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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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Sano R, Shiota M, Miyake T, Miyagi Y. Blunt Tipped Forceps Guided Bag Placement when Contained Power Morcellation is Performed for Laparoscopic and Robotic Surgery. Gynecol Minim Invasive Ther 2023; 12:181-182. [PMID: 37807991 PMCID: PMC10553603 DOI: 10.4103/gmit.gmit_27_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 10/10/2023] Open
Affiliation(s)
- Rikiya Sano
- Department of Gynecology, Miyake Ofuku Clinic, Okayama, Japan
| | - Mitsuru Shiota
- Department of Gynecologic Oncology, Kawasaki Medical School, Kurashiki, Japan
| | - Takahito Miyake
- Department of Obstetrics and Gynecology, Miyake Clinic, Okayama, Japan
| | - Yasunari Miyagi
- Department of Gynecology, Miyake Ofuku Clinic, Okayama, Japan
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Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series. Eur J Obstet Gynecol Reprod Biol 2023; 282:124-127. [PMID: 36708659 DOI: 10.1016/j.ejogrb.2023.01.015] [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: 10/26/2022] [Revised: 01/10/2023] [Accepted: 01/15/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Laparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH. STUDY DESIGN We report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients' characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery. RESULTS Patients' median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34-143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1-3) and no postoperative complications within 30 days from surgery were recorded. CONCLUSIONS LSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.
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Bryant-Smith A, Lowe J, Lam A. Getting square pegs out through round holes: A survey of Australian and New Zealand Gynaecologists regarding specimen retrieval. Aust N Z J Obstet Gynaecol 2022; 62:894-900. [PMID: 36225109 PMCID: PMC10092616 DOI: 10.1111/ajo.13618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate morcellation practices among Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). MATERIALS AND METHODS RANZCOG Fellows were invited to complete an online survey. This anonymous, cross-sectional survey consisted of 29 questions regarding demographics and morcellation practices. RESULTS Four hundred and thirty eight (19.04%) of 2300 RANZCOG Fellows responded, and of these 258 (11.22%) completed the entire survey; analysis was undertaken on data from the latter respondents. Respondents were broadly representative of all RANZCOG Fellows regarding gender, age, and location. Of the respondents, 53.10% considered themselves advanced laparoscopic surgeons. Of respondents who had worked as gynaecology consultants prior to 2014, 39.39% used uncontained power morcellation prior to 2014, compared to 17.58% since (a decrease of 44.63%). The most common reasons for utilising uncontained power morcellation less often were the 2014 Food and Drug Administration warnings (40.31%), risk of adverse outcomes (33.72%), and recommendations from colleges such as RANZCOG (27.13%). When undertaking an operation that required specimen extraction, the most common methods used were: employing an open approach from the get-go (utilised by respondents in 31.01% of such cases); contained manual morcellation (28.90%); and conversion to intra-operative laparotomy (10.10%). CONCLUSIONS There has been a strong trend away from uncontained power morcellation since 2014, with a 36.00% increase in clinicians who never use uncontained power morcellation, and an 80.65% decrease in clinicians who always use this method of specimen extraction. The most common reason cited for employing uncontained power morcellation less often was the 2014 Food and Drug Administration's warnings.
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Affiliation(s)
- Alison Bryant-Smith
- Centre for Advanced Reproductive Endosurgery, Sydney, Australia.,Royal Women's Hospital, Melbourne, Australia
| | - Jessica Lowe
- Centre for Advanced Reproductive Endosurgery, Sydney, Australia.,Concord Repatriation General Hospital, Sydney, Australia
| | - Alan Lam
- Centre for Advanced Reproductive Endosurgery, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
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Wright JD, Chen L, Melamed A, Clair CMS, Hou JY, Khoury-Collado F, Gockley A, Accordino M, Hershman DL, Xu X. Containment Bag Use Among Women Who Undergo Hysterectomy With Laparoscopic Power Morcellation. Obstet Gynecol 2022; 140:371-380. [PMID: 35926199 DOI: 10.1097/aog.0000000000004886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/19/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To estimate trends in use of laparoscopic power morcellators in women undergoing minimally invasive hysterectomy and to examine use of containment systems in these patients in relation to safety guidance from the U.S. Food and Drug Administration (FDA). METHODS We examined data that were recorded in the Premier Healthcare Database from patients who underwent laparoscopic supracervical hysterectomy from 2010 to 2018. Patients were stratified based on use of laparoscopic power morcellators. The cohort was further stratified as either pre-FDA guidance (2010 quarter 1-2014 quarter 1) or post-FDA guidance (2014 quarter 2-2018 quarter 2). Interrupted time series analyses were performed to determine the effect of FDA guidance on the use of laparoscopic power morcellators and containment bags. RESULTS Among 67,115 patients, laparoscopic power morcellator use decreased from 66.7% in 2013 quarter 4 to 13.3% by 2018 quarter 2. The likelihood of laparoscopic power morcellator use decreased by 9.5% for each quarter elapsed in the post-FDA warning period (risk ratio [RR] 0.91, 95% CI 0.90-0.91). Containment bag use rose from 5.2% in 2013 quarter 4 to 15.2% by 2018 quarter 2. The likelihood of containment bag use increased by 3% for each quarter elapsed in the post-FDA warning period (RR 1.03, 95% CI 1.02-1.05). Among women who had laparoscopic power morcellator use, uterine cancers or sarcomas were identified in 54 (0.17%) before the FDA guidance compared with seven (0.12%) after the guidance ( P =.45). Containment bags were used in 11.1% of women with uterine cancers or sarcomas before the FDA guidance compared with 14.3% after the guidance ( P =.12). The perioperative complication rate was 3.3% among women who had laparoscopic power morcellator use without a containment bag compared with 4.5% ( P =.001) in those with a containment bag (aRR 1.35, 95% CI 1.12-1.64). CONCLUSION Use of laparoscopic power morcellators has decreased over time. Containment bag use increased after the FDA's 2014 guidance; however, most procedures employing laparoscopic power morcellators are still performed without a containment bag.
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Affiliation(s)
- Jason D Wright
- Columbia University College of Physicians and Surgeons, the Joseph L. Mailman School of Public Health, Columbia University, the Herbert Irving Comprehensive Cancer Center, and NewYork-Presbyterian Hospital, New York, New York; and Yale University School of Medicine, New Haven, Connecticut
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Reactionary Medicine: The Unwarranted Demise of Power Morcellation. Obstet Gynecol 2022; 140:369-370. [PMID: 35926211 DOI: 10.1097/aog.0000000000004907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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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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Wu B, David G. Information, relative skill, and technology abandonment. JOURNAL OF HEALTH ECONOMICS 2022; 83:102596. [PMID: 35303551 DOI: 10.1016/j.jhealeco.2022.102596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/16/2022] [Accepted: 01/27/2022] [Indexed: 06/14/2023]
Abstract
We study the role of relative task-specific skill in explaining the heterogeneity in physicians' technology abandonment decisions in response to negative information shocks. We show that after an unexpected FDA safety warning on the use of minimally invasive hysterectomies, physicians alter their procedural mix towards open procedures and away from the minimally invasive procedures. This effect is less pronounced for physicians more skilled in performing minimally invasive procedures relative to open procedures, highlighting relative skill as an explanation for differential technology abandonment. Since physicians with higher relative skill are more likely to use minimally invasive procedures before the FDA safety communication, we find that the FDA intervention led to a substantial increase in practice variation across physicians with different relative skill levels. These findings are consistent with a theoretical model that predicts physicians' response to new information regarding the effectiveness of medical technology.
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Affiliation(s)
- Bingxiao Wu
- Department of Economics, Rutgers University, 75 Hamilton St, New Brunswick, NJ, 08901 USA.
| | - Guy David
- Department of Health Care Management, The Wharton School, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 305 Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA, 19104 USA.
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Roy M, Musa F, Taylor SE, Huang M. Uterine Sarcomas: How to Navigate an Ever-Growing List of Subtypes. Am Soc Clin Oncol Educ Book 2022; 42:1-10. [PMID: 35471831 DOI: 10.1200/edbk_350955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Uterine sarcomas are rare mesenchymal tumors that are aggressive cancers. The rarity of these tumors, and consequently limited prospective data, has made surgical management of uterine sarcomas challenging. One major obstacle in the management of uterine sarcomas is establishing the diagnosis prior to surgery, which is crucial for appropriate intraoperative management. This paper serves to review aspects of surgical management of uterine sarcomas that remain unanswered. Distinguishing common benign myomas from rare uterine sarcomas is important for operative planning and subspecialty care because benign myomas are frequently managed with minimally invasive hysterectomy or myomectomy, whereas the mainstay of management of uterine sarcomas is hysterectomy without specimen fragmentation. Preoperative clinical presentation, serum studies, imaging, and histologic examination all have limitations in establishing a preoperative diagnosis. In addition, patients are often of reproductive age and desire fertility preservation. Although surgery remains the cornerstone for management, high-quality data guiding best practices are sparse. Morcellation should be avoided. Expert pathologic review, imaging to assess for metastatic disease, and consideration of hormone receptor testing are advisable. Recent data have further informed surgical approach and fertility preservation in early-stage disease, but controversy remains. Despite substantial advancement in the medical management of uterine sarcomas, surgical management of uterine sarcomas remain challenging. Larger studies with long-term follow-up are needed to guide fertility preservation surgery options, both local resection and ovarian preservation, further in young women. Development of novel methods to differentiate between benign and malignant uterine masses is needed.
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Affiliation(s)
- Molly Roy
- Sylvester Comprehensive Center Cancer/University of Miami Miller School of Medicine, Miami, FL
| | | | | | - Marilyn Huang
- Sylvester Comprehensive Center Cancer/University of Miami Miller School of Medicine, Miami, FL
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Xu X, Desai VB, Schwartz PE, Gross CP, Lin H, Schymura MJ, Wright JD. Safety Warning about Laparoscopic Power Morcellation in Hysterectomy: A Cost-Effectiveness Analysis of National Impact. WOMEN'S HEALTH REPORTS 2022; 3:369-384. [PMID: 35415718 PMCID: PMC8994439 DOI: 10.1089/whr.2021.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/09/2022]
Abstract
Background: Following a 2014 safety warning (that laparoscopic power morcellation may increase tumor dissemination if patients have occult uterine cancer), hysterectomy practice shifted from laparoscopic to abdominal approach. This avoided morcellating occult cancer, but increased perioperative complications. To inform the national impact of this practice change, we examined the cost-effectiveness of hysterectomy practice in the postwarning period, in comparison to counterfactual hysterectomy practice had there been no morcellation warning. Materials and Methods: We constructed a decision tree model to simulate relevant outcomes over the lifetime of patients in the national population undergoing hysterectomy for presumed benign indications. The model accounted for both hysterectomy- and occult cancer-related outcomes. Probability-, cost-, and utility weight-related input parameters were derived from analysis of the State Inpatient Databases, State Ambulatory Surgery and Services Databases, data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry, and published literature. Results: With an estimated national sample of 353,567 adult women, base case analysis showed that changes in hysterectomy practice after the morcellation warning led to a net gain of 867.15 quality-adjusted life years (QALYs), but an increase of $19.54 million in costs (incremental cost-effectiveness ratio = $22,537/QALY). In probabilistic sensitivity analysis, the practice changes were cost-effective in 54.0% of the simulations when evaluated at a threshold of $50,000/QALY, which increased to 70.9% when evaluated at a threshold of $200,000/QALY. Conclusion: Hysterectomy practice changes induced by the morcellation warning are expected to be cost-effective, but uncertainty in parameter values may affect the cost-effectiveness results.
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Affiliation(s)
- Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vrunda B. Desai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- CooperSurgical, Inc., Trumbull, Connecticut, USA
| | - Peter E. Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Haiqun Lin
- Division of Nursing Science, Rutgers University School of Nursing, Newark, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Newark, New Jersey, USA
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, New York, USA
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Chikazawa K, Imai K, Ko H, Ichi N, Misawa M, Kuwata T. Risk factors associated with perineal and vaginal lacerations and vaginal removal in total laparoscopic hysterectomy. Gynecol Minim Invasive Ther 2022; 11:150-154. [PMID: 36158298 PMCID: PMC9491053 DOI: 10.4103/gmit.gmit_118_21] [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: 11/02/2021] [Revised: 02/10/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives: This study aimed to identify risk factors associated with perineal and vaginal lacerations related to vaginal removal during total laparoscopic hysterectomy (TLH). Materials and Methods: We retrospectively assessed 134 patients who underwent TLH, of whom 44 (32.8%) had vaginal lacerations. Results: Univariate analysis revealed that for patients with myomas and adenomyosis, gonadotropin-releasing hormone agonist use and myomas with a transverse diameter of ≥5 cm were significant risk factors, while multiparity (vaginal delivery) was a protective factor for perineal and vaginal lacerations. Moreover, multivariate analysis indicated that multiparity was the only statistically significant protective factor. For cervical intraepithelial neoplasia, endometrial cancer, and endometrial hyperplasia, only a uterine transverse diameter of ≥5 cm was a significant risk factor for perineal or vaginal lacerations. Conclusion: For patients with large myomas, multiple vaginal delivery was a protective factor, and in patients with normal-sized uteri, a uterine transverse diameter of ≥5 cm was a risk factor for perineal or vaginal lacerations.
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What We Know about the Long-Term Risks of Hysterectomy for Benign Indication-A Systematic Review. J Clin Med 2021; 10:jcm10225335. [PMID: 34830617 PMCID: PMC8622061 DOI: 10.3390/jcm10225335] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/02/2021] [Accepted: 11/06/2021] [Indexed: 12/29/2022] Open
Abstract
Hysterectomy is the most common treatment option in women with uterine fibroids, providing definitive relief from the associated burdensome symptoms. As with all surgical interventions, hysterectomy is associated with risk of complications, short-term morbidities, and mortality, all of which have been described previously. However, information on the potential long-term risks of hysterectomy is only recently becoming available. A systematic literature review was performed to identify studies published between 2005 and December 2020 evaluating the long-term impact of hysterectomy on patient outcomes. A total of 29 relevant studies were identified. A review of the articles showed that hysterectomy may increase the risk of cardiovascular events, certain cancers, the need for further surgery, early ovarian failure and menopause, depression, and other outcomes. It is important to acknowledge that the available studies examine possible associations and hypotheses rather than causality, and there is a need to establish higher quality studies to truly evaluate the long-term consequences of hysterectomy. However, it is of value to consider these findings when discussing the benefits and risks of all treatment options with patients with uterine fibroids to allow for preference-based choices to be made in a shared decision-making process. This is key to ensuring that patients receive the treatment that best meets their individual needs.
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Anapolski M, Schellenberger A, Alkatout I, Panayotopoulos D, Gut A, Soltesz S, Schiermeier S, Papathemelis T, Noé GK. Preclinical safety testing and initial experience of a morcellation bag with four sealable ports. Sci Rep 2021; 11:20882. [PMID: 34686761 PMCID: PMC8536670 DOI: 10.1038/s41598-021-99934-1] [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: 04/13/2021] [Accepted: 09/30/2021] [Indexed: 11/09/2022] Open
Abstract
Electromechanical morcellation-so called power morcellation-is a minimally invasive approach to remove bulky lesions such as uterine fibroids. The spread of benign and malignant tissue due to morcellation is a major concern that might limit the use of laparoscopic interventions. We present an in vitro evaluation of the safety characteristics of a four-port endobag with closable trocar sleeves, and describe physical properties of the bag that may or may not allow passage through the hole. In addition, we report our preliminary experience of this tool when used for laparoscopic supracervical hysterectomies. The behavior of the endobag during the extraction process was analyzed by extracting opened and re-sealed bags filled with 20 ml blue dye solution through a wooden template, with incisions measuring 10 to 24 mm. The endobag was used in 50 subtotal hysterectomies during the morcellation procedure. In the in vitro test, no dye loss was recorded for incisions measuring 11-24 mm. The mean force required to pull the bag through the template was inversely proportional to incision size. No bag rupture occurred during the surgical procedures. The mean time taken to prepare the bag for morcellation was 7.1 min (range, 4-14 min), the mean duration of subtotal hysterectomy was 53.4 min (range, 20-194 min). The mean weight of the removed body of the uterus was 113.8 g (range, 13-896 g), the mean weight of tissue and fluid remaining in the bag after morcellation 7.9 g (range, 0-39 g). In the in vitro setting, the improved endobag signifies greater patient safety during bag extraction, along with less tissue traumatization due to a smaller incision in the abdominal wall. The improved ergonomic features of the bag permit the insertion of three trocars in the lower abdomen and avoid closure of unused access ports. Our preliminary experience has shown that the device can be used under routine conditions. Failure rates will be evaluated in future studies.
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Affiliation(s)
- Michael Anapolski
- Department of Obstetrics and Gynecology, Community Hospital Dormagen, University of Witten-Herdecke, Dr.-Geldmacher-St. 20, 41540, Dormagen, Germany.
| | | | - Ibrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Alexander Gut
- Department of Obstetrics and Gynecology, Community Hospital Grevenbroich, Grevenbroich, Germany
| | - Stefan Soltesz
- Department of Anesthesiology, Community Hospital Dormagen, Dormagen, Germany
| | - Sven Schiermeier
- Department of Obstetrics and Gynecology, University Witten-Herdecke, Witten, Germany
| | - Thomas Papathemelis
- Department of Obstetrics and Gynecology, St. Marien Hospital Amberg, Amberg, Germany
| | - Günter K Noé
- Department of Obstetrics and Gynecology, Community Hospital Dormagen, University of Witten-Herdecke, Dr.-Geldmacher-St. 20, 41540, Dormagen, Germany
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Parker W, Siedhoff M, Pritts E. Regarding "Comparison of the Number of Spindle Cells in Peritoneal Washings between Laparoscopic Myomectomy with Morcellation and Open Myomectomy without Morcellation". J Minim Invasive Gynecol 2021; 28:2089. [PMID: 34662741 DOI: 10.1016/j.jmig.2021.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 11/18/2022]
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Tyan P, Hawa N, Carey E, Urbina P, Chen FR, Sparks A, Amdur R, Moawad G. Trends and Perioperative Outcomes across Elective Benign Hysterectomy Procedures from the ACS-NSQIP 2007-2017. J Minim Invasive Gynecol 2021; 29:365-374.e2. [PMID: 34610464 DOI: 10.1016/j.jmig.2021.09.714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Paul Tyan
- Capital Women's Care (Drs. Tyan and Hawa), Leesburg, Virginia.
| | - Nadim Hawa
- Capital Women's Care (Drs. Tyan and Hawa), Leesburg, Virginia
| | - Erin Carey
- Division of Minimally Invasive Gynecologic Surgery, University of North Carolina Chapel Hill (Dr. Carey), Chapel Hill, North Carolina
| | | | - Frank R Chen
- Department of Anesthesiology, Hospital of the University of Pennsylvania (Dr. Chen), Philadelphia, Pennsylvania
| | | | | | - Gaby Moawad
- Division of Minimally Invasive Gynecologic Surgery (Dr. Moawad), George Washington University Health Science Center, Washington, District of Columbia
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Neis F, Reisenauer C, Kraemer B, Wagner P, Brucker S. Retrospective analysis of secondary resection of the cervical stump after subtotal hysterectomy: why and when? Arch Gynecol Obstet 2021; 304:1519-1526. [PMID: 34453213 PMCID: PMC8553675 DOI: 10.1007/s00404-021-06193-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/14/2021] [Indexed: 12/26/2022]
Abstract
Purpose The rates of hysterectomy are falling worldwide, and the surgical approach is undergoing a major change. To avoid abdominal hysterectomy, a minimally invasive approach has been implemented. Due to the increasing rates of subtotal hysterectomy, we are faced with the following questions: how often does the cervical stump have to be removed secondarily, and what are the indications? Methods This was a retrospective, single-centre analysis of secondary resection of the cervical stump conducted from 2004 to 2018. Results Secondary resection of the cervical stump was performed in 137 women. Seventy-four percent of the previous subtotal hysterectomy procedures were performed in our hospital, and 26% were performed in an external hospital. During the study period, 5209 subtotal hysterectomy procedures were performed at our hospital. The three main indications for secondary resection of the cervical stump were prolapse (31.4%), spotting (19.0%) and cervical dysplasia (18.2%). Unexpected histological findings (premalignant and malignant) after subtotal hysterectomy resulted in immediate (median time, 1 month) secondary resection of the cervical stump in 11 cases. In four patients, the indication was a secondary malignant gynaecological disease that occurred more than 5 years after subtotal hysterectomy. The median time between subtotal hysterectomy and secondary resection of the cervical stump was 40 months. Secondary resection of the cervical stump was performed vaginally in 75.2% of cases, laparoscopically in 20.4% of cases and abdominally in 4.4% of cases. The overall complication rate was 5%. Conclusion Secondary resection of the cervical stump is a rare surgery with a low complication rate and can be performed via the vaginal or laparoscopic approach in most cases. The most common indications are prolapse, spotting and cervical dysplasia. If a secondary resection of the cervical stump is necessary due to symptoms, 66.6% will be performed within the first 6 years after subtotal hysterectomy.
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Affiliation(s)
- Felix Neis
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany.
| | - Christl Reisenauer
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany
| | - Bernhard Kraemer
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany
| | - Philipp Wagner
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany
| | - Sara Brucker
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany
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Abstract
ABSTRACT Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.
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Xu X, Desai VB, Wright JD, Lin H, Schwartz PE, Gross CP. Hospital variation in responses to safety warnings about power morcellation in hysterectomy. Am J Obstet Gynecol 2021; 224:589.e1-589.e13. [PMID: 33359176 DOI: 10.1016/j.ajog.2020.12.1207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/17/2020] [Accepted: 12/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes. OBJECTIVE This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy. STUDY DESIGN This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions. RESULTS Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72). CONCLUSION Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.
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Affiliation(s)
- Xiao Xu
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT.
| | - Vrunda B Desai
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Medical Affairs, CooperSurgical, Inc, Trumbull, CT
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Haiqun Lin
- Division of Nursing Science, School of Nursing, Rutgers University, Newark, NJ
| | - Peter E Schwartz
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Cary P Gross
- Internal Medicine, Yale School of Medicine, New Haven, CT; Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT
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19
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Preoperative MRI and LDH in women undergoing intra-abdominal surgery for fibroids: Effect on surgical route. PLoS One 2021; 16:e0246807. [PMID: 33561167 PMCID: PMC7872248 DOI: 10.1371/journal.pone.0246807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Our institution implemented a preoperative protocol to identify high-risk cases for which power morcellation should be avoided. MATERIAL AND METHODS In this retrospective cohort study, an institutional protocol requiring preoperative Magnetic Resonance Imaging with diffusion-weighted imaging and serum Lactate Dehydrogenase levels was implemented. Chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. RESULTS A total of 1,085 women were included, 479 before and 606 after implementation of the Magnetic Resonance Imaging / Lactate Dehydrogenase protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p = 0.022) and women using tamoxifen (2% vs. 0%, p = 0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of open surgery for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (open hysterectomy rate was 19% vs. 16% in pre- and post-protocol groups, respectively, P = 0.463, and open myomectomy rate was 10% vs. 9% rates in pre- and post-protocol groups, respectively, P = 0.776). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p<0.001) and an increased use of containment bags (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of women who had abnormal Magnetic Resonance Imaging / and Lactate Dehydrogenase results, abnormal Magnetic Resonance Imaging results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal Magnetic Resonance Imaging and Lactate Dehydrogenase tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal Lactate Dehydrogenase results alone did not influence route. CONCLUSIONS Rates of MIS procedures were decreased for women with abnormal preoperative Magnetic Resonance Imaging results. False positive results appear to be one of the main drivers for the use of an open surgical route.
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Advantages of, and Adaptations to, Enhanced Recovery Protocols for Perioperative Care during the COVID-19 Pandemic. J Minim Invasive Gynecol 2020; 28:481-489. [PMID: 33359742 PMCID: PMC7833787 DOI: 10.1016/j.jmig.2020.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/20/2022]
Abstract
Objective This review formulates the rationale for using enhanced recovery protocols (ERPs) to standardize and optimize perioperative care during this high-risk time to minimize poor outcomes owing to provider, patient, and system vulnerabilities. Data Sources n/a Methods of Study Selection A literature review using key Medical Subject Headings terms was performed—according to methods described by the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines—on studies that described enhanced recovery and coronavirus disease (COVID-19). Tabulation, Integration, and Results Modifications to our existing ERPs related to the COVID-19 pandemic should include new accommodations for patient education, preoperative COVID-19 testing, prehabilitation, and intraoperative infection as well as thromboembolism risk reduction. Conclusion ERPs are evidence-based, best practice guidelines applied across the perioperative continuum to mitigate surgical stress, decrease complications, and accelerate recovery. These benefits are part of the high-value–care equation needed to solve the clinical, operational, and financial challenges of the current COVID-19 pandemic. The factors driving outcomes on ERPs, such as the provision of minimally invasive surgery, warrant careful consideration. Tracking patient outcomes and improving care in response to outcomes data are key to the success of clinical care protocols such as ERPs. Numerous emerging clinical registries and reporting systems have been activated to provide outcomes data on the impact of COVID-19. This will inform and change surgical practice as well as provide opportunity to learn if the advantages that surgeons, patients, and the healthcare system might gain from using ERPs during a pandemic are meaningful.
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Mynbaev OA, Sparic R, Stark M, Malvasi A, Marinelli E, Zaami S, Tinelli A. The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective. Curr Pharm Des 2020; 26:318-325. [PMID: 32013843 DOI: 10.2174/1381612826666200204093737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/27/2020] [Indexed: 12/23/2022]
Abstract
Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.
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Affiliation(s)
- Ospan A Mynbaev
- Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russian Federation
| | | | - Michael Stark
- Department of Obstetrics and Gynecology, GVM Care & Research Santa Maria Hospital, Bari, Italy. Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russian Federation
| | - Antonio Malvasi
- Clinical Centre of Serbia, Clinic for Gynecology and Obstetrics, and University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Enrico Marinelli
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, "Veris delli Ponti" Hospital, Scorrano, Lecce, Italy
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Abstract
This study aimed to assess the prevalence and occult rates of uterine leiomyosarcoma (ULMS) in women with smooth-muscle tumors undergoing gynecological surgery. A retrospective study was performed at an academic cancer center from 2008 to 2015. Patients undergoing either hysterectomy or myomectomy via laparoscopic, abdominal, vaginal, and hysteroscopic approaches were identified with the validated pathology diagnosis of either ULMS or leiomyomas. All patients initially operated at our institute were included and reviewed. The prevalence and occult rates of ULMS were calculated and compared between different age groups.Twenty-eight patients with original ULMS were identified in 9556 gynecological surgeries. The prevalence of overall and occult ULMS in our study was 0.25% (1 in 345 patients) and 0.07% (1 in 1429 patients). The proportion of occult in all ULMSs was 25%. The prevalence rates of overall ULMS were 0.21%, 0.13%, 0.52%, 2.12%, and 6.67% in the 30 to 39, 40 to 49, 50 to 59, 60 to 69, and ≥70-year age groups, respectively. There was a significantly increased risk of ULMS after 50 years of age. The prevalence rates of occult ULMS were 0.05%, 0.08%, and 0.12% for the 30 to 39, 40 to 49, and 50 to 59 year age groups, respectively. There was no statistically significant difference among age the groups. The prevalence of ULMS was 0.41% and 0.16% for solitary and multiple tumor masses, respectively. Patients with solitary uterine tumors were at a significantly increased risk of ULMS (OR = 2.601, 95% CI = 1.108-6.141).Our retrospective data in part reflects the clinical characteristics of overall and occult ULMS and forms the basis for further prevention of occult ULMS.
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Affiliation(s)
- Lingxiang Wang
- Department of Gynecology
- Cancer Institute, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Hebei, China
| | - Shumei Li
- Cancer Institute, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Hebei, China
| | | | | | - Baoen Shan
- Cancer Institute, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Hebei, China
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Chang OH, Ferrando CA. Occult Uterine Malignancy at the Time of Sacrocolpopexy in the Context of the Safety Communication on Power Morcellation by the FDA. J Minim Invasive Gynecol 2020; 28:788-793. [PMID: 32681994 DOI: 10.1016/j.jmig.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE The objective of this study was to determine the incidence of occult uterine malignancy at the time of sacrocolpopexy with concurrent hysterectomy, in the context of practice pattern changes as a result of the 2014 Food and Drug Administration (FDA) power morcellation safety communication. DESIGN Retrospective chart review. SETTING Tertiary care referral center in the United States. PATIENTS A total of 839 patients who underwent sacrocolpopexy from January 2004 to December 2018. INTERVENTIONS All patients received a concurrent hysterectomy without a diagnosis of suspected or confirmed gynecologic malignancy before surgery. Trends of surgeries were compared before and after the 2014 FDA power morcellation safety communication. MEASUREMENTS AND MAIN RESULTS Demographic and perioperative data were collected from the system-wide electronic medical record. Operative and pathology reports were reviewed to determine the method of specimen retrieval and specimen pathology results. A total of 238 patients (28.4%) had a hysterectomy at the time of sacrocolpopexy. There were no cases of occult uterine malignancy (0%, 95% CI 0%-1.6%). There was 1 case of borderline tumor of the ovary. The most common mode of hysterectomy over the 15-year period was laparoscopic hysterectomy (n = 84, 35.3%), followed by vaginal hysterectomy (n = 63, 26.5%). After the FDA communication, the most common form of hysterectomy changed significantly to vaginal hysterectomy (n = 35, 55.6%; p <.001). When comparing the first 2 years after the announcement (2014-2016) to the subsequent 2 years (2017-2018), there was again a significant increase in the use of laparoscopic hysterectomy in the latter time period (7.3% vs 40.9%; p <.001). CONCLUSION In this cohort of patients undergoing sacrocolpopexy with concurrent hysterectomy, the incidence of occult uterine malignancy was low. After the FDA safety communication, practice patterns with regard to the mode of hysterectomy changed, but the magnitude of these changes were transient.
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Affiliation(s)
- Olivia H Chang
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio (all authors)..
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio (all authors)
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MacKoul P, Danilyants N, Touchan F, van der Does LQ, Haworth LR, Kazi N. Laparoscopic-assisted myomectomy with uterine artery occlusion at a freestanding ambulatory surgery center: a case series. ACTA ACUST UNITED AC 2020; 17:7. [PMID: 32565764 PMCID: PMC7296894 DOI: 10.1186/s10397-020-01075-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/02/2020] [Indexed: 12/17/2022]
Abstract
Background Non-hysteroscopic myomectomy is infrequently performed in a freestanding ambulatory setting, in part due to risks of intraoperative hemorrhage. There are also concerns about increased surgical risks for morbidly obese patients in this setting. The purpose of this study is to report the surgical outcomes of a series of laparoscopic-assisted myomectomy (LAM) cases at a freestanding ambulatory surgery center (ASC), including a comparative analysis of outcomes in morbidly obese patients (BMI > 40 kg/m2). Methods A retrospective comparative analysis was performed of 969 women, age 18 years or older, non-pregnant, who underwent LAM by one of two high volume, laparoscopic gynecologic surgical specialists at a freestanding ambulatory surgery center serving the Washington, DC area, between October 2013 and February 2019. Reversible occlusion was performed laparoscopically by placing a latex-based rubber catheter as a tourniquet around the isthmus of the uterus, causing a temporary occlusion of the bilateral uterine arteries. Permanent occlusion was performed laparoscopically via retroperitoneal dissection and uterine artery ligation at the origin of the anterior branch of the internal iliac artery. Minilaparotomy was performed for specimen removal in all cases. No power morcellation was used. Postoperative complications were graded using the Clavien-Dindo Classification system. Outcomes were compared across BMI categories using Pearson Chi-Square. Results Average myoma weight and size were 422.7 g and 8.3 cm, respectively. Average estimated blood loss (EBL) was 192.1 mL; intraoperative and grade 3 postoperative complication rates were 1.4% and 1.6%, respectively. While EBL was significantly higher in obese and morbidly obese patients, this difference was not clinically meaningful, with no significant difference in blood transfusion rates. There were no statistically significant intraoperative or postoperative complication rates across BMI categories. There was a low rate of hospital transfers (0.7%) for all patients. Conclusion Laparoscopic-assisted myomectomy can be performed safely in a freestanding ambulatory surgery setting, including morbidly obese patients. This is especially important in the age of COVID-19, as elective surgeries have been postponed due to the 2020 pandemic, which may lead to a dramatic and permanent shift of outpatient surgery from the hospital to the ASC setting.
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Affiliation(s)
- Paul MacKoul
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Natalya Danilyants
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Faraj Touchan
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Louise Q van der Does
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Leah R Haworth
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
| | - Nilofar Kazi
- The Center for Innovative GYN Care, 3206 Tower Oaks Blvd., Suite 200, Rockville, MD 20852 USA
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25
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Abstract
PURPOSE OF REVIEW This paper aims to review recent findings related to uterine morcellation. RECENT FINDINGS In 2014, the US Food and Drug Administration (FDA) issued a safety communication warning against the use of laparoscopic power morcellators. A risk of occult uterine sarcoma in women is 1/770 to 1/10,000. Our goal is to minimize the risk of spillage due to morcellation and balance it with other risks due to different surgical approaches. In case of a presence of sarcoma risk factors, any form of morcellation should be contraindicated. Power morcellation should be limited to myomectomies. In peri- and postmenopausal age, an endometrial biopsy is highly recommended before surgery with expected morcellation. It is important to explain to the patient the risks of morcellation and the risks and benefits of different surgical approaches. Finally, women should be informed that the prognosis of leiomyosarcoma is poor regardless of the method of removal.
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Affiliation(s)
- Michael J Halaska
- Department of Obstetrics and Gynaecology, Faculty Hospital Kralovske Vinohrady and 3rd Medical Faculty, Charles University in Prague, Šrobárova 1150/50, Praha 10, 100 34, Prague, Czech Republic.
| | - Myriam Gracia
- Gynaecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Rene Laky
- Division of Gynaecology, Medical University of Graz, Graz, Austria
| | - Ignacio Zapardiel
- Gynaecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
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Li ZJ, Jia ZX, Zheng YQ. A new technique for supracervical hysterectomy: Anterograde vaginal subtotal hysterectomy. Medicine (Baltimore) 2020; 99:e20006. [PMID: 32481265 PMCID: PMC7249868 DOI: 10.1097/md.0000000000020006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To review the results of a novel method of subtotal hysterectomy, called anterograde vaginal subtotal hysterectomy (AVSH), and to compare them with those of laparoscopic subtotal hysterectomy (LSH).We recruited 100 women with non-prolapsed uteruses and benign lesions of the uterus who required surgery. Of these, 60 underwent AVSH and 40 underwent LSH. Clinical data included average operation time, average volume of bleeding, postoperative anal exsufflation time, operative complications, average length of hospital stay and average hospital maintenance fee.There were no significant differences in terms of average operation time, average length of hospital stay, or operative complications between the AVSH and LSH groups. The AVSH group showed early postoperative anal exsufflation (P = .000), and had a low average hospital maintenance fee (P = .000). The AVSH group showed a higher perioperative bleeding volume than the LSH group (P = .001), which may be a result of the relatively amateur AVSH technique.AVSH is a minimally invasive, safe and feasible surgical procedure, with favorable early postoperative anal exsufflation and a low average hospital maintenance fee.
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Affiliation(s)
- Zi-Jun Li
- Department of Gynecology, ZheJiang QuHua Hospital, QuZhou, ZheJiang
| | - Zhen-Xiang Jia
- Department of Gynecology, Women and Children Hospital of TaiAn, TaiAn, ShanDong, China
| | - Ya-Qin Zheng
- Department of Gynecology, ZheJiang QuHua Hospital, QuZhou, ZheJiang
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Han AKW, Hong K, Kim M, Kim MK, Kim ML, Jung YW, Yun BS, Seong SJ. Unexpected uterine smooth muscle tumor of uncertain malignant potential and sarcoma: A single center cohort study in South Korea. Taiwan J Obstet Gynecol 2020; 59:275-281. [PMID: 32127150 DOI: 10.1016/j.tjog.2020.01.017] [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] [Accepted: 06/24/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the risk of encountering unexpected uterine smooth muscle tumors of uncertain malignant potential (STUMPs) or sarcomas during surgical treatment of mesenchymal tumors of the uterus using morcellation. MATERIAL AND METHODS Data were collected retrospectively from subjects who were pathologically diagnosed with uterine leiomyoma or its variants, STUMP or other premalignant mesenchymal tumors of uterus, or sarcoma during surgical treatment between July 2014 and June 2017. RESULTS A total of 3785 women were investigated; 2824 laparoscopic procedures (74.6%) were performed, and an electronic power morcellator was used in 1636 patients (43.2%). Sixteen women (0.42%) were diagnosed with STUMP and 14 (0.37%) were diagnosed with uterine sarcoma. The incidence rate of unexpected STUMP or uterine sarcoma was 0.61% (23 of 3785 women); unexpected STUMP in 13 (0.34%), and unexpected sarcoma was in 10 (0.26%). Moreover, the unexpected leiomyosarcoma rate was 0.08% (3 in 3785). The rate of unintended morcellation of STUMPs was relatively high at 0.26% (10 in 3785), however, that for uterine sarcomas was 0.05% (2 in 3785). CONCLUSION The risks of unintended morcellation were very low for sarcomas and STUMPs, although the risk of the latter was approximately 5-fold that of the former. To reduce the unintended dissemination of tumors, patients suspected of having malignancies should be provided adequate information regarding their treatment options as well as their associated risks. Meanwhile, improved preoperative screening methods for STUMP and sarcoma should be established.
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Affiliation(s)
- Anthony Kyung Woo Han
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Republic of Korea
| | - Kirim Hong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Republic of Korea
| | - Miseon Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Republic of Korea
| | - Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Republic of Korea
| | - Mi-La Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Republic of Korea.
| | - Yong Wook Jung
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Republic of Korea
| | - Bo Seong Yun
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Republic of Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul, Republic of Korea
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Odejinmi F, Aref-Adib M, Liou N, Sideris M, Mallick R. Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision? In Vivo 2020; 33:1393-1401. [PMID: 31471384 DOI: 10.21873/invivo.11616] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/24/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.
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Affiliation(s)
| | | | - Natasha Liou
- Whipps Cross Hospital, Barts Health NHS Trust, London, U.K
| | - Michail Sideris
- Women's Health Research Unit, Queen Mary University of London, London, U.K
| | - Rebecca Mallick
- Princess Royal Hospital, Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, U.K.
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Abstract
OBJECTIVE To characterize long-term national trends in surgical approach for hysterectomy after the U.S. Food and Drug Administration (FDA) warning against power morcellation for laparoscopic specimen removal. METHODS This was a descriptive study using data from the American College of Surgeons National Surgical Quality Improvement Program from 2012 to 2016. We identified hysterectomies using Current Procedural Terminology codes. We used an interrupted time-series analysis to evaluate abdominal and supracervical hysterectomy trends surrounding The Wall Street Journal article first reporting morcellation safety concerns and the FDA safety communication. We compared categorical and continuous variables using χ, t, and Wilcoxon rank sum tests. RESULTS We identified 179,950 hysterectomies; laparoscopy was the most common mode of hysterectomy in every quarter. Before The Wall Street Journal article, there was no significant change in proportion of abdominal hysterectomies (0.3% decrease/quarter, P=.14). After The Wall Street Journal article, use of abdominal hysterectomy increased 1.1% per quarter for two quarters through the FDA warning (P<.001), plateaued for three quarters until March 2015 (P=.65), then decreased by 0.8% per quarter through 2016 (P<.001). Supracervical hysterectomy volume continuously decreased after the FDA warning (1.0% decrease per quarter, P<.001) and after three quarters (0.7% decrease per quarter, P=.01), then plateaued from April 2015 through 2016 (0.05% decrease per quarter, P=.40). Mode of supracervical hysterectomy was unchanged from 2012 to 2013 (P=.43), followed by two quarters of significant increase in proportion of supracervical abdominal hysterectomies (11.7%/quarter, P<.001). This change in mode of supracervical hysterectomy then plateaued through 2016 (P=.06). CONCLUSION Despite early studies suggesting that minimally invasive hysterectomy decreased in response to safety concerns regarding power morcellation, we found that this effect reversed 1 year after the FDA safety communication. However, there was a sustained decline in supracervical hysterectomy, and the remaining supracervical hysterectomies were more likely to be performed using laparotomy.
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Racial Disparities in Response to a US Food and Drug Administration Safety Communication Regarding the Use of Power Morcellation for the Treatment of Uterine Leiomyoma. J Minim Invasive Gynecol 2020; 27:178-185.e1. [DOI: 10.1016/j.jmig.2019.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 12/26/2022]
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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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Herrinton LJ, Raine-Bennett T, Liu L, Alexeeff SE, Ramos W, Suh-Burgmann B. Outcomes of Robotic Hysterectomy for Treatment of Benign Conditions: Influence of Patient Complexity. Perm J 2019; 24:19.035. [PMID: 31905335 DOI: 10.7812/tpp/19.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Robotic hysterectomy may offer advantages for complex cases over the conventional laparoscopic approach. OBJECTIVE To assess the association of surgical approach (robotic vs conventional) with blood loss, risks of readmission, reoperation, complications, and average operative time. METHODS In a retrospective cohort study, we used the electronic medical records of Kaiser Permanente Northern California, 2011 to 2015, to estimate outcomes of robotic and conventional laparoscopic hysterectomy among women with complex or noncomplex benign disease. Mixed-effects regression models accounted for patient characteristics and surgeon volume. RESULTS The study included 560 robotic and 6785 conventional laparoscopic cases. Overall, 1836 patients (25%) met criteria for being complex. The average operative time was 152 minutes for robotic hysterectomy and 157 minutes for conventional laparoscopic hysterectomy (p < 0.0001). Complex surgical cases averaged 190 minutes and noncomplex cases averaged 144 minutes. The difference in operative time for high-volume surgeons treating complex patients with robotic hysterectomy vs conventional hysterectomy was 21 minutes faster (p < 0.05). After adjustment, the risk of blood loss at least 51 mL was lower for robotic surgery than for conventional surgery for complex and noncomplex patients. Other than risk of urinary tract complications, we observed no differences in the risks of complications or risk of reoperation between robotic and conventional laparoscopy for complex and noncomplex patients. CONCLUSION For women with complex disease, the robotic approach, when used by a higher-volume surgeon, may be associated with shorter operative time and slightly less blood loss, but not with lower risk of complications.
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Affiliation(s)
| | | | | | | | - Wilfredo Ramos
- Department of Obstetrics and Gynecology, Sacramento Medical Center, CA
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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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Lerner V, Ringel N, Meyer J, Bennett G, Boyd L. Magnetic Resonance Imaging to Rule out Leiomyosarcoma in Patients Undergoing Surgery for Leiomyomas: A Real World Experience in an Unenhanced Patient Population. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2019.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Veronica Lerner
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Nancy Ringel
- Department of Obstetrics and Gynecology, MedStar Health, Washington, DC
| | - Jessica Meyer
- Department of Obstetrics and Gynecology, New York University Langone Health, NewYork, NY
| | - Genevieve Bennett
- Department of Radiology, New York University Langone Health, NewYork, NY
| | - Leslie Boyd
- Department of Obstetrics and Gynecology, New York University Langone Health, NewYork, NY
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Purvis R, Voltzke K, Louie M, Moulder J. Disparity in Uterine Leiomyomata Care in Black Women in Years Prior to and After Adoption of the Affordable Care Act. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2019.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Rebecca Purvis
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kristin Voltzke
- University of North Carolina at Chapel Hill School of Public Health, Chapel Hill, NC
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janelle Moulder
- Department of Obstetrics and Gynecology, University of Tennessee (UT), Graduate School of Medicine/UT Medical Center Knoxville, Knoxville, TN
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Racial/Ethnic Disparities/Differences in Hysterectomy Route in Women Likely Eligible for Minimally Invasive Surgery. J Minim Invasive Gynecol 2019; 27:1167-1177.e2. [PMID: 31518712 DOI: 10.1016/j.jmig.2019.09.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 01/30/2023]
Abstract
STUDY OBJECTIVE Evaluate racial/ethnic variation in hysterectomy surgical route in women likely eligible for minimally invasive hysterectomy. DESIGN Cross-sectional study. SETTING Multistate including Colorado, Florida, Maryland, New Jersey, and New York. PATIENTS Women aged ≥18 years without diagnoses of leiomyomas, obesity, or previous abdominopelvic surgery who underwent hysterectomy for benign conditions from the State Inpatient and Ambulatory Surgery Databases, 2010-2014. INTERVENTIONS None. Primary exposure is race/ethnicity. MEASUREMENTS AND MAIN RESULTS Racial/ethnic variation in annual hysterectomy rates and surgical route. To calculate hysterectomy rates per 100 000 women/year, denominators were adjusted for the proportion of women with previous hysterectomy. A marginal structural log binomial regression model was used to estimate adjusted standardized prevalence ratios (aPRs) for vaginal or laparoscopic vs abdominal hysterectomy, controlling for clustering within hospitals. In addition, hospitals were stratified into quintiles to examine surgical route in hospitals that serve a higher vs lower proportion of African American patients. A total of 133 082 adult women underwent hysterectomy for benign conditions from 2010 to 2014. Annual laparoscopic rates increased more slowly for African Americans (1.6-fold) than for whites (1.8-fold) and Hispanics (1.9-fold). African American and Hispanic women were less likely to undergo vaginal (aPR = 0.93; 95% confidence interval [CI], 0.90-0.96 and aPR = 0.95; 95% CI 0.93-0.97, respectively) and laparoscopic hysterectomy (aPR = 0.90; 95% CI, 0.87-0.94 and aPR = 0.95; 95% CI, 0.92-0.98, respectively) than white women; Asian/Pacific Islander women were less likely to undergo vaginal hysterectomy (aPR = 0.88; 95% CI, 0.81-0.96). Hospitals serving a higher proportion of African American persons performed more abdominal and fewer vaginal procedures across all groups, and more racial/ethnic minority women sought care at those hospitals than white women. CONCLUSION African American, Hispanic, and Asian/Pacific Islander women eligible for minimally invasive hysterectomy were more likely than white women to receive abdominal hysterectomy. The proportion of all women undergoing abdominal hysterectomy was highest at hospitals serving higher proportions of African American persons. This difference in treatment type can lead to disparities in outcomes, in part owing to their association with complications.
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Xiao J, Zhang R, Teng Y, Liu B. Disseminated peritoneal leiomyomatosis following laparoscopic myomectomy: a case report. J Int Med Res 2019; 47:5301-5306. [PMID: 31500489 PMCID: PMC6997780 DOI: 10.1177/0300060519859137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Disseminated peritoneal leiomyomatosis (DPL) is a rare benign disease
characterized by tumors derived from smooth muscles throughout the abdominal
cavity. DPL has been reported following laparoscopic myomectomy or hysterectomy;
however, few reports have described DPL after abdominal myomectomy or
hysterectomy. In the present case, two intra-abdominal masses were incidentally
discovered on imaging during a routine medical checkup of a 45-year-old woman
who had undergone laparoscopic uterine myomectomy 10 years previously. The
masses were later found to be near the ascending colon and between the liver and
right kidney. A malignancy or stromal tumor was suspected, and the patient
underwent exploratory surgery. Histopathologic examination revealed that the
masses were leiomyomas. Considering the patient’s history of gynecologic
surgery, we believe that this was a rare case of DPL following laparoscopic
uterine myomectomy.
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Affiliation(s)
| | - Ruopeng Zhang
- Peking Union Medical College Hospital, Beijing, China.,Peking Union Medical College, Beijing, China
| | - Yue Teng
- Peking Union Medical College Hospital, Beijing, China.,Peking Union Medical College, Beijing, China
| | - Beizhan Liu
- Peking Union Medical College Hospital, Beijing, China
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Abstract
OBJECTIVE To estimate the prevalence of corpus uteri, cervix uteri, and ovarian malignancy in women undergoing hysterectomy or myomectomy for presumed benign indications. METHODS We conducted a secondary analysis of data from the 2014-2015 American College of Surgeons National Surgical Quality Improvement Program. Adult women undergoing hysterectomies and myomectomies without evidence for known or suspected cancer at the beginning of surgery were identified from the database. Our primary outcome measure was pathology-confirmed malignancy in the corpus uteri, cervix uteri, and ovary. We performed adjusted logistic regression analysis to examine the association of patient characteristics with the risk for malignancy. RESULTS Our sample included 24,076 women undergoing hysterectomy and 2,368 women undergoing myomectomy. Malignancy of the corpus uteri was found in 1.44% (95% CI 1.29-1.59%) of the women undergoing hysterectomy. The prevalence varied considerably across surgical routes with the rate being 0.23% (95% CI 0.06-0.58%) in laparoscopic supracervical hysterectomy and 1.89% (95% CI 1.65-2.14%) in total laparoscopic or laparoscopic-assisted vaginal hysterectomy. Older women were significantly more likely to have preoperatively undetected malignancy of the corpus uteri (adjusted odds ratio 6.46, 95% CI 4.96-8.41 for age 55 years or older vs age 40-54 years). Additionally, 0.60% (95% CI 0.50-0.70%) and 0.19% (95% CI 0.14-0.25%) of the women undergoing hysterectomy were found to have malignancy of the cervix uteri and the ovary, respectively. Among patients undergoing myomectomy, 0.21% (95% CI 0.03-0.40%) were found to have malignancy of the corpus uteri with no occult cervical or ovarian cancer identified. CONCLUSION Prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route.
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Rising From the Ashes: Minimally Invasive Surgery in the Wake of Power Morcellation. Obstet Gynecol 2019; 134:225-226. [PMID: 31348208 DOI: 10.1097/aog.0000000000003386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rey Valzacchi GM, Rosas P, Uzal M, Gil SJ, Viglierchio VT. Incidence of Leiomyosarcoma at Surgery for Presumed Uterine Myomas in Different Age Groups. J Minim Invasive Gynecol 2019; 27:926-929. [PMID: 31260748 DOI: 10.1016/j.jmig.2019.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/22/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE To evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups. DESIGN A retrospective cohort study. SETTING A tertiary referral hospital. PATIENTS All women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016. INTERVENTIONS Laparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS A total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%). CONCLUSION The incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe.
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Affiliation(s)
- Guido M Rey Valzacchi
- Department of Gynecology, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina.
| | - Patricio Rosas
- Department of Gynecology, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina
| | - Mariano Uzal
- Department of Gynecology, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina
| | - Santiago J Gil
- Department of Gynecology, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina
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Kajimura T, Sato S, Murakami A, Hayashi-Okada M, Nakashima K, Sueoka K, Sugino N. Overexpression of carbonyl reductase 1 inhibits malignant behaviors and epithelial mesenchymal transition by suppressing TGF-β signaling in uterine leiomyosarcoma cells. Oncol Lett 2019; 18:1503-1512. [PMID: 31423217 PMCID: PMC6607169 DOI: 10.3892/ol.2019.10429] [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: 11/27/2018] [Accepted: 05/22/2019] [Indexed: 12/31/2022] Open
Abstract
Carbonyl reductase 1 (CBR1) has been reported to be involved in cancer progression. Recently, we found that CBR1 overexpression inhibited malignant behaviors and the epithelial mesenchymal transition (EMT) in uterine cervical cancer. It remained unclear whether this was also the case in uterine leiomyosarcoma (uLMS), which is derived from mesenchymal cells and is a much more malignant gynecological tumor. A number of previous studies suggested that malignant behaviors are associated with EMT, even in mesenchymal malignant tumors. In the present study, we investigated whether CBR1 inhibits malignant behaviors and EMT in uLMS. We established clones of uLMS cells (SKN cells) and uterine sarcoma cells (MES-SA cells) that overexpressed CBR1. Cell proliferative, migratory and invasive activities were suppressed by CBR1 overexpression, accompanied by increases in the expressions of epithelial markers (E-cadherin and cytokeratin) and decreases in the expressions of mesenchymal markers (N-cadherin and fibronectin), suggesting that CBR1 overexpression inhibits malignant behaviors and EMT in uLMS cells. In addition, transforming growth factor-β (TGF-β) production and the subsequent signaling and phosphorylation of Smad were suppressed in the clones. To investigate the association between TGF-β and EMT, SKN cells were treated with TGF-β or a TGF-β receptor blocker (SB431542). EMT was promoted by TGF-β and inhibited by SB431542. In conclusion, this is the first study, to the best of the authors' knowledge, showing that CBR1 overexpression inhibits malignant behaviors and EMT in uLMS cells. The present study provided novel insight demonstrating that the suppressive effect of CBR1 is mediated through TGF-β signaling.
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Affiliation(s)
- Takuya Kajimura
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Shun Sato
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Akihiro Murakami
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Maki Hayashi-Okada
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Kengo Nakashima
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Kotaro Sueoka
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Norihiro Sugino
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
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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: 3] [Impact Index Per Article: 0.6] [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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Perioperative Antibiotic Use and Associated Infectious Outcomes at the Time of Myomectomy. Obstet Gynecol 2019; 133:626-635. [DOI: 10.1097/aog.0000000000003160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Shim SH, Suh JH, Park JE, Lee SJ, Lee JY, Kim SN, Kang SB. Predictors of 30-day morbidity after hysterectomy for benign disease. Int J Gynaecol Obstet 2019; 144:302-308. [PMID: 30578682 DOI: 10.1002/ijgo.12752] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/21/2018] [Accepted: 12/20/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the 30-day morbidity rate after hysterectomy for benign disease and identify predictors of 30-day morbidity. METHODS A retrospective study was conducted among women undergoing hysterectomy for benign indications between January 1, 2010, and December 31, 2015, at Konkuk University Hospital, South Korea. Multivariable regression analysis identified independent factors for morbidity. RESULTS 1609 women were included. 30-day morbidity rates were 4.5% (n=72) for the whole cohort: 7.5% (28/371), 3.2% (22/686), and 4.0% (22/552) for abdominal hysterectomy, laparoscopic-assisted vaginal hysterectomy (LAVH), and vaginal hysterectomy, respectively. The most common 30-day postoperative morbidities were urinary complications (1.2%, 20/1609), wound infection (0.9%, 14/1609), and blood transfusion more than 4 units (0.7%, 11/1609). In multivariate regression analysis, Charlson comorbidity index of 2 or more, operative time, and estimated blood loss were independently associated with morbidity. Propensity score-matching indicated no difference in morbidity rates for the abdominal hysterectomy and LAVH or vaginal hysterectomy groups (P=0.351), whereas the LAVH or vaginal hysterectomy groups were more strongly associated with operation time, estimated blood loss, and length of postoperative hospital stay. CONCLUSION Comorbidity index, operative time, and blood loss were independently associated with morbidity following hysterectomy. These findings supported the preoperative optimization of comorbidities and the appropriate selection of surgical approaches.
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Affiliation(s)
- Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Jung-Hwa Suh
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Ji-Eun Park
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Sun-Joo Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Ji-Young Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Soo-Nyung Kim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
| | - Soon-Beom Kang
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea
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Smooth Muscle Cells in Pelvic Washings at Time of Benign Hysterectomy. J Minim Invasive Gynecol 2018; 26:1144-1148. [PMID: 30502499 DOI: 10.1016/j.jmig.2018.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To evaluate if smooth muscle cells can be detected in pelvic washings at the time of intact hysterectomy. DESIGN A multicentered pilot cohort study (Canadian Task Force classification II-2). SETTING Two academically affiliated tertiary referral centers. PATIENTS Patients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. INTERVENTIONS Pelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, and slides were stained using hematoxylin and eosin, smooth muscle actin, and desmin and interpreted by 1 expert pathologist at each institution. MEASUREMENTS AND MAIN RESULTS Thirty-eight subjects were recruited; 3 subjects were excluded because of unplanned morcellation. Smooth muscle uterine cells were detected in 1 prewash specimen and 2 postwash specimens. The group with positive washings was noted to have longer procedure times (136 vs 114 minutes), lower blood loss (25 vs 86 mL), and higher uterine weight (242 vs 234 g) compared with negative washings group. CONCLUSION Tissue dissemination of uterine cells may be possible at the time of hysterectomy. Larger prospective studies are needed to better describe the incidence of and risk factors for tissue dissemination.
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Occult Malignancy Rate of 1498 Hysterectomies or Myomectomies with Morcellation: A Retrospective Single-Arm Study. J Obstet Gynaecol India 2018; 69:188-193. [PMID: 31686755 DOI: 10.1007/s13224-018-1190-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/10/2018] [Indexed: 10/27/2022] Open
Abstract
Background and Purpose Since April 2014, the FDA warns against the use of morcellation during minimally invasive uterine surgery because of the risk of occult malignant spreading in the abdominal cavity. It is clear, however, that more studies are needed to define the incidence of occult uterine cancers, its risk factors, preoperative identification and postoperative follow-up. The present retrospective single-arm study defines the prevalence of occult uterine malignancies in a large group of patients treated with hysterectomy or myomectomy for benign indications. Methods In the year of 2014, 1498 women admitted for a myomectomy or hysterectomy in benign conditions at the clinic of minimally invasive surgery (Minimal Invasive Chirurgie or MIC) in Berlin (Germany) were included in this study. The morcellated uterine specimens of operated patients were histologically analyzed for the presence of cancerous tissue. Results We detected malignancies in three of the 1498 women (0.2%): two patients had endometrial cancer, while we observed cervical cancer in situ in the third patient. No sarcoma was found. Conclusion We detected a very low prevalence of occult uterine malignancy which is in line with several other recent studies. To define a clear policy on the use of morcellation, more studies are required. In the meantime, patients should be informed about the risks of morcellation in case of undetected cancer prior to surgery.
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Nygaard I. In gratitude. Am J Obstet Gynecol 2018; 219:517-518. [PMID: 30471889 DOI: 10.1016/j.ajog.2018.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Ingrid Nygaard
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT.
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