Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward?

Endometriosis is a chronic debilitating disease that affects nearly 10% of women of the reproductive age. Although the treatment modalities of endometriosis are numerous, surgical excision of the endometriotic implants and nodules remains the sole cytoreductive approach. Laparoscopic excision of endometriosis was proven to be beneficial in improving the postoperative pain and fertility. Moreover, it was also proved to be safe and efficient in treating the visceral localization of deep endometriosis, such as urinary and colorectal endometriosis. More recently, robotic-assisted surgery gained attention in the field of endometriosis surgery. Although the robotic technology provides a 3D vision of the surgical field and 7-degree of freedom motion, the safety, efficacy, and cost-effectiveness of this approach are yet to be determined. With this paper, we aim to review the available evidence regarding the role of robotic surgery in the management of endometriosis along with the current practices in the field.

The Feasibility of Practical Training in Minimally Invasive Surgery at Medical School-A Prospective Study on the Pelvitrainer

Background and Objectives: The acquisition of practical skills at medical school is an important part of the multidimensional education program of future physicians. However, medical schools throughout the world have been slow in incorporating practical skills in their curriculum. Therefore, the aims of the present prospective study were (a) to demonstrate the feasibility of such surgical training, (b) to objectify its benefit in medical education, and (c) to investigate the impact of such training on subsequent career choices. Material and Methods: We introduced a two-day laparoscopy course on the pelvitrainer as part of the curriculum of the gynecological internship of fifth year medical students from 2019 to 2020. The results of the students' training were matched to those of surgeons who completed the same curriculum in a professional postgraduate laparoscopy course from 2017 to 2020 in a comparative study design. Additionally, we performed a questionnaire-based evaluation of the impact of the course on medical education and subsequent career choices directly before and after completing the course. Results: A total of 261 medical students and 206 physicians completed the training program. At baseline, the students performed significantly more poorly than physicians in a median of three of four exercises (p < 0.001). However, this evened out in the final runs, during which students performed more poorly than physicians only in one exercise and even better than physicians in one. The general integration of surgical training in medical school curricula was rated very low (12.4% on the VAS, IQR 3-16%) despite the high demand for such training. In the survey, the course was deemed very beneficial for medical education (median VAS 80.7%, IQR 73-98%), but did not appear to influence the students' subsequent career preferences. Conclusions: The acquisition of practical surgical skills during medical school is significantly under-represented in many medical faculties. The benefits of such training, as demonstrated in our study, would improve the education of future physicians.

The Present and the Future of Medical Therapies for Adenomyosis: A Narrative Review

Uterine Adenomyosis is a benign condition characterized by the presence of endometrium-like epithelial and stromal tissue in the myometrium. Several medical treatments have been proposed, but still, no guidelines directing the management of adenomyosis are available. While a hysterectomy is typically regarded as the definitive treatment for adenomyosis, the scarcity of high-quality data leaves patients desiring fertility with limited conservative options. Based on the available data, the levonorgestrel-IUD appears to offer the most favorable outcomes. Other treatments, including GnRH antagonists, dienogest, prolactin, and oxytocin modulators, show promise; however, further data are required to establish their efficacy definitively. Furthermore, there are many emerging therapies that have been developed that seem worthy of consideration in the near future. The aim of this narrative review was to explore the current medical treatments available for adenomyosis and to provide a glimpse of future therapies under assessment. For this scope, we performed a literature search on PubMed and Medline from incept to September 2022 using the keywords: "medical treatment", "non-steroidal anti-inflammatory", "progesterone intrauterine device", "dienogest", "combined oral contraceptives", "gonadotropin releasing hormone agonist", "gonadotropin releasing hormone antagonist", "danazol", "aromatase inhibitors", "ulipristal acetate", "anti-platelet therapy", "dopamine", "oxytocin antagonists", "STAT3", "KRAS", "MAPK", "micro-RNA", "mifepristone", "valproic acid", "levo-tetrahydropalamatine", and "andrographolide". The search was limited to articles in English, with subsequent screening of abstracts. Abstracts were screened to select relevant studies.

Strategies and factors to maximize cost-effectiveness of robotic surgery in benign gynecological disease

Operating room procedures account for half of the gross hospital cost in the United States per annum. Hysterectomy is the eighth most common surgery nationally, with more than 300,000 cases every year. Since the introduction of robotic surgery in benign gynecology, concern has been raised regarding the increased cost without significant improvements in outcomes or practice. Surgeon volume, complication rates, length of hospital stay, and selected intraoperative instrumentation are all factors that have a direct effect on cost in robotic surgery. Cost is indirectly influenced by the OR team workflow, postoperative processes to expedite discharge, and converting surgery to the ambulatory setting. More research is needed to develop evidence-based practices for cost containment in robotic surgery.

Adenomyosis: An Updated Review on Diagnosis and Classification

Adenomyosis is a commonly diagnosed benign condition characterized by the presence of ectopic endometrial glands within the underlying myometrium. The most common presenting signs and symptoms are abnormal uterine bleeding, chronic pelvic pain, and infertility. The clinical relevance of this condition is evident in both medical and surgical care. Histopathology and imaging studies are used for the diagnosis and classification of adenomyosis, which are hallmarks of the advancement of our ability to diagnose adenomyosis. Importantly, the diagnosis and classification of adenomyosis lacks standardization due to the nature of imaging techniques, features of adenomyosis, and the clinical spectrum of adenomyosis. We reviewed the literature to summarize the available classification systems for adenomyosis and highlight the different imaging approaches and histologic criteria used in diagnosis. Despite the high prevalence of the disease, there is no clear consensus on one classification system. We provide a review of some of the classification systems available and discuss their strengths and limitations.

Eyes, menstruation and endometriosis

Vicarious menstruation refers to cyclical bleeding outside the uterine cavity during the menstrual cycle. Haemolacria, or blood in tears, is a rare medical phenomenon that can occur with menstruation or in association with endometriosis. Endometriosis, defined by the presence of endometrial-like tissue in extra-uterine sites, affects around 10% of fertile women; the ocular system is one of the rarest sites it can be present in. Endometriosis usually requires a biopsy for diagnosis, and the anatomic difficulty of obtaining a biopsy of the ocular system makes ocular endometriosis diagnosis more obscure. However, few cases have been described in the literature and due to the psychological, physical, and social implications of haemolacria on the patient, treatment is of utmost importance. We reviewed the literature on ocular endometriosis and ocular vicarious menstruation with the aim to discuss the clinical presentation, necessary workup and various treatment modalities, while also shedding light on the connection between the eyes and endometriosis in general. It is hypothesised that uterine endometrial cells can travel lymphatically or haematogenously and deposit extra-uterine endometriotic lesions that bleed in response to hormonal changes in the menstrual cycle. Additionally, the conjunctival vasculature has been found to be responsive to hormonal changes due to the presence of oestrogen and progesterone receptors, causing bleeding at the corresponding sites, even without endometriotic lesions. Clinical correlation of the haemolacria with the menstrual cycle can suffice for a diagnosis of vicarious menstruation, and thus opens the possibility of treatment to provide symptomatic treatment for the patient.

3D imaging reconstruction and laparoscopic robotic surgery: A winning combination for a 5 complex case of multiple myomectomy

3D imaging reconstruction can be valuable tool to improve the outcome of minimally invasive multiple myomectomy.

A stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage

OBJECTIVE

To propose a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage.

DESIGN

A narrated video footage of the surgical approach of a clinical case with extensive adenomyosis and recurrent abortions. Institutional review board approval was obtained (No 3.725.458).

SETTING

A university center.

PATIENT(S)

We present a case of a 37-year-old patient, gravida 4 para 0 with a history of 3 first trimester miscarriages after spontaneous pregnancies, and a 20-week spontaneous abortion after an in vitro fertilization pregnancy. She underwent 2 laparoscopic excisions of deeply infiltrative endometriosis and was treated with gonadotropin-releasing hormone for 6 months and dienogest for a year with no improvement of her adenomyosis. Currently, she experiences moderate dysmenorrhea and desires future fertility.

INTERVENTION(S)

For 3 months, gonadotropin-releasing hormone analogues were used before performing the robotic surgery for adenomyosis resection and abdominal cerclage. (Step 1) Control the blood supply with a tourniquet placed lateral to the uterine arteries at the level of the internal cervical os, and a diluted solution of vasopressin 20% is administered at the area to be excised. (Step 2) Uterine incision: we use a vertical uterine incision with monopolar scissors, extended anteriorly and posteriorly. (Step 3) Resection of adenomyosis: carried with monopolar scissors using pure cut current. It is recommended that 0.5-1 cm of the myometrium is maintained around the uterine cavity as well as the serosa. (Step 4) Flap 1: interrupted sutures with vicryl 2.0 are used to approximate the inner myometrium close to the endometrial cavity, and a 2.0 barbed suture is used to approximate the inner myometrium of the contralateral side of the incision to the ipsilateral outer myometrium. (Step 5) Flap 2: another 2.0 barbed suture is used to approximate the outer myometrium of the contralateral side to the base of the repaired inner myometrial layer. (Step 6) Serosal closure: the serosa is approximated with a barbed suture in a baseball fashion before the tourniquet is released and hemostasis is ensured. (Step 7) Abdominal cerclage: a mersilene tape is placed medial to the uterine arteries at the level of the internal cervical os and a tape is tied anteriorly.

MAIN OUTCOME MEASURE(S)

Description of a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage.

RESULT(S)

The operating time was 255 min with minimal estimated blood loss (250ml). She was discharged with no complaints. Three months postoperatively, dysmenorrhea significantly improved, and the magnetic resonance imaging showed a good anatomic result. An embryo transfer is planned at 6 months postoperatively.

CONCLUSION(S)

A minimally invasive approach to fertility-sparing management of diffuse adenomyosis is safe and feasible with good anatomical results. However, it should be noted that after the removal of uterine adenomyosis, the patient should be advised on the high risk of uterine rupture during pregnancy. Robotic cerclage may also be performed concomitantly in cases of 2nd-trimester recurrent abortions.

Improvement of Post-Operative Quality of Life in Patients 2 Years after Minimally Invasive Surgery for Pain and Deep Infiltrating Endometriosis

This study addressed the improvement in the quality of life of patients 2 years after minimally invasive surgery for painful deep infiltrating endometriosis (DIE), evaluated with EHP-5 (Endometriosis Health Profile-5) scores and the intensity of dysmenorrhea and dyspareunia. This was a retrospective study, performed in a referral centre for endometriosis, between January 2010 and January 2019. EHP-5 scores were complete for 54 patients, and two subgroups were analysed: classic laparoscopy (CL) vs. robotic laparoscopy (RL), and conservative surgery (ConservS) vs. total surgery (TS). There was an important decrease in 2-year post-operative EHP-5 scores in the global population (pre-op: 61.36 (42.18−68.75) and 2-year post-op: 20.45 (0−38.06); p < 0.001). The Visual Analogic Scale (VAS) was also lower for dysmenorrhea (pre-op: 8 (7−9.75) vs. 2-year post-op: 3 (2−5.25); p < 0.001) and dyspareunia (pre-op: 6 (3.1−8.9) vs. 2-year post-op: 3 (0−6); p < 0.001). In the subgroup analysis, EHP-5 scores were improved in the RL group (pre-op: 65.9 (59.09−71.02) vs. 2-year post-op: 11.4 (0−38.06); p < 0.001) and the CL group (pre-op: 50 (34.65−68.18) vs. 2-year post-op: 27.27 (14.20−40.90); p < 0.001), with a slight advantage for RL (p = 0.04), and the same improvements were found for ConservS (pre-op: 61.4 (38.06−71.59) vs. 2-year post-op: 22.7 (11.93−38.07); p < 0.001) and TS groups (pre-op: 61.59 (51.70−68.75) vs. 2-year post-op: 13.63 (0−44.30); p < 0.001). Minimally invasive surgery improved the quality of life for DIE patients 2 years after surgery, and conservative surgery showed comparable results to total surgery.

Association of Preoperative Enzian Score with Postoperative Fertility in Patients with Deep Pelvic Endometriosis

INTRODUCTION

Endometriosis is a chronic inflammatory disease with a negative impact on fertility. The Enzian classification provides a precise description of deep pelvic endometriotic lesions, especially in the retroperitoneal area, from preoperative pelvic MRI scans. However, it is not known if it is correlated with postoperative fertility.

STUDY OBJECTIVE

To determine if there is an association between the preoperative Enzian score and postoperative fertility after deep pelvic endometriosis surgery.

DESIGN

We conducted a descriptive, retrospective study using information from the ENDOREN database.

SETTING

This was a retrospective study at the Department of Obstetrics and Gynecology at Rennes University Hospital (France) from January 2013 to May 2019 PATIENTS AND INTERVENTIONS: We used information from the ENDOREN database that included all women who underwent surgery for deep endometriosis and wish to conceive. This surgery was intended in a view to achieve a complete removal of endometriosis.

MEASUREMENTS

The Enzian score was calculated from preoperative MRI scans, and total, spontaneous, and after In Vitro Fertilization (IVF) live births and pregnancies outcomes were collected from the patients'computerized medical records. Univariate and multivariate analysis was performed.

RESULTS

Sixty-eight patients were included. The live-birth rate was 35% (24/68). According to the Enzian classification, 25 patients (35%) were classified in compartment A, 64 patients (94%) in compartment B, and 27 (40%) in compartment C. In multivariate analysis, positive predictor of live birth was single Enzian B score (OR=4.7[1.21; 18.81], p=0.03), negative predictors were uterine adenomyosis and a history of endometriosis surgery. In multivariate analysis, positive predictor of spontaneous live birth was EFI score ≥7 (OR =22.434; CI [1.138; 442.190]). In multivariate analysis, positive predictor was Enzian A score (OR=15.9[2.2; 114.7], p=0.006), and negative predictors was uterine adenomyosis and Enzian B score (OR=0.01[0; 0.495], p=0.02) for live birth after IVF.

CONCLUSION

The present retrospective study cannot strongly conclude about fertility and correlation with Enzian score because the groups are too small. However, it seems that when solely the compartment B is involved by endometriosis, complete full removal of endometriosis leads to better post-operative live births results. Other studies must be done to determine if Enzian classification based on preoperative pelvic MRI could be clinical value in the decision-making strategy for managing infertile patients with deep pelvic endometriosis.

Robot-assisted Sacrocolpopexy for Recurrent Pelvic Organ Prolapse: Insights for a Challenging Surgical Setting

BACKGROUND

No consensus exists regarding the management of recurrent pelvic organ prolapse (POP). The aim of this study was to evaluate robot-assisted laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse (POP), and to investigate postoperative outcomes.

METHODS

We conducted a single-centre retrospective study including 10 consecutive patients who underwent a robot-assisted sacrocolpopexy for symptomatic POP recurrence from February 2017 to December 2019. Recurrence rates and patient satisfaction, measured by the Pelvic Floor Impact Questionnaire (PFIQ-7) were recorded.

RESULTS

Median age was 57 years (IQR: 54-67). No intraoperative complications were reported. The median hospital stay after surgery was 2 nights (IQR: 1-4). Two patients (20%) experienced early recurrence: at 1 month for one and at 4.5 months for the other. The median follow-up for the remaining eight patients was 18 months (IQR: 12-23). Among the recurrence-free patients, the median PFIQ-7 score was 11.4 at 12 months.

CONCLUSIONS

Robot-assisted sacrocolpopexy is feasible and safe for the management of POP recurrence, with a high patient satisfaction.

Adenomyosis and infertility

PURPOSE

Adenomyosis is a poorly understood entity with no unified treatment protocol. It has been thought to only affect the quality of life of older women, but growing evidence is highlighting the increased frequency of adenomyosis in younger patients and its possible effects on fertility outcomes. This can have a great impact on how clinicians screen, diagnose, and treat this condition. The aim of this review is to explore the relationship between adenomyosis and infertility.

METHODS

A literature search of the keywords "adenomyosis", "infertility", "pregnancy" and "fertility" was conducted using the PubMed and Medline search engines. The articles selected were observational, systematic reviews, meta-analyses, and randomized controlled trials. The search was limited to English, abstracts were screened, and articles were selected.

RESULTS

The literature reports lower clinical pregnancy rates, lower live birth rates, higher miscarriage rates, and higher odds of adverse obstetric outcomes in patients with adenomyosis. Treatment seems to be associated with higher pregnancy rates and live births rates.

CONCLUSION

An association between adenomyosis and infertility seems to exist, and treatment could lead to improved fertility outcomes.

Endometrioma and assisted reproductive technology: a review

PURPOSE

Endometriomas are a common cause of infertility necessitating assisted reproductive technology (ART). It had been previously thought that surgical removal of the endometriomas prior to ART would improve reproductive outcomes, but recent data suggests that surgical cystectomy might affect the ovarian reserve, decreasing the chances of ART success. The aim of this article is to review the literature on the effects of endometrioma surgery on ART outcomes providing an overview of the current evidence and assessing the need for further studies.

METHODS

A literature search was performed using PubMed and MEDLINE databases to identify studies that discuss endometriomas and assisted reproductive technology before versus after surgery.

RESULTS

In women with an endometrioma requiring ART, growing evidence suggests that surgery might result in damage to the ovarian reserve and further decrease chances of fertility. However, pregnancy rates, implantation rates, fertilization rates, and live birth rates seemed to be consistently similar across both groups.

CONCLUSION

The current evidence is inconclusive on whether endometriomas should be surgically removed prior to ART. Further large randomized controlled trials are needed for a definite answer, and until then, management should be individualized.

Trends and Perioperative Outcomes across Elective Benign Hysterectomy Procedures from the ACS-NSQIP 2007-2017

STUDY OBJECTIVE

In this study, we describe trends of all 3 routes of hysterectomy, patient demographics, and perioperative morbidity among women undergoing surgery for benign indications between 2007 and 2017. We also sought to compare the rates of extended length of stay (ELOS) and readmission rates among the laparoscopic, abdominal, and transvaginal routes.

STUDY DESIGN

A retrospective cohort study.

STUDY SETTING

National database study.

PATIENTS

The American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent an elective hysterectomy for benign indication between 2007 and 2017.

INTERVENTIONS

Patients were identified using Current Procedural Terminology codes and excluded if their indication for surgery included cancer and pelvic organ prolapse diagnoses based on International Classification of Diseases codes. The collected variables of interest included age, body mass index, American Society of Anesthesiologists classification, uterine weight of >250 grams, and operative time. Our outcomes of interest included ELOS and readmission within 30 days. ELOS was defined as a hospital admission of 2 days or more after laparoscopic and transvaginal hysterectomy and greater than 3 days for an abdominal hysterectomy. Summary statistics were used to evaluate shifts in patient characteristics and postoperative outcomes by hysterectomy route and year of surgery. Multivariable logistic regression analysis, stratified by year, comparing laparoscopic with transvaginal and abdominal hysterectomies was performed.

MEASUREMENTS AND MAIN RESULTS

There were 224 357 patients who met the inclusion and exclusion criteria. Of those, 132 567 (59.1%) underwent a laparoscopic hysterectomy, 30 105 (13.4%) a vaginal hysterectomy, and 61 685 (27.5%) an abdominal hysterectomy. The rate of laparoscopic hysterectomy increased by >200% between 2007 and 2017, whereas the rates of transvaginal and abdominal hysterectomies steadily decreased (-58% and -42%, respectively) The mean age, median obesity, and American Society of Anesthesiologists classification increased among women undergoing hysterectomy across all routes with the sharpest increase within the laparoscopic hysterectomy group (% increase in mean age [2.1%, 1.3%, 0.7%] and mean body mass index [9.1%, 4.3%, 3.7%] for laparoscopic, transvaginal, and abdominal routes, respectively). In 2017, the odds of ELOS were 29% lower for those who received laparoscopic than those who received abdominal hysterectomy (p <.001). Comparing the rates of readmission between the laparoscopic and abdominal hysterectomy groups shows that the odds of readmission are significantly lower for patients who receive a laparoscopic hysterectomy across all 11 years (p <.001).

CONCLUSION

The rates of laparoscopic hysterectomy have been steadily increasing over the past 11 years. This large retrospective study confirms the lowest rates of readmission and ELOS within the laparoscopic hysterectomy group despite the rising medical complexity of the patients.

Malnutrition is Associated with Poor Postoperative Outcomes Following Laparoscopic Hysterectomy

Background:

Malnutrition continues to be pervasive among the general population, with rates as high as 50% of patients undergoing surgical procedures. Data is limited about women undergoing surgery for non-malignant gynecologic indications (generally elective laparoscopic hysterectomies, after failed conservative measures). With the significant increase in benign gynecologic surgery, it is of the upmost importance that surgeons optimize modifiable risk factors for patients undergoing laparoscopic hysterectomy. The purpose of this study is to identify the impact of malnutrition on postoperative outcomes in patients undergoing laparoscopic hysterectomy for benign conditions.

Methods:

A retrospective cohort study was conducted utilizing data that was collected through the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) Database. All patients that underwent laparoscopic hysterectomy for benign indications were identified. Patients with malnutrition were identified by either low albumin (≤ 3.5 g/dL), low body mass index (≤ 18.5), or 10% weight loss within 6 months. The frequency of postoperative complications was evaluated with univariate and multivariate analyses where appropriate.

Results:

Following adjustment, multivariate analysis illustrated pre-operative malnutrition to be a risk factor for the following complications: any complication, death, bleeding requiring transfusion, wound, cardiac, pulmonary, renal, thromboembolic, sepsis complications, extended length of stay, and reoperation (p ≤ 0.05 for all).

Conclusion:

Malnourished patients were at significantly higher risk of developing postoperative complications during the acute postoperative period. With elective laparoscopic hysterectomies, pre-operative evaluation and intervention for malnutrition should be considered to improve nutritional status.

Lymphadenectomy in endometrial cancer - achieving more with less?

The lymph node status of patients with endometrial cancer is known to be a crucial determinant for the prognosis of the disease. It also provides the indication for further adjuvant treatment. The staging of endometrial cancer by surgery has been a controversial issue for more than 30 years. The significant complication rate after lymphadenectomy and the development of minimally invasive surgery have led to the use of sentinel lymph node (SLN) mapping. In the present review, we present the development of surgical staging procedures in patients with endometrial cancer and summarize the recently expanding body of published literature on the subject. SLN mapping is a safe and accurate technique, especially when indocyanine green is used as a tracer. SLN mapping appears to reduce complication rates as well as costs without affecting the oncologic outcome. Large prospective studies are needed to establish the effects of SLN mapping on the outcome of disease, especially in high-risk patients with endometrial cancer. Furthermore, the need for additional systematic lymphadenectomy prior to adjuvant radio-chemotherapy in patients diagnosed with isolated lymph node metastasis during SLN biopsy must be investigated further. This might pave the way for a new surgical approach in patients with endometrial cancer.

Black Women's Psychosocial Experiences with Seeking Surgical Treatment for Uterine Fibroids: Implications for Clinical Practice

INTRODUCTION

Black women are more likely to undergo surgery for uterine fibroids compared with non-Black women. However, few studies have characterized the psychosocial experiences of Black women seeking fibroid treatment. We aimed to identify factors that shape Black women's fibroid management decisions; explore how discrimination based on race, class, and gender feature in treatment-seeking experiences, and compare experiences across age and socioeconomic status.

METHODS

We conducted semistructured interviews with 37 Black women undergoing surgery for fibroid management. We used a thematic analysis to code transcripts and identify themes.

RESULTS

Participants were predominately single, college educated, and insured. Respondents reported that patient-doctor interactions, support from social networks, fertility consequences, and fear of fibroid malignancy influenced their fibroid management decisions. Knowledge and perceptions of fibroids were also influenced by community norms and differed by socioeconomic status; women of higher socioeconomic status had greater fibroid awareness than women of lower socioeconomic status. Discrimination was discussed in the context of historical inequity against Black women, with one participant questioning whether Black women were valued less in clinical settings compared with non-Black women. Although several women discussed positive experiences seeking fibroids care, others expressed medical mistrust or said that alternative management options were not offered by clinicians.

CONCLUSIONS

Fibroid management decisions were influenced not only by interactions with clinicians and social networks, and concerns about fertility and fibroid malignancy, but also by broader social and historical conditions. These findings suggest that clinicians should deliver intersectional gynecologic care that centers the voices of Black women seeking fibroid treatment.

Intraoperative tranexamic acid to decrease blood loss during myomectomy: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Myomectomy is associated with a significant risk of hemorrhage. Tranexamic acid is a synthetic lysine derivative with antifibrinolytic activity used in other surgical disciplines to reduce blood loss during surgery. However, its utility in gynecologic surgery is not well understood.

OBJECTIVE

This study aimed to determine the effect of early administration of intravenous tranexamic acid on perioperative bleeding and blood transfusion requirements in women undergoing myomectomy.

STUDY DESIGN

This study was a double-blinded, randomized, placebo-controlled trial conducted in an academic teaching hospital. Women with symptomatic fibroids thought to be at risk for large intraoperative blood loss who met the following criteria were included in the study: (1) at least 1 fibroid ≥10 cm, (2) any intramural or broad ligament fibroid ≥6 cm, and/or (3) at least 5 total fibroids based on preoperative imaging. Patients were randomized to receive a single intravenous bolus injection of tranexamic acid 15 mg/kg (intervention group) versus an intravenous bolus injection of saline of equivalent volume (placebo group) 20 minutes before the initial surgical incision. Perioperative bleeding was defined by measuring intraoperative estimated blood loss, change between pre- and postoperative hemoglobin, and frequency of blood transfusions. Estimated blood loss was calculated by combining the blood volume collected within the suction canister and the weight of used sponges. The 2 groups were compared for age; body mass index; perioperative hemoglobin and hematocrit; perioperative blood loss; duration of surgery; blood transfusion requirements; and the number, total weight, and volume of myomas removed.

RESULTS

A total of 60 patients (30 per arm) were enrolled into the study between March 1, 2015, and January 29, 2018. Age, body mass index, baseline hemoglobin and/or hematocrit, number and total weight of myomas removed, and size of myomas did not differ between arms. Of 60 patients, 32 (53%) had laparoscopic myomectomy, 24 (40%) had robotic myomectomy, and 4 (7%) had laparotomy. Median estimated blood loss was 200 mL for the tranexamic acid group and 240 mL for the placebo group (P=.88). There was no difference in median duration of surgery (165 vs 164 minutes; P=.64) or change in perioperative hemoglobin (1.00 vs 1.1 g/dL; P=.64). Patients in the tranexamic acid group did not require blood transfusions; however, 4 patients (13.3%) in the placebo group (P=.11) required blood transfusions.

CONCLUSION

Intravenous administration of tranexamic acid in patients undergoing laparoscopic or robotic myomectomies was not associated with decreased blood loss.

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes.

DATA SOURCES

We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications").

METHODS OF STUDY SELECTION

Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.

TABULATION, INTEGRATION, AND RESULTS

Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I² = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I² = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I² = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I² = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I² = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I² = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I² = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I² = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I² = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I² = 71%).

CONCLUSION

Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.

Pudendal Neurolysis: 6-Step Laparoscopic Approach

OBJECTIVE

To demonstrate the safety and feasibility of the laparoscopic approach to perform pudendal neurolysis in a case of pudendal nerve entrapment syndrome [1-3].

DESIGN

A video tutorial that highlights the laparoscopic steps to performing pudendal neurolysis, with a focus on the main anatomic landmarks [4,5].

SETTING

A tertiary care regional hospital.

INTERVENTIONS

This video shows a 6-step approach to laparoscopic pudendal neurolysis for the treatment of pudendal nerve entrapment between the sacrospinous and sacrotuberous ligaments [2,6-8]. Step 1: Identification of the umbilical artery. Step 2: Dissection and development of the lateral paravesical space until the pelvic floor. Step 3: Identification of the arcus tendineus of the endopelvic fascia. Step 4: Identification of the ischial spine and the sacrospinous ligament covered by the coccygeus muscle. Step 5: Coagulation and section of the coccygeus muscle and the sacrospinous ligament. Step 6: Medialization of the pudendal nerve until its entrance into the Alcock canal.

CONCLUSION

This video demonstrates the safety, feasibility, and reproducibility of laparoscopic pudendal neurolysis in 6 steps. A minimally invasive approach is adequate to treat the pudendal compression until the Alcock canal [2].

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

Surgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis.

DATA SOURCES

We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction.

METHODS OF STUDY SELECTION

Study Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted.

TABULATION, INTEGRATION AND RESULTS

Out of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18-0.63; I² = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09-0.51; I² = 0%; p  <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32-1.69; I² = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14-0.66; I² = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4-1.31; I² = 63%; p = .28).

CONCLUSION

Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.

Comparing benign laparoscopic and abdominal hysterectomy outcomes by time

BACKGROUND

While laparoscopic hysterectomy has benefits compared to abdominal hysterectomy, the operative times are longer. Longer operative times have been associated with negative outcomes. This study's purpose was to elucidate if there is an operative time at which 30-day outcomes for laparoscopic hysterectomy become inferior to a more expeditiously completed abdominal hysterectomy.

METHODS

This was a retrospective cohort study (Canadian Task Force classification II-2) using the American College of Surgeons National Surgical Quality Improvement Program database to identify women undergoing hysterectomy for benign indications from 2010 to 2016 by current procedural terminology code. Hysterectomy cases were stratified by approach and 60-min intervals. 30-day post-operative outcomes were analyzed by operative time and approach.

RESULTS

109,821 hysterectomies were included in our analysis, of which 66,560 (61%) were laparoscopic, and 43,261 (39%) were abdominal. In a multivariable logistic regression analysis comparing outcomes by surgical approach and operative time, there was no time combination in which patients who had a abdominal hysterectomy had significantly lower odds of the composite complications variable. This was true even in laparoscopic hysterectomies greater than 240 min compared to abdominal hysterectomies completed between 20 and 60 min. When compared to laparoscopic hysterectomies greater than 240 min, abdominal hysterectomies between 20 and 60 min had lower odds of sepsis and abdominal hysterectomies less than 180 min had lower odds of urinary tract infection.

CONCLUSION

Given that benefits persist even in prolonged cases, a laparoscopic approach should be offered to most patients undergoing benign hysterectomy. Surgical efficiency should be prioritized for any surgical approach.

Association of operative time with outcomes in minimally invasive and abdominal myomectomy

OBJECTIVE(S)

To determine the association of operative time (ORT) with perioperative morbidity and whether there is an ORT at which minimally invasive myomectomy becomes inferior to laparotomy.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Myomectomy cases identified by CPT code from 2005 to 2016.

INTERVENTION(S)

Cases were stratified and analyzed by surgical approach and 90-minute intervals.

MAIN OUTCOME MEASURE(S)

Thirty-day postoperative morbidity.

RESULT(S)

A total of 11,709 myomectomies were identified; 4,673 (39.9%) were minimally invasive, 6,997 (59.8%) were abdominal, and 39 (0.3%) were conversions. The incidence of complications significantly increased with ORT. After adjusting for confounders, mean ORT in minutes (95% confidence interval) was 113 (111-115) for abdominal, 156 (153-159) for minimally invasive, and 172 (148-200) for conversions. Despite shorter ORT, morbidity was greater in abdominal cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%). The minimally invasive approach in general had lower odds of complications (odds ratio, 0.23; 95% confidence interval, 0.19-0.26). However, when minimally invasive surgery ORT reached ≥ 270 minutes, the odds of a composite complication variable increased compared with abdominal cases <90 minutes (odds ratio, 2.30; 95% confidence interval, 1.69-3.13). Of minimally invasive cases, 88% were completed in <270 minutes.

CONCLUSION(S)

ORT was predictive of complications for both minimally invasive and abdominal myomectomies. Despite longer ORTs, minimally invasive procedures generally had superior 30-day outcomes up to 270 minutes. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach.

Predictors of Overnight Admission After Laparoscopic Myomectomy in a High-Volume Minimally Invasive Gynecologic Surgery Setting

STUDY OBJECTIVE

Our primary goal was to uncover preoperative and intraoperative risk factors that prevented same-day discharge (SDD) after myomectomy in a setting where SDD was the standard of care. Uncovered predictors would serve to enhance patient counseling and medical optimization before surgery.

DESIGN

Single-center retrospective cohort study.

SETTING

Urban university hospital center, by fellowship-trained minimally invasive gynecologic surgeons.

PATIENTS

A total of 315 consecutive patients undergoing minimally invasive myomectomy between March 2012 and May 2018.

INTERVENTION

Minimally invasive myomectomy.

MEASUREMENTS AND MAIN RESULTS

Preoperative and intraoperative characteristics were collected for analysis as predictors of SDD vs overnight admission. Comparisons of demographic, clinical, imaging, and operative characteristics were made using appropriate statistical methods for normally distributed, skewed, and categorical variables. Length of stay was analyzed as a categorical variable, SDD vs overnight admission. A logistic regression model was used to evaluate SDD vs any overnight stay. Out of the 315 patients undergoing laparoscopic myomectomy, 208 (66.03%) were discharged on the same day, and 107 (33.96%) were admitted for at least 1 day after surgery. The patients were more likely to be admitted overnight if they were of Asian ethnicity (p = .01), or if they had a lower preoperative Hct (36.15 vs 37.57; p < .003). An increase in any myoma characteristic metric was associated with overnight stay after surgery; these included mean myoma weight (512.0 g vs 310.1 g; p < .001), estimated size of the largest myoma on imaging (9.01 cm vs 7.77 cm; p < .001), and number of myomas removed (6.59 vs 5.57; p = .021). Other statistically significant differences between the overnight admission and SDD groups were mean estimated blood loss (599.4 mL vs 221.9 mL; p < .001), operative time (224.4 minutes vs 140.9 minutes; p < .001), and surgery end time (15:02 hours vs 12:43 hours; p < .001). Intraoperative complications associated with overnight admission were estimated blood loss >1 L (p < .001) and any intraoperative transfusion (p < .001). The adjusted logistic regression model identified an increase in operative time (by 60 minutes) and later surgery end time (by 60 minutes) as predictors of an overnight stay, whereas an 5% increase in preoperative hematocrit was associated with a 34% decrease in odds for an overnight stay.

CONCLUSION

Perioperative factors, such as preoperative hematocrit, and myoma characteristics, as well as intraoperative factors, such as prolonged operative time and surgery end-time, are independent predictors of overnight hospital admission after minimally invasive myomectomy. Our present data can be used to provide better patient counseling before surgery.

Effect of postoperative partial bladder filling after minimally invasive hysterectomy on postanesthesia care unit discharge and cost: a single-blinded, randomized controlled trial

BACKGROUND

Hysterectomy is one of the most common surgical procedures performed each year with substantial related health care costs. This trial studied the effect of postoperative bladder backfilling to submicturition level in the operating room and its effect on early postoperative patient care and related cost.

OBJECTIVE

The objective of the study was to compare the effect of bladder backfilling on early postoperative patient care and related cost.

STUDY DESIGN

This was a randomized, single-blinded, controlled trial conducted between April 2016 and February 2017 at a single urban university hospital providing tertiary care for minimally invasive gynecologic surgery. Ninety-one patients undergoing straight-stick laparoscopic and robot-assisted hysterectomy by minimally invasive gynecologic surgeons for benign indications were recruited. The bladder was partially backfilled with 150 mL of normal saline postoperatively in the intervention group and drained in the control group, as per standard of care. Main outcomes studied were time needed to void, time spent in the postanesthesia care unit, and postanesthesia care unit cost after minimally invasive hysterectomy. Our secondary outcomes were postoperative complications.

RESULTS

Forty-six patients (50.5%) were randomized to the intervention group, and 45 patients (49.5%) to the control group. Baseline comparative analysis of demographics and preoperative patient-specific variables, surgical history, intraoperative characteristics, and administered medications found the 2 groups to be largely homogenous. After regression analyses for adjustment, we found a significant reduction in the time needed to void, time spent in the postanesthesia care unit, and postanesthesia care unit-associated cost in the intervention group. Patients voided 64.9 minutes earlier than the control group (P = .015) ans spent 64 fewer minutes in the postanesthesia care unit (P = .006), resulting in $401.5 (USD) saving per patient (P = .006). None of the patients encountered any postoperative complications.

CONCLUSION

Based on the findings of this randomized clinical trial, postoperative bladder backfilling to submicturition level shortens the time needed for patients to void in the postanesthesia care unit, resulting in shorter postanesthesia care unit stay and resultant cost savings. Conservatively projecting our findings on minimally invasive hysterectomy procedure is estimated to result in $69 million to $139 million (USD) per year in savings. Initiating similar investigations in other ambulatory surgical fields will likely result in a more substantial impact.

Impact of Chronic Obstructive Pulmonary Disease on Laparoscopic Hysterectomy Outcome

Background and Objectives:

Limited research exists on the association between chronic obstructive pulmonary disease (COPD) and morbidity and mortality after laparoscopic hysterectomy. The objective of this study is to examine the following: 1) which demographics and comorbidities are most likely to present concurrently in patients with COPD? 2) Are patients with COPD undergoing laparoscopic hysterectomy at increased risk for development of postoperative complications within 30 days?

Methods:

Retrospective cohort study using data collected from 2007 to 2016 from the American College of Surgeons National Surgical Quality Improvement Program database. All patients who underwent laparoscopic hysterectomy were identified by Current Procedural Terminology codes and stratified based on COPD status. Univariate and multivariate analyses were completed to define odds ratios for postoperative complications within 30 days of laparoscopic hysterectomy.

Results:

This study included 100,518 laparoscopic hysterectomy patients (COPD = 1,130 [1.12%]); (no COPD = 99,388 [98.8%]). Patients with COPD developed more postoperative complications, including pneumonia, reintubation, renal insufficiency, and sepsis. COPD was identified as an independent risk factor for pneumonia (OR, 4.098; 95% CI, 2.222–7.519) and reintubation (OR, 4.348; 95% CI, 2.387–7.937). Patients with COPD had extended length of hospital stay.

Conclusion:

Patients with COPD who undergo laparoscopic hysterectomy have increased risk of experiencing postoperative pneumonia, reintubation, renal insufficiency, and sepsis. Overall, postoperative complication rates remain low, but gynecologists should consider the pulmonary disease status of patients when assessing preoperative risk.