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Kim R, Pepin K, Dmello M, Clark N, Ajao M, Einarsson J, Rassier SC. Current Methods of Tissue Extraction in Minimally Invasive Surgical Treatment of Uterine Fibroids. JSLS 2022; 26:JSLS.2022.00036. [PMID: 36071994 PMCID: PMC9385112 DOI: 10.4293/jsls.2022.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background and Objectives: Since the 2014 Food and Drug Administration communication regarding the use of power morcellation, gynecologists have adopted alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by gynecologic surgeons for tissue extraction following minimally invasive hysterectomy or myomectomy for fibroids. Methods: An online survey was distributed to all AAGL members and responses were collected between March 26, 2019 and April 17, 2019. Results: Four hundred thirty-six respondents completed the survey. For hysterectomy, the most common methods of tissue extraction were manual morcellation through the colpotomy (72.4%) or minilaparotomy (66.9%). Nearly one-third (31.7%) endorsed using power morcellation. For myomectomy, manual morcellation via minilaparotomy (71.9%) was the most common approach, followed by power morcellation (35.7%). Use of containment bags was common. Minilaparotomy incisions were typically three cm and most often at the umbilicus. Geographic differences were detected, particularly with power morcellation. During hysterectomy, 18.4% of US-based surgeons reported its use, compared to 56.9% of nonUS-based surgeons. During myomectomy, 20.5% of US-based surgeons reported its use compared to 67.5% of their international counterparts. Age, years in practice, fellowship training, and practice location were all significantly associated with power morcellator use. Conclusion: A large majority of practitioners are performing manual morcellation through the colpotomy or minilaparotomy. Use of containment bags is common with all routes of tissue removal. Power morcellation use is less common in the United States than in other countries.
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Affiliation(s)
- Renita Kim
- Department of Obstetrics, Gynecology, and Reproductive Science, Mt, Sinai Hospital, New York, New York
| | - Kristen Pepin
- Department of Obstetrics and Gynecology, New York-Presbyterian Weill, Cornell Medical Center, New York, New York
| | - Monalisa Dmello
- Department of Obstetrics and Gynecology, Brigham and Women's, Hospital, Boston, Massachusetts
| | - Nisse Clark
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mobolaji Ajao
- Department of Obstetrics and Gynecology, Brigham and Women's, Hospital, Boston, Massachusetts
| | - Jon Einarsson
- Department of Obstetrics and Gynecology, Brigham and Women's, Hospital, Boston, Massachusetts
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Xu X, Desai VB, Schwartz PE, Gross CP, Lin H, Schymura MJ, Wright JD. Safety Warning about Laparoscopic Power Morcellation in Hysterectomy: A Cost-Effectiveness Analysis of National Impact. WOMEN'S HEALTH REPORTS 2022; 3:369-384. [PMID: 35415718 PMCID: PMC8994439 DOI: 10.1089/whr.2021.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/09/2022]
Abstract
Background: Following a 2014 safety warning (that laparoscopic power morcellation may increase tumor dissemination if patients have occult uterine cancer), hysterectomy practice shifted from laparoscopic to abdominal approach. This avoided morcellating occult cancer, but increased perioperative complications. To inform the national impact of this practice change, we examined the cost-effectiveness of hysterectomy practice in the postwarning period, in comparison to counterfactual hysterectomy practice had there been no morcellation warning. Materials and Methods: We constructed a decision tree model to simulate relevant outcomes over the lifetime of patients in the national population undergoing hysterectomy for presumed benign indications. The model accounted for both hysterectomy- and occult cancer-related outcomes. Probability-, cost-, and utility weight-related input parameters were derived from analysis of the State Inpatient Databases, State Ambulatory Surgery and Services Databases, data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry, and published literature. Results: With an estimated national sample of 353,567 adult women, base case analysis showed that changes in hysterectomy practice after the morcellation warning led to a net gain of 867.15 quality-adjusted life years (QALYs), but an increase of $19.54 million in costs (incremental cost-effectiveness ratio = $22,537/QALY). In probabilistic sensitivity analysis, the practice changes were cost-effective in 54.0% of the simulations when evaluated at a threshold of $50,000/QALY, which increased to 70.9% when evaluated at a threshold of $200,000/QALY. Conclusion: Hysterectomy practice changes induced by the morcellation warning are expected to be cost-effective, but uncertainty in parameter values may affect the cost-effectiveness results.
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Affiliation(s)
- Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vrunda B. Desai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- CooperSurgical, Inc., Trumbull, Connecticut, USA
| | - Peter E. Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Haiqun Lin
- Division of Nursing Science, Rutgers University School of Nursing, Newark, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Newark, New Jersey, USA
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, New York, USA
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Yang J, Fan X, Gao J, Li D, Xu Y, Chen G. Cost effectiveness analysis of total laparoscopic hysterectomy versus total abdominal hysterectomy for uterine fibroids in Western China: a societal perspective. BMC Health Serv Res 2022; 22:252. [PMID: 35209891 PMCID: PMC8867663 DOI: 10.1186/s12913-022-07644-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As a common female pelvic tumor, uterine fibroids remain the leading cause for hysterectomy in China. Hysterectomy provides a good surgical treatment of uterine fibroids, and it guarantees the removal of all uterine fibroids without lower risk of recurrence. This study compares the cost effectiveness of total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH) for women with uterine fibroids from a societal perspective. METHODS An economic analysis was conducted in 392 patients (TLH n = 75; TAH n = 317), including all relevant costs over a 12-month time horizon. Primary outcome was major surgical complications; secondary outcomes were postoperative discomfort symptoms and time of return to normal activities. Clinical, outcomes and costs data were collected from medical records, telephone survey and financial information system. Generalized linear models were used to assess costs and outcomes differences between the two groups. Incremental cost effectiveness ratio (ICER) was used to estimate the cost effectiveness. RESULTS Mean direct costs were $2,925.71 for TLH, $2,436.24 for TAH, respectively. Mean indirect costs were $1,133.22 for TLH, $1,394.85 for TAH, respectively. Incremental societal costs were $256.86 (95%CI: 249.03-264.69). Mean differences in outcome were: 4.53% (95%CI: 4.35-4.71) for major surgical complications; 6.75% (95%CI: 6.45-7.05) for postoperative discomfort symptoms; 1.27 (95%CI: 1.23-1.30) weeks for time to return to normal activities. ICER of TLH was $5,669.16 (95%CI: 5,384.76-5,955.56) per complication averted, $3,801.54 (95%CI: 3,634.81-3,968.28) per postoperative discomfort symptoms averted and $202.96 (95%CI: 194.97-210.95) per week saved to return to normal activities. CONCLUSIONS TLH is cost effective compared with TAH in preventing additional complications based on our estimated conservative threshold in China. The findings provide useful information for researchers to conduct further cost effectiveness analysis based on prospective study which can provide stronger and more evidence, in China. In addition, the data may be useful for Chinese health care policy-makers and medical insurance payers to make related health care decisions.
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Affiliation(s)
- Jinjuan Yang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, People's Republic of China
| | - Xiaojing Fan
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China.
| | - Jianmin Gao
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China.
| | - Dan Li
- School of Public Management, Northwest University School, Xi'an, 710127, People's Republic of China
| | - Yongjian Xu
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China
| | - Gang Chen
- Monash Business School, Monash University, Clayton, VIC, 3145, Australia
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Abstract
OBJECTIVE To evaluate the cost-effectiveness of surgical treatment pathways for apical prolapse. STUDY DESIGN We constructed a stochastic Markov model to assess the cost-effectiveness of vaginal apical suspension, laparoscopic sacrocolpopexy, and robotic sacrocolpopexy. We modeled over 5 and 10 years, with 9 pathways accounting for up to 2 separate surgical repairs, recurrence of symptomatic apical prolapse, reoperation, and complications, including mesh excision. We calculated costs from the health care system's perspective. RESULTS Over 5 years, compared with expectant management, all surgical treatment pathways cost less than the willingness-to-pay threshold of US $50,000 per quality adjusted life-years. However, among surgical treatments, all but 2 pathways were dominated. Of the remaining 2, laparoscopic sacrocolpopexy followed by vaginal repair for apical recurrence was not cost-effective compared with the vaginal-only approach (incremental cost-effectiveness ratio [ICER], >$500,000). Over 10 years, all but the same 2 pathways were dominated. However, starting with the laparoscopic approach in this case was more cost-effective with an ICER of US $6,176. If the laparoscopic approach was not available, starting with the robotic approach similarly became more cost-effective at 10 years (ICER, US $35,479). CONCLUSIONS All minimally invasive surgical approaches for apical prolapse repair are cost-effective when compared with expectant management. Among surgical treatments, the vaginal-only approach is the only cost-effective option over 5 years. However, over a longer period, starting with a laparoscopic (or robotic) approach becomes cost-effective. These results help inform discussions regarding the surgical approach for prolapse.
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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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Tran AQ, Greene N, Cass I. The Impact of Annual Surgical Volume on Patient Outcomes in Laparoscopic Hysterectomy. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Arthur-Quan Tran
- Department of Obstetrics and Gynecology, Cedars–Sinai Medical Center, Los Angeles, CA
| | - Naomi Greene
- Department of Obstetrics and Gynecology, Cedars–Sinai Medical Center, Los Angeles, CA
| | - Ilana Cass
- Department of Obstetrics and Gynecology, Cedars–Sinai Medical Center, Los Angeles, CA
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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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Laparoscopic myomectomy and morcellation: A review of techniques, outcomes, and practice guidelines. Best Pract Res Clin Obstet Gynaecol 2017; 46:99-112. [PMID: 29078975 DOI: 10.1016/j.bpobgyn.2017.09.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/11/2017] [Indexed: 12/14/2022]
Abstract
Laparoscopic myomectomy is a minimally invasive surgical approach to treat symptomatic uterine fibroids in women wishing for a uterine-sparing procedure. With careful patient selection, these procedures are associated with favorable reproductive outcomes and low perioperative morbidity. Current available methods for specimen retrieval include power and hand morcellation. The 2014 FDA safety warnings regarding power morcellation arose from concerns about the spread of occult malignancy and prompted widespread use of containment systems that may limit spread of myometrial cells. Investigation into the clinical effects of laparoscopic myomectomy and uncontained morcellation on the prognosis and spread of occult leiomyosarcoma has yielded mixed results. Other complications of uncontained power morcellation exist, including the development of parasitic leiomyomas. The FDA safety warnings have greatly influenced trends in benign gynecologic surgery, and survey data reflect trends in providers' opinions of these trends. In conclusion, recommendations for the current practice of laparoscopic myomectomy and morcellation are reviewed.
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Louie M, Moulder JK, Donnellan N, Hur HC, Siedhoff MT. Clinical Application of Morcellation: Provider Perceptions Survey (the CAMPPS Study). J Gynecol Surg 2017. [DOI: 10.1089/gyn.2016.0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Michelle Louie
- Division of Minimally Invasive Gynecologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janelle K. Moulder
- Division of Minimally Invasive Gynecologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nicole Donnellan
- Division of Minimally Invasive Gynecologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Hye-Chun Hur
- Division of Minimally Invasive Gynecologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Matthew T. Siedhoff
- Division of Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Uccella S, Casarin J, Marconi N, Cromi A, Morosi C, Gisone B, Pinelli C, Ghezzi F. Laparoscopic Versus Open Hysterectomy for Benign Disease in Women with Giant Uteri (≥1500 g): Feasibility and Outcomes. J Minim Invasive Gynecol 2016; 23:922-7. [PMID: 27223048 DOI: 10.1016/j.jmig.2016.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 05/03/2016] [Accepted: 05/09/2016] [Indexed: 12/18/2022]
Abstract
UNLABELLED STUDY OBJECTIVE To evaluate perioperative outcomes and complications of laparoscopic hysterectomy (LH) in women with giant uteri (≥1.5 kg) compared with open abdominal hysterectomy (AH), which is considered the reference. DESIGN A retrospective analysis of prospectively collected data (Canadian Task Force Classification II-2). SETTING An academic research center. PATIENTS All consecutive women who underwent hysterectomy for uteri weighing ≥1500 g (total = 51) between 2000 and 2015 were analyzed. Twenty-seven (53%) patients had been scheduled for the laparoscopic approach (LH), whereas 24 (48%) had been scheduled for AH. INTERVENTIONS Hysterectomy ± mono/bilateral salpingo-oophorectomy. MAIN OUTCOME MEASURES Perioperative details, incidence, severity, and type of complications were analyzed according to surgical approach (AH vs LH). We also evaluated the trends over time in terms of perioperative outcomes. RESULTS AH was associated with a shorter operative time (97.5 vs 160 minutes, p = .004) compared with LH. Blood loss (200 vs 225 mL, p = .21) and the decrease in postoperative hemoglobin (-1.2 vs -1.1, p = .89) were similar between AH and LH. Intra- and postoperative complications were similar between the 2 groups; however, hospital stay was significantly shorter in the LH group (median = 3 days vs 1 day, p < .001). A significant trend toward a progressive increase in the use of the minimally invasive approach was registered through the years (p = .001). Parallel to this increase, we observed a significant reduction in terms of length of stay. Moreover, a decrease in the total number of complications, mainly because of a decrease in the rate of early minor events, was observed through the years. CONCLUSIONS Our experience shows that LH can be considered a feasible procedure, even in cases of uteri ≥1.5 kg, with significant advantages over open surgery in terms of postoperative hospital stay.
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Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy.
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Nicola Marconi
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Chiara Morosi
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Baldo Gisone
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Ciro Pinelli
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, F. Del Ponte Hospital, Varese, Italy
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