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Amoah A, Chiu S, Quinn SD. Choice of primary and secondary outcomes in randomised controlled trials evaluating treatment for uterine fibroids: a systematic review. BJOG 2021; 129:345-355. [PMID: 34536313 DOI: 10.1111/1471-0528.16933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Core outcome sets aim to reduce research heterogeneity and standardise reporting, allowing meaningful comparisons between studies. OBJECTIVES To report on outcomes used in randomised controlled trials (RCTs) investigating uterine fibroid treatments, towards the development of a core outcome set for fibroid research. SELECTION STRATEGY Database search of MEDLINE, PubMed, EMBASE and CINAHL (inception to July 2021) for all English-language RCTs involving surgical or radiological fibroid treatments. DATA COLLECTION AND ANALYSIS A total of 1885 texts were screened for eligibility by two reviewers independently according to PRISMA methodology. JADAD and Management of Otitis Media with Effusion in Cleft Palate (MOMENT) scores were used to assess methodological and outcome reporting quality of studies, respectively. Outcomes were mapped to nine domains. Non-parametric tests for correlation and to compare group medians were undertaken. MAIN RESULTS There were 23 primary outcomes (23 outcome measures) and 173 secondary outcomes (95 outcome measures) reported in 60 RCTs (5699 participants). The domains with highest frequency of primary outcomes reported were bleeding and quality of life (QoL). The most frequent primary outcomes were postoperative pain, QoL and menstrual bleeding. No primary outcomes were mapped to fertility domains. Median MOMENT outcome score was 5 (interquartile range 3). There was correlation between MOMENT outcome score and JADAD scores (r = 0.491, P = 0.0001), publishing journal impact factor (r = 0.419, P = 0.008) and publication year (r = 0.332, P = 0.01). CONCLUSION There is substantial variation in the outcomes reported in fibroid RCTs. There is a need for a core outcome set for fibroid research, to allow improved understanding regarding the effects of different treatments.
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Affiliation(s)
- A Amoah
- Imperial College London, London, UK
| | - S Chiu
- Imperial College London, London, UK.,Northwick Park Hospital, London Northwest University Healthcare NHS Trust, Harrow, UK
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Pepin K, Cope A, Einarsson JI, Cellini J, Cohen SL. Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review. J Minim Invasive Gynecol 2020; 28:619-643. [PMID: 32977002 DOI: 10.1016/j.jmig.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. DATA SOURCES Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. METHODS OF STUDY SELECTION Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. TABULATION, INTEGRATION, AND RESULTS The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. CONCLUSION Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.
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Affiliation(s)
- Kristen Pepin
- Department of Obstetrics & Gynecology, Weill Cornell Medical Center, New York, New York (Dr. Pepin).
| | - Adela Cope
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
| | - Jon I Einarsson
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital (Dr. Einarsson)
| | - Jacqueline Cellini
- Department of Research & Instruction, Harvard TH Chan School of Public Health (Ms. Cellini), Boston, Massachusetts
| | - Sarah L Cohen
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
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Lambat Emery S, Pluchino N, Petignat P, Tille JC, Pache JC, Pinto J, Botsikas D, Dubuisson J. Cell Spillage after Contained Electromechanical Morcellation Using a Specially Designed In-Bag System for Laparoscopic Myomectomy: Prospective Cohort Pilot Study. J Minim Invasive Gynecol 2019; 26:1351-1356. [PMID: 30710637 DOI: 10.1016/j.jmig.2019.01.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/18/2019] [Accepted: 01/27/2019] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE Few reports have investigated the use of endoscopic retrieval bags in the context of laparoscopic myomectomy with electromechanical morcellation. We performed a leak test of a specially designed endoscopic bag system in women undergoing laparoscopic myomectomy with contained electromechanical morcellation. DESIGN CLASSIFICATION Prospective study. SETTING University hospital. PATIENTS Thirty-one women undergoing laparoscopic myomectomy with contained electromechanical morcellation. INTERVENTIONS Electromechanical morcellation was introduced for large specimen extraction during laparoscopic procedures. Complications such as retained/disseminated parasitic tissue were documented. MEASUREMENTS AND MAIN RESULTS Systematic peritoneal washings were performed at 3 specific times: at baseline, T1, once the peritoneal cavity was accessed laparoscopically; T2, when the myometrial incision was closed after myomectomy; and T3, after contained electromechanical morcellation. After retrieval of the endoscopic bag from the abdominal cavity, visual inspection and water test on the bag with NaCl infiltration were performed to detect leaks attributed to intraoperative perforations. A pathologist performed cytologic analyses on the 3 washings. The mean endoscopic bag procedure duration was 9 minutes. The use of a specially designed endoscopic bag system was found to be easy in 45% of cases, and no complications were reported. Cytologic washings were positive for smooth muscle cell detection in 8 cases (25.8%) at T2 and 3 cases (9.7%) at T3. All positive cases at T3 already had detectable smooth muscle cells at T2. After retrieval from the abdominal cavity, perforations on the optic access of the endoscopic bag were observed in 3 cases. CONCLUSION The results from this pilot study are encouraging. The use of a specially designed endoscopic bag system could be an adjuvant to reduce the risk of disseminating cells during myomectomy.
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Affiliation(s)
- Shahzia Lambat Emery
- Department of Gynecology (Drs. Lambat, Pluchino, Petignat, Pinto, and Dubuisson).
| | - Nicola Pluchino
- Department of Gynecology (Drs. Lambat, Pluchino, Petignat, Pinto, and Dubuisson)
| | - Patrick Petignat
- Department of Gynecology (Drs. Lambat, Pluchino, Petignat, Pinto, and Dubuisson)
| | | | | | - Joana Pinto
- Department of Gynecology (Drs. Lambat, Pluchino, Petignat, Pinto, and Dubuisson)
| | - Diomidis Botsikas
- Department of Radiology (Dr. Botsikas), Geneva University Hospitals, Geneva, Switzerland
| | - Jean Dubuisson
- Department of Gynecology (Drs. Lambat, Pluchino, Petignat, Pinto, and Dubuisson)
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In-bag manual versus uncontained power morcellation for laparoscopic myomectomy: randomized controlled trial. Fertil Steril 2016; 105:1369-1376. [PMID: 26801067 DOI: 10.1016/j.fertnstert.2015.12.133] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/10/2015] [Accepted: 12/21/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate whether manualin-bag morcellation could be efficiently proposed as alternative to the uncontained power technique. DESIGN Randomized controlled trial. SETTING Academic hospital. PATIENT(S) One hundred fifty-two premenopausal women eligible for myomectomy were screened, and 104 were randomized. INTERVENTION(S) Patients were randomized into two groups. In the experimental group, "in-bag" protected morcellation was performed. In the control group, patients were treated by uncontained power myoma removal. MAIN OUTCOME MEASURE(S) The primary endpoint was the comparison of morcellation operative time (MOT). The secondary endpoints were the comparisons of total operative time (TOT), simplicity of morcellation (as defined by the surgeon using a visual analogue scale scale), intraoperative blood loss, rate of complications, and postoperative outcomes. RESULT(S) A sample size of 51 per group (n = 102) was planned. Between March 2014 and January 2015, patients were randomized as follows: 53 to the experimental group and 51 to the control group. Most demographic characteristics were similar across groups. MOT was observed to be similar in both study groups (16.18 ± 8.1 vs. 14.35 ± 7.8 minutes, in the experimental and control groups, respectively). Fibroid size was identified as the principal factor influencing morcellation time (Pearson coefficient 0.484 vs. 0.581, in the experimental and control groups, respectively). No significant difference in TOT, simplicity of morcellation, delta Hb, postoperative pain, and postoperative outcomes were observed between groups. CONCLUSION(S) The protected manual in-bag morcellation technique represents a time-efficient and feasible alternative, which does not interfere with surgical outcomes in women undergoing laparoscopic myomectomy. CLINICAL TRIAL REGISTRATION NCT02086435.
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Montella F, Cosma S, Riboni F, Dealberti D, Benedetto C, Abate S. A Safe and Simple Laparoscopic Cold Knife Section Technique for Bulky Uterus Removal. J Laparoendosc Adv Surg Tech A 2015; 25:755-9. [PMID: 26275047 DOI: 10.1089/lap.2014.0640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Morcellation of a bulky uterus after total laparoscopic hysterectomy (TLH) is a challenge for those dealing with advanced laparoscopic surgery. However, there are no laparoscopic standardized procedures available to date. We developed a laparoscopic cold knife technique with the aim of demonstrating a simple and reproducible method of sectioning and vaginal retrieval of the bulky uterus. MATERIALS AND METHODS From June 2012 to June 2014, patients who underwent TLH for benign indication, with a uterus size over 12 gestational weeks, were prospectively admitted into the clinical study. Before specimen vaginal retrieval, uterine section was achieved by Chardonnens' cold knife with the aim of obtaining two uterus halves sectioned longitudinally and held together only by the posterior cervical wall. We performed the procedure in a containment system to avoid myometrial spillage into the abdomen. RESULTS Twenty-nine women with a bulky uterus were treated by TLH and the cold knife section technique. The uterine size ranged from 240 to 850 g (median, 460 g), and the average morcellation operative time was 11.3 minutes. All procedures were completed successfully without complications. CONCLUSIONS Our data suggest that the cold knife uterine section technique after TLH is a feasible, simple, and reproducible method of bulky uterus morcellation, even if further research is advisable to fully evaluate the advantages of this procedure.
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Affiliation(s)
- Fabio Montella
- 1 Department of Gynecology and Obstetrics, G. Borea Hospital , Sanremo, Italy
| | - Stefano Cosma
- 2 Department of Gynecology and Obstetrics, University of Torino , S. Anna Hospital, Torino, Italy
| | - Francesca Riboni
- 3 Department of Gynecology and Obstetrics, SS. Antonio e Biagio e Cesare Arrigo Hospital , Alessandria, Italy
| | - Davide Dealberti
- 3 Department of Gynecology and Obstetrics, SS. Antonio e Biagio e Cesare Arrigo Hospital , Alessandria, Italy
| | - Chiara Benedetto
- 2 Department of Gynecology and Obstetrics, University of Torino , S. Anna Hospital, Torino, Italy
| | - Sergio Abate
- 1 Department of Gynecology and Obstetrics, G. Borea Hospital , Sanremo, Italy
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Bogani G, Uccella S, Cromi A, Serati M, Casarin J, Sturla D, Ghezzi F. Electric Motorized Morcellator Versus Transvaginal Extraction for Myoma Retrieval After Laparoscopic Myomectomy: A Propensity-matched Analysis. J Minim Invasive Gynecol 2014; 21:928-34. [PMID: 24780382 DOI: 10.1016/j.jmig.2014.04.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/12/2014] [Accepted: 04/17/2014] [Indexed: 10/25/2022]
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Sharon A. Gynecare Morcellex Sigma®. J Obstet Gynaecol India 2014; 64:226-7. [DOI: 10.1007/s13224-014-0568-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Lund CM, Ragle CA, Lutter JD, Farnsworth KD. Use of a motorized morcellator for elective bilateral laparoscopic ovariectomy in standing equids: 30 cases (2007–2013). J Am Vet Med Assoc 2014; 244:1191-7. [DOI: 10.2460/javma.244.10.1191] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Milad MP, Milad EA. Laparoscopic Morcellator-Related Complications. J Minim Invasive Gynecol 2014; 21:486-91. [DOI: 10.1016/j.jmig.2013.12.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 12/02/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
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Driessen SRC, Arkenbout EA, Thurkow AL, Jansen FW. Electromechanical morcellators in minimally invasive gynecologic surgery: an update. J Minim Invasive Gynecol 2014; 21:377-83. [PMID: 24462590 DOI: 10.1016/j.jmig.2013.12.121] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 12/16/2013] [Accepted: 12/31/2013] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE To assess all electromechanical morcellators used in gynecology to achieve an objective comparison between them and to make suggestions for improvements in future developments. DESIGN Literature review. INTERVENTION The PubMed, Web of Science, EMBASE, and MAUDE databases were systematically searched for all available literature using the terms "morcellator," "morcellators," "morcellate," "morcellation," and "morcellated." All articles with information on morcellation time and morcellated tissue mass or the calculated morcellation rate of electromechanical morcellators used for gynecologic laparoscopic surgery were included. For general data of an existing morcellator, the manufacturer was contacted and Google was searched. Data for morcellation rate, type of procedure, and general characteristics were compared. MEASUREMENTS AND MAIN RESULTS Seven articles were suitable for analysis, and 11 different morcellators were found. In the past decades the morcellation rate has increased. The described morcellation rate ranged from 6.2 to 40.4 g/min. Motor peeling is currently the fastest working principle. Comparing hysterectomy and myomectomy per device, the Morcellex and Rotocut morcellators demonstrated a higher morcellation rate for myomectomy, 25.9 vs 30 g/min and 28.4 vs 33.1 g/min, respectively, although the X-Tract morcellator showed a higher rate for hysterectomy, 14.2 vs 11.7 g/min. CONCLUSION Over the years, the morcellator has improved with respect to the morcellation rate. However, the morcellation process still has limitations, including tissue scattering, morcellator-related injuries, and the inevitable small blade diameter, which all come at the expense of the morcellation rate and time. Therefore, development of improved morcellators is required, with consideration of the observed limitations.
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Affiliation(s)
- Sara R C Driessen
- Department of Gynecology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ewout A Arkenbout
- Department of BioMechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Andreas L Thurkow
- Department of Gynecology, Sint Lucas Andreas Ziekenhuis, Amsterdam, The Netherlands
| | - Frank-Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, the Netherlands.
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Isakov A, Murdaugh KM, Burke WC, Zimmerman S, Roche E, Holland D, Einarsson JI, Walsh CJ. A New Laparoscopic Morcellator Using an Actuated Wire Mesh and Bag. J Med Device 2014. [DOI: 10.1115/1.4026294] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Laparoscopic morcellation is a technique used in gynecological surgeries such as hysterectomy and myomectomy to remove uteri and uterine fibroids (leiomyomas) through a small abdominal incision. Current morcellators use blades or bipolar energy to cut tissue into small pieces that are then removed through laparoscopic ports in a piecewise manner. These existing approaches have several limitations; (1) they are time consuming as the tissue must be manually moved over the devices during the cutting step and removal is piecewise, (2) they can lead to accidental damage to surrounding healthy tissue inside the body and (3) they do not provide safe containment of tissue during the morcellation process which can lead to seeding (spreading and regrowth) of benign or potentially cancerous tissue. This paper describes a laparoscopic morcellator that overcomes these limitations through a new design that is based on an enclosed, motor-actuated mesh that applies only an inward-directed cutting force to the tissue after it has been loaded into the protective mesh and bag. The deterministic design approach that led to this concept is presented along with the detailed electromechanical design. The prototype is tested on soft vegetables and an animal model to demonstrate successful morcellation and how the device would be compatible with current clinical practice. Results show that the time required to morcellate with the new device for a set of tests on animal tissue is relatively uniform across samples with widely varying parameters. Including tissue manipulation and extraction time, the new device is shown to have an improvement in terms of speed over current morcellators. The mean time for cutting animal tissue ranging from 100 g to 360 g was 30 s with small variations due to initial conditions. The time for cutting is expected to remain approximately constant as tissue size increases. There is also minimal risk of the protective bag ripping due to the inward-cutting action of the mesh, thereby potentially significantly reducing the risk of seeding during clinical procedures; thus, further increasing patient safety. Finally, this design may be applicable to other procedures involving removal of tissue in nongynecologic surgeries, such as full or partial kidney or spleen removal.
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Affiliation(s)
- Alexander Isakov
- Harvard University, Department of Physics, Cambridge, MA 02138 e-mail:
| | - Kimberly M. Murdaugh
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA 02138
| | - William C. Burke
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA 02138
| | - Sloan Zimmerman
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA 02138
| | - Ellen Roche
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA 02138
- Wyss Institute, Boston, MA 02155
| | - Donal Holland
- Department of Mechanical and Manufacturing Engineering, Trinity College, Dublin 2, Ireland
| | | | - Conor J. Walsh
- Harvard University, School of Engineering and Applied Sciences, Cambridge, MA 02138
- Wyss Institute, Boston, MA 02155
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Ramesh B, Vidyashankar M, Bharathi B. Single incision laparoscopic myomectomy. JOURNAL OF GYNECOLOGICAL ENDOSCOPY AND SURGERY 2012; 2:61-3. [PMID: 22442539 PMCID: PMC3304287 DOI: 10.4103/0974-1216.85288] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Single port laparoscopic surgery (SPLS), also called SILS is the natural extension of multi-incisional laparoscopic surgery, in the quest for reduction of traumatic insult and residual scarring to the patient. Today with the evolution of newer instruments, bidirectional self-retaining sutures, and surgical experience we are able to perform many surgeries in gynecology.
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Affiliation(s)
- B Ramesh
- Dr. Ramesh Hospital, High Tech Super Speciality Hospital for Gynecology, Laparoscopy, and Infertility, Bangalore, India
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