Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review

OBJECTIVE

To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint.

DATA SOURCES

PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible.

METHODS OF STUDY SELECTION

This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy.

TABULATION, INTEGRATION, AND RESULTS

The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss.

CONCLUSION

Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021233300.

Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries.

DATA SOURCES

PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included.

METHODS

Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals.

RESULTS

Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures.

CONCLUSION

Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

Surgical Education for the Twenty-first Century: Beyond the Apprentice Model

Traditionally, surgery has been taught by an apprentice model, where the learner imitates the actions of a skilled mentor. Although effective, this model is inefficient because it requires learners to be exposed to a large number of surgeries performed by a limited number of dedicated teaching faculty. In addition, competence is proved with subjective evaluations. Because of changes in modern medical practice, specifically reimbursement issues, resident work hour restrictions, and need for reliable and valid credentials, the critical components of the apprentice model are eroding. A paradigm shift is needed in modern surgical education.

Histologic evaluation of human cadaveric fascia lata in a rabbit vagina model

The purpose of this study was to evaluate the histologic response of human cadaveric fascia lata after vaginal implantation. Freeze-dried, gamma-irradiated cadaveric fascia lata from three lots was implanted between the rectovaginal membrane and vaginal epithelium in New Zealand white rabbits. Rabbits were killed at 2, 4, 8, and 12 weeks after implantation. At necropsy, gross findings were described and specimens for routine cultures were taken. Histologic evaluation determined graft integrity, neovascularization, inflammatory response, and host tissue incorporation. Nine rabbits were available for histologic analysis and 14 for gross and microbiologic analysis. Vaginal erosions occurred with three grafts. The remainder were adherent to the surrounding tissues. Erosion was associated with bacterial colonization of the graft. Autolysis of one graft occurred at 4 weeks. Over time, the inflammatory response decreased and neovascularization increased; by 12 weeks, the graft collagen was replaced by host collagen. Cadaveric fascia lata serves as scaffolding for host tissue incorporation with replacement by host collagen.

Further characterization of the supine empty stress test for predicting low valsalva leak point pressures

The aim of this study is to determine if the diagnostic accuracy of the supine empty stress test (SEST) differs depending on the volume of residual urine. We performed a review of all patients who were diagnosed with stress urinary incontinence (SUI) via multi-channel urodynamics including valsalva leak point determinations (VLPP). A SEST was performed and the residual urine recorded via catheterization. The test-specific indices of the SEST for the prediction of low VLPP (defined as <60 cm H(2)0) were determined for varying residual volumes. Ninety-nine patients were included. Regardless of residual volume, low sensitivities, specificities and positive predictive values were demonstrated. Sensitivity and positive predictive values were further reduced and negative predictive values were improved slightly with higher residual volume. The highest negative predictive value was 89% at a residual volume of greater than 10 mL. Residual urine volume has minimal impact on the utility of the SEST.

Changes in tensile strength of cadaveric human fascia lata after implantation in a rabbit vagina model

PURPOSE

We determined changes in tensile properties after vaginal implantation of human cadaveric fascia lata.

MATERIALS AND METHODS

Baseline tensile properties were determined for freeze-dried, gamma irradiated human cadaveric fascia lata from 3 separate lots. Fascial strips (2 x 0.5 cm.) from 2 lots were implanted between the rectovaginal membrane and vaginal mucosa in New Zealand white rabbits. The strips were excised en bloc 12 weeks after implantation. Tensile property measurements were repeated and compared with pre-implantation values.

RESULTS

Pre-implantation interlot and intralot variability in baseline tensile properties was significant. After implantation there was an approximate 90% decrease in tensile strength from baseline values. There was no gross evidence of graft autolysis.

CONCLUSIONS

The decrease in tensile strength of cadaveric fascial graft was significant after implantation in this model.

Electrochemical recognition of analytes using quaternary ammonium binaphthyl salts

The electrooxidation of quaternary ammonium binaphthyl salts is shown to proceed by a quasi-reversible one-electron process. The oxidation of an aza-crown ether substituted binaphthyl salt is affected by the presence of lithium and sodium ions in solution and there is shown to be a linear relationship between the limiting current for the process and the concentration of Li+ and Na+. The electrochemistry of the binaphthyl salt is also shown to be affected by the addition of organic cations to the solution, showing that these receptors could form the basis of analytical devices which could be made specific to a range of analytes.

Does hysterectomy without adnexectomy in patients with prior tubal interruption increase the risk of subsequent hydrosalpinx?

OBJECTIVE

Our purpose was to examine the hypothesis that hysterectomy without adnexectomy after tubal interruption is associated with the development of hydrosalpinx.

STUDY DESIGN

In this case-control study, patients with a pathologic diagnosis of hydrosalpinx were compared with a group of patients undergoing adnexectomy without a hydrosalpinx. The incidence of prior tubal interruption followed by hysterectomy in the two groups was compared.

RESULTS

There was a statistically significant association between the development of hydrosalpinx and a history of hysterectomy after tubal interruption. Nine of 38 cases and 2 of 45 controls had a history of tubal interruption (odds ratio 6.67, P =.019).

CONCLUSIONS

Patients undergoing hysterectomy who have had a tubal interruption may be at risk for the development of hydrosalpinx because this combination of procedures results in a segment of tube that is blocked at both ends. If further study bears out this association, consideration should be given to performing salpingectomy at the time of hysterectomy even if the ovaries are being left behind.

Variability of reported techniques for performance of the pubovaginal sling procedure

The aim of this study was to determine the commonly used techniques for sling surgery. A questionnaire was distributed to the attendees at the 20th Annual Scientific Meeting of the American Urogynecologic Society. Techniques addressed included the type and length of the graft material, the fixation point, and the methods of sling tensioning. Type of training and monthly surgical volume was also determined. Sixty-five gynecologic and urologic surgeons responded to the survey, the majority of whom were fellowship-trained urogynecologists (68%). The median monthly operative experience was 8 anti-incontinence procedures, including 3.5 pubovaginal slings. There was wide inter-respondent variability in all techniques except fixation point. There was also large intra-respondent variability in sling technique: 42% reported the use of differing graft materials, 19% noted using differing graft lengths, and 19% employed variable tensioning methods. Type of training and operative experience did not predict surgical technique(s) or consistency. Our conclusion was that there is wide variability in the techniques of sling performance.

Electrochemical recognition of chiral species using quaternary ammonium binaphthyl salts

The use of ephedrine-substituted quaternary ammonium binaphthyl salts as molecular receptors is demonstrated. The electrochemical oxidation of the receptor is affected by the binding of an analyte in solution. The binding site on the binaphthyl salt has been determined using computer modeling and confirmed using 1D and 2D NMR studies. It is shown that the sensitivity of the receptor is related to the size of the analyte. Axially chiral binaphthyl salts are shown to bind chiral analytes in a different manner and this is demonstrated using lactic and mandelic acid. The presence of a polar functional group on the analyte is also shown to have an effect on the guest-host interaction.

Surgical management of stress urinary incontinence: consideration for an algorithmic approach

Stress urinary incontinence is defined as the symptomatic loss of urine related to increases in intra-abdominal pressure. A variety of nonsurgical therapies with varying degrees of effectiveness and patient acceptance are available. If nonsurgical therapies fail, then multiple surgical options exist, including retropubic urethropexy, bulking agents, pubovaginal slings, and sling variants. A surgical algorithm based on the amount of anterior vaginal wall prolapse (including urethrovesical mobility) and urethral sphincter function utilizing these procedures is reported herein.

Perioperative changes in serum creatinine after gynecologic surgery

OBJECTIVE

The purpose of this study was to prospectively determine the normal range of postoperative changes in serum creatinine levels when bilateral ureteral patency was confirmed by cystoscopy.

STUDY DESIGN

A total of 187 consecutive patients who had undergone major gynecologic surgery were evaluated prospectively. All patients had undergone perioperative cystoscopy to evaluate for ureteral patency, and creatinine levels had been determined before and 24 hours after surgery.

RESULTS

The mean change in serum creatinine level was 0.01 mg/dL, and the changes for the central 95% ranged from -0.2 to 0.3 mg/dL. With a previously defined cutoff value of an increase of >0.2 mg/dL after operation to indicate ureteral obstruction, specificity and negative predictive values (when compared with cystoscopic findings) were 98% and 100%, respectively.

CONCLUSION

Creatinine levels change minimally during the immediate postoperative period in the absence of ureteral compromise. If bilateral ureteral patency was demonstrated after operation in our population, creatinine level elevations were always <0.3 mg/dL.

Laparoscopic versus open Burch retropubic urethropexy: comparison of morbidity and costs when performed with concurrent vaginal prolapse repairs

OBJECTIVE

The purpose of this study was to determine the morbidity and cost that are associated with laparoscopic and open Burch retropubic urethropexy when they are performed with concurrent vaginal prolapse repairs.

STUDY DESIGN

We conducted a retrospective study of all patients who had undergone laparoscopic (n = 76) or open (n = 143) Burch retropubic urethropexy with at least 1 concurrent vaginal repair for symptomatic prolapse. We compared demographic data, level of prolapse, operative and postoperative details, medical and surgical histories, complications, and hospital charges.

RESULTS

The group with open retropubic urethropexy had an older age, greater degree of prolapse, fewer concurrent hysterectomies, and a greater number of vaginal procedures than the group with laparoscopic retropubic urethropexy. There were minimal differences in complications and no differences in the estimated blood loss, operative time, hemoglobin change, hospitalization, or hospital charges between the 2 groups.

CONCLUSION

Traditional benefits of laparoscopic retropubic urethropexy were not apparent when vaginal prolapse repairs were performed.

Harvesting autologous fascia lata for pelvic reconstructive surgery: techniques and morbidity

OBJECTIVE

To determine donor site morbidity associated with harvesting of fascia lata.

STUDY DESIGN

We reviewed medical records and evaluated responses to mailed questionnaires from all patients who underwent fascia lata harvesting during a 54-month period. Data were collected about immediate complications and long-term morbidity related to the donor site.

RESULTS

The study comprised 71 patients. Immediate postoperative complications were limited to 1 (1%) hematoma that required drainage, 2 (3%) seromas, and 5 (7%) cases of cellulitis that required oral antibiotics. Questionnaire response rate was 77%, with a mean follow-up of 25 months. Of the responders, 22 (40%) reported mild symptoms, 3 (5%) reported clinically significant symptoms related to the donor leg, and 7 (13%) expressed dissatisfaction because of unacceptable cosmesis (n = 5), leg discomfort (n = 5), or both.

CONCLUSION

There was little immediate postoperative morbidity. Although many patients may be expected to report long-term symptoms related to the donor leg, these symptoms are generally mild, and the incidence of patient dissatisfaction is relatively low.

Electrochemical recognition of charged species using quaternary ammonium binaphthyl salts

The effects of ionic analytes on the electrochemical properties of quaternary ammonium binaphthyl salts are described in this work. The stability of the binaphthyl radicals and hence the reversibility of the electrochemical response are discussed in terms of molecular structure. The ability of azacrown derivatised binaphthyl salts to act as amperometric receptors is ascribed to the strain imparted in the cyclic ammonium ring when Li+ ions complex with them. It is also shown that the redox properties of quaternary ammonium binaphthyl salts are pH dependent in aqueous solutions, but that reversible redox properties can be observed in extremely basic solutions. The effect of anions binding to the quaternary ammonium cation can be seen in the redox properties of the binaphthyl moiety and the use of a chiral binding site for enantiomeric recognition is also demonstrated.

Endometriosis: correlation between histologic and visual findings at laparoscopy

OBJECTIVE

The purpose of this study was to correlate the diagnosis of endometriosis on the basis of visualization at laparoscopy with the pathologic diagnosis.

STUDY DESIGN

A prospective study of 44 patients undergoing laparoscopy for the evaluation of chronic pelvic pain was carried out. All areas suggestive of endometriosis were excised and examined pathologically. Peritoneal biopsy specimens were obtained from areas of normal-appearing peritoneum to rule out microscopic endometriosis. All lesions were identified by anatomic site. Visual and histologic American Fertility Society scores were compared. The positive predictive value, sensitivity, negative predictive value, and specificity were determined for visually identified endometriosis versus the histologic correlate.

RESULTS

The mean prevalence of abnormalities visually consistent with endometriosis was 36%, with 18% confirmed histologically. The positive predictive value was 45%; sensitivity, 97%; negative predictive value, 99%; and specificity, 77%; for visual versus histologic diagnosis of endometriosis. Thirty-six percent of the diagnoses were downstaged on the basis of histologic findings.

CONCLUSION

A diagnosis of endometriosis should be established only after histologic confirmation.

Laparoscopic radical parametrectomy and pelvic and aortic lymphadenectomy for vaginal carcinoma: A case report

OBJECTIVE

The objective of this study was to examine the feasibility of laparoscopic radical parametrectomy after previous hysterectomy.

METHODS

This was a prospective study of a patient with vaginal adenocarcinoma after previous simple hysterectomy. The technique of radical parametrectomy with vaginectomy and pelvic and aortic lymphadenectomy as used for open cases for years was performed laparoscopically.

RESULTS

The operating time was 270 min, the estimated blood loss was 200 mL, and the duration of hospitalization was 3 days. There were no intraoperative or postoperative complications.

CONCLUSIONS

Radical parametrectomy with vaginectomy and pelvic and aortic lymphadenectomy can be successfully accomplished laparoscopically.

Contralateral pelvic and aortic lymph node metastasis in clinical stage I epithelial ovarian cancer

Bilateral pelvic and aortic node lymphadenectomy is recommended for clinically localized unilateral epithelial ovarian adenocarcinoma (International Federation of Gynecologists and Obstetricians stage IA). The laterality of nodal metastasis in clinical stage I disease is rarely documented in the literature. Some authors have reported that ipsilateral node dissection is adequate for staging. A patient with contralateral pelvic and aortic lymph node metastasis and clinical stage I epithelial ovarian adenocarcinoma is presented. Pathologic findings were consistent with contralateral-only lymph node metastasis. This case illustrates the importance of bilateral lymph node sampling for appropriate staging of clinically localized epithelial ovarian cancer.