Laparoscopic and vaginal approaches to hysterectomy in the obese

Systematic review and meta-analysis of the pelvic organ prolapse and vaginal prolapse among the global population

Background

Pelvic organ prolapse (POP) occurs when one or more pelvic organs (uterus, bowel, bladder or top of the vagina) descend from their normal position and bulge into the vagina. Symptoms include pelvic discomfort, fullness, and changes in bladder or bowel function. Treatment ranges from conservative approaches to surgery, depending on symptom severity. Surgical methods include vaginal wall repair, with or without hysterectomy, or via laparoscopic, robotic or open techniques. Common complications include bleeding, infection, and urinary or bowel dysfunction.

Methods

A systematic review was conducted, and a protocol was registered with PROSPERO (CRD42022346051). Publications from 30 April 1980 to 30 April 2023 were retrieved from multiple databases. Data were analysed using random-effects and common-effects models with subgroup and sensitivity analyses.

Findings

Forty-four studies met the inclusion criteria, with 29 studies used for meta-analysis of vaginal prolapse surgery outcomes. Sixteen studies focused on patients who had undergone hysterectomy alongside prolapse repair.

Interpretation

Patients who underwent vaginal prolapse surgery with hysterectomy experienced higher operative and postoperative complication rates than those without hysterectomy. Increased risks included hospital readmission, POP recurrence and re-operation. The review highlighted a lack of diversity in terms of ethnicity, age and comorbidity status, which are essential to fully understanding the impact of POP. Future research should focus on these underrepresented factors.

Robotic-assisted, laparoscopic, and vaginal hysterectomy in morbidly obese patients with endometrial hyperplasia and endometrial cancer

BACKGROUND

Hysterectomy for endometrial hyperplasia and endometrial cancer in morbidly obese patients is challenging. Here, we reported data regarding three minimally invasive approaches.

METHOD

This is a multicenter retrospective study evaluating 30-day and 90-day surgery-related outcomes of morbidly obese patients (those with BMI > 40kg/m2) undergoing robotic-assisted, laparoscopic, and vaginal hysterectomy.

RESULTS

Charts of 95 morbidly obese patients who underwent surgery for endometrial cancer were retrieved. Overall, robotic-assisted, laparoscopic, and vaginal surgeries were performed in 35 (36.8%), 38 (40%), and 22 (23.2%) patients, respectively. Patients having robotic-assisted surgery experienced longer operative time than patients having vaginal and laparoscopic approaches (p < 0.001). Surgical approaches did not influence the risk of having intraoperative and severe (Clavien-Dindo grade 3 or more) postoperative complications. No 90-day mortality occurred.

CONCLUSIONS

Robotic-assisted, laparoscopic, and vaginal surgery represent three safe and feasible minimally invasive approaches to manage morbidly obese patients with endometrial hyperplasia and endometrial cancer.

Vaginal hysterectomy for the treatment of low-risk endometrial cancer: Surgical technique, costs, and perioperative and oncologic results

OBJECTIVES

This study aimed to describe an operative technique for vaginal hysterectomy (VH) and assess the costs, perioperative, and oncological outcomes for this procedure when used in the treatment of patients with low-risk endometrial cancer (LREC).

METHODS

A retrospective analysis of medical records was conducted on patients who underwent VH to treat precursor and invasive endometrial lesions between April 2019 and November 2021 at a single center in São Paulo, Brazil.

RESULTS

Thirty-four patients met the inclusion criteria. The mean patient age was 61.9 years, and the mean body mass index (BMI) was 34. Obese patients (BMI ≥ 30) accounted for 77% of the sample. Preoperative functional capacity measures were Eastern Cooperative Oncology Group (ECOG) 0-1 and ECOG-2 for 91% and 9% of the patients, respectively. The mean operative time and length of hospital stay were 109 min and 1.2 days, respectively. Four patients had a conversion of the surgical route to laparotomy. No major intraoperative complications were observed. Patients who underwent surgical conversion had a greater uterine volume (227 versus 107 mL, p = 0.006) and longer operative time (177 versus 96 min, p = 0.001). The total cost associated with VH was, on average, US$ 2058.77 (R$ 10,925.91), representing 47% of the cost associated with non-vaginal routes. Twenty-eight patients received a definitive diagnosis of endometrial carcinoma; of these, three received adjuvant radiotherapy. The mean follow-up period was 34.6 months for the patients diagnosed with cancer. One case of disease recurrence occurred 16.6 months after surgery, with one death at 28.6 months of follow-up.

CONCLUSIONS

These findings suggest that VH could be a feasible and cost-effective alternative for selected patients with LREC in low-resource settings.

Endometrial Cancer Risk Among Germline BRCA1/2 Pathogenic Variant Carriers: Review of Our Current Understanding and Next Steps

PURPOSE

To review the literature exploring endometrial cancer (EC) risk among surgical candidates with germline BRCA1/2 pathogenic variants (PVs) to guide decisions around risk-reducing (rr) hysterectomy in this population.

DESIGN

A comprehensive review was conducted of the current literature that influences clinical practice and informs expert consensus. We present our understanding of EC risk among BRCA1/2 PV carriers, the risk-modifying factors specific to this patient population, and the available research technology that may guide clinical practice in the future. Limitations of the existing literature are outlined.

RESULTS

Patients with BRCA1/2 PVs, those with a personal history of tamoxifen use, those who desire long-term hormone replacement therapy, and/or have an elevated BMI are at higher risk of EC, primarily endometrioid EC and/or uterine papillary serous carcinoma, and may benefit from rr-hysterectomy. Although prescriptive clinical guidelines specific to BRCA1/2 PV carriers could inform decisions around rr-hysterectomy, limitations of the current literature prevent more definitive guidance at this time. A large population-based study of a contemporary cohort of BRCA1/2 PV carriers with lifetime follow-up compared with cancer-gene negative controls would advance this topic and facilitate care decisions.

CONCLUSION

This review validates a potential role for rr-hysterectomy to address EC risk among surgical candidates with BRCA1/2 PVs. Evidence-based clinical guidelines for rr-hysterectomy in BRCA1/2 PV carriers are essential to ensure equitable access to this preventive measure, supporting insurance coverage for patients with either BRCA1 or BRCA2 PVs to pursue rr-hysterectomy. Overall, this review highlights the complexity of EC risk in BRCA1/2 PV carriers and offers a comprehensive framework to shared decision making to inform rr-hysterectomy for BRCA1/2 PV carriers.

Challenges of morbid obesity in gynecological practice

Obesity is currently a global pandemic, with increasing trends worldwide. Data from the WHO, US CDC, and the UK show an increasing trend, with 50% and 25% of the US population expected to be obese and morbidly obese by 2030. Obesity affects several aspects of health, with increased risks of cardiovascular disease, diabetes, metabolic syndrome, and several malignancies. Morbid obesity significantly impacts several aspects of female life and health, from adolescence, through the reproductive years, to the postmenopausal age group. In gynecology, there is a higher prevalence of menstrual disorders and infertility and reduced success rates of assisted reproduction; increased risk of miscarriage; pelvic organ prolapse; and endometrial, ovarian, and breast cancers. Surgery in the patient with morbid obesity is associated with several logistical challenges as well as increased surgical and peri-operative risks and increased cost. In this review, we provide an overview of the current literature, with a focus on challenges of morbid obesity in gynecological practice.

vNOTES Hysterectomy: What about Obese Patients?

STUDY OBJECTIVE

To compare the surgical outcomes of hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for patients with body mass index (BMI) <30 and BMI ≥30.

DESIGN

A retrospective cohort study.

SETTING

A French teaching hospital.

PATIENTS

All patients who underwent a vNOTES hysterectomy from February 2020 to January 2022 were included (N = 200). The vNOTES approach was chosen for all patients requiring a hysterectomy, unless the procedure was for endometriosis or cancer (except grade 1 endometrioid adenocarcinoma).

INTERVENTIONS

Patients were categorized into 2 groups based on their BMI (<30 or ≥30 kg/m²). The population characteristics, surgical outcomes, and hospitalization outcomes were compared. The main outcome was the intraoperative conversion rate. Secondary end points were blood loss, operative time, perioperative and postoperative complications, and same-day surgery management.

MEASUREMENTS AND MAIN RESULTS

A total of 146 patients were included in the BMI <30 group, and 54 patients in the BMI ≥30 group. There was no statistical difference between obese and nonobese patients concerning intraoperative conversion (p = .150), with 4 cases occurring in the BMI <30 group (2.74%) and 4 occurring in the BMI ≥30 group (7.41%). Operative times were longer in obese patients (115.93 min [±55.28] vs 79.78 min [±40.38], p <.001). There was no significant difference in blood loss (p = .337) or perioperative and postoperative complications (p = .346 and p = .612, respectively). The ability to complete the surgery as a same-day procedure was no different between obese and nonobese patients (p = .150).

CONCLUSION

The results concerning intraoperative conversion and perioperative and postoperative complications show that vNOTES hysterectomies seem to be feasible for obese patients. When same-day surgery was decided before surgery, no more obese than nonobese patients were converted to conventional hospitalization. Further studies are needed to confirm these observations.

Prognostic outcomes and risk factors for recurrence after laser vaporization for cervical intraepithelial neoplasia: a single-center retrospective study

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is a precancerous lesion that may progress to invasive cervical cancer without intervention. We aim to examine the prognostic outcomes and risk factors for recurrence after laser vaporization for CIN 3, CIN 2 with high-risk human papillomavirus (HPV) infection, and CIN 1 persisting for more than 2 years.

METHODS

Between 2008 and 2016, a total of 1070 patients underwent cervical laser vaporization using a carbon dioxide laser. We performed a retrospective review of their medical records to assess their clinical characteristics, pathologic factors, and prognostic outcomes.

RESULTS

The mean patient age was 34 years (range 18-64 years). The preoperative diagnosis was CIN 1 in 27 patients, CIN 2 in 485 patients, and CIN 3 in 558 patients. Over a median follow-up period of 15 months, the 2-year recurrence rate was 18.9%, and the 5-year recurrence rate was 46.5%. The 2-year retreatment rate was 12.6%, and the 5-year retreatment rate was 30.5%. We diagnosed 9 patients with invasive cancer after treatment; all patients underwent combined multidisciplinary treatment, and there were no deaths during follow-up. The recurrence-free interval was correlated with patient age (hazard ratio [HR], 1.028; 95% CI 1.005-1.051; P = 0.0167), body mass index (HR, 1.052; 95% CI 1.008-1.098; P = 0.0191), and glandular involvement (HR, 1.962; 95% CI 1.353-2.846; P = 0.0004).

CONCLUSIONS

Cervical laser vaporization is effective and useful for patients with CIN who wish to preserve fertility. However, patients with glandular involvement, older age, and higher body weight require close follow-up for recurrence.

Laparoscopic “Core-Pulling” Salpingectomy: A Novel and Minimally Invasive Modified Salpingectomy

The present study aimed to evaluate the feasibility, safety, and efficacy of laparoscopic “core-pulling” salpingectomy for tubal pregnancy. Laparoscopic core-pulling salpingectomy is a novel and minimally invasive salpingectomy variant, whose technical details are described here. In this retrospective study, 154 patients with tubal pregnancy underwent laparoscopic salpingectomy. In total, 76 and 78 patients underwent laparoscopic core-pulling salpingectomy (LCPS) and conventional multiport laparoscopic salpingectomy (MPLS), respectively. Then, clinical characteristics, intraoperative findings, and operative outcomes were compared between the 2 groups. Surgery was successful in all 154 patients, and no significant differences were found between the LCPS and MPLS groups in clinical characteristics, intraoperative findings, and operative outcomes. These findings indicated that LCPS is feasible and constitute a practical alternative to conventional salpingectomy.

Surgical Care for Women with Endometrial Cancer in Florida

Objective: The goal of this research was to analyze if disparities in route of hysterectomy for endometrial cancer exist in Florida. Materials and Methods: In this retrospective cohort study, Florida inpatient and ambulatory surgery databases (2014-2016) were examined to find cases of patients with endometrial cancer who underwent hysterectomy in the state. Logistic regression models were used to compare patient- and hospital-level factors associated with having minimally invasive surgery (MIS) versus open surgery, and complications in patients having open hysterectomy versus MIS. Results: Overall, 6513 patients met the inclusion criteria. MIS was performed in 81.4% of cases. The odds of using a minimally invasive approach to hysterectomy (vaginal, robotic, or laparoscopic) were significantly lower for black women (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34-0.50) as well as for other non-white patients (OR: 0.64; 95% CI: 0.49-0.84). Patients with Medicaid (OR: 0.42; 95% CI: 0.30-0.59) or Medicare managed care (OR: 0.73; 95% CI: 0.59-0.91), or who received care at a teaching hospital (OR: 0.82; 95% CI: 0.68-0.98) or government hospital (OR: 0.50; 95% CI: 0.38-0.65) were also less likely to receive MIS. Patients receiving care at a high-volume (OR: 1.69; 95% CI: 1.30-2.20) or medium-volume (OR: 3.11; 95% CI: 2.37-4.08) hospital, or patients who were located in the Central (OR: 1.71; 95% CI: 1.17-2.48) or Peninsula (OR: 1.73; 95% CI: 1.17-2.56) regions, compared to the Florida Panhandle, had greater odds of receiving MIS. Conclusions: Although Florida has a high adoption of MIS for treating endometrial cancer, disparities persist. Efforts of state-level entities should focus on improving access to minimally invasive hysterectomy for racial minorities with endometrial cancer.

Considerations for minimally invasive gynecologic surgery in obese patients

PURPOSE OF REVIEW

The purpose is to review the key anatomical and physiological changes in obese patients and their effects on preoperative, intraoperative, and postoperative care and to highlight the best practices to safely extend minimally invasive approaches to obese patients and provide optimal surgical outcomes in this high-risk population.

RECENT FINDINGS

Minimally invasive surgery is safe, feasible, and cost-effective for obese patients. Obesity is associated with anatomical and physiological changes in almost all organ systems, which necessitates a multimodal approach and an experienced, multidisciplinary team. Preoperative counseling, evaluation, and optimization of medical comorbidities are critical. The optimal minimally invasive approach is primarily determined by the patient's anatomy and pathology. Specific intraoperative techniques and modifications exist to maximize surgical exposure and panniculus management. Postoperatively, comprehensive medical management can help prevent common complications in obese patients, including hypoxemia, venous thromboembolism, acute kidney injury, hyperglycemia, and prolonged hospitalization.

SUMMARY

Given significantly improved patient outcomes, minimally invasive approaches to gynecological surgery should be considered for all obese patients with particular attention given to specific perioperative considerations and appropriate referral to an experienced minimally invasive surgeon.

Opportunistic salpingectomy during vaginal hysterectomy for a benign pathological condition

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the surgical feasibility of opportunistic salpingectomy or salpingo-oophorectomy during benign vaginal hysterectomy (HV) and the prevalence of occult tubal lesions.

METHODS

In this prospective study from 1 September 2013 to 1 November 2015, the prevalence of bilateral salpingectomy with or without ovariectomy and the prevalence of histopathological and immunohistochemical tubal abnormalities were assessed.

RESULTS

A total 115 patients were included. Bilateral salpingectomy was performed in 85 patients (73.92%; group A) and was technically impossible in 30 patients (26.08%; group B). Older patients (62.9 vs 57.5 years, p = 0.009), menopausal status (83.33% vs 62.35%, p = 0.03) and elevated BMI (27.58 vs 25.05 p = 0.03) were statistically associated with failure of salpingectomy. There was only one case of postoperative hemorrhage in group A. There was no difference with regard to intra- or postoperative complications, blood loss, and operating time between the two groups. Among the 67 fallopian tubes analyzed with a validated histopathological protocol, there were 8 (11.94%) immunohistochemical abnormalities with a "p53 signature."

CONCLUSIONS

With the recent demonstration of a tubal origin of most ovarian cancer, opportunistic salpingectomy could be a theoretically relevant prevention strategy. Bilateral salpingectomy could be performed during benign vaginal hysterectomy by experienced surgeons. The advantages and disadvantages of exclusive salpingectomy during pelvic floor surgery should be discussed with the patients.

Randomized controlled trial of thermal balloon ablation versus vaginal hysterectomy for leiomyoma-induced heavy menstrual bleeding

OBJECTIVE

To compare the efficacy of thermal balloon ablation (TBA) with that of vaginal hysterectomy in the treatment of leiomyoma-induced heavy menstrual bleeding (HMB).

METHODS

An open-label randomized controlled trial was conducted between November 1, 2012, and October 31, 2014, in a tertiary care hospital in Delhi, India. Eligible women with HMB (aged ≥40 years, uterus size ≤14 weeks of pregnancy, leiomyoma ≤5 cm, uterocervical length ≤12 cm) were randomly assigned (1:1) to undergo TBA or vaginal hysterectomy using computer-generated random number tables. The primary outcome was the number of women in the TBA group with HMB 6 months after surgery. Analyses were by intention to treat.

RESULTS

Each group contained 20 women. No women in the TBA group had HMB at 6 months. Nineteen women were amenorrheic by 6 months and one was hypomenorrheic.

CONCLUSION

TBA can replace vaginal hysterectomy in some perimenopausal women with uterine leiomyomas. Clinical Trials Registry India: CTRI/2016/07/007119.