1
|
Benito V, Lubrano A, León L, Molano F, Pinar B. Does iatrogenic tumor rupture during surgery have prognostic implications for the outcome of uterine sarcomas? Int J Gynecol Cancer 2020; 30:1726-1732. [PMID: 32948637 DOI: 10.1136/ijgc-2020-001745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Tumor rupture during surgery is a risk factor for recurrence of sarcomas in other locations. However, the independent impact of rupture on prognosis is uncertain in uterine sarcomas. The aim of this study was to evaluate whether uterine rupture impacts outcomes in patients with uterine sarcoma. METHODS A retrospective analysis was carried out of all consecutive patients with uterine sarcoma managed at the Department of Gynecology and Obstetrics of the Complejo Hospitalario Universitario Insular-Materno Infantil of the Canary Islands, Spain between January 1990 and December 2016. Inclusion criteria included all patients with histologically proven uterine sarcoma. Exclusion criteria included patients with endometrial carcinoma (non-sarcomatous) and carcinosarcomas. During this period, 1981 patients were diagnosed with a uterine malignancy; 1799 were excluded because of a diagnosis of endometrial carcinoma and 85 patients were excluded for a diagnosis of carcinosarcoma. Thus, the final sample included 97 patients with uterine sarcoma (4.9%). These included leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, and liposarcoma. Surgical resection was the primary treatment, including open, laparoscopic and vaginal surgery. Survival rates were analyzed using the Kaplan-Meier method. RESULTS The median age was 52 years (range 25-90); 49.5% (48) were pre-menopausal. Distribution per histological type was: 46.4% (45) leiomyosarcoma, 23.7% (23) high-grade endometrial stromal sarcoma, 17.5% (17) low-grade endometrial stromal sarcoma, 11.3% (11) adenosarcoma, and 1% (1) liposarcoma. Uterine leiomyoma was the most frequent pre-operatively suspected diagnosis (49.5%). Iatrogenic rupture of the tumor during surgery occurred in 25.3% of cases (23). International Federation of Gynecology and Obstetrics stages I-II and III-IV were identified in 74.2% (72) and 25.8% (25) of patients, respectively. The median tumor size was 8 cm (range 2-40). The recurrence rate was 47.8% (11) for patients with intra-operative tumor rupture and 25% (17) for patients without uterine rupture (p=0.03). Disease-free survival rates at 1, 2, and 5 years for patients with uterine rupture were 72.7%, 55.4%, and 13.9%, respectively, with a median time of 39 months (95% CI 2.9 to 75). For those patients without uterine rupture, disease-free survival rates at 1, 2, and 5 years were 84.8%, 76.1%, and 71.3%, respectively, with a mean time of 208.6 months (95% CI 169 to 248.3) (p=0.01). Multivariate analysis showed that stage, histological type, and iatrogenic tumor rupture during surgery were all independent prognostic factors for overall survival (OR 7.9, 95% CI 1.6 to 38.2, p=0.01); OR 5.3, 95% CI 2.1 to 13, p<0.0001; and OR 2.6, 95% CI 1.1 to 6.5, respectively, p=0.03). CONCLUSION Considering that uterine sarcomas, especially leiomyosarcomas, often occur in pre-menopausal women as bulky tumors requiring laparotomy and that they are rarely diagnosed pre-operatively, efforts should be made to avoid iatrogenic uterine rupture during surgery as it impairs patient survival.
Collapse
Affiliation(s)
- Virginia Benito
- Gynecology and Obstetrics, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Canarias, Spain
| | - Amina Lubrano
- Gynecology and Obstetrics, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Canarias, Spain
| | - Laureano León
- Pathology, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Canarias, Spain
| | - Fernando Molano
- Medical Oncology, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Canarias, Spain
| | - Beatriz Pinar
- Radiation Oncology, Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Oxley SG, Mallick R, Odejinmi F. Laparoscopic Myomectomy: An Alternative Approach to Tackling Submucous Myomas? J Minim Invasive Gynecol 2019; 27:155-159. [PMID: 30926366 DOI: 10.1016/j.jmig.2019.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/14/2019] [Accepted: 03/21/2019] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVE To evaluate the differences in perioperative outcomes and immediate complication rates between laparoscopic myomectomy for submucous myomas and laparoscopic myomectomy for myomas in other locations. DESIGN Retrospective cohort study. SETTING University-affiliated hospital in London. PATIENTS A total of 350 patients with symptomatic uterine myomas underwent laparoscopic myomectomy. Thirty-three of these were performed for submucous myomas (group 1), and 317 were for myomas in other uterine locations (group 2). INTERVENTIONS Analysis of prospectively collected data on patient demographics, myoma characteristics, perioperative outcomes, and immediate complications. MEASUREMENTS AND MAIN RESULTS Patient demographics, including age, body mass index, and parity, were similar in the 2 groups. No significant differences in myoma characteristics were seen between groups 1 and 2, including the mean dimension of largest myoma (7.1 vs 7.8 cm, respectively; p = .35), mean number of myomas removed (3.8 vs 4.1; p = .665), and mean mass of myomas removed (142.0 g vs 227.3 g; p = .186). There were also no significant between-group differences in any perioperative outcomes, including mean blood loss (226.8 mL vs 266.4 mL; p = .373), duration of surgery (103 minutes vs 113 minutes; p = .264), and duration of hospital stay (1.4 days vs 1.7 days; p = .057). No complications arose from laparoscopic resection of submucous myomas. CONCLUSION Laparoscopic myomectomy for submucous myomas has similar perioperative outcomes and immediate complications as laparoscopic myomectomy for other myomas and can be considered for large or type 2 submucous myomas.
Collapse
Affiliation(s)
- Samuel George Oxley
- Department of Women's Health, Whipps Cross Hospital, Barts Health NHS Trust, London, United Kingdom (Drs. Oxley and Odejinmi).
| | - Rebecca Mallick
- Department of Women's Health, Brighton and Sussex University Hospitals NHS Trust, Princess Royal Hospital, Haywards Heath, United Kingdom (Dr. Mallick)
| | - Funlayo Odejinmi
- Department of Women's Health, Whipps Cross Hospital, Barts Health NHS Trust, London, United Kingdom (Drs. Oxley and Odejinmi)
| |
Collapse
|
6
|
Tanos V, Berry KE, Frist M, Campo R, DeWilde RL. Prevention and Management of Complications in Laparoscopic Myomectomy. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8250952. [PMID: 29693017 PMCID: PMC5859837 DOI: 10.1155/2018/8250952] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 02/04/2018] [Indexed: 11/18/2022]
Abstract
Myomectomy aims to preserve fertility, treat abnormal uterine bleeding, and alleviate pain. It should cause minimal damage to the endometrium, while being tolerable and durable, and reduce the incidence of myoma recurrence and complications including bleeding, hematoma, adhesions, and gravid uterus perforation. Training and experience are crucial to reduce complications. The surgical strategy depends on imaging information on the myomas. The position of the optical and secondary ports will determine the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the suturing quality. Appropriate hysterotomy length relative to myoma size can decrease bleeding, coagulation, and suturing times. Bipolar coagulation of large vessels, while avoiding carbonization and myometrium gaps after suturing, may decrease the risk of myometrial hematoma. Quality surgery and the use of antiadhesive barriers may reduce the risk of postoperative adhesions. Slow rotation of the beveled morcellator and good control of the bag could reduce de novo myoma and endometriosis. Low intra-abdominal CO2 pressure may reduce the risk of benign and malignant cell dissemination. The benefits a patient gains from laparoscopic myomectomy are greater than the complication risks of laparoscopic morcellation. Recent publications on laparoscopic myomectomies demonstrate reduced hospitalization stays, postoperative pain, blood loss, and recovery compared to open surgery.
Collapse
Affiliation(s)
- V. Tanos
- University of Nicosia Medical School, Nicosia, Cyprus
- European Academy for Gynecological Surgery (Nicosia Branch), 55-57 Andrea Avraamidi St., Strovolos, 2024 Nicosia, Cyprus
- Aretaeio Hospital, Strovolos, Nicosia, Cyprus
| | - K. E. Berry
- St George's, University of London MBBS Programme at the University of Nicosia Medical School, Nicosia, Cyprus
| | - M. Frist
- St George's, University of London MBBS Programme at the University of Nicosia Medical School, Nicosia, Cyprus
| | - R. Campo
- European Society Gynaecological Endoscopy, Leuven, Belgium
- The European Academy for Gynecological Surgery, Leuven, Belgium
- Life Expert Centre, Schipvaartstraat 4, 3000 Leuven, Belgium
| | - R. L. DeWilde
- European Society Gynaecological Endoscopy, Leuven, Belgium
- Cahir Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany
| |
Collapse
|