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Chen Y, jiang J, He M, Zhong K, Tang S, Deng L, Wang Y. Nomogram for predicting difficult total laparoscopic hysterectomy: a multi-institutional, retrospective model development and validation study. Int J Surg 2024; 110:3249-3257. [PMID: 38537077 PMCID: PMC11175783 DOI: 10.1097/js9.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/12/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Total laparoscopic hysterectomy (TLH) is the most commonly performed gynaecological surgery. However, the difficulty of the operation varies depending on the patient and surgeon. Subsequently, patient's outcomes and surgical efficiency are affected. The authors aimed to develop and validate a preoperative nomogram to predict the operative difficulty in patients undergoing TLH. METHODS This retrospective study included 663 patients with TLH from Southwest Hospital and 102 patients from 958th Hospital in Chongqing, China. A multivariate logistic regression analysis was used to identify the independent predictors of operative difficulty, and a nomogram was constructed. The performance of the nomogram was validated internally and externally. RESULTS The uterine weight, history of pelvic surgery, presence of adenomyosis, surgeon's years of practice, and annual hysterectomy volume were identified as significant independent predictors of operative difficulty. The nomogram demonstrated good discrimination in the training dataset [area under the receiver operating characteristic curve (AUC), 0.827 (95% CI, 0.783-0.872], internal validation dataset [AUC, 0.793 (95% CI, 0.714-0.872)], and external validation dataset [AUC, 0.756 [95% CI, 0.658-0.854)]. The calibration curves showed good agreement between the predictions and observations for both internal and external validations. CONCLUSION The developed nomogram accurately predicted the operative difficulty of TLH, facilitated preoperative planning and patient counselling, and optimized surgical training. Further prospective multicenter clinical studies are required to optimize and validate this model.
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Affiliation(s)
- Yin Chen
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Jiahong jiang
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Min He
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Kuiyan Zhong
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Shuai Tang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Li Deng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Yanzhou Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
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Zorzato PC, Ferrari FA, Garzon S, Franchi M, Cianci S, Laganà AS, Chiantera V, Casarin J, Ghezzi F, Uccella S. Advanced bipolar vessel sealing devices vs conventional bipolar energy in minimally invasive hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:1165-1174. [PMID: 37955717 PMCID: PMC10894136 DOI: 10.1007/s00404-023-07270-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE To compare conventional bipolar electrosurgery with advanced bipolar vessel sealing (ABVS) devices for total laparoscopic hysterectomy (TLH). METHODS A systematic review was conducted by searching Scopus, PubMed/MEDLINE, ScienceDirect, and Cochrane Library from January 1989 to November 2021. We identified all studies comparing ABVS devices with conventional bipolar electrosurgery in TLH and reporting at least one of the following outcomes: total blood loss, total operative time, hospital stay, perioperative complications, or costs. Meta-analysis was conducted with a random effect model reporting pooled mean differences and odds ratios (ORs) with related 95% confidence intervals (CIs). RESULTS Two randomized controlled trials and two retrospective studies encompassing 314 patients were included out of 615 manuscripts. The pooled estimated total blood loss in the ABVS devices group was lower than conventional bipolar electrosurgery of 39 mL (95% CI - 65.8 to - 12.6 mL; p = .004). The use of ABVS devices significantly reduced the total operative time by 8 min (95% CI - 16.7 to - 0.8 min; p = .033). Hospital stay length did not differ between the two groups, and a comparable overall surgical complication rate was observed [OR of 0.9 (95% CI 0.256 - 3.200; p = .878]. CONCLUSIONS High-quality evidence comparing ABVS devices with conventional bipolar electrosurgery for TLH is lacking. ABVS devices were associated with reduced total blood loss and operative time; however, observed differences seem clinically irrelevant. Further research is required to clarify the advantages of ABVS devices over conventional bipolar electrosurgery and to identify cases that may benefit more from their use.
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Affiliation(s)
- Pier Carlo Zorzato
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Filippo Alberto Ferrari
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Simone Garzon
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy.
| | - Massimo Franchi
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Stefano Cianci
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, Paolo Giaccone Hospital, Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Stefano Uccella
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
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Schoenen S, de Landsheere L. Defining a Uterine Extraction Score based on a Volume/Access Ratio in Total Hysterectomy: a retrospective cohort study. Facts Views Vis Obgyn 2024; 16:75-81. [PMID: 38551477 PMCID: PMC11198889 DOI: 10.52054/fvvo.16.1.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024] Open
Abstract
Background Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility. Objectives Our main objective was to determine a predictive score of uterine extraction feasibility to optimise surgical planning of total hysterectomy. As secondary objectives, we examined the correlation between uterine volume predicted by preoperative ultrasound and the final weight of the surgical specimen and analysed the impact of the uterine extraction modality on operative and hospitalisation times. Materials and Methods We defined a Uterine Extraction Score (UES) based on the ratio between uterine sizes and vaginal access. This score was retrospectively applied to a cohort of 178 patients who were hysterectomised for benign conditions between January 2019 and December 2022. Main outcome measures The UES allows identification of three groups of decreasing feasibility of vaginal extraction, symbolised by traffic light colours: green - vaginal extraction without morcellation, orange -vaginal extraction with morcellation, red - abdominal morcellation by mini-laparotomy or primary laparotomy. Results The results show that the UES--predicted, and the observed routes of extraction concord in 92% of cases. There is a strong correlation between estimated volume and final uterine weight. Uterine morcellation lengthens the operative time and the hospital stay. Conclusions The UES seems to be a reliable tool to predict the route of uterine extraction in total hysterectomy. What is new? The development of a new scoring system empowers surgeons with decisive information to enhance perioperative outcomes.
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Hurni Y, Fung H, Simonson C, Serio MD, Lachat R, Bodenmann P, Seidler S, Huber D. Impact of Uterine Weight and Shape on vNOTES Hysterectomy: Analysis of 238 Consecutive Cases. J Minim Invasive Gynecol 2024; 31:115-122. [PMID: 37981263 DOI: 10.1016/j.jmig.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
STUDY OBJECTIVE To compare the perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies for different uterine weights and shapes. DESIGN Observational study. SETTING Swiss teaching hospital. PATIENTS Women who underwent vNOTES hysterectomy for benign conditions between May 2020 and July 2023 (N = 238). Patients were divided into 4 subgroups depending on uterus weight and shape. Uteri weighting <280 g were classified as type 0. Uteri weighting ≥280 g were categorized as type 1 (no vascular pedicle displacement), type 2 (cranial displacement of adnexal vascular pedicles), and type 3 (displacement of uterine arteries). INTERVENTIONS All women underwent vNOTES hysterectomies. We compared perioperative outcomes for the 4 subgroups. MEASUREMENT AND MAIN RESULTS We classified 168 patients (70.6%) as uterus type 0, 33 patients (13.9%) as type 1, 24 patients (10.1%) as type 2, and 13 patients (5.4%) as type 3. Mean uterine weight was 135.8 ± 59.5 g in type 0, 398.0 ± 167.3 g in type 1, 603.5 ± 217.9 g in type 2, and 661.7 ± 281.6 g in type 3. Operative time in type 0 (65.1 ± 30.9 minutes) and type 1 (65.1 ± 24.0 minutes) was shorter than in type 2 (102.3 ± 60.0 minutes) and type 3 (115.2 ± 40.3 minutes). Blood losses were more significant in type 2 (158.5 ± 212.0 mL) and type 3 (158.5 ± 110.7 mL) than in type 0 (85.6 ± 113.5 mL). No difference in the rate of total complications among groups was observed (8.3%, 3.0%, 12.5%, and 15.4% in types 0, 1, 2, and 3, respectively). CONCLUSION The displacement of the vascular pedicles seems associated with longer operative time and more blood loss and could represent a marker for technical difficulty in vNOTES hysterectomy. However, it does not influence the perioperative complication rate.
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Affiliation(s)
- Yannick Hurni
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber).
| | - Helen Fung
- Faculty of Medicine, University of Geneva, Geneva, Switzerland (Ms. Fung)
| | - Colin Simonson
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Marcello Di Serio
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Régine Lachat
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Pauline Bodenmann
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Stéphanie Seidler
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Daniela Huber
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber); Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland (Dr. Huber)
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Purohit R, Sharma JG, Meher D. A Vagino-Laparoscopic Strategy for Hysterectomy of Large Uteri to Ease Surgical Challenges. Int J Womens Health 2023; 15:369-379. [PMID: 36942049 PMCID: PMC10024491 DOI: 10.2147/ijwh.s400587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/02/2023] [Indexed: 03/15/2023] Open
Abstract
Purpose To develop a vagino-laparoscopic strategy for hysterectomy (VLH) to treat uteri with large fibroids at ≥ 16 weeks of gestation to ease surgical challenges. Patients and Methods This was an observational study conducted in our private general hospital on 64 consecutive cases involving uteri with large and benign fibroids at ≥ 16 weeks of gestation. We excluded cases with an associated ventro-fixed uterus and large cervical fibroids. Interventions The VLH strategy involves vaginal separation of the uterosacral with the uterine arteries followed by laparoscopic separation of the remaining upper pedicles. The uterus was then removed vaginally. Results The largest uteri receiving treatment was at 26 weeks of gestation and the mean uterus weight was 869.60 ± 275.10 g (range: 500-1900 g). The VLH strategy was successful in 63 (98.43%) cases irrespective of the configuration of the uterus. One case (1.56%) required mini-laparotomy conversion due to the need for adhesiolysis; this case exhibited extensive adhesion of the rectum to the posterior wall of the uterus due to a history of previous myomectomy of the posterior wall. There were no conversions due to failed laparoscopic exposure of the adnexal or uterine vascular pedicles, or due to uncontrolled intraoperative bleeding. There were no cases of urinary tract injury or other major complications. The vaginal detachment of uterosacral ligaments before the laparoscopic phase of the VLH strategy increased upwards mobility and dislodged the cervico-isthmic level of large uteri from the narrow lower aspect of the pelvis to the upper wider part of the pelvis; this eased the surgical challenges associated with such cases and avoided complications during laparoscopy. Conclusion We developed a vagino-laparoscopic strategy for hysterectomy that can ease the technical challenges associated with the majority of large uteri.
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Affiliation(s)
- Ramkrishna Purohit
- Purohit General Hospital, Bargarh, Odisha, India
- Correspondence: Ramkrishna Purohit, Purohit General Hospital, Bargarh, Odisha, 768028, India, Email
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Outcomes of In-bag Transvaginal Extraction in a Series of 692 Laparoscopic Myomectomies: Results from a Large Retrospective Analysis. J Minim Invasive Gynecol 2022; 29:1331-1338. [PMID: 36150421 DOI: 10.1016/j.jmig.2022.09.009] [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: 05/22/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE Transvaginal extraction is a feasible method to remove surgical specimen. In this study, we aim to report our experience with in-bag transvaginal specimen retrieval after laparoscopic myomectomy over the past 15 years. DESIGN Single-center retrospective analysis. SETTING Academic hospital. PATIENTS Women who underwent laparoscopic myomectomy from January 2005 to April 2021. INTERVENTION Posterior colpotomy and in-bag transvaginal extraction of the surgical specimen. MEASUREMENTS AND MAIN RESULTS We collected and analyzed data about patients' characteristics, main indication for surgery, and intra- and postoperative (within 30 days) complications. RESULTS A total of 692 women underwent transvaginal specimen retrieval after laparoscopic myomectomy (mean largest myoma diameter: 6.64 ± 2.21 cm; mean specimen weight: 177 ± 140 g; mean operative time: 84.1 ± 37.1 minutes; mean blood loss: 195 ± 191 mL). Within 30-days, we reported the following colpotomy-related complications: a total of 4 cases (0.6%) of vaginal bleeding, 3 of which resolved spontaneously (1 case required readmission with new colporrhaphy under general anesthesia), and 2 cases (0.3%) of vaginal pain, with no underlying cause identified on physical examination and pelvic ultrasound. Specimen weight was positively correlated with longer operative time, intraoperative blood loss, and length of hospital stay. CONCLUSION Posterior colpotomy and in-bag transvaginal extraction can be considered a feasible option for retrieval of surgical specimens after laparoscopic myomectomy.
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Uccella S, Kho RM, Garzon S, Casarin J, Zorzato PC, Ghezzi F. The Large Uterus Classification System: a prospective observational study. BJOG 2021; 128:1526-1533. [PMID: 33988895 PMCID: PMC8362220 DOI: 10.1111/1471-0528.16753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/22/2022]
Abstract
Objective To investigate the Large Uterus Classification System (LUCS) ability to predict surgical outcomes and complications in total laparoscopic hysterectomies (TLHs) for large uteri. Design Prospective observational study. Setting Two referral centres. Population or sample Three hundred and ninety‐two women who underwent TLH for a large uterus (uterine fundus at or over the transverse umbilical line). Methods Between 2004 and 2019, the intraoperative LUCS was estimated in all patients. The LUCS considers the uterine and adnexal vascular pedicles displacement. Type 1 is without vascular pedicles displacement. Type 2 has the cephalad displacement of adnexal vascular pedicles. The uterine vessels displacement regardless of adnexal pedicles defines Type 3. Main outcome measures Patients’ characteristics with perioperative outcomes were prospectively collected and compared between the three types of large uteri. Results Two hundred and fifty‐one (64%), 82 (20.9%) and 59 (15.1%) women had Type 1, Type 2 and Type 3 uteri, respectively. Women with Type 1 uteri had a lower uterine weight, shorter operative time, less blood loss and lower complication rates than women with Types 2 and 3. The conversion rate to laparotomy in Type 1 was similar to that in Type 2 (odds ratio [OR] 0.98; 95% CI 0.32–3.56) but lower than Type 3 (OR 0.35; 95% CI 0.14–0.97); in Type 2 it was lower than Type 3, although without the conventional statistical significance (OR 0.36; 95% CI 0.13–1.13; P = 0.07). Multivariable analysis showed that the uterine Type (1 versus 2–3) was independently associated with the total complications rate (OR 2.00; 95% CI 1.09–3.68; P = 0.02). Conclusions The LUCS appears associated with surgical outcomes and complications, potentially stratifying the surgical risk and guiding the surgical technique in TLHs for large uteri. Tweetable abstract The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri. The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.
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Affiliation(s)
- S Uccella
- Division of Obstetrics and Gynaecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - R M Kho
- Department Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S Garzon
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - J Casarin
- Department of Obstetrics and Gynaecology, F. Del Ponte Hospital, University of Insubria, Varese, Italy
| | - P C Zorzato
- Division of Obstetrics and Gynaecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - F Ghezzi
- Department of Obstetrics and Gynaecology, F. Del Ponte Hospital, University of Insubria, Varese, Italy
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