Surgical trends for benign ovarian tumors among hospitals of different accreditation levels: An 11-year nationwide population-based descriptive study in Taiwan

Bilateral oophorectomy and the risk of hepatocellular carcinoma in women with hepatitis C: A population-based study

OBJECTIVE

Patients with chronic hepatitis C virus (HCV) infection are at high risk of developing hepatocellular carcinoma (HCC). Previous studies suggested that menopause may increase the risk of HCC. We investigated the association between bilateral oophorectomy (BO) and the risk of HCC in women with HCV infection.

STUDY DESIGN

We used data from the National Health Insurance Research Database of Taiwan and conducted a matched cohort study.

MAIN OUTCOME MEASURES

The main outcome was HCC. We used a competing risk model to adjust for potential confounding factors.

RESULTS

From 1997-2013, we identified 2176 patients with BO and 8704 controls. A total of 107 HCC cases (4.9 %, 107/2176) were identified in the BO group compared with 465 HCC cases (5.3 %, 465/8704) in the control group. The incidence rates were 506.3 and 538.9 cases per 100,000 person-years among the HCV-infected patients with and without BO, respectively. The competing risk model showed that BO did not increase the risk of developing HCC. Furthermore, a sub-analysis of only women under 50 years of age similarly showed that BO did not increase the risk of developing HCC after adjusting for additional covariates. The log-rank test revealed that whether or not the patients had received HRT, patients with BO did not have an increased risk of developing HCC (non-BO vs BO with HRT, p = 0.10; non-BO vs BO without HRT, p = 0.09). The use of HRT after BO did not influence the risk of developing HCC.

CONCLUSIONS

This study examined a large dataset with a long follow-up period to test the relationship between BO and the risk of HCC in HCV-infected women. Our findings suggest that BO did not increase the risk of HCC, regardless of HRT usage, in these women.

Use of human fibrin glue (Tisseel) versus suture during transvaginal natural orifice ovarian cystectomy of benign and non-endometriotic ovarian tumor: a retrospective comparative study

Background

To evaluate the use of a human fibrin glue (Tisseel) for minor bleeding control and approximation of ovarian defect during transvaginal natural orifice ovarian cystectomy (TNOOC) of benign and non-endometriotic ovarian tumors.

Methods

A total of 125 women with benign and non-endometriotic ovarian tumors who underwent TNOOC between May 2011 and January 2020: 54 with the aid of Tisseel and 71 with traditional suture for hemostasis and approximation of ovarian defect. Surgical outcomes such as length of surgery, operative blood loss, postoperative pain score, and postoperative hospital stay were recorded. Before and immediately (10 days) and at 6 months after the procedure, serum anti-Müllerian hormone (AMH) levels were also determined.

Results

Complete hemostasis and approximation of ovarian defect were achieved in all cases. No significant difference was noted in the operating time, operative blood loss, postoperative pain scores after 12, 24 and 48 h, length of postoperative stay, and baseline AMH levels between the two groups. The operation did not have a negative effect on the immediate and 6-month postoperative AMH levels in the suture group. However, the decline in the AMH levels was significant immediately after surgery in the Tisseel group, nevertheless, no significant difference was noted in the AMH levels at 6 months (3.3 vs. 1.7 mg/mL; p = 0.042, adjusted p = 0.210).

Conclusion

The use of Tisseel in TNOOC of benign and non-endometriotic ovarian tumors without suturing the ovarian tissue is clinically safe and feasible.

Comparative analysis of vaginal natural orifice transluminal endoscopic surgery versus transumbilical laparoendoscopic single-site surgery in ovarian cystectomy

AIM

To objectively assess the safety, feasibility, advantages and disadvantages and health economics benefits of vaginal natural orifice transluminal endoscopic surgery (vNOTES) versus transumbilical laparoendoscopic single-site surgery (TU-LESS) in ovarian cystectomy.

METHODS

We retrospectively analyzed the data of all patients in our hospital who had undergone vNOTES and TU-LESS ovarian cystectomy due to 'unilateral ovarian cyst' from March 2019 to May 2020. Patients were classified into vNOTES group (86) and TU-LESS group (210) based on surgical paths. The patients' general characteristics and perioperative outcomes were compared.

RESULTS

All 296 patients completed surgery with no need to switch to conventional laparoscopy or laparotomy procedures. There were no complications of Grade III, IV, V in Clavien-Dindo classification. There were two patients in the vNOTES group and four patients in the TU-LESS group with complications of Grade I, all of whom were treated with antipyretic drugs for postoperative fever. One patient in the TU-LESS group presented the complication of Grade II and was treated with blood transfusion due to postoperative anemia. The two groups had similar general characteristics. Perioperative outcomes: The visual analogue scale (VAS) scores 24 h postoperation were significantly lower in the vNOTES group than in the TU-LESS group. The cosmetic scores were significantly higher in the vNOTES group than in the TU-LESS group. Postoperative stay and time of flatus after surgery were significantly shorter in the vNOTES group than in the TU-LESS group. There was not significant statistical differences between the two groups in operation time, estimated blood loss, Hb decrease at 48 h postoperation, maximum body temperature in 48 h after surgery and hospital costs.

CONCLUSION

It was proved to be safe and feasible in ovarian cystectomy by vNOTES. It worked better than TU-LESS in relieving postoperative pain, shortening postoperative stay and improving cosmetic effects and so on. As an emerging surgical path, large sample multicenter randomized controlled trials are required to further verify its safety and advantages.

Subsequent Development of Epithelial Ovarian Cancer After Ovarian Surgery for Benign Ovarian Tumor: A Population-Based Cohort Study

Purpose

The goal of the current study is to determine the risk of subsequent development of epithelial ovarian cancer (EOC) in women after ovarian surgery for benign ovarian tumors.

Patients and Methods

We conducted the nationwide population-based historic cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan. Eleven thousand six hundred twenty women who underwent ovarian surgery for ovarian benign diseases were analyzed. The collected data included age, types of ovarian surgery, medical history by Charlson comorbidity index (CCI), infertility (yes/no), pelvic inflammatory disease (PID) (yes/no), tubal ligation (yes/no), total/subtotal hysterectomy (TH/STH) (yes/no), and endometrioma (yes/no). We used the Kaplan-Meier method and the Log-rank test to evaluate the risk factors. Cox proportional hazard methods were used to evaluate risk factors for the subsequent development of EOC. Multivariate analysis using Cox stepwise forward regression was conducted for the covariate selected in univariate analysis. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using the Wald test.

Results

Subsequent EOC incidence rate (IR, incidence per 10,000 person-years) of women after ovarian surgery for benign ovarian tumors was 2.98. Separating into four groups based on different age, IR of EOC was 1.57 (<30 years), 4.71 (30-39 years), 3.59 (40-49 years) and 0.94 (≥50 years), respectively. Univariate and multivariate analyses identified only high level of CCI (≥2 or more) as an independent risk factor for subsequent development of EOC in women after ovarian surgery for benign ovarian tumors (HR 59.17, 95% CI 7.50-466.80 in women with CCI level of 2 and HR 190.68, 95% CI 24.33-2494.19, in women with CCI level ≥3, respectively).

Conclusion

Our results, if confirmed, suggest that women with other comorbidities (CCI) should be well informed that they may have a higher risk of subsequent development of EOC when ovarian surgery is planned even though the final pathology showed a benign ovarian tumor.

Learning Curve Analysis of Transvaginal Natural Orifice Adnexal Surgery

STUDY OBJECTIVE

This study was designed to evaluate the learning curve of transvaginal natural orifice surgery (NOS) for adnexal tumors based on the type of procedure (adnexectomy or cystectomy).

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care university hospital.

PATIENTS

One hundred thirty-six women with adnexal tumors.

INTERVENTIONS

A series of 136 consecutive transvaginal NOS for adnexal tumor were performed between April 2011 and June 2016. Eighty-five patients (62.5%) had undergone cystectomy, and 51 patients (37.5%) had undergone adnexectomy.

MEASUREMENTS AND MAIN RESULTS

The transvaginal NOS procedures included vaginal, endoscopic, single-port access techniques and were divided into 2 categories: adnexectomy and cystectomy. Operating time was electronically recorded and was defined as the time from the creation of a posterior colpotomy incision until the complete closure of the posterior colpotomy opening. The average operating time for the cystectomy and adnexectomy groups was 42.7 and 37.7 minutes, respectively (p = .015). The learning curve was analyzed using the cumulative summation method and showed that 36 cases were needed to achieve proficiency in transvaginal NOS for ovarian cystectomy. However, there was no significant cut-off point to determine the number of patients who had undergone adnexectomy.

CONCLUSION

A well-trained gynecologic endoscopist can achieve surgical proficiency in transvaginal NOS cystectomy after 36 cases. It is suggested that the surgical transvaginal NOS procedure should begin with adnexectomy rather than with cystectomy to avoid initial technical challenges.

Natural orifice transluminal endoscopic surgery-assisted versus laparoscopic ovarian cystectomy (NAOC vs. LOC): a case-matched study

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has shown its prospection as a minimally invasive endoscopic surgery. This study aimed to examine the safety and efficacy of combined NOTES and vaginal approach, natural orifice transluminal endoscopic surgery-assisted ovarian cystectomy (NAOC), in the conservative management of benign ovarian tumors.

METHODS

Records were reviewed for the 34 consecutive NAOC procedures between May 2011 and March 2014. Age, body mass index, parity, size of the mass, and bilaterality of the mass were used to select comparable patient who had undergone laparoscopic ovarian cystectomy (LOC).

RESULTS

A total of 277 patients were recruited in this study (243 LOCs and 34 NAOCs, respectively). There was no incidence of switching to abdominal laparotomy. Length of operation and length of postoperative stay were significantly greater in the LOC group than in the NAOC group, but total hospital charges were similar in both groups. There was no difference in febrile morbidity between the two groups but more estimated blood loss (EBL) in NAOC group, although EBL was <50 mL in the two groups. Linear correlations of mass size with operating time and EBL existed in LOC group, but not in NAOC group.

CONCLUSION

NAOC can be safely performed for benign and large ovarian tumors. Besides, NAOC offers a superior operative efficiency compared with LOC.