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Cooper NAM, Daniels NF, Magama Z, Aref-Adib M, Odejinmi F. Opportunities for change and levelling up: a trust wide retrospective analysis of 8 years of laparoscopic and abdominal myomectomy. Facts Views Vis Obgyn 2024; 16:195-201. [PMID: 38950533 DOI: 10.52054/fvvo.16.2.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Background Laparoscopic myomectomy is increasingly considered the gold standard uterine preserving procedure and has well documented benefits over the open approach. Barriers that women have in accessing the most appropriate treatment need to be addressed to ensure optimal patient care and outcomes. Objectives To analyse rates of open and laparoscopic myomectomy at a large NHS trust and identify how many cases could potentially have been performed laparoscopically, and any variation between sites. Materials and Methods A retrospective review of preoperative imaging reports and a surgical database containing information for all myomectomies performed between 1st January 2015 and 31st December 2022. Main outcome measures Number of procedures suitable for alternative surgical approach; length of hospital stay; estimated blood loss; cost differences. Results 846 myomectomies were performed; 656 by laparotomy and 190 by laparoscopy. 194/591 (32.8%) open myomectomies could have been performed laparoscopically and 26/172 (15.1%) laparoscopic myomectomies may have been better performed via an open approach. Length of hospital stay, and estimated blood loss were significantly higher in the open group. Had cases been performed as indicated by pre-operative imaging, the cost differences ranged from -£115,752 to £251,832. Conclusions There is disparity in access to the gold standard care of laparoscopic myomectomy. Due to multifactorial reasons, even at sites where the rate of laparoscopic myomectomy is high, there is still underutilisation of this approach. It is clear that there is scope for change and "levelling up" of this imbalance. What is new? Robust pathways and guidelines must be developed, and more laparoscopic surgeons should be trained to optimise care for women with fibroids.
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Güven CM, Uysal D. In-bag abdominal manual morcellation versus contained power morcellation in laparoscopic myomectomy: a comparison of surgical outcomes and costs. BMC Surg 2023; 23:106. [PMID: 37118798 PMCID: PMC10148462 DOI: 10.1186/s12893-023-02007-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/13/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND To compare the surgical outcomes and costs of in-bag abdominal manual morcellation (AMM) and contained power morcellation (PM) in laparoscopic myomectomy. METHODS A total of 61 patients were divided into two groups based on their myomectomy specimen extraction methods: AMM group (n = 33) and electromechanical contained PM group (n = 28). The surgical outcomes and cost were compared between groups. During AMM, a glove bag (in 27 patients) and an endo bag were used (in 6 patients) according to the myoma size. RESULTS Morcellation time (18 ± 9.2 min vs. 37.4 ± 14.1 min) and total operation time (100 ± 24.3 min vs. 127 ± 33.1 min) were significantly lower in the AMM group compared to those in the PM group. Other surgical outcomes, which were similar between groups, included delta hemoglobin, length of hospital stay and VAS score at 12 and 24 h postoperatively. There were no per- or postoperative complications in both group with no conversion to laparotomy. One patient was transfused with two units of erythrocyte suspension postoperatively in the PM group. Sarcoma was not diagnosed in any of the cases in both group. CONCLUSION The in-bag AMM or contained PM for specimen extraction resulted in similar outcomes in terms of delta hemoglobin, postoperative pain intensity (VAS score at 12 and 24 h postoperatively), the need for additional analgesia, and the length of hospital stay; however, total operation time and morcellation time were significantly shorter in the AMM group, indicating a prominent advantage. Significant cost-effectiveness is also a critical advantage of in-bag AMM compared to containing PM.
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Affiliation(s)
- Cenk Mustafa Güven
- Department of Obstetrics and Gynecology, Izmir Private Can Hospital, İzmir, Turkey.
| | - Dilek Uysal
- Department of Obstetrics and Gynecology, Atatürk Training and Research Hospital, University of Katip Çelebi, İzmir, Turkey
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Herman A, Duraiswamy N, Nandy P, Price V, Gibeily G, Hariharan P. Mechanical and leakage integrity testing considerations for evaluating the performance of tissue containment systems. Sci Rep 2023; 13:5104. [PMID: 36991010 PMCID: PMC10060240 DOI: 10.1038/s41598-023-31847-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
Tissue containment systems (TCS) are medical devices that may be used during morcellation procedures during minimally invasive laparoscopic surgery. TCS are not new devices but their use as a potential mitigation for the spread of occult malignancy during laparoscopic power morcellation of fibroids and/or the uterus has been the subject of interest following reports of upstaging of previously undetected sarcoma in women who underwent a laparoscopic hysterectomy. Development of standardized test methods and acceptance criteria to evaluate the safety and performance of these devices will speed development, allowing for more devices to benefit patients. As a part of this study, a series of preclinical experimental bench test methods were developed to evaluate the mechanical and leakage performance of TCS that may be used in power morcellation procedures. Experimental tests were developed to evaluate mechanical integrity, e.g., tensile, burst, puncture, and penetration strengths for the TCS, and leakage integrity, e.g., dye and microbiological leakage (both acting as surrogates for blood and cancer cells) through the TCS. In addition, to evaluate both mechanical integrity and leakage integrity as a combined methodology, partial puncture and dye leakage was conducted on the TCS to evaluate the potential for leakage due to partial damage caused by surgical tools. Samples from 7 different TCSs were subjected to preclinical bench testing to evaluate leakage and mechanical performance. The performance of the TCSs varied significantly between different brands. The leakage pressure of the TCS varied between 26 and > 1293 mmHg for the 7 TCS brands. Similarly, the tensile force to failure, burst pressure, and puncture force varied between 14 and 80 MPa, 2 and 78 psi, and 2.5 N and 47 N, respectively. The mechanical failure and leakage performance of the TCS were different for homogeneous and composite TCSs. The test methods reported in this study may facilitate the development and regulatory review of these devices, may help compare TCS performance between devices, and increase provider and patient accessibility to improved tissue containment technologies.
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Affiliation(s)
- Alexander Herman
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - Nandini Duraiswamy
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - Poulomi Nandy
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - Veronica Price
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - George Gibeily
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - Prasanna Hariharan
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA.
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Sarcoma of the Uterus. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/074, April 2021). Geburtshilfe Frauenheilkd 2022; 82:1337-1367. [PMID: 36467974 PMCID: PMC9715351 DOI: 10.1055/a-1897-5124] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose This is an official guideline, published and coordinated by the Germany Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG). Because of their rarity and heterogeneous histopathology, uterine sarcomas are challenging in terms of their clinical management and therefore require a multidisciplinary approach. To our knowledge, there are currently no binding evidence-based recommendations for the appropriate management of this heterogeneous group of tumors. Methods This S2k guideline was first published in 2015. The update published here is once again the result of the consensus of a representative interdisciplinary committee of experts who were commissioned by the Guidelines Committee of the DGGG to carry out a systematic search of the literature on uterine sarcomas. Members of the participating professional societies achieved a formal consensus after a structured consensus process. Recommendations 1.1 Epidemiology, classification, staging of uterine sarcomas. 1.2 Symptoms, general diagnostic workup, general pathology or genetic predisposition to uterine sarcomas. 2. Management of leiomyosarcomas. 3. Management of low-grade endometrial stromal sarcomas. 4. Management of high-grade endometrial stromal sarcoma and undifferentiated uterine sarcomas. 5. Management of adenosarcomas. 6. Rhabdomyosarcomas of the uterus in children and adolescents. 7. Follow-up of uterine sarcomas. 8. Management of morcellated uterine sarcomas. 9. Information provided to patients.
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Wang W, Liang H, Zhao F, Yu H, Rong C, Feng W, Chen Q, Yang Y, Li Q, Feng D, Dong Y, Xue M, Liang J, Ling B. A Novel Multi-Port Containment System for Laparoscopic Power Morcellation to Prevent Tumoral Spread: A Retrospective Cohort Study. Front Surg 2022; 9:803950. [PMID: 35187057 PMCID: PMC8850355 DOI: 10.3389/fsurg.2022.803950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To report a novel multi-port containment (NMC) system for laparoscopic power morcellation to prevent tumoral spread and to evaluate its safety, validity, and feasibility. Methods This retrospective study included women who underwent laparoscopic myomectomy (LM) between January 2014 and August 2020 at a single academic institution. The NMC system was used in the study group (n = 193); the control group underwent unprotected LM (n = 1753). Results After 1:1 propensity score matching, no significant differences in the baseline characteristics were observed between 193 matched pairs. Bag damages were detected in two cases in the study group before morcellation, and the NMC systems were replaced. There were no significant differences between the two groups in terms of the complications, total operative time, estimated blood loss, or postoperative hospitalization duration. In the study group, all operations were completed and no system rupture or leakage was observed. The median follow-up times were 21 and 54 months in the study and control groups, respectively. There was no peritoneal tissue spread in the study group. However, three (3/5, 0.6%) and six (6/1,753, 0.3%) patients in the control group experienced malignant and benign peritoneal tissue spread, respectively. Conclusion The NMC system for laparoscopic power morcellation is valid, safe, and feasible for preventing a tumor spread.
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Affiliation(s)
- Wenhui Wang
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Haiyan Liang
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Fang Zhao
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Huan Yu
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Chunhong Rong
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Weiwei Feng
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Beijing University of Chinese Medicine, Beijing, China
| | - Qingyun Chen
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Yanjun Yang
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Qian Li
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Dingqing Feng
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Yuxiao Dong
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Beijing University of Chinese Medicine, Beijing, China
| | - Ming Xue
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Jing Liang
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Jing Liang
| | - Bin Ling
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Beijing University of Chinese Medicine, Beijing, China
- Bin Ling
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Feghali EJ, Laganà AS, Daccache A, Bitar R, Garzon S, Uccella S, Petousis S, Sleiman Z. Endobag use in laparoscopic gynecological surgeries: a systematic review. MINIM INVASIV THER 2021; 31:698-703. [PMID: 34730067 DOI: 10.1080/13645706.2021.1982727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this systematic review was to assess the characteristics of endobags present in the market, the weight of specimen removed, complications of the operations and time required for in-bag morcellation in women undergoing laparoscopic gynecologic surgeries. MATERIAL AND METHODS We performed a systematic review, including prospective and retrospective studies, with or without randomized allocation of the patients, using endobags in laparoscopic gynecologic surgeries. We extracted data about study design, type and price of bag used, type of surgical procedure, specimen weight, mean time for morcellation and for total surgical procedure, complications. RESULTS We included 11 studies, including a total of 1160 patients, in which the investigators used MorSafe, Endocatch II autosuture, More-Cell-Safe, Endocatch, EcoSac and LapBag. A wide range of specimens were morcellated with the largest successfully morcellated specimen weighing 2314 gr. Only half of the studies comparing uncontained and contained morcellation found a significant increase of total operative time. Finally, the number of complications was not increased when endobag was used. CONCLUSION According to our systematic review, in-bag (contained) morcellation can be considered as a safe and unexpensive option, associated with a very low number of complications, even with large specimens.
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Affiliation(s)
- Elio Junior Feghali
- Lebanese American University Medical Center - Rizk Hospital, Beirut, Lebanon
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Aimee Daccache
- Lebanese American University Medical Center - Rizk Hospital, Beirut, Lebanon
| | - Roger Bitar
- Lebanese American University Medical Center - Rizk Hospital, Beirut, Lebanon
| | - Simone Garzon
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - Stamatios Petousis
- 2nd Department of Obstetrics and Gynecology, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Ippokratio General Hospital, Thessaloniki, Greece
| | - Zaki Sleiman
- Lebanese American University Medical Center - Rizk Hospital, Beirut, Lebanon
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Touboul C, Legendre G, Agostini A, Akladios C, Bendifallah S, Bolze PA, Bouet PE, Chauvet P, Collinet P, Dabi Y, Delotte J, Deffieux X, Dion L, Gauthier T, Kerbage Y, Koskas M, Millet P, Narducci F, Ouldamer L, Ploteau S, Santulli P, Golfier F. [Guidelines for Clinical Practice of the French College of Obstetricians and Gynecologists 2021: Prophylactic procedures associated with gynecologic surgery]. ACTA ACUST UNITED AC 2021; 49:805-815. [PMID: 34520857 DOI: 10.1016/j.gofs.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications. DESIGN A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded. METHODS The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation. RESULTS The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature. CONCLUSIONS A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.
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Affiliation(s)
- C Touboul
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Tenon (AP-HP), Sorbonne Université, 4, rue de la Chine, 75020 Paris, France.
| | - G Legendre
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU Anger, 4, rue Larrey, 49933 Angers cedex 9, France
| | - A Agostini
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital de la Conception (AP-HM), Marseille, France
| | - C Akladios
- Service de Gynécologie Obstétrique et Médecine de la Reproduction des hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - S Bendifallah
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Tenon (AP-HP), Sorbonne Université, 4, rue de la Chine, 75020 Paris, France
| | - P A Bolze
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'hôpital Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - P E Bouet
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU Anger, 4, rue Larrey, 49933 Angers cedex 9, France
| | - P Chauvet
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU Estaing, 1, place Lucie-Aubrac, 63000 Clermont-Ferrand, France
| | - P Collinet
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Jeanne-de-Flandre, avenue Eugène-Avinée, 59000 Lille, France
| | - Y Dabi
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Tenon (AP-HP), Sorbonne Université, 4, rue de la Chine, 75020 Paris, France
| | - J Delotte
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital de l'Archet 2, 151, route de Saint-Antoine, 06200 Nice, France
| | - X Deffieux
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'hôpital A.-Béclêre (AP-HP), 157, rue de la Porte-de-Trivaux, 92140 Clamart, France
| | - L Dion
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du Centre Hospitalier Universitaire de Rennes, 16, boulevard de Bulgarie, 35200 Rennes, France
| | - T Gauthier
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU de Limoges, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Y Kerbage
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Jeanne-de-Flandre, avenue Eugène-Avinée, 59000 Lille, France
| | - M Koskas
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de de l'hôpital Bichat (AP-HP), 46, rue Henri-Huchard, 75018 Paris, France
| | - P Millet
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital de l'Archet 2, 151, route de Saint-Antoine, 06200 Nice, France
| | - F Narducci
- Département de Cancérologie Gynécologique, Centre de Lutte Contre le Cancer Oscar-Lambret, Lille, France
| | - L Ouldamer
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU de Tours, 2, boulevard Tonnellé, 37000 Tours, France
| | - S Ploteau
- Service de Gynécologie Obstétrique et Médecine de la Reproduction du CHU de Nantes, 38 bd Jean-Monnet, 44093 Nantes cedex 1, France
| | - P Santulli
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'Hôpital Cochin (AP-HP), 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - F Golfier
- Service de Gynécologie Obstétrique et Médecine de la Reproduction de l'hôpital Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
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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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Kan X, Shen X, Feng L, Hu Y, Yu J, Yang X. Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery. Exp Ther Med 2021; 22:913. [PMID: 34306187 DOI: 10.3892/etm.2021.10345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/09/2021] [Indexed: 11/06/2022] Open
Abstract
The aim of this retrospective study was to compare the safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and determine their effect on the pregnancy rate after surgery. In total, 86 cases with uterine fibroids were selected among patients who were admitted in the Zhangqiu District Maternal and Child Health Care Hospital during the period of April, 2016 to April, 2017. Patients who underwent laparoscopic myomectomy were enrolled in group A (n=42), and those who underwent traditional laparotomy were placed in group B (n=44). The general linear data and the operative indicators were compared. The VAS scores, serum IFN-γ, IL-6, VEGF levels and clinical efficacy of the two groups were also compared one week after surgery. Postoperative pregnancy rates and complications in both groups were also compared. No significant differences were observed in general data between the two groups (P>0.05). The intra-operative blood loss in the group A was lower than that in group B (P<0.05), the average time of operation, hospital stays (days), and anal exhaust time in group A were shorter than those in group B (P<0.05). The pain degrees at 3, 6 and 18 h after surgery for patients in the group A were significantly lower than those of the group B (P<0.05). There was no significant difference IL-6 and VEGF levels in the serum between groups A and B before and after surgery (P>0.05); however, the level of IFN-γ expression, one week after surgery, in group B was significantly higher than that in group A (P<0.05). The pregnancy rate in the experimental group was higher than that in the control group (P<0.05), and the incidence rate of complications in group A was significantly lower than that in group B (P<0.05). Results presented in the present study suggested that compared to traditional laparotomy, laparoscopic myomectomy is a more advantageous method in terms of safety, efficacy and pregnancy rate after surgery.
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Affiliation(s)
- Xueqiao Kan
- Delivery Room, Zhangqiu District Maternal and Child Health Care Hospital, Jinan, Shandong 250200, P.R. China
| | - Xiaoxia Shen
- Department of Nursing, Zhangqiu District Maternal and Child Health Care Hospital, Jinan, Shandong 250200, P.R. China
| | - Li Feng
- Department of Obstetrics, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Yuqing Hu
- Department of Endocrinology, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Jiadong Yu
- Department of Personnel, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Xiaoju Yang
- Department of Obstetrics, East Hospital of Tongji University, Shanghai 200120, P.R. China
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10
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Marchand GJ, Carpenter A, Ware K, Vallejo J, King A, Anderson S, Ruther S, Brazil G, Cieminski K, Ulibarri H, Calteux N, Sainz K. Complete Laparoscopic Removal and Staging of a Large Ovarian Malignancy: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930659. [PMID: 33859154 PMCID: PMC8057284 DOI: 10.12659/ajcr.930659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/08/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Advances in minimally invasive surgery are essential for the improvement of patient care, overall health care efficiency, and total cost reductions. Morcellation, the technique used in the present case, is often used to aid minimally invasive laparoscopic procedures, whereby larger tissue specimens are broken down and divided to be removed via smaller incisions. Morcellation has become controversial in the medical community owing to the risk of the procedure spreading an occult malignancy. CASE REPORT A 47-year-old woman with obesity presented with right-sided pelvic pain and suspicion of ovarian torsion. The patient experienced severe acute pain and was taken to the operating room for laparoscopy to remove the left-sided adnexal mass seen on imaging. During surgery, there was no evidence of torsion, and the mass was perfused. During removal of the entire tumor, blunt instruments were utilized for in-bag manual morcellation to avoid spillage of the contents of the bag, which were then sent for frozen section analysis, and a diagnosis of adenocarcinoma of the ovary was made. Once the tumor was removed, a board-certified gynecologic oncologist was consulted to assist with the remainder of the procedure. Following this, the ovarian cancer staging procedure was able to be completed laparoscopically. CONCLUSIONS This technique of in-bag manual morcellation using blunt instruments allows laparoscopic procedures to be performed on large tissue specimens with potential malignancies without spreading cancerous tissue, overcoming the associated risks of dissemination of malignancy. This technique is therefore more beneficial to patients.
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Affiliation(s)
- Greg J. Marchand
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
| | - Andrea Carpenter
- Department of Medicine, Midwestern University School of Medicine, Glendale, AZ, U.S.A
| | - Kelly Ware
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
- International University of Health Sciences, Basseterre, St. Kitts
| | - Jannelle Vallejo
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
- Washington University of Health and Science, San Pedro, Belize
| | - Alexa King
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
| | - Sienna Anderson
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
| | - Stacy Ruther
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
| | - Giovanna Brazil
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
| | - Kaitlynne Cieminski
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
| | - Hollie Ulibarri
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
| | - Nicolas Calteux
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
| | - Katelyn Sainz
- Department of Minimally Invasive Surgery, The Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, U.S.A
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11
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Lee SR, Lee ES, Eum HR, Lee YJ, Lee SW, Park JY, Suh DS, Kim DY, Kim SH, Kim YM, Kim YT. New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique. J Clin Med 2021; 10:654. [PMID: 33567699 PMCID: PMC7914728 DOI: 10.3390/jcm10040654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 12/26/2022] Open
Abstract
Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a "locking suture on myoma (LSOM)" technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.
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Affiliation(s)
- Sa Ra Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Eun Sil Lee
- Department of Obstetrics and Gynecology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul 04401, Korea;
| | - Hye Rim Eum
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Young-Jae Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Shin-Wha Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Jeong Yeol Park
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Dae-Shik Suh
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Dae-Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Sung Hoon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Yong-Man Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
| | - Young-Tak Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.R.E.); (Y.-J.L.); (S.-W.L.); (J.Y.P.); (D.-S.S.); (D.-Y.K.); (S.H.K.); (Y.-M.K.); (Y.-T.K.)
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Mynbaev OA, Sparic R, Stark M, Malvasi A, Marinelli E, Zaami S, Tinelli A. The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective. Curr Pharm Des 2020; 26:318-325. [PMID: 32013843 DOI: 10.2174/1381612826666200204093737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/27/2020] [Indexed: 12/23/2022]
Abstract
Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.
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Affiliation(s)
- Ospan A Mynbaev
- Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russian Federation
| | | | - Michael Stark
- Department of Obstetrics and Gynecology, GVM Care & Research Santa Maria Hospital, Bari, Italy. Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russian Federation
| | - Antonio Malvasi
- Clinical Centre of Serbia, Clinic for Gynecology and Obstetrics, and University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Enrico Marinelli
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, "Veris delli Ponti" Hospital, Scorrano, Lecce, Italy
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13
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Comparison of the Number of Spindle Cells in Peritoneal Washings between Laparoscopic Myomectomy with Morcellation and Open Myomectomy without Morcellation. J Minim Invasive Gynecol 2020; 28:1391-1396. [PMID: 33152530 DOI: 10.1016/j.jmig.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE This study evaluated peritoneal washings for the detection of spindle cells (SCs) in laparoscopic and open myomectomies. DESIGN Prospective, nonrandomized clinical trial. SETTING An academic tertiary referral center. PATIENTS Women suspected of having benign uterine myoma undergoing laparoscopic or open myomectomy from October 2016 to April 2018. INTERVENTIONS Washing of the peritoneal cavity to detect SCs was performed twice during the laparoscopic myomectomy. The first washing was after the closure of the myometrial incision and before morcellation. The second one was performed after morcellation. The procedure was also performed once during the open myomectomy, after the completion of the myomectomy and the closure of the incision. After a peritoneal washing with 200 mL normal saline, 30 mL liquid was collected and sent to the laboratory for SC detection. Surgical parameters such as operating time, mean change in serum hemoglobin level, complications, length of hospital stay, and readmission were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS A total of 150 participants were included in the analysis: 78 in the laparoscopic group and 72 in the open myomectomy group. After morcellation, the incidence of SCs was 2.6% (n = 2) and 6.9% (n = 5) in the laparoscopic and open myomectomy groups, respectively (p = .204). CONCLUSION SCs were observed in both the laparoscopic and open myomectomy groups. Thus, morcellation alone could not be the cause for SC dissemination, which might also be triggered by the manipulation of myoma(s).
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Pepin K, Cope A, Einarsson JI, Cellini J, Cohen SL. Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review. J Minim Invasive Gynecol 2020; 28:619-643. [PMID: 32977002 DOI: 10.1016/j.jmig.2020.09.013] [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: 07/30/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. DATA SOURCES Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. METHODS OF STUDY SELECTION Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. TABULATION, INTEGRATION, AND RESULTS The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. CONCLUSION Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.
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Affiliation(s)
- Kristen Pepin
- Department of Obstetrics & Gynecology, Weill Cornell Medical Center, New York, New York (Dr. Pepin).
| | - Adela Cope
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
| | - Jon I Einarsson
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital (Dr. Einarsson)
| | - Jacqueline Cellini
- Department of Research & Instruction, Harvard TH Chan School of Public Health (Ms. Cellini), Boston, Massachusetts
| | - Sarah L Cohen
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
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15
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Abstract
PURPOSE OF REVIEW This paper aims to review recent findings related to uterine morcellation. RECENT FINDINGS In 2014, the US Food and Drug Administration (FDA) issued a safety communication warning against the use of laparoscopic power morcellators. A risk of occult uterine sarcoma in women is 1/770 to 1/10,000. Our goal is to minimize the risk of spillage due to morcellation and balance it with other risks due to different surgical approaches. In case of a presence of sarcoma risk factors, any form of morcellation should be contraindicated. Power morcellation should be limited to myomectomies. In peri- and postmenopausal age, an endometrial biopsy is highly recommended before surgery with expected morcellation. It is important to explain to the patient the risks of morcellation and the risks and benefits of different surgical approaches. Finally, women should be informed that the prognosis of leiomyosarcoma is poor regardless of the method of removal.
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Affiliation(s)
- Michael J Halaska
- Department of Obstetrics and Gynaecology, Faculty Hospital Kralovske Vinohrady and 3rd Medical Faculty, Charles University in Prague, Šrobárova 1150/50, Praha 10, 100 34, Prague, Czech Republic.
| | - Myriam Gracia
- Gynaecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Rene Laky
- Division of Gynaecology, Medical University of Graz, Graz, Austria
| | - Ignacio Zapardiel
- Gynaecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
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16
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Zullo F, Venturella R, Raffone A, Saccone G. In-bag manual versus uncontained power morcellation for laparoscopic myomectomy. Cochrane Database Syst Rev 2020; 5:CD013352. [PMID: 32374421 PMCID: PMC7202470 DOI: 10.1002/14651858.cd013352.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag morcellation may avoid the dissemination of tissue fragments. OBJECTIVES To evaluate the effectiveness and safety of protected in-bag extracorporeal manual morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power morcellation. SEARCH METHODS On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA We included all randomised controlled trials comparing in-bag extracorporeal manual morcellation versus intracorporeal uncontained power morcellation during laparoscopic myomectomy in premenopausal women. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow. MAIN RESULTS We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The morcellation operative time was a little longer for the in-bag manual morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events. AUTHORS' CONCLUSIONS There are limited data on the effectiveness and safety of in-bag morcellation at the time of laparoscopic myomectomy compared to uncontained power morcellation. We were unable to determine the effects of in-bag morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag morcellation improves total operative time or ease of morcellation compared to control. Regarding morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag morcellation compared to uncontained morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual morcellation to intracorporeal uncontained power morcellation at the time of laparoscopic myomectomy. Both trials had morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.
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Affiliation(s)
- Fulvio Zullo
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Roberta Venturella
- Department of Obstetrics and Gynaecology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Antonio Raffone
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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Morcellation During Total Laparoscopic Hysterectomies: Implications of the Use of a Contained Bag System. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:839-845. [PMID: 32273084 DOI: 10.1016/j.jogc.2019.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study sought to report the feasibility and clinical implications of in-bag morcellation for total laparoscopic hysterectomy (TLH). METHODS Women who required uterine morcellation during TLH from January 2017 to December 2018 (at the Centre Hospitalier Universitaire de Québec - CHUL, Québec, QC) were included. Women with a preoperative suspicion of malignancy were excluded (Canadian Task Force classification II-2). RESULTS During the 2-year study period, uterine morcellation was required in 42% (106 of 252) of women undergoing TLH. Mean uterine weight of morcellated uterus was 541 ± 291 g, with 11 of 106 uteri weighing >1000 g. In-bag morcellation was attempted in 84 of 106 (79%) and successfully performed in 79 of 84 (94%) women. Failures resulted from inability to insert the specimen into the bag or apparent perforation. Uncontained morcellation was chosen for 22 of 106 (21%) women, most of whom underwent vaginal morcellation of the uterus. Total operative time was 40 minutes longer for the in-bag morcellation group (170 ± 48 vs. 130 ± 43 min; P < 0.001), although this difference can be partly explained by the higher mean uterine size compared with the uncontained morcellation group (580 ± 309 vs. 391 ± 122 g; P = 0.01). In a subgroup analysis of 16 women, the mean times of installation and extraction of the bag were estimated to be 17 ± 9 and 4 ± 3 minutes, respectively. Complications were infrequent (2 of 106) and occurred in the in-bag morcellation group. CONCLUSION In-bag morcellation is feasible in a high proportion of women undergoing laparoscopic hysterectomy and is associated with an increase in operative time. Larger studies will be required in order to better assess the risk of complications with in-bag morcellation and the potential benefits of this technique, namely, reducing the spread of tissue.
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Zaami S, Zupi E, Lazzeri L, Stark M, Malvasi A, Signore F, Marinelli E. Medicolegal Issues in Power Morcellation: Cautionary Rules for Gynecologists to Avoid Unfavorable Outcomes. J Minim Invasive Gynecol 2020; 27:583-592. [PMID: 31954185 DOI: 10.1016/j.jmig.2019.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 11/26/2022]
Abstract
Power morcellation in laparoscopic surgery enables specialists to carry out minimally invasive procedures such as hysterectomies and myomectomies by cutting specimens into smaller pieces using a rotating blade and removing pieces through a laparoscope. Unexpected uterine sarcoma treated by surgery involving tumor disruption could be associated with poor prognosis. The current study aims to shed light on power morcellation from a medicolegal perspective: the procedure has resulted in adverse outcomes and litigation, and compensation for plaintiffs, as published in various journals cited in PubMed and MEDLINE, Cochrane Library, EMBASE, and GyneWeb. Considering the claims after the US Food and Drug Administration warnings on morcellation, the current study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia, superior court of New Jersey, and US district court of Minnesota) between 1995 and 2019. Legal records show that courts determine professional responsibility regarding complications, making it essential to document adherence to safety protocols and specific guidelines, when available. Sound medical practices and clearly stated institute best practices result in better patient outcomes and are important when unfavorable clinical outcomes occur; adverse legal decisions can be avoided if there are grounds to prove professional conformity with specific guidelines and the unpredictability of an event.
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Affiliation(s)
- Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome (Drs. Zaami and Marinelli); Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, (Drs. Zupi and Lazzeri), Italy; The New European Surgical Academy (NESA), Berlin, Germany (Dr. Stark); ELSAN Group Hospitals, Paris, France (Dr. Stark); International Translational Medicine and Biomodelling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), Moscow Region, Russia (Dr. Malvasi); Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care and Research, Bari (Dr. Malvasi); Department of Obstetrics and Gynecology, Misericordia Hospital, Grosseto (Dr. Signore), Italy
| | - Errico Zupi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome (Drs. Zaami and Marinelli); Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, (Drs. Zupi and Lazzeri), Italy; The New European Surgical Academy (NESA), Berlin, Germany (Dr. Stark); ELSAN Group Hospitals, Paris, France (Dr. Stark); International Translational Medicine and Biomodelling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), Moscow Region, Russia (Dr. Malvasi); Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care and Research, Bari (Dr. Malvasi); Department of Obstetrics and Gynecology, Misericordia Hospital, Grosseto (Dr. Signore), Italy.
| | - Lucia Lazzeri
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome (Drs. Zaami and Marinelli); Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, (Drs. Zupi and Lazzeri), Italy; The New European Surgical Academy (NESA), Berlin, Germany (Dr. Stark); ELSAN Group Hospitals, Paris, France (Dr. Stark); International Translational Medicine and Biomodelling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), Moscow Region, Russia (Dr. Malvasi); Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care and Research, Bari (Dr. Malvasi); Department of Obstetrics and Gynecology, Misericordia Hospital, Grosseto (Dr. Signore), Italy
| | - Michael Stark
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome (Drs. Zaami and Marinelli); Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, (Drs. Zupi and Lazzeri), Italy; The New European Surgical Academy (NESA), Berlin, Germany (Dr. Stark); ELSAN Group Hospitals, Paris, France (Dr. Stark); International Translational Medicine and Biomodelling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), Moscow Region, Russia (Dr. Malvasi); Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care and Research, Bari (Dr. Malvasi); Department of Obstetrics and Gynecology, Misericordia Hospital, Grosseto (Dr. Signore), Italy
| | - Antonio Malvasi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome (Drs. Zaami and Marinelli); Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, (Drs. Zupi and Lazzeri), Italy; The New European Surgical Academy (NESA), Berlin, Germany (Dr. Stark); ELSAN Group Hospitals, Paris, France (Dr. Stark); International Translational Medicine and Biomodelling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), Moscow Region, Russia (Dr. Malvasi); Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care and Research, Bari (Dr. Malvasi); Department of Obstetrics and Gynecology, Misericordia Hospital, Grosseto (Dr. Signore), Italy
| | - Fabrizio Signore
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome (Drs. Zaami and Marinelli); Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, (Drs. Zupi and Lazzeri), Italy; The New European Surgical Academy (NESA), Berlin, Germany (Dr. Stark); ELSAN Group Hospitals, Paris, France (Dr. Stark); International Translational Medicine and Biomodelling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), Moscow Region, Russia (Dr. Malvasi); Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care and Research, Bari (Dr. Malvasi); Department of Obstetrics and Gynecology, Misericordia Hospital, Grosseto (Dr. Signore), Italy
| | - Enrico Marinelli
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome (Drs. Zaami and Marinelli); Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, (Drs. Zupi and Lazzeri), Italy; The New European Surgical Academy (NESA), Berlin, Germany (Dr. Stark); ELSAN Group Hospitals, Paris, France (Dr. Stark); International Translational Medicine and Biomodelling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), Moscow Region, Russia (Dr. Malvasi); Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care and Research, Bari (Dr. Malvasi); Department of Obstetrics and Gynecology, Misericordia Hospital, Grosseto (Dr. Signore), Italy
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Abstract
Fibroid tissue extraction during hysterectomy and myomectomy has become increasingly controversial. A wave of research has tried to clarify difficult questions around the prevalence of occult malignancies, the effect of morcellation on cancer outcomes, proper informed consent, and surgical options for tissue extraction. This review examines the history of these controversies and discusses tissue extraction techniques and continued areas of debate in the field.
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Denschlag D, Ackermann S, Battista MJ, Cremer W, Egerer G, Follmann M, Haas H, Harter P, Hettmer S, Horn LC, Juhasz-Boess I, Kast K, Köhler G, Kröncke T, Lindel K, Mallmann P, Meyer-Steinacker R, Mustea A, Petru E, Reichardt P, Schmidt D, Strauss HG, Tempfer C, Thiel F, Ulrich U, Vogl T, Vordermark D, Gass P, Beckmann MW. Sarcoma of the Uterus. Guideline of the DGGG and OEGGG (S2k Level, AWMF Register Number 015/074, February 2019). Geburtshilfe Frauenheilkd 2019; 79:1043-1060. [PMID: 31656317 DOI: 10.1055/a-0882-4116] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 12/21/2022] Open
Abstract
Aims This is an official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). Because of their rarity and heterogeneous histopathology, uterine sarcomas are challenging in terms of how they should be managed clinically, and treatment requires a multidisciplinary approach. To our knowledge, there are currently no binding evidence-based recommendations for the appropriate management of this heterogeneous group of tumors. Methods This S2k guideline was first published in 2015. The update published here is the result of the consensus of a representative interdisciplinary group of experts who carried out a systematic search of the literature on uterine sarcomas in the context of the guidelines program of the DGGG, OEGGG and SGGG. Members of the participating professional societies achieved a formal consensus after a moderated structured consensus process. Recommendations The consensus-based recommendations and statements include the epidemiology, classification, staging, symptoms, general diagnostic work-up and general pathology of uterine sarcomas as well as the genetic predisposition to develop uterine sarcomas. Also included are statements on the management of leiomyosarcomas, (low and high-grade) endometrial stromal sarcomas and undifferentiated uterine sarcomas and adenosarcomas. Finally, the guideline considers the follow-up and morcellation of uterine sarcomas and the information provided to patients.
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Affiliation(s)
| | | | - Marco Johannes Battista
- Universitätsmedizin Mainz, Klinik und Poliklinik für Geburtshilfe und Frauengesundheit, Mainz, Germany
| | | | | | | | | | - Philipp Harter
- Klinik für Gynäkologie und Gynäkologische Onkologie, Kliniken Essen Mitte, Essen, Germany
| | | | - Lars-Christian Horn
- Abteilung für Mamma-, Urogenital, und Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ingolf Juhasz-Boess
- Klinik für Gynäkologie, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Karin Kast
- Universitätsklinik Dresden, Dresden, Germany
| | - Günter Köhler
- Deutsches klinisches Kompetenzzentrum für genitale Sarkome und Mischtumoren, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas Kröncke
- Klinik für Radiologie, Klinikum Augsburg, Augsburg, Germany
| | - Katja Lindel
- Klinik für Radioonkologie, Klinikum Karlsruhe, Karlsruhe, Germany
| | - Peter Mallmann
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Köln, Köln, Germany
| | | | | | - Edgar Petru
- Universitäts-Frauenklinik Graz, Graz, Austria
| | - Peter Reichardt
- Klinik für interdisziplinäre Onkologie, Helios Kliniken Berlin-Buch, Berlin, Germany
| | | | - Hans-Georg Strauss
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Halle, Halle/Saale, Germany
| | | | - Falk Thiel
- Frauenklinik, Alb Fils Kliniken, Göppingen, Germany
| | - Uwe Ulrich
- Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus Berlin, Paul Gerhardt Diakonie, Berlin, Germany
| | - Thomas Vogl
- Institut für diagnostische und interventionelle Radiologie, Universitätsklinikum Frankfurt, Frankfurt/Main, Germany
| | - Dirk Vordermark
- Universitätsklinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle, Halle/Saale, Germany
| | - Paul Gass
- Frauenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; Comprehensive Cancer Center (CCC) Erlangen-EMN, Erlangen, Germany
| | - Matthias W Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; Comprehensive Cancer Center (CCC) Erlangen-EMN, Erlangen, Germany
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Venturella R, Vaiarelli A, Cimadomo D, Pedri S, Lico D, Mazzilli R, Mocciaro R, Rienzi L, Di Carlo C, Ubaldi FM, Zullo F. State of the art and emerging drug therapies for female infertility. Gynecol Endocrinol 2019; 35:835-841. [PMID: 31032671 DOI: 10.1080/09513590.2019.1603289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
At present, infertility is a key-issue. When applicable, in vitro fertilization (IVF) has become the standard approach to treat this condition but a thorough investigation and, whenever possible, the individual diagnosis of the underlying causes of infertility are required. For many female causes, indeed, efficient medical therapies are available to achieve a fast solution of the problem. This review is based on the relevant literature indexed in PubMed and SCOPUS and is focused on the most recent clinical literature on the treatment of women (and couples) affected from infertility. The reduction in IVF treatment burden and risks are now considered pivotal to set 'patient-friendly' therapies and represent crucial issues for both patients and physicians. To this end, the researchers are now focusing their attention on old drugs with new indications and new compounds with more appropriate functions, to improve the compliance of the women and reduce the burden of infertility, a condition that is becoming an important issue in the modern world, also for the Public Health System.
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Affiliation(s)
- Roberta Venturella
- Department of Obstetrics & Gynaecology, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | | | | | - Sara Pedri
- Department of Obstetrics & Gynaecology, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Daniela Lico
- Department of Obstetrics & Gynaecology, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Rossella Mazzilli
- G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
- Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Rita Mocciaro
- Department of Obstetrics & Gynaecology, AO Annunziata di Cosenza, Cosenza, Italy
| | - Laura Rienzi
- G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Costantino Di Carlo
- Department of Obstetrics & Gynaecology, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | | | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples "Federico II", Naples, Italy
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Prospective Evaluation of Manual Morcellation Techniques: Minilaparotomy versus Vaginal Approach. J Minim Invasive Gynecol 2019; 26:702-708. [DOI: 10.1016/j.jmig.2018.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/17/2018] [Accepted: 07/22/2018] [Indexed: 12/25/2022]
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23
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Di Cello A, Borelli M, Marra ML, Franzon M, D'Alessandro P, Di Carlo C, Venturella R, Zullo F. A more accurate method to interpret lactate dehydrogenase (LDH) isoenzymes' results in patients with uterine masses. Eur J Obstet Gynecol Reprod Biol 2019; 236:143-147. [PMID: 30925450 DOI: 10.1016/j.ejogrb.2019.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/16/2019] [Accepted: 03/18/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Since there are no approved reliable biomarkers for detecting preoperatively uterine sarcoma, lactate dehydrogenase (LDH) isoenzymes are usually required. We first evaluated the role of LDH isoenzymes in detecting uterine sarcoma risk, and then we tried to introduce a model to easily interpret the biochemical results. METHODS We retrospectively retrieved records of patients who underwent surgical treatment for uterine masses from 2004 to 2016, and we compared data of 2211 patients with a definitive surgical diagnosis of uterine fibroids and 43 with uterine sarcomas. Quantitative relationships between serum LDH isoenzymes levels, as different single markers or in multiple assays, and the final diagnosis were investigated. RESULTS LDH isoenzymes levels significantly differed between patients with benign uterine masses or sarcomas. LDH3 isoenzyme exhibited better predictive performances than the other four isoforms. Combining LDH3 with LDH1 isoenzymes into an inverse algebraic relationship, named Uterine mass Magna Graecia (U.M.G.) risk index, the accuracy of markers in discriminating between benign and suspicious malignant uterine masses was significantly enhanced, sensitivity at 100% and specificity at 99.6%, with nine false positive over 2211 benignant cases and no false negative over 43 sarcomas. CONCLUSIONS This retrospective analysis suggests to consider U.M.G. risk index as an inexpensive and accurate prognostic index that, once validated in a prospective study, may help clinicians in discriminating between benignant and suspicious malignant uterine masses.
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Affiliation(s)
- Annalisa Di Cello
- Unit of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Italy.
| | - Massimo Borelli
- PhD School of PhD Programmes Life Sciences and technologies, University "Magna Graecia" of Catanzaro, Italy
| | - Maria Luisa Marra
- Unit of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Italy
| | - Marco Franzon
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Pietro D'Alessandro
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Costantino Di Carlo
- Unit of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Italy
| | - Roberta Venturella
- Unit of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
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Aoki Y, Kanao H, Kikuchi I, Nomura H, Okamoto S, Hisa T, Sugihara T, Kitano R, Omatsu K, Tanigawa T, Takeshima N. Comparison of the Technical Feasibility and Safety of Three Contained Morcellation Techniques: A Pilot Study in an Animal Model. J Minim Invasive Gynecol 2018; 26:1288-1296. [PMID: 30562578 DOI: 10.1016/j.jmig.2018.12.008] [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: 09/12/2018] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE To compare 3 laparoscopic contained morcellation techniques in terms of feasibility and safety. DESIGN Pilot study in an animal model (Canadian Task Force classification II-1). SETTING Gynecologic oncology department at a cancer institute in Japan. PATIENTS Porcine model. INTERVENTIONS Three contained morcellation techniques were tested, each multiple times in 1 of 3 anesthetized female pigs: manual morcellation (8 times), dual-site power morcellation (8 times), and single-site power morcellation (6 times). All were tested on beef tongue introduced abdominally. MEASUREMENTS AND MAIN RESULTS The following variables were compared: bag insertion time, morcellation time, bag removal time, total in-bag morcellation time, and the volume of pneumoperitoneum CO2 consumed. Bag rupture was evaluated ex vivo on completion of the procedure. Bag insertion time (in minutes) was significantly greater for dual-site morcellation (10.91 ± 3.38) than for manual (4.58 ± 2.47, p = .003) or single-site power (7.25 ± .77, p = .014) morcellation. Bag removal time (in minutes) was also significantly greater for dual-site morcellation (.85 ± .11 vs .27 ± .14, p<.001, vs .33 ± .59, p = .001). Total in-bag morcellation time, although greatest for manual morcellation at 21.4 ± 10.2 minutes, did not differ significantly between techniques. CO2 consumption was significantly low for manual morcellation. Visual inspection revealed no bag damage when manual morcellation was performed, but bag damage occurred in 3 dual-site cases and in 1 single-site case. CONCLUSION Considering preventing specimen leakage as the main aim of contained morcellation, the bag used for power morcellation needs improvement. Although manual morcellation requires an umbilical wound of about 25 mm, the absence of bag damage, acceptable total morcellation time, relatively low CO2 consumption, and nonuse of a power device, which translate to an economic benefit, lead us to conclude that manual morcellation will remain advantageous into the future.
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Affiliation(s)
- Yoichi Aoki
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan.
| | - Hiroyuki Kanao
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Iwaho Kikuchi
- Department of Obstetrics and Gynecology, Juntendo Urayasu Hospital (Dr. Kikuchi), Urayasu, Japan
| | - Hidetaka Nomura
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Syuhei Okamoto
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Tsuyoshi Hisa
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Takeru Sugihara
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Rie Kitano
- Department of Obstetrics and Gynecology, Tsuchiura Kyodo General Hospital (Dr. Kitano), Tsuchiura, Japan
| | - Kohei Omatsu
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Terumi Tanigawa
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Nobuhiro Takeshima
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
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Single port access laparoscopic subtotal hysterectomy using contained manual morcellation: Experience from a tertiary referral center in Taiwan. Taiwan J Obstet Gynecol 2018; 57:28-31. [PMID: 29458899 DOI: 10.1016/j.tjog.2017.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To describe the surgical outcomes of single port access laparoscopic subtotal hysterectomy (LSH) using in-bag manual morcellation and evaluate the feasibility of this procedure. MATERIALS AND METHODS Thirty patients with symptomatic leiomyoma or adenomyosis were enrolled. A 2-cm transverse incision was made at the umbilicus and single port apparatus (LagiPort) was applied. After dissection of vesicouterine peritoneum from the uterus, the uterine ligaments and vessels were secured and transected by Gyrus PK cutting forceps. Cervical amputation at the level of internal os was made by SupraLoop (Karl Storz). The uterine corpus was put into an Endobag before morcellation. The opening of Endobag was exteriorized from the umbilical incision and the uterine corpus was removed in a contained manner by manual morcellation with a scalpel. RESULTS This procedure was successfully performed on all patients. Neither laparotomic conversion nor additional port was needed. The mean age and mean BMI of the patients were 43.63 years and 24.02 kg/㎡. The mean operative time was 148 min and the estimated blood loss in most patients was less than 150 ml. The median weight of uterine corpus was 214 g. No intraoperative complications occurred in any patient. One patient was diagnosed with unexpected endometrioid adenocarcinoma FIGO grade 1 postoperatively. One patient reported cyclic bleeding and underwent a transvaginal trachelectomy 17 months later. CONCLUSION Single port access LSH using contained manual morcellation represents a safe and feasible alternative to conventional LSH using open power morcellation.
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Wu MY, Ding DC, Chu TY, Hong MK. Robotic-Assisted “Containment Before Resection and Manual Morcellation” Using a Tissue Pouch for a Solid Ovarian Tumor of Unknown Characteristics. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Meng-Yu Wu
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Minimally Invasive Gynecology Surgery Center, Hualien Tzu Chi Hospital, Hualien, Taiwan
| | - Tang-Yuan Chu
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Minimally Invasive Gynecology Surgery Center, Hualien Tzu Chi Hospital, Hualien, Taiwan
| | - Mun-Kun Hong
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Minimally Invasive Gynecology Surgery Center, Hualien Tzu Chi Hospital, Hualien, Taiwan
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27
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Manual morcellation compared to power morcellation during robotic myomectomy. J Robot Surg 2018; 13:209-214. [DOI: 10.1007/s11701-018-0837-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/10/2018] [Indexed: 12/16/2022]
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Raspagliesi F, Bogani G, Lorusso D. The impact of morcellation on survival outcomes of undiagnosed uterine sarcoma. Gynecol Oncol Rep 2018; 23:37-38. [PMID: 29892685 PMCID: PMC5993516 DOI: 10.1016/j.gore.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Francesco Raspagliesi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Department of Gynecologic Oncology, Milan, Italy
| | - Giorgio Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Department of Gynecologic Oncology, Milan, Italy
| | - Domenica Lorusso
- Fondazione IRCCS Istituto Nazionale dei Tumori, Department of Gynecologic Oncology, Milan, Italy
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Tissue Extraction Techniques for Leiomyomas and Uteri During Minimally Invasive Surgery. Obstet Gynecol 2017; 130:1251-1260. [DOI: 10.1097/aog.0000000000002334] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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In-Bag Morcellation as a Routine for Laparoscopic Hysterectomy. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6701916. [PMID: 29318153 PMCID: PMC5727682 DOI: 10.1155/2017/6701916] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023]
Abstract
Tissue morcellation during laparoscopic hysterectomy carries the risk of spreading cells from unsuspected malignancy. Contained morcellation inside a bag is supposed to minimize this risk. The present study evaluated routine use of in-bag morcellation during laparoscopic hysterectomy in a consecutive patient cohort (n = 49). The system used was More-Cell-Safe (A.M.I. Austria). Median age was 47 (35 to 76) years and BMI 25.1 (18.8 to 39.8). Indications for hysterectomy were fibroids (71.4%), adenomyosis (16.3%), prolapse (8.2%), and bleeding disorders (4.1%). 48 (98%) patients underwent supracervical hysterectomy and 1 (2%) underwent total hysterectomy. No unsuspected malignancy occurred. Median weight of extirpated tissue was 195 g (18 to 1110). Residual tissue and/or fluid in the bag amounted to 29 g (0 to 291). Median overall duration of surgeries was 100.5 min, and median time associated with the use of the bag was 10 min (5 to 28), significantly correlated with uterine volume (p = 0.0094) and specimen weight (p = 0.0002), but not with patient's BMI (p = 0.6970). Technical success rate for contained morcellation was 93.9%. Peritoneal washings after contained morcellation were all negative for malignant or smooth muscle cells.
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Wong M, De Wilde RL, Isaacson K. Reducing the spread of occult uterine sarcoma at the time of minimally invasive gynecologic surgery. Arch Gynecol Obstet 2017; 297:285-293. [PMID: 29128980 DOI: 10.1007/s00404-017-4575-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/19/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE This review covers the most recent evidence to discuss the incidence of occult uterine sarcoma, whether morcellation increases tumor dissemination or mortality, and whether there is a difference between different types of morcellation. We will also discuss techniques to reduce the spread of an undiagnosed uterine sarcoma. METHOD A comprehensive literature search was made in Pubmed, Medline, the Cochrane Library, and Google Scholar for articles related to the incidence of occult uterine sarcoma after morcellation. RESULTS Fibroids are benign uterine tumors and are a common indication for gynecologic surgery. Increasingly, gynecologists are approaching these surgeries with minimally invasive techniques. Uterine sarcomas are rare malignant mesenchymal tumors that are difficult to distinguish preoperatively from uterine fibroids. CONCLUSION During a minimally invasive surgery, there is a risk of disseminating an occult sarcoma during tissue extraction. Minimally invasive gynecologists are tasked with balancing taking a minimally invasive approach, which is shown to result in better patient outcomes, with minimizing the risk of spreading an occult sarcoma.
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Affiliation(s)
- Marron Wong
- Newton-Wellesley Hospital, Center for Minimally Invasive Gynecologic Surgery, Harvard Medical School, Newton, MA, USA
| | - Rudy Leon De Wilde
- Department of Gynecology, Obstetrics and Gynecological Oncology at Pius Hospital, University Hospital for Gynecology-Carl von Ossietzky University, Oldenburg, Germany.
| | - Keith Isaacson
- Newton-Wellesley Hospital, Center for Minimally Invasive Gynecologic Surgery, Harvard Medical School, Newton, MA, USA
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Clark NV, Cohen SL. Tissue Extraction Techniques During Laparoscopic Uterine Surgery. J Minim Invasive Gynecol 2017; 25:251-256. [PMID: 28866098 DOI: 10.1016/j.jmig.2017.07.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 10/18/2022]
Abstract
Morcellation allows minimally invasive approaches to surgery even in the presence of large uteri or myomas. Recent restrictions in the use of power morcellation, as well as concerns regarding the potential for morcellation to disseminate malignant tissue, have initiated investigation and innovation to find safer methods. This review examines current techniques for tissue extraction during uterine surgery, with a focus on contained power morcellation and contained manual morcellation via mini-laparotomy or colpotomy. Videos are included to demonstrate these methods.
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Affiliation(s)
- Nisse V Clark
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah L Cohen
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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Amemiya K, Adachi K, Sasamoto N, Yamamoto Y. Transumbilical extraction of 151-300-g myomas without morcellator versus conventional laparoscopic myomectomy with power morcellator. Gynecol Minim Invasive Ther 2017; 6:162-166. [PMID: 30254906 PMCID: PMC6135198 DOI: 10.1016/j.gmit.2017.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 05/20/2017] [Accepted: 06/01/2017] [Indexed: 12/27/2022] Open
Abstract
Study objective: The aim of this study was to compare the surgical outcomes, particularly the specimen retrieval time, between two methods of laparoscopic myomectomy: transumbilical retrieval of the myoma without a morcellator and conventional retrieval of the myoma using a power morcellator via the left lower quadrant. Design: Retrospective study. Setting: Public hospital. Patients: Seventy-four women undergoing laparoscopic myomectomy. Interventions: Laparoscopic myomectomy followed by myoma retrieval via transumbilical extraction or electric motorized morcellator extraction. Measurements and main results: Seventy-four patients undergoing laparoscopic myomectomy followed by myoma retrieval via transumbilical extraction or electric motorized morcellator extraction were studied. Significant differences were observed in the average weight of the retrieved myomas between the transumbilical and morcellator groups (141.0 vs. 262.8 g, respectively; p < 0.001). Therefore, we chose 27 patients whose total specimen weight was 151–300 g; 13 patients were in the transumbilical extraction group and 14 were in the electric motorized morcellator group. No significant differences were observed in patient characteristics between the two groups. The operative time, blood loss volume, and myoma retrieval time were similar between the two groups. Conclusion: Laparoscopic myomectomy with transumbilical extraction for myoma retrieval is a feasible method for specimens weighing up to 300 g.
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Affiliation(s)
- Kyoka Amemiya
- Department of Obstetrics and Gynecology, Itami City Hospital, Hyogo, Japan
| | - Kazushige Adachi
- Department of Obstetrics and Gynecology, Minoh City Hospital, Osaka, Japan
| | - Naoko Sasamoto
- Department of Obstetrics and Gynecology, Minoh City Hospital, Osaka, Japan
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Sarcoma Risk in Uterine Surgery in a Tertiary University Hospital in Germany. Int J Gynecol Cancer 2017; 27:961-966. [DOI: 10.1097/igc.0000000000000988] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Taylan E, Sahin C, Zeybek B, Akdemir A. Contained Morcellation: Review of Current Methods and Future Directions. Front Surg 2017; 4:15. [PMID: 28352629 PMCID: PMC5348539 DOI: 10.3389/fsurg.2017.00015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/28/2017] [Indexed: 11/30/2022] Open
Abstract
Power morcellation of surgical specimen during laparoscopic surgery is a practical technology that provides the opportunity to perform several minimally invasive procedures. However, this technology brought forward additional risks and complications associated with dissemination of both benign and malignant tissues inside the abdominal cavity. Based on startling cases, Food and Drug Administration (FDA) announced a discouraging statement on the use of power morcellators that decreased the number of minimally invasive approaches in the following period. As a response to these concerns and negative impacts of the FDA statement, researchers developed several new approaches resulting in contained or in-bag morcellation methods. In this review, we aimed to discuss these current methods and provide an insight for future developments.
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Affiliation(s)
- Enes Taylan
- Laboratory of Molecular Reproduction and Fertility Preservation, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, New York Medical College, New York, NY, USA; Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Cagdas Sahin
- Department of Obstetrics and Gynecology, Ege University School of Medicine , Izmir , Turkey
| | - Burak Zeybek
- Department of Obstetrics and Gynecology, University of Texas Medical Branch , Galveston, TX , USA
| | - Ali Akdemir
- Department of Obstetrics and Gynecology, Ege University School of Medicine , Izmir , Turkey
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Robotic-Assisted Laparoscopic Myomectomy versus Traditional Laparoscopic Myomectomy: Are They the Same? CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0182-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Complex Laparoscopic Myomectomy with Severe Adhesions Performed with Proper Preventive Measures and Power Morcellation Provides a Safe Choice in Certain Infertility Cases. Case Rep Obstet Gynecol 2016; 2016:4705790. [PMID: 27668110 PMCID: PMC5030427 DOI: 10.1155/2016/4705790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 08/04/2016] [Accepted: 08/18/2016] [Indexed: 11/18/2022] Open
Abstract
Laparoscopic myomectomy offers a real benefit to infertile patients with uterine fibroids and peritoneal adhesions. The procedure requires a skilled surgeon and laparoscopy technique to minimize adhesion formation and other proven benefits. Restrictions arise since this procedure requires power morcellation for fibroid tissue extraction. Two years ago, the Food and Drug Administration in the United States of America (FDA) issued the alert on power morcellation for uterine leiomyomas, addressing the risk of malignant cell spreading within the abdominal cavity (actual risk assessment from 1 in 360 to 1 in 7400 cases). We review a 30-year-old female, without previous gestations, hypermenorrhea, intermenstrual bleeding, and chronic pelvic pain. Transvaginal ultrasound reports multiple fibroids in the right portion of a bicornuate uterus. Relevant history includes open myomectomy 6 years before and a complicated appendectomy, developing peritonitis within a year. Laparoscopy revealed multiple adhesions blocking uterine access, a bicornuate uterus, and myomas in the expected site. Myomectomy was performed utilizing power morcellation with good results. FDA recommendations have diminished this procedure's selection, converting many to open variants. This particular case was technically challenging, requiring morcellation, and safety device deployment was impossible, yet the infertility issue was properly addressed. Patient evaluation, safety measures, and laparoscopy benefits may outweigh the risks in particular cases as this one.
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Falcone T, Flyckt R. Tissue extraction technique at the time of laparoscopic myomectomy. Fertil Steril 2016; 105:1158-1159. [PMID: 26900978 DOI: 10.1016/j.fertnstert.2016.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Tommaso Falcone
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rebecca Flyckt
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
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