Electric motorized morcellator versus transvaginal extraction for myoma retrieval after laparoscopic myomectomy: a propensity-matched analysis

Transvaginal versus transabdominal specimen extraction in minimally invasive surgery: a systematic review and meta-analysis

AIM

Natural orifice specimen extraction (NOSE) is an alternative to conventional transabdominal retrieval. We aimed to compare outcomes following transvaginal specimen extraction (TVSE) and transabdominal specimen extraction (TASE) in minimally invasive abdominal surgery.

METHODS

An electronic database search of PubMed, Embase and CENTRAL was performed from inception until March 2023. Comparative studies evaluating TVSE versus TASE in adult female patients were included. Studies involving transanal NOSE, endoluminal surgery, or TVSE with concomitant hysterectomy were excluded. Weighted mean differences (WMD) and odds ratio were estimated for continuous and dichotomous outcomes respectively. Primary outcomes were postoperative day 1 (POD1) pain and length of stay (LOS). Secondary outcomes were operative time, rescue analgesia, morbidity, and cosmesis. A review of sexual, oncological, and technical outcomes was performed.

RESULTS

Thirteen studies (2 randomised trials, 11 retrospective cohort studies), involving 1094 patients (TASE 583, TVSE 511), were included in the analysis. Seven studies involved colorectal disease and six assessed gynaecological conditions. TVSE resulted in significantly decreased POD1 pain (WMD 1.08, 95% CI: 0.49, 1.68) and shorter LOS (WMD 1.18 days, 95% CI: 0.14, 2.22), compared to TASE. Operative time was similar between both groups, with fewer patients requiring postoperative rescue analgesia with TVSE. Overall morbidity rates, as well as both wound-related and non-wound related complication rates were better with TVSE, while anastomotic morbidity rates were comparable. Cosmetic scores were higher with TVSE. TVSE did not result in worse sexual or oncological outcomes.

CONCLUSION

TVSE may be feasible and beneficial compared to TASE when performed by proficient laparoscopic operators, using appropriate selection criteria. Continued evaluation with prospective studies is warranted.

The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon

Myomectomy is one of the most common surgical procedure in the field of gynecology. However, the role of laparoscopic myomectomy is still debated for many factors, including surgical considerations, safety and fertility concerns, long-term outcomes, and cost-related issues. The aim of this study is to evaluate the surgical peri- and post-operative outcomes of laparoscopic and abdominal myomectomy. A systematic search for studies was performed up to June 2023 through MEDLINE, Pubmed, Embase. Studies reporting the comparison of surgical and obstetrical outcomes in laparoscopic versus laparotomic myomectomy were included for the following outcomes: time of surgery, estimated blood loss, decrease of postoperative hemoglobin, hospital stay, intra-operative complication rates, postoperative complications rates, postoperative analgesic use, postoperative pain at 24 h and pregnancy rate. The meta-analysis was performed using the Cochrane Review software. Fifty-six relevant articles were retrieved through the process of evidence acquisition. Eleven articles met inclusion criteria, for a total of 2,133 patients undergoing laparoscopic or laparotomic myomectomy. The estimated blood loss [standard mean differences (SMD) 0.72, IC 95 % 0.22 to 1.22], the hospital stays [SMD 3.12, IC 95 % 0.57 to 4.28], were significantly lower in laparoscopic than in open group. No statistically significant difference in intra-operative and post-operative complication rates, in pregnancy rate and others obstetrical outcomes between two surgical approaches were found. The findings of present metanalysis suggest that laparoscopic myomectomy offers multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need, without a significant increase in complication rates and similar results in obstetrical outcomes when compared to abdominal myomectomy. However, the presence of few randomized studies on selected population may limit the generalizability of the findings to the entire population. Therefore, more well-designed studies or large population programdata to draw definitive conclusions are therefore warranted.

Hysterectomy Using Vaginal Natural Orifice Transluminal Endoscopic Surgery Compared with Classic Laparoscopic Hysterectomy: A New Advantageous Approach? A Systematic Review on Surgical Outcomes

INTRODUCTION

Minimally invasive surgery aims to reduce surgical trauma and post-operative morbidity. Natural orifice transluminal endoscopic surgery is a safe and valid surgical option for hysterectomy. The present systematic review aims to compare hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) with laparoscopic hysterectomy in terms of efficacy, surgical outcomes, complications, and cost.

MATERIALS AND METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It includes randomized controlled trials, controlled clinical trials, prospective or retrospective cohorts, case-control studies, and previous systematic reviews. Inclusion criteria are as follows: female patients undergoing hysterectomy for benign pathologies by vNOTES or laparoscopic hysterectomy. The assessed outcomes were the following: conversion rate, mean uterus weight (g), operative time (mins), hospital stay (days), peri-operative complications, post-operative complications, peri-operative blood loss (mL), blood transfusion needs, post-operative day 1 hemoglobin (Hb) change (g/dL), post-operative pain level (VAS), and cost (USD) in both techniques.

RESULTS

Seven studies were included. vNOTES hysterectomy was not inferior to laparoscopic hysterectomy regarding surgical outcomes, with a shorter operative time, shorter recovery time, less post-operative pain, and fewer post-operative complications. There was no significant difference in the rate of peri-operative complications and no differences in peri-operative blood loss, post-operative day 1 Hb change, and transfusions. Nevertheless, vNOTES hysterectomy was shown to be more expensive than its laparoscopic counterpart.

CONCLUSIONS

While the feasibility and safety of the vNOTES hysterectomy were already established, this review also underlines the noninferiority of this technique when compared to laparoscopic hysterectomy in terms of surgical outcomes. In addition, vNOTES hysterectomy was associated with faster operating time, shorter hospital stay, and better post-operative pain scores compared with laparoscopic hysterectomy.

Accidental Morcellation of Uterine Leiomyosarcoma Influences Relapse Free Survival but Does Not Negatively Influence Overall Survival

Background: Uterine leiomyosarcoma (LMS) is a rare entity amongst malignant gynaecological tumours and is mostly diagnosed after surgery for benign leiomyoma (LM) of the uterus. As minimal invasive surgery is widely used, the morcellation of LM and the uterus is rather common. As there is little known about the impact of the morcellation of LMS on local and distant metastases, as well as overall survival, we carried out a large-scale retrospective study. Methods: A total of 301 LMS cases from the German Clinical Competence Centre for Genital Sarcomas and Mixed Tumours were analysed. We distinguished morcellated and non-morcellated LMS from pT1 and >pT1 tumours. Fine−Gray competing risks regressions and cumulative incidence rates were computed for the time to local recurrence, distant metastases, and patient death. Results: The recurrence free interval in pT1 LMS was significantly lower in the morcellation group with a 2-year cumulative incidence rate of 49% vs. 26% in non-morcellated LMS (p = 0.001). No differences were seen in >pT1 tumours. Distant metastases were more frequently found in non-morcellated pT1 LMS compared to the morcellated cases (5-year cumulative incidence: 54% vs. 29%, p < 0.001). There was no significant difference in time to death between both groups neither in the pT1 stages nor in >pT1 disease. Subdistribution hazard ratios estimated by multivariable competing risks regressions for the morcellation of pT1 LMS were 2.11 for local recurrence (95% CI 1.41−3.16, p < 0.001) and 0.52 for distant metastases (95% CI 0.32−0.84, p = 0.008). Conclusions: Tumour morcellation is not associated with OS for pT1 tumours. The morcellation of pT1 LMS seems to prolong the time to distant metastases whereas local recurrence is more likely to occur after the morcellation of pT1 LMS.

Preoperative Differentiation of Uterine Leiomyomas and Leiomyosarcomas: Current Possibilities and Future Directions

The distinguishing of uterine leiomyosarcomas (ULMS) and uterine leiomyomas (ULM) before the operation and histopathological evaluation of tissue is one of the current challenges for clinicians and researchers. Recently, a few new and innovative methods have been developed. However, researchers are trying to create different scales analyzing available parameters and to combine them with imaging methods with the aim of ULMs and ULM preoperative differentiation ULMs and ULM. Moreover, it has been observed that the technology, meaning machine learning models and artificial intelligence (AI), is entering the world of medicine, including gynecology. Therefore, we can predict the diagnosis not only through symptoms, laboratory tests or imaging methods, but also, we can base it on AI. What is the best option to differentiate ULM and ULMS preoperatively? In our review, we focus on the possible methods to diagnose uterine lesions effectively, including clinical signs and symptoms, laboratory tests, imaging methods, molecular aspects, available scales, and AI. In addition, considering costs and availability, we list the most promising methods to be implemented and investigated on a larger scale.

Total surgical time in laparoscopic supracervical hysterectomy with laparoscopic in-bag-morcellation compared to laparoscopic supracervical hysterectomy with uncontained morcellation

Background

A possible solution to the problem of cell dissemination through laparoscopic uncontained morcellation during laparoscopic supracervical hysterectomy (LASH) is the use of laparoscopic in-bag morcellation. One criticism regarding the use of in-bag morcellation is the additional surgical time associated with this procedure.

Objectives

In this retrospective study we compared the total surgical time in LASH with laparoscopic in-bag morcellation (107 cases from 2016-2018) and LASH with uncontained morcellation (47 cases from 2015-2017).

Materials and Methods

All surgeries were performed in the same department of minimally invasive gynaecological surgery by a total of three experienced surgeons for the indication of bleeding disorder and / or dysmenorrhea.

Main outcome measures

We measured and compared total surgical time, surgical outcome, blood loss and complications in LASH with in-bag morcellation and with uncontained morcellation.

Results

Total surgical time in both procedures do not show a significant difference. Considering the learning curve in laparoscopic bag use, the total surgical time in LASH with laparoscopic in-bag morcellation is shorter than total surgical time in LASH with uncontained morcellation. Laparoscopic in-bag morcellation consumes time for bag use and handling, but saves time as it eliminates the need for meticulous sampling of lost tissue fragments and the complex lavage of the peritoneal cavity after morcellation. There is no difference between both groups in terms of blood loss, complications and surgical results.

Conclusion/What is new?

We conclude that LASH with in-bag morcellation is not related to additional surgical time when compared to LASH with uncontained morcellation.

Endobag use in laparoscopic gynecological surgeries: a systematic review

PURPOSE

The purpose of this systematic review was to assess the characteristics of endobags present in the market, the weight of specimen removed, complications of the operations and time required for in-bag morcellation in women undergoing laparoscopic gynecologic surgeries.

MATERIAL AND METHODS

We performed a systematic review, including prospective and retrospective studies, with or without randomized allocation of the patients, using endobags in laparoscopic gynecologic surgeries. We extracted data about study design, type and price of bag used, type of surgical procedure, specimen weight, mean time for morcellation and for total surgical procedure, complications.

RESULTS

We included 11 studies, including a total of 1160 patients, in which the investigators used MorSafe, Endocatch II autosuture, More-Cell-Safe, Endocatch, EcoSac and LapBag. A wide range of specimens were morcellated with the largest successfully morcellated specimen weighing 2314 gr. Only half of the studies comparing uncontained and contained morcellation found a significant increase of total operative time. Finally, the number of complications was not increased when endobag was used.

CONCLUSION

According to our systematic review, in-bag (contained) morcellation can be considered as a safe and unexpensive option, associated with a very low number of complications, even with large specimens.

The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective

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.

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review

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.

Culdotomy in laparoscopic myomectomy and its limits

OBJECTIVE

To examine the results and limits of culdotomy method for removal of myoma from the abdomen while preserving its integrity in laparoscopic myomectomy. To determine if this is a good option for tissue extraction.

DESIGN

Retrospective analysis of data collected prospectively.

SETTING

A gynecology and obstetrics training and research hospital.

PATIENTS

A total of 102 patients who underwent laparoscopic myomectomy with culdotomy for tissue extraction.

RESULTS

A total of 102 patients underwent laparoscopic myomectomy between September 2017 and April 2019, and tissues were taken from the abdomen by culdotomy. The mean myoma diameter was 7.7 ± 2.4 cm (4-15 cm) and the mean weight was 161 ± 120 g (20-602 g). The mean duration of surgery was 95 ± 41 min (36-214 min). All myomas were extracted with preservation of their integrity, except in 2 patients. In 87 patients, the myoma was less than 10 cm, and all myomas in this group could be easily extracted from the vagina. The myoma was between 11 and 13 cm in 13 patients. Of these, 8 were extracted without difficulty, 5 could barely be extracted, and superficial vaginal lacerations occurred in 4 of these patients. Due to the inability to extract myomas intact in 2 patients (14 and 15 cm), vaginal mechanical morcellation was performed. In terms of vaginal births, 34 patients (33.3 %) had never had vaginal births, and 68 patients (66.7 %) had a history of vaginal birth. The largest myoma extracted from a woman who had not given birth was 12 cm (345 g). The largest myoma extracted from a woman who had given birth was 13 cm (490 g). None had major complications. No signs of infection were detected on the 7th and 30th postoperative days, and no operative dyspareunia was detected at 6-month follow-up.

CONCLUSION

In the present study, it was seen that myomas up to 13 cm (490 g) in multiparous and 12 cm (350 g) in nulliparous could be removed from the culdotomy while maintaining their integrity. Culdotomy is a safe, inexpensive and effective method for myoma extraction.

Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

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.

Transabdominal versus transvaginal specimen extraction in mini-laparoscopic surgery

AIM

The objective of this study was to present our experiences of tissue extraction via the transvaginal (TV) route after a mini-laparoscopic gynecological surgery and compare them with our transabdominal (TA) specimen extraction experiences.

METHODS

This prospective randomized controlled study was conducted in a tertiary care center between July 2014 and February 2016. Fifty-eight women who were undergoing mini-laparoscopy for adnexal mass removal were randomized into two groups according to the surgical specimen removal by the TV route (n = 28) or the TA route (n = 30). The main outcome measures were the postoperative incisional pain, cosmetic outcomes and overall satisfaction rate. The secondary outcome measures were additional blood loss, additional operation duration and the need for morcellation.

RESULTS

The TV group had significantly lower visual analog scale scores than the TA group at 6 and 24 h postoperatively. The morcellation needs were lower in the TV group than in the TA group. Three months after the surgery, the participants scored a higher rate of overall satisfaction in the cosmetic outcomes in the TV group than in the TA group.

CONCLUSION

Tissue extraction through a posterior colpotomy after mini-laparoscopic surgery may be a feasible technique for improving cosmetic results, decreasing postoperative pain and decreasing the need for morcellation when compared to TA specimen retrieval.

Minimally invasive surgery improves short-term outcomes of nerve-sparing radical hysterectomy in patients with cervical cancer: a propensity-matched analysis with open abdominal surgery

Objectives

Nerve-sparing radical hysterectomy has been implemented in order to reduce pelvic floor dysfunctions in women undergoing radical surgery for cervical cancer. Here, we aimed to investigate if the adoption of laparoscopic surgery impacts on patients' outcomes.

Methods

Data of consecutive patients affected by cervical cancer who had laparoscopic nerve-sparing radical hysterectomy were matched 1:1 with an historical cohort of patients undergoing open procedure. A propensity-score matched algorithm was applied.

Results

Thirty-five patients' pairs (70 patients: 35 undergoing laparoscopic vs. 35 undergoing open abdominal nerve-sparing radical hysterectomy) were included. Demographic and baseline oncologic characteristics were balanced between groups. Patients undergoing laparoscopic surgery had similar operative time than patients undergoing open abdominal procedures (249 [±91.5] vs. 223 [±65.0] minutes; p=0.066). Laparoscopic approach correlated with lower blood loss (30.5 [±11.0] vs. 190 [90.4] mL; p<0.001) and shorter hospital stay (3.2 [±1.2] vs. 5.4 [2.0] days; p=0.023). Patients undergoing laparoscopy experienced a lower 30-day pelvic floor dysfunction rate than patients having open surgery. Moreover, they experienced shorter recovery of bladder function than patients having open procedures (median, 7 vs. 9 days; p=0.004, log-rank test).

Conclusion

Laparoscopic approach resulted in a faster recovery of bladder function in comparison to open surgery for patients undergoing nerve-sparing radical hysterectomy.

Contained Power Morcellation Versus Transvaginal Extraction for Retrieval of Laparoscopically Removed Myomas: A Comparison of Perioperative Outcomes

Objective. To evaluate clinical and operative outcomes of transvaginal extraction (TVE) and contained power morcellation (CPM) for myoma retrieval after laparoscopic myomectomy. Materials and Methods. Prospective data from 35 consecutive cases using CPM were compared with retrospective data of all cases using TVE from December 2014 to January 2017. Patients were matched 1:1 based on myoma diameter. A total of 62 women were included in the final analysis. Specimen retrieval was performed using the TVE or CPM within an insufflated isolation bag. Results. Age, body mass index, mode of prior obstetric delivery, history of previous abdominal surgery, indication for myomectomy, and the myoma(s) characteristics were similar between groups. Retrieval time was significantly shorter in the TVE group compared with the CPM group: 10 minutes (3-15 minutes) versus 17 minutes (14-42 minutes); P < .001. Time required for placement of the instruments was 9.7 minutes for the isolation bag and 0.5 minutes for the vaginal extractor. Additional analgesic administration for pain relief was necessary in 13 patients (42%) in the TVE group and 23 patients (72%) in the CPM group ( P = .01). Total cost of the hospital stay was significantly higher in the CPM group compared with the TVE group ( P < .001). Estimated blood loss and duration of hospital stay were similar between groups. Conclusion. Both CPM and TVE can be used for safe retrieval of large myomas that are removed laparoscopically. Compared with CPM, TVE was associated with a shorter retrieval time, less postoperative pain, and less hospital costs.

Transvaginal contained tissue extraction after laparoscopic myomectomy: a cohort study

OBJECTIVE

To describe the technique and report perioperative outcomes of transvaginal contained extraction of surgical specimens at laparoscopic myomectomy.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Two Italian referral centres for gynaecological minimally invasive surgery.

POPULATION

Consecutive patients who underwent laparoscopic myomectomy.

METHODS

Tissue extraction was accomplished following laparoscopic myomectomy in a specimen retrieval bag via a posterior colpotomy incision. If morcellation was necessary, this was performed extracorporeally, using a scalpel within the specimen retrieval pouch, whose edges were exteriorised through the vaginal introitus.

MAIN OUTCOME MEASURES

Intra- and postoperative complications.

RESULTS

A total of 316 women underwent transvaginal specimen retrieval with enclosed manual morcellation. The mean myomectomy specimen weight was 154 ± 128 g, and the mean operative time was 79 ± 26 minutes. No intraoperative complications occurred related to the specimen extraction or morcellation technique, or from rupture of the retrieval bag. Two (0.6%) women had a haemoperitoneum that spontaneously resolved and 16 (5.1%) had fever postoperatively. The final pathological diagnosis was benign in all cases. At the 30-day follow-up, no pelvic infection, vaginal dehiscence, or complaints of dyspareunia were recorded.

CONCLUSIONS

Contained transvaginal extraction of fibroid specimens can be performed safely and efficiently in most women undergoing laparoscopic myomectomy. This technique represents a valuable minimally invasive alternative to intracorporeal morcellation.

TWEETABLE ABSTRACT

Transvaginal contained morcellation at laparoscopic myomectomy is a valuable alternative to intracorporeal morcellation.

Transumbilical extraction of 151-300-g myomas without morcellator versus conventional laparoscopic myomectomy with power morcellator

Study objective:

The aim of this study was to compare the surgical outcomes, particularly the specimen retrieval time, between two methods of laparoscopic myomectomy: transumbilical retrieval of the myoma without a morcellator and conventional retrieval of the myoma using a power morcellator via the left lower quadrant.

Design:

Retrospective study.

Setting:

Public hospital.

Patients:

Seventy-four women undergoing laparoscopic myomectomy.

Interventions:

Laparoscopic myomectomy followed by myoma retrieval via transumbilical extraction or electric motorized morcellator extraction.

Measurements and main results:

Seventy-four patients undergoing laparoscopic myomectomy followed by myoma retrieval via transumbilical extraction or electric motorized morcellator extraction were studied. Significant differences were observed in the average weight of the retrieved myomas between the transumbilical and morcellator groups (141.0 vs. 262.8 g, respectively; p < 0.001). Therefore, we chose 27 patients whose total specimen weight was 151–300 g; 13 patients were in the transumbilical extraction group and 14 were in the electric motorized morcellator group. No significant differences were observed in patient characteristics between the two groups. The operative time, blood loss volume, and myoma retrieval time were similar between the two groups.

Conclusion:

Laparoscopic myomectomy with transumbilical extraction for myoma retrieval is a feasible method for specimens weighing up to 300 g.

Assessment of selected perioperative parameters in patients undergoing laparoscopic and abdominal supracervical hysterectomy

Introduction

Subtotal hysterectomy is a method of treatment of patients with mild changes in the uterine body. Laparoscopic methods are increasingly used in surgical gynaecology. One of the limitations of laparoscopy is the proper level of operating surgeon's training, which may be assessed with the use of the learning curve. The aim of the study was to compare data regarding the perioperative period in patients who underwent subtotal hysterectomy with the two methods, and to establish a learning curve for laparoscopic subtotal hysterectomy.

Material and methods

One hundred and twenty-seven patients qualified for subtotal hysterectomy due to mild disturbances in the uterine body participated in the study. The study was conducted at the Clinical Department of Gynaecology and Obstetrics of Fryderyk Chopin Provincial Specialist Hospital in Rzeszów in 2012-2013.

Results

The time of laparoscopic subtotal hysterectomy is longer than that of the classical surgical procedure. Uterine myomas are the main indication for subtotal hysterectomy. Laparoscopic operation results in lower blood loss compared to the classical surgical method. The mean age of the patients operated due to mild changes in the uterine body is similar in both groups. Patients who are obese or have undergone Caesarean sections are more frequently qualified for the classical surgery. The study revealed a reduction in time of laparoscopic subtotal hysterectomy by ca. 31 minutes (33%).

Conclusions

Laparoscopic subtotal hysterectomy is a method chosen by operating surgeons for patients with a lower perioperative risk. The period of the study made it possible to determine a learning curve for laparoscopic subtotal hysterectomy.

Morcellator's Port-site Metastasis of a Uterine Smooth Muscle Tumor of Uncertain Malignant Potential After Minimally Invasive Myomectomy

Since the safety warning from the US Food and Drug Administration on the use of power morcellators, minimally invasive procedures involving the removal of uterine myomas and large uteri are under scrutiny. Growing evidence suggests that morcellation of undiagnosed uterine malignancies is associated with worse survival outcomes of patients affected by uterine sarcoma. However, to date, only limited data regarding morcellation of low-grade uterine neoplasms are available. In the present article, we reported a case of a (morcellator) port-site implantation of a smooth muscle tumor that occurred 6 years after laparoscopic morcellation of a uterine smooth muscle tumor of uncertain potential. This case highlights the effects of intra-abdominal morcellation, even in low-grade uterine neoplasms. Caution should be used when determining techniques for tissue extraction; the potential adverse consequences of morcellation should be more fully explored.

Uterine myomata: Organ-preserving surgery

Most women with uterine myoma are asymptomatic and do not require any treatment. However, myoma can also lead to menorrhagia, pressure symptoms, abdominal pain, and infertility. Management of symptomatic women with myoma depends on several factors, including age, desire for fertility, and myoma characteristics. Uterine myoma that distorts the uterine cavity, either submucous myoma or intramural myoma, with a submucous component reduces fertility, and is associated with increased uterine bleeding. The treatment of choice is hysteroscopic myomectomy or abdominal myomectomy, preferably by laparoscopy. Robotic assistance in laparoscopic myomectomy leads to outcomes similar to conventional laparoscopic myomectomy. However, it is expensive. Newer techniques include either laparoscopic or transcervical radiofrequency thermal ablation.

Surgical Management of Abnormal Uterine Bleeding in Fertile Age Women

Abnormal uterine bleeding is a common gynecological disease and represents one of the most frequent reasons for hospital admission to a specialist unit, often requiring further surgical treatment. Following the so-called PALM-COEIN system we will attempt to further clarify the surgical treatments available today. The first group (PALM) is characterized by structural lesions, which may be more appropriately treated by means of surgical management. Although hysterectomy remains the definitive and decisive choice, there are many alternative techniques available. These minimally invasive procedures offer the opportunity for a more conservative approach. Precise and accurate counseling facilitates better patient selection, based on the patient's desires, age and disease type, allowing treatment to be individually tailored to each woman.

A new in-bag system to reduce the risk of tissue morcellation: development and experimental evaluation during laparoscopic hysterectomy

INTRODUCTION

Minimal invasive approaches have proven beneficial for patients undergoing myomectomy and hysterectomy, but necessary tissue morcellation carries the risk of cell dissemination in rare cases of inadvertent malignancy. Performing the morcellation process within a contained bag system may prevent spilling and therefore enhance safety of the laparoscopic procedures.

MATERIAL AND METHODS

The present study describes the development and experimental evaluation of a new bag system in vitro and in vivo in a pig model of laparoscopic supracervical hysterectomies.

RESULTS

The main results on n = 8 procedures with in-bag morcellation compared to n = 8 controls without bag indicate reproducible feasibility and protective effect of the new bag, which is the first published to our knowledge that does not require puncturing in a standard multiport laparoscopy setting. Overall surgery time was significantly prolonged in the bag group by 12.86 min (P = 0.0052; 95 % confidence interval 4.64-21.07), but peritoneal washings were negative for muscle cells in all cases with bag use, compared to positive cytology in 5/8 cases without bag (P = 0.0256).

CONCLUSION

Clinical trials will now be necessary to investigate the reproducibility of these encouraging data in human application.

Hysterectomy in patients with previous cesarean section: comparison between laparoscopic and vaginal approaches

OBJECTIVE

To evaluate surgery-related outcomes of laparoscopic (LH) and vaginal hysterectomy (VH) in patients with a history of previous cesarean section (CS).

STUDY DESIGN

Data on 289 consecutive patients with a history of CS undergoing VH (n = 49, 17%) and LH (n = 219, 76%) were collected. Basic descriptive statistics, univariate and multivariate analyses were performed to evaluate surgery-related outcomes. A propensity-matched algorithm was applied in order to reduce allocation biases between groups.

RESULTS

Patients undergoing LH were more likely to have a history of multiple cesarean sections (44% vs. 18%; p = 0.001). Additionally, uterine weight was greater among patients undergoing LH than VH (median weight: 235 (range, 45-2830) vs. 150 (range, 40-710)g; p < 0.001). Three patients in each group experienced procedural bladder injuries (3/219 (1%) vs. 3/49 (6%); p = 0.07; RR: 1.65; 95%CI: 0.74, 3.68). The rate of grade 3 or worse postoperative complications was balanced between LH and VH (1% vs. 0%; p = 1.00). Patients undergoing LH experienced a shorter length of hospital stay in comparison to patients undergoing VH (1 vs. 2 days; p = 0.02). Considering the overall population, we observed via multivariate analysis that age (OR: 1.003 (95%CI: 1.001, 1.004) per 10-year increase in age; p = 0.002), VH (OR: 17.80 (95%CI: 1.762, 180,378); p = 0.01) and number of cesarean sections ≥ 2 (OR: 27.70 (95%CI: 1.976, 388,285); p = 0.01) increased the risk of developing bladder injuries during hysterectomy.

CONCLUSIONS

LH is a safe and feasible procedure in patients with previous CS, and it is associated with a low bladder injury rate.

Open power morcellation versus contained power morcellation within an insufflated isolation bag: comparison of perioperative outcomes

STUDY OBJECTIVE

To compare perioperative outcomes, particularly operative time, between uncontained and in-bag power morcellation of uterine tissue at the time of laparoscopic surgery.

DESIGN

Canadian Task Force classification II-3.

SETTING

Academic tertiary care hospitals.

PATIENTS

Women undergoing laparoscopic hysterectomy or myomectomy who required morcellation of uterine tissue for specimen extraction.

INTERVENTIONS

Outcomes among patients who had in-bag power morcellation were compared with outcomes among patients who had traditional power morcellation. The technique for in-bag morcellation entails placing the specimen into a large containment bag within the abdomen, insufflating the bag within the peritoneal cavity, and then using a power morcellator to remove the specimen from inside the bag.

MEASUREMENTS AND MAIN RESULTS

The cohort consisted of 85 consecutive patients who underwent surgery with morcellation of uterine tissue. Prospective data collected from 36 patients who underwent in-bag morcellation were compared with retrospective data collected from the immediately preceding 49 patients who had uncontained power morcellation. Baseline demographics were comparable between the 2 groups although women who underwent in-bag morcellation were on average older than the open morcellation group (mean age in years [standard deviation], 49.19 [1.12] vs 44.06 [8.93]; p = .01). The mean operating room time was longer in the in-bag morcellation group (mean time in minutes [standard deviation], 119.0 [55.91] vs 93.13 [44.90]; p = .02). The estimated blood loss, specimen weight, hospital length of stay, and perioperative complication rate did not vary between the 2 groups. Operative times did not vary significantly by surgeon. There were no cases of malignancy or isolation bag disruption.

CONCLUSIONS

In-bag power morcellation, a tissue extraction technique developed to reduce the risk of tissue dissemination, results in perioperative outcomes comparable with the traditional laparoscopic approach. In this cohort, the mean operative time was prolonged by 26 minutes with in-bag morcellation but may potentially be reduced with further refinement of the technique.