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Della Corte L, Guarino MC, Vitale SG, Angioni S, Mercorio A, Bifulco G, Giampaolino P. C-section technique vs minilaparotomy after minimally invasive uterine surgery: a retrospective cohort study. Arch Gynecol Obstet 2024; 309:219-226. [PMID: 37796281 PMCID: PMC10769909 DOI: 10.1007/s00404-023-07239-7] [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: 08/01/2023] [Accepted: 09/13/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE Uterine leiomyomas are benign uterine tumors. The choice of surgical treatment is guided by patient's age, desire to preserve fertility or avoid "radical" surgical interventions such as hysterectomy. In laparotomy, the issue of extracting the fibroid from the cavity does not arise. However, in laparoscopy and robotic surgery, this becomes a challenge. The aim of the present study was to determine the optimal surgical approach for fibroid extraction following laparoscopic or robotic myomectomy in terms of postoperative pain, extraction time, overall surgical time, scar size, and patient satisfaction. METHODS A total of 51 patients met the inclusion criteria and were considered in our analysis: 33 patients who had undergone the "ExCITE technique" (Group A), and 18 patients a minilaparotomy procedure (Group B), after either simple myomectomy, multiple myomectomy, supracervical hysterectomy, or total hysterectomy. The diagnosis of myoma was histologically confirmed in all cases. RESULTS Regarding the postoperative pain evaluation, at 6 h, patients reported 4 [3-4] vs 6 [5.3-7] on the VAS in Group A and B, as well as at 12 h, 2 [0-2] vs 3.5 [2.3-4] in Group A and B, respectively: both differences were statistically significant (p < 0.001). No statistically significant difference at 24 h from surgery was found. All patients in Group A were satisfied with the ExCITE technique, while in Group B only 67% of them. The length of the hospital stay was significantly shorter in Group A as compared to Group B (p = 0.007). In terms of the operative time for the extraction of the surgical specimen, overall operative time, and the scar size after the surgery, there was a statistically significant difference for those in Group A. CONCLUSION The ExCITE technique does not require specific training and allows the surgeon to offer a minimally invasive surgical option for patients, with also an aesthetic result. It is a safe and standardized approach that ensures tissue extraction without the need for mechanical morcellation.
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Affiliation(s)
- Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131, Naples, Italy.
| | - Maria Chiara Guarino
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124, Cagliari, Italy
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124, Cagliari, Italy
| | - Antonio Mercorio
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Giuseppe Bifulco
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
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Zouzoulas D, Tsolakidis D, Pavlidi OI, Pappas PD, Theodoridis T, Pados G, Pervana S, Pazarli E, Grimbizis G. Rate of Leiomyosarcomas during Surgery for Uterine Fibroids: 8-Year Experience of a Single Center. J Clin Med 2023; 12:7555. [PMID: 38137623 PMCID: PMC10743724 DOI: 10.3390/jcm12247555] [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: 10/06/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
The aim of this study is to investigate the prevalence of occult malignant mesenchymal tumors in patients operated on for uterine fibroids in relation to the surgical approach and type of operation. A retrospective review of all patients that underwent surgery for uterine fibroids (January 2011-December 2018) at the 1st Department of Obstetrics & Gynecology at "Papageorgiou" Hospital. The surgical approach and clinicopathological characteristics were analyzed. A total of 803 patients were operated on: 603 (75.1%) with laparotomy, 187 (23.3%) laparoscopically, and 13 (1.6%) vaginally. Furthermore, 423 (52.7%) patients underwent hysterectomy and 380 (47.3%) myomectomies. Laparoscopy and myomectomy were offered to younger patients with fewer smaller uterine fibroids and were associated with statistically significant shorter hospitalization. The pathological reports revealed: 690 (86%) benign leiomyomas, 32 (4%) cellular leiomyomas, 29 (3.6%) degenerated leiomyomas, 22 (2.7%) adenomyomas, 18 (2.2%) atypical-bizarre leiomyomas, 1 (0.1%) STUMP, 5 (0.65%) endometrial stromal sarcomas, and 6 (0.75%) cases of leiomyosarcomas (LMS). All LMS were preoperatively characterized as suspicious and underwent abdominal hysterectomy. Morcellation was offered in two cases of atypical leiomyomas, with no morcellation-associated complication. Laparoscopy as a valuable surgical approach for young patients with fewer in number and smaller in size fibroids is associated with shorter hospitalization. The risk of unintended morcellation of LMS seems to be very low and can be reduced with careful preoperative work-up but not eliminated.
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Affiliation(s)
- Dimitrios Zouzoulas
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Dimitrios Tsolakidis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Olga I. Pavlidi
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Panagiotis D. Pappas
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Theodoros Theodoridis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - George Pados
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Stavroula Pervana
- Anatomical Pathology Laboratory, “Papageorgiou” Hospital, 56403 Thessaloniki, Greece
| | - Elsa Pazarli
- Anatomical Pathology Laboratory, “Papageorgiou” Hospital, 56403 Thessaloniki, Greece
| | - Grigoris Grimbizis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
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Falus N, Lazarou G, Gabriel I, Sabatino N, Grigorescu B. Contained specimen morcellation during robotics-assisted laparoscopic supracervical hysterectomy for pelvic organ prolapse. Int Urogynecol J 2023; 34:2783-2789. [PMID: 37490062 DOI: 10.1007/s00192-023-05586-2] [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: 03/29/2023] [Accepted: 05/22/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive procedures; however specimen removal without intraperitoneal spillage of potential pathology remains challenging. The primary aim of our study is to determine the factors affecting contained manual morcellation (CMM) of specimens during RALSH for POP surgery. The secondary aim of the study is to report complications associated with CMM and on specimen pathology. METHODS A total of 67 sequential patients underwent RALSH with concomitant robotics-assisted sacrocolpopexy or uterosacral vaginal suspension. Factors analyzed to affect CMM were specimen weight, length of skin and fascia incisions, patient age, body mass index (BMI), and estimated blood loss (EBL). RESULTS Median CMM time was 11 min (1 to 46) and specimen weight 62 g (19 to 711). Median patient age was 56 years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50 ml (10 to 150). Median skin and fascial incision lengths were 3 cm (1.5 to 7), and 3.5 cm (1.5 to 8). CMM time was significantly dependent on specimen weight (p < 0.0001) and length of rectus fascia incision (p < 0.0126). There was no gross tissue spillage or bag ruptures. Uterine pathology revealed normal tissue (26%), leiomyoma (47%), adenomyosis (49%), and endometriosis (14%). 4.5% of specimens had evidence of microscopic neoplasm, and 5 years after surgery patients were cancer free. CONCLUSION Contained manual extraction of the uterus and/or adnexae at the time of RALSH for POP surgery is a viable, safe, and efficient method of specimen removal.
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Affiliation(s)
- Nicole Falus
- NYIT College of Osteopathic Medicine, Old Westbury, NY, USA
| | - George Lazarou
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, NYU Long Island School of Medicine, 259 1st Street, Mineola, NY, 11501, USA
| | - Iwona Gabriel
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, NYU Long Island School of Medicine, 259 1st Street, Mineola, NY, 11501, USA
| | - Nicholas Sabatino
- Department of Obstetrics & Gynecology, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Bogdan Grigorescu
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics & Gynecology, NYU Long Island School of Medicine, 259 1st Street, Mineola, NY, 11501, USA.
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Devassy R, Devassy RR, de Wilde MS, Krentel H, Adlan A, Torres-de la Roche LA, De Wilde RL. The Future of Minimal-Access Myoma Surgery with In-Bag Contained Morcellation. J Clin Med 2023; 12:jcm12113628. [PMID: 37297823 DOI: 10.3390/jcm12113628] [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: 11/15/2022] [Revised: 02/27/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023] Open
Abstract
Contained electromechanical morcellation has emerged as a safety approach for laparoscopic myomatous tissue retrieval. This retrospective single-center analysis evaluated the bag deployment practicability and safety of electromechanical in-bag morcellation when used for big surgical benign specimens. The main age of patients was 39.3 years (range 21 to 71); 804 myomectomies, 242 supracervical hysterectomies, 73 total hysterectomies, and 1 retroperitoneal tumor extirpation were performed. A total of 78.7% of specimens weighed more than 250 g (n = 881) and 9% more than 1000 g. The largest specimens, weighing 2933 g, 3183 g, and 4780 g, required two bags for complete morcellation. Neither difficulties nor complications related to bag manipulation were recorded. Small bag puncture was detected in two cases, but peritoneal washing cytology was free of debris. One retroperitoneal angioleiomyomatosis and three malignancies were detected in histology (leiomyosarcoma = 2; sarcoma = 1); therefore, patients underwent radical surgery. All patients were disease-free at 3 years follow-up, but one patient presented multiple abdominal metastases of the leiomyosarcoma in the third year; she refused subsequent surgery and was lost from follow-up. This large series demonstrates that laparoscopic bag morcellation is a safe and comfortable method to remove large and giant uterine tumors. Bag manipulation takes only a few minutes, and perforations rarely occur and are easy to detect intraoperatively. This technique did not result in the spread of debris during myoma surgery, potentially avoiding the additional risk of parasitic fibroma or peritoneal sarcoma.
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Affiliation(s)
- Rajesh Devassy
- Department of Obstetrics and Gynecology, Minimal-Access Surgery & Oncology, Dubai London Clinic and Speciality Hospital, Dubai 3371500, United Arab Emirates
| | - Rohan Rajesh Devassy
- Faculty of Medicine, Kasturba Medical College, MAHE, Mangalore 575001, Karnataka, India
| | - Maya Sophie de Wilde
- University Hospital for Gynecology, Pius Hospital, University Medicine Oldenburg, 26121 Oldenburg, Germany
| | - Harald Krentel
- Clinic of Gynecology, Obstetrics, Oncology and Senology, Bethesda Hospital, 47053 Duisburg, Germany
| | - Aizura Adlan
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | | | - Rudy Leon De Wilde
- University Hospital for Gynecology, Pius Hospital, University Medicine Oldenburg, 26121 Oldenburg, Germany
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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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Mercorio A, Della Corte L, Vetrella M, Russo M, Serafino P, Palumbo M, Viciglione F, Cafasso V, Bifulco G, Giampaolino P. Uterine fibroids morcellation: a puzzle topic. MINIM INVASIV THER 2022; 31:1008-1016. [DOI: 10.1080/13645706.2022.2095872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Antonio Mercorio
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, Naples, Italy
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, Naples, Italy
| | - Martino Vetrella
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, Naples, Italy
| | - Mario Russo
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, Naples, Italy
| | - Paolo Serafino
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, Naples, Italy
| | - Mario Palumbo
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, Naples, Italy
| | - Francesco Viciglione
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, Naples, Italy
| | - Valeria Cafasso
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giuseppe Bifulco
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, Naples, Italy
| | - Pierluigi Giampaolino
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
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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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N o 371 - Le morcellement durant la chirurgie gynécologique: Son utilisation, ses complications et les risques liés à la présence de tumeurs malignes insoupçonnées. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 41:127-138. [PMID: 30580825 DOI: 10.1016/j.jogc.2018.11.017] [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: 11/23/2022]
Abstract
OBJECTIF La présente directive clinique conseille les gynécologues quant au recours au morcellement tissulaire pendant une chirurgie gynécologique. RéSULTATS: Le morcellement effectué au cours d'une chirurgie gynécologique peut permettre l'ablation de masses utérines volumineuses, offrant ainsi aux femmes une solution chirurgicale à effraction minimale. Les conséquences oncologiques indésirables du morcellement tissulaire devraient être atténuées par l'amélioration de la sélection des patientes, la tenue d'examens préopératoires et l'adoption de techniques novatrices réduisant au minimum la dispersion tissulaire. ÉVIDENCE: La littérature publiée a été récupérée au moyen de recherches menées dans PubMed et Medline au printemps 2014 à l'aide d'une terminologie contrôlée (« leiomyosarcoma », « uterine neoplasm », « uterine myomectomy », « hysterectomy ») et de mots-clés (« leiomyoma », « endometrial cancer », « uterine sarcoma », « leiomyosarcoma », « morcellation »). Les résultats retenus provenaient de revues systématiques, d'essais cliniques randomisés, d'essais cliniques contrôlés et d'études observationnelles de langue anglaise ou française. Aucune restriction de date n'a été imposée. Les recherches ont été refaites régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en juillet 2017. Nous avons également tenu compte de la littérature grise (non publiée) trouvée sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes liés aux technologies de la santé, dans des collections de directives cliniques et dans des registres d'essais cliniques, et obtenue auprès d'associations nationales et internationales de médecins spécialistes. VALEURS La qualité des données probantes a été évaluée en fonction des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, INCONVéNIENTS ET COûTS: Les gynécologues offrent aux femmes une chirurgie à effraction minimale pouvant comprendre le recours à un morcellateur électromécanique pour faciliter le retrait des tissus. Les femmes devraient être informées que l'utilisation d'un morcellateur en présence de tumeurs utérines (sarcomes, tumeurs endométriales), cervicales ou tubo-ovariennes jusque-là insoupçonnées est associée à un risque accru de dissémination. Le morcellement tissulaire devrait être précédé d'une évaluation complète, d'une sélection appropriée des patientes et de l'obtention du consentement éclairé de ces dernières, et devrait être effectué par des chirurgiens ayant une formation adéquate en matière de pratiques de morcellement tissulaire sûres. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Murji A, Scott S, Singh SS, Bougie O, Leyland N, Laberge PY, Vilos GA. No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 41:116-126. [PMID: 30580824 DOI: 10.1016/j.jogc.2018.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery. OUTCOMES Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. EVIDENCE Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation. SUMMARY STATEMENTS RECOMMENDATIONS.
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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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Schuttringer E, Beleche T. The impact of recent power morcellator risk information on inpatient surgery and patient outcomes. J Comp Eff Res 2019; 9:53-65. [PMID: 31840551 DOI: 10.2217/cer-2019-0093] [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] [Indexed: 11/21/2022] Open
Abstract
Aim: We examine the impact of the new risk information about a surgical device on surgery and patient outcomes for hysterectomy in the inpatient setting. Methods: We utilize a difference-in-differences approach to assess the impact of new risk information on patient outcomes in the inpatient setting between 2009 and 2014. The inpatient data come from a nationally representative sample of hospitalizations in the USA. We use the likelihood of laparoscopic surgery, measures of resource use and surgical complications as outcome variables. Results: We estimate a three-percentage point decrease in the likelihood of receiving laparoscopic hysterectomy, a one-percentage point increase in the likelihood of experiencing a surgical complication and no impact on resource use, relative to pre-existing means. Conclusion: Our findings show that there was movement away from laparoscopic surgery in the months following the dissemination of new risk information. These changes had limited effect on patient outcomes.
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Affiliation(s)
- Ehren Schuttringer
- Food & Drug Administration Office of the Commissioner, 10903 New Hampshire Ave, Silver Spring, Maryland, MD 20993, USA
| | - Trinidad Beleche
- Food & Drug Administration Office of the Commissioner, 10903 New Hampshire Ave, Silver Spring, Maryland, MD 20993, USA
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Parkash V, Fadare O. Endometrial Carcinoma: Grossing, Frozen Section Evaluation, Staging, and Sentinel Lymph Node Evaluation. Surg Pathol Clin 2019; 12:329-342. [PMID: 31097107 DOI: 10.1016/j.path.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This article gives an overview of the pathologic assessment of resection specimens removed for uterine carcinoma. Areas of controversy and recent developments in pathologic staging are addressed. This includes assessment of myometrial invasion in the setting of adenomyosis, fallopian tube involvement, and vascular invasion. An overview of the role and evaluation of sentinel node assessments in the staging of endometrial carcinoma is provided.
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Affiliation(s)
- Vinita Parkash
- Department of Pathology and Obstetrics and Gynecology, Yale School of Medicine, PO Box 208070, New Haven, CT 06510, USA.
| | - Oluwole Fadare
- Department of Pathology, Anatomic Pathology Division, University of California San Diego Health, 9300 Campus Point Drive, Suite 1-200, MC 7723, La Jolla, CA 92037, USA
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14
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Iatrogenic parasitic myoma and iatrogenic adenomyoma after laparoscopic morcellation: A mini-review. J Adv Res 2019; 20:1-8. [PMID: 31080671 PMCID: PMC6505034 DOI: 10.1016/j.jare.2019.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 02/05/2023] Open
Abstract
Parasitic myoma and adenomyoma are two different pathologies. Both diseases are iatrogenic conditions developed after morcellation. Each entity has different clinical and paraclinical findings. The common point of pathogenesis is morcellation. Both diseases may be avoided by using in-bag morcellation or by switching to other surgical procedures.
Laparoscopy is widely recognized as a procedure of choice for gynaecological surgery. Myomectomy and hysterectomy are the most frequently performed surgical procedures in gynaecology. A morcellator is often used in myomectomies or subtotal hysterectomies, but morcellation may cause rare complications, such as parasitic iatrogenic myoma or adenomyoma. To improve patient counselling, proper risk estimation as well as risk factor identification should be acknowledged. This article aimed to review the literature on parasitic myoma and adenomyoma and to compare these diseases in terms of clinical, surgical, and prognostic factors. All published literature (case series and case reports) on iatrogenic myoma and adenomyoma was reviewed using PubMed/MEDLINE and ScienceDirect resources. Despite both conditions having an iatrogenic origin, iatrogenic parasitic myoma and adenomyoma are two different entities in terms of clinical manifestations as well as intraoperative particularities, with a common point: iatrogenic complication. A possible solution to avoid these iatrogenic complications is by using in-bag morcellation or switching to another surgical procedure (e.g., a vaginal or abdominal approach). It is concluded that parasitic myoma and iatrogenic adenomyoma are two different iatrogenic morcellator-related complications. In patients with a history of uterus or myoma morcellation who report pelvic symptoms, iatrogenic parasitic myoma or adenomyoma should be considered in the differential diagnosis.
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15
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Devassy R, Cezar C, Krentel H, Verhoeven HC, Devassy R, de Wilde MS, Torres-de la Roche LA, de Wilde RL. Feasibility of myomatous tissue extraction in laparoscopic surgery by contained in – bag morcellation: A retrospective single arm study. Int J Surg 2019; 62:22-27. [DOI: 10.1016/j.ijsu.2018.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/07/2018] [Accepted: 12/18/2018] [Indexed: 12/24/2022]
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16
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Gerashchenko AV, Filonenko TG, Golubinskaya EP, Kalfa MA, Kriventsov MA. Morcellation-Induced Leiomyomatosis Peritonealis Disseminata: A Rare Case Report. IRANIAN JOURNAL OF MEDICAL SCIENCES 2019; 44:60-64. [PMID: 30666077 PMCID: PMC6330526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Leiomyomatosis peritonealis disseminata (LPD) is a benign disease characterized by the presence of multiple small nodules on the omentum, parietal, and visceral peritoneum. It corresponds to leiomyoma and often resembles metastases of malignant tumors; however, with favorable prognosis. Here we describe a 46-year-old woman, diagnosed with LPD, to demonstrate the etiopathogenesis of the developed leiomyomatosis following endoscopic extirpation of the uterus with the use of a power morcellator. The patient was operated for diffuse leiomyoma using a power morcellator. Six months later, during a follow-up visit, disseminated tumor nodes on the peritoneum were revealed. Histological and immunohistochemical (smooth muscle α-actin, vimentin, estrogen receptors, progesterone receptors, and Ki67) study confirmed the diagnosis of LPD. As part of the follow-up, certain regression of the tumor nodes was noted against the backdrop of the onset of menopause and the corresponding decline of estrogen levels. Currently, the prognosis is favorable and follow-up is ongoing. Such cases are rare, but the condition is particularly important due to its iatrogenic nature. It has attracted the attention of the Food and Drug Administration (FDA) because power morcellation is probably associated with the risk of spreading suspected cancerous tissue. The existing high risk of iatrogenic LPD formation indicates the need for detailed reporting of all similar clinical cases, including the established pathogenetic and pathomorphological mechanisms of this process to prevent morcellator-related complications.
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17
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Natural orifice transluminal endoscopic surgery (NOTES) subtotal hysterectomy: A feasibility study. Taiwan J Obstet Gynecol 2018; 57:355-359. [DOI: 10.1016/j.tjog.2018.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2017] [Indexed: 12/30/2022] Open
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18
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Gupta N, Mohling S, Mckendrick R, Elkattah R, Holcombe J, Furr RS, Boren T, DePasquale S. Perioperative outcomes of robotic hysterectomy with mini-laparotomy versus open hysterectomy for uterus weighing more than 250 g. J Robot Surg 2018; 12:641-645. [PMID: 29453729 DOI: 10.1007/s11701-018-0792-7] [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: 12/14/2017] [Accepted: 02/12/2018] [Indexed: 11/25/2022]
Abstract
To compare perioperative outcomes in patients undergoing robotic hysterectomy and extraction of specimen via mini-laparotomy (RHML) versus open hysterectomy (OH) when uterus weighs more than 250 g. To study the factors determining the length of hospital stay in 2 groups. A retrospective analysis of all hysterectomies performed for uterus weighing more than 250 g from the year 2012 to 2015 was conducted. A total of 140 patients were divided into 2 groups based on the type of surgery; RHML (n = 82) and OH (n = 58). Mini-laparotomy consisted of a customised incision connecting 2 left lateral port sites for specimen extraction after completing the hysterectomy robotically. Patient factors and perioperative outcomes were compared using Student's t tests and Chi-square analysis. Mean length of stay (RHML = 1.4 days; OH = 3.4 days), estimated blood loss (EBL) (RHML = 119.9 ml; OH = 547.5 ml) and operative time (RHML = 191.5 min; OH = 162.8 min) were significantly different. No significant differences were noted for patient BMI, age, comorbidities, intraoperative complications, pathology of uterus and uterus weight. Postoperative complications were significantly different between two groups (RHML = 6.0%; OH = 15.5%; p = .021). None of the patients stayed less than 24 h in OH group compared to 59.8% patients in RHML group. Type of procedure (p = .004) and EBL (p = .002) significantly predicted the length of stay. Patients undergoing RHML have significantly shorter length of stay, EBL and postoperative complications than OH. The operative time for RHML was longer than OH, but the overall decreased length of stay overcomes this disadvantage. RHML approach retains the benefits of da Vinci, while simultaneously preserving the specimen.
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Affiliation(s)
- Natasha Gupta
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA.
- Dept. of Obstetrics and Gynecology, Erlanger Health System, 979 E. 3rd Street, Suite C720, Chattanooga, TN, 37403, USA.
| | - Shanti Mohling
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
| | - Rebecca Mckendrick
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
- Department of Gynecologic Oncology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
| | - Rayan Elkattah
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
| | - Jenny Holcombe
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
- Department of Gynecologic Oncology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
| | - Robert S Furr
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
| | - Todd Boren
- Department of Gynecologic Oncology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
| | - Stephen DePasquale
- Department of Gynecologic Oncology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA
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20
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Sizzi O, Manganaro L, Rossetti A, Saldari M, Florio G, Loddo A, Zurawin R, van Herendael B, Djokovic D. Assessing the risk of laparoscopic morcellation of occult uterine sarcomas during hysterectomy and myomectomy: Literature review and the ISGE recommendations. Eur J Obstet Gynecol Reprod Biol 2018; 220:30-38. [DOI: 10.1016/j.ejogrb.2017.10.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW Controversy exists surrounding extraction of tissue in gynecologic surgery using morcellators following cases of disseminated uterine cancers discovered after the use of electromechanical morcellators. This chapter traces the history of tissue extraction in gynecology and reviews the evolving scientific data and opinions regarding the future of morcellation. RECENT FINDINGS Since the initial Food and Drug Administration warning about morcellation in 2014, subsequent studies do not support the Food and Drug Administration's high incidence of occult uterine cancer. Current research continues, focusing on methods of contained tissue morcellation, both laparoscopically and vaginally. SUMMARY Minimally invasive surgical techniques have revolutionized gynecology, drastically reducing the need for open procedures. To maximize patient safety while preserving the rapid recovery and low morbidity of laparoscopic and vaginal approaches, optimal methods of tissue extraction need to be developed and promulgated.
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22
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Katon JG, Gray K, Callegari L, Gardella C, Gibson C, Ma E, Lynch KE, Zephyrin L. Trends in hysterectomy rates among women veterans in the US Department of Veterans Affairs. Am J Obstet Gynecol 2017; 217:428.e1-428.e11. [PMID: 28578175 DOI: 10.1016/j.ajog.2017.05.057] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 05/09/2017] [Accepted: 05/23/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prior studies demonstrate a higher prevalence of hysterectomy among veterans compared with nonveterans. While studies identify overall decreasing hysterectomy rates in the United States, none report rates of hysterectomy among women veterans. Given the increasing numbers of women veterans using Veterans Affairs health care, there is an ongoing need to ensure high-quality gynecology care. Therefore, it is important to examine current hysterectomy trends, including proportion of minimally invasive surgeries, among veterans using Veterans Affairs health care. OBJECTIVE Our objective was to describe hysterectomy trends and utilization of minimally invasive hysterectomy in the Veterans Affairs healthcare system. STUDY DESIGN This longitudinal study used Veterans Affairs clinical and administrative data from fiscal year 2008 to 2014 to identify hysterectomies provided or paid for by Veterans Affairs. Crude and age-adjusted hysterectomy rates were calculated by indication (benign or malignant), mode (abdominal, laparoscopic, vaginal, robotic assisted, unspecified), and source of care (provided vs paid for by Veterans Affairs). Mode and indication for hysterectomy were classified using International Classification of Diseases, ninth revision, codes. The distribution of hysterectomy mode in each year was calculated by indication and source of care. RESULTS Between fiscal year 2008 and fiscal year 2014, the total hysterectomy rate decreased from 4.0 per 1000 to 2.6 per 1000 unique women veteran Veterans Affairs users. Age-adjusted rates of abdominal hysterectomy for benign indications decreased over the study period from 1.54 per 1000 (95% confidence interval, 1.40-1.69) to 0.77 per 1000 (95% confidence interval, 0.69-0.85) for procedures provided by Veterans Affairs and 0.77 per 1,000 (95% confidence interval, 0.69-0.85) to 0.29 per 1,000 (95% confidence interval, 0.23-0.34) for those paid for by Veterans Affairs. Among hysterectomies for benign indications provided by (n = 5296) or paid for (n = 2610) by Veterans Affairs, the percentage of hysterectomies performed abdominally decreased from 67.2% to 46.8% and from 68.9% to 57.6%, respectively. CONCLUSION These findings suggest that gynecology care provided within Veterans Affairs has kept pace with national trends in reducing hysterectomy rates and increasing utilization of minimally invasive surgical techniques.
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Affiliation(s)
- Jodie G Katon
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value Driven Care, US Department of Veterans Affairs, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Department of Health Services, University of Washington School of Public Health, Seattle, WA.
| | - Kristen Gray
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value Driven Care, US Department of Veterans Affairs, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Lisa Callegari
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value Driven Care, US Department of Veterans Affairs, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Department of Health Services, University of Washington School of Public Health, Seattle, WA; Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA
| | - Carolyn Gardella
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA; Veterans Affairs Puget Sound Healthcare System Medical Center, Seattle, WA
| | - Carolyn Gibson
- San Francisco Veterans Affairs Health Care System, San Francisco, CA; Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Erica Ma
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value Driven Care, US Department of Veterans Affairs, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kristine E Lynch
- Department of Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, UT; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Laurie Zephyrin
- Women's Health Services, Veterans Affairs Office of Patient Care Services, Washington, DC; Department of Obstetrics and Gynecology, New York University Langone School of Medicine, New York, NY
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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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Regarding "Incidence of Occult Uterine Malignancy Following Vaginal Hysterectomy with Morcellation". J Minim Invasive Gynecol 2017; 25:186. [PMID: 28797658 DOI: 10.1016/j.jmig.2017.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 11/22/2022]
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