING

United Kingdom.

PATIENTS/POPULATION

157 National Health Service (NHS) hospital trusts (organisation comprising of one or more hospitals) offering gynaecological services.

INTERVENTION

A questionnaire was emailed between March-July 2018 and completed by Lead/ Directors of Gynaecology within each organisation. Descriptive statistics were used to present results from this study.

MEASUREMENTS/RESULTS

We assessed power morcellation practice patterns, informed consent processes and outcomes over the last 12 months. We received 136 responses (87 % response rate). Power morcellation was performed by a third (59, 37.6 %) of all UK hospitals. The median number of gynecologists performing morcellation per organisation was 2 (Q1-Q3: 2-4). A median of 7 morcellators (Q1-Q3: 0-17) were purchased and 7 morcellators (Q1-Q3: 1.25-15.75) used per annum. A median of 10 (Q1-Q3: 2.0-15.0) laparoscopic hysterectomies and 5 (Q1-Q3: 0.5-9.0) myomectomies requiring morcellation were performed per annum. Almost, a third of hospitals did not perform an endometrial biopsy or MRI. 79.7 % (47) of trusts consented for power morcellation and 76 %, (46) explained risk of inadvertent leiomyosarcoma. 83.3 %, (50) had no patient literature and almost half had no audit process 45 %, (27).

CONCLUSION

Current UK practice does not reflect recommendations from the AAGL or BSGE. Deficiencies were identified in pre-operative evaluation, local governance procedures, and consenting practices regarding use of a power morcellator and risk of occult leiomyosarcoma.