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Tahapary M, Timmerman S, Ledger A, Dewilde K, Froyman W. Implementation of robot-assisted myomectomy in a large university hospital: a retrospective descriptive study. Facts Views Vis Obgyn 2023; 15:243-250. [PMID: 37742201 PMCID: PMC10643016 DOI: 10.52054/fvvo.15.3.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Background: Myomectomy is often the preferred treatment for symptomatic patients with myomas who wish to preserve their fertility, with a shift from open surgery towards minimally invasive techniques. Objectives Retrospective study assessing patient and surgery characteristics, follow-up, and outcomes of robot-assisted myomectomy (RAM) and abdominal myomectomy (AM) in women treated between January 1, 2018, and February 28, 2022, in a Belgian tertiary care hospital. Materials and Methods A descriptive analysis was conducted on consecutive patients who underwent myomectomies. 2018 was considered the learning curve for RAM. Main outcome measures We assessed rate of open surgery, operation time, postoperative hospital stay, and operative complications. Results In total, 94 RAMs and 15 AMs were performed. The rate of AMs was 56.5% in 2018 versus 2.3% after the learning curve. The median operation time for RAM was 136.5 minutes and 131 minutes for AM. Conversion rate for RAM was 0%. The median postoperative hospital stay after RAM was 1 night and 4 nights for AM. Postoperative complication rate was low, with only 14.9% and 33.3% of patients requiring pharmacological treatment of complications after RAM or AM, respectively. No surgical re-intervention was needed in any group. Conclusions Implementation of RAM at our centre resulted in a significant reduction of open surgery rate. RAM demonstrated shorter hospital stays and a lower incidence of complications compared to AM. What is new? Our study highlights the successful adoption of RAM, showcasing its potential to replace AM even in complex cases. The findings affirm the safety and feasibility of RAM, supporting its use as a valuable technique for minimally invasive myomectomy.
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Richtarova A, Boudova B, Dundr P, Lisa Z, Hlinecka K, Zizka Z, Fruhauf F, Kuzel D, Slama J, Mara M. Uterine smooth muscle tumors with uncertain malignant potential: analysis following fertility-saving procedures. Int J Gynecol Cancer 2023; 33:701-706. [PMID: 36898699 PMCID: PMC10176401 DOI: 10.1136/ijgc-2022-004038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
OBJECTIVE The aim of this study was to analyze the clinical and reproductive outcomes of patients treated with myomectomy who were histologically diagnosed with uterine smooth muscle tumor of uncertain malignant potential (STUMP). METHODS Patients who were diagnosed with STUMP and underwent a myomectomy at our institution between October 2003 and October 2019 were identified. Variables of interest obtained from the institution's database included patient age, relevant medical history, pre-operative appearance of the tumor on ultrasound, parameters of the surgical procedure, histopathological analysis of the tumor, post-operative clinical course, and course of follow-up, including reinterventions and fertility outcomes. RESULTS There were a total of 46 patients that fulfilled the criteria of STUMP. The median patient age was 36 years (range, 18-48 years) and the mean follow-up was 47.6 months (range, 7-149 months). Thirty-four patients underwent primary laparoscopic procedures. Power morcellation was used for specimen extraction in 19 cases (55.9% of laparoscopic procedures). Endobag retrieval was used in nine patients and six procedures were converted to an open approach due to the suspicious peri-operative appearance of the tumor. Five patients underwent elective laparotomy due to the size and/or number of tumors; three patients had vaginal myomectomy; two patients had the tumor removed during planned cesarean section; and two underwent hysteroscopic resection.There were 13 reinterventions (five myomectomies and eight hysterectomies) with benign histology in 11 cases and STUMP histology in two cases (4.3% of all patients). We did not observe any recurrence as leiomyosarcoma or other uterine malignancy. We did not observe any deaths related to the diagnosis. Twenty-two pregnancies were recorded among 17 women, which resulted in 18 uncomplicated deliveries (17 by cesarean section and one vaginal), two missed abortions, and two pregnancy terminations. CONCLUSIONS Our study found that uterus-saving procedures and fertility-preservation strategies in women with STUMP are feasible, safe, and seem to be associated with a low risk of malignant recurrence, even while maintaining the mini-invasive laparoscopic approach.
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Affiliation(s)
- Adela Richtarova
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Barbora Boudova
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Pavel Dundr
- Department of Pathology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Zdenka Lisa
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Kristyna Hlinecka
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Zdenek Zizka
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Filip Fruhauf
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - David Kuzel
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Jiri Slama
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Michal Mara
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
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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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Lok J, Tse KY, Lee EYP, Wong RWC, Cheng ISY, Chan ANH, Leung CKL, Cheung ANY, Ip PPC. Intraoperative Frozen Section Biopsy of Uterine Smooth Muscle Tumors: A Clinicopathologic Analysis of 112 Cases With Emphasis on Potential Diagnostic Pitfalls. Am J Surg Pathol 2021; 45:1179-1189. [PMID: 34074809 DOI: 10.1097/pas.0000000000001746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Frozen sections of uterine smooth muscle tumors are infrequently required, and related diagnostic difficulties are seldom discussed. We analyzed the clinicopathologic features of 112 frozen sections of uterine smooth muscle tumors and determined the accuracy, reasons for deferrals, and causes of interpretational errors. Most patients (median age, 45 y) presented with pelvic mass symptoms (53%). The main reasons for a frozen section examination were an abnormal gross appearance including loss of the usual whorled pattern of leiomyoma (36 cases, 32.1%), and intraoperative discovery of an abnormal growth pattern and extrauterine extension of a uterine tumor (28 cases, 25%). There were 9 leiomyosarcomas and 103 leiomyomas, including 18 benign histologic variants. An accurate diagnosis of malignancy was achieved in all leiomyosarcomas, with the exception of a myxoid leiomyosarcoma. In 99 cases (88%), the frozen section diagnosis concurred with the permanent section diagnosis (false positives, 0.9%; false negatives, 0%). Misinterpretation of stromal hyalinization as tumor cell necrosis in a leiomyoma with amianthoid-like fibers was a major discrepancy. Two minor discrepancies did not lead to a change in management. The diagnosis was deferred in 10 cases (8.9%) because of stromal alterations, unusual cellular morphology, uncertain type of necrosis, and abnormal growth patterns. Thus, although various stromal and cellular alterations can cause diagnostic uncertainty, leading to deferrals, frozen section diagnosis of uterine smooth muscle tumors has a high accuracy rate. While a definitive frozen section diagnosis of malignancy may be made when there is unequivocal atypia, indisputable mitotic figures, and tumor cell necrosis, it is important to remember that nonmyogenic mesenchymal tumors may also mimic uterine smooth muscle tumors. In a frozen section setting, it would be sufficient to issue a diagnosis of "malignant mesenchymal tumor." For tumors that do not meet the criteria for malignancy, issuing a frozen section diagnosis of "atypical mesenchymal tumor and defer the histologic subtyping to the permanent sections" is appropriate.
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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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Comparison of the Number of Spindle Cells in Peritoneal Washings between Laparoscopic Myomectomy with Morcellation and Open Myomectomy without Morcellation. J Minim Invasive Gynecol 2020; 28:1391-1396. [PMID: 33152530 DOI: 10.1016/j.jmig.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE This study evaluated peritoneal washings for the detection of spindle cells (SCs) in laparoscopic and open myomectomies. DESIGN Prospective, nonrandomized clinical trial. SETTING An academic tertiary referral center. PATIENTS Women suspected of having benign uterine myoma undergoing laparoscopic or open myomectomy from October 2016 to April 2018. INTERVENTIONS Washing of the peritoneal cavity to detect SCs was performed twice during the laparoscopic myomectomy. The first washing was after the closure of the myometrial incision and before morcellation. The second one was performed after morcellation. The procedure was also performed once during the open myomectomy, after the completion of the myomectomy and the closure of the incision. After a peritoneal washing with 200 mL normal saline, 30 mL liquid was collected and sent to the laboratory for SC detection. Surgical parameters such as operating time, mean change in serum hemoglobin level, complications, length of hospital stay, and readmission were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS A total of 150 participants were included in the analysis: 78 in the laparoscopic group and 72 in the open myomectomy group. After morcellation, the incidence of SCs was 2.6% (n = 2) and 6.9% (n = 5) in the laparoscopic and open myomectomy groups, respectively (p = .204). CONCLUSION SCs were observed in both the laparoscopic and open myomectomy groups. Thus, morcellation alone could not be the cause for SC dissemination, which might also be triggered by the manipulation of myoma(s).
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Liu X, Tang J, Luo Y, Wang Y, Song L, Wang W. Comparison of high‐intensity focused ultrasound ablation and secondary myomectomy for recurrent symptomatic uterine fibroids following myomectomy: a retrospective study. BJOG 2020; 127:1422-1428. [DOI: 10.1111/1471-0528.16262] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2020] [Indexed: 12/24/2022]
Affiliation(s)
- X Liu
- Department of Ultrasound Chinese PLA General HospitalMedical School of Chinese PLA Beijing China
- Department of Ultrasound Beijing Tiantan HospitalCapital Medical University Beijing China
| | - J Tang
- Department of Ultrasound Chinese PLA General HospitalMedical School of Chinese PLA Beijing China
| | - Y Luo
- Department of Ultrasound Chinese PLA General HospitalMedical School of Chinese PLA Beijing China
| | - Y Wang
- Department of Ultrasound Chinese PLA General HospitalMedical School of Chinese PLA Beijing China
| | - L Song
- Department of Gynaecology Chinese PLA General HospitalMedical School of Chinese PLA Beijing China
| | - W Wang
- Department of Ultrasound Chinese PLA General HospitalMedical School of Chinese PLA Beijing China
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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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Implementing robotic assisted myomectomy in surgical practice – a retrospective cohort study. ACTA ACUST UNITED AC 2019. [DOI: 10.1186/s10397-019-1059-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Abstract
Background
To compare surgical outcomes of patients with leiomyomas after robotic-assisted laparoscopic myomectomy (RALM), laparoscopic myomectomy (LsM), or laparotomic myomectomy (LtM) and to construct a useful algorithm for the best modus operandi for uterine leiomyomas.
Methods
Design: A retrospective chart review. Data included patient (age and BMI) and fibroid characteristics (number, measurements of the primary fibroid, type, and location), operating time, blood loss, hospitalization length, complications during and after surgery, and complications during posttreatment pregnancies. Comparisons were based on chi-square and two-sample t tests. Setting: University teaching hospital. Patients: Between 1 January 2009 and 31 December 2016, 51 RALMs, 84 LsMs, and 52 LtMs were performed at our institution. Interventions: Three different approaches of myomectomy were performed: robotic-assisted laparoscopy (RALM), laparoscopy (LsM), and laparotomy (LtM).
Results
There was no significant difference in the distribution of the location and the type of myoma between the three groups. The mean size of the largest myoma removed by LsM, RALM, and LtM was 60.9, 70.8, and 92.6 mm (p < 0.05), respectively. Surgical outcomes between the three modalities were comparable except for increased mean blood loss and postoperative bleeding and longer hospital stay for patients with LtM and for longer operation time when performing RALM.
Conclusion
RALM should replace open surgery if feasible and should not replace traditional laparoscopy unless other benefits are proven.
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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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Takeda A, Tsuge S, Shibata M, Shinone S, Nakamura H, Watanabe K. Identification of Leiomyoma Cell Sheets in Peritoneal Washings Retrieved by an Intraoperative Red Blood Cell Salvage Device during Laparoscopic-Assisted Myomectomy with in-Bag Manual Tissue Extraction: A Pilot Study. J Minim Invasive Gynecol 2018; 25:1266-1273. [DOI: 10.1016/j.jmig.2018.03.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 03/23/2018] [Accepted: 03/29/2018] [Indexed: 02/07/2023]
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van den Haak L, van der Eijk AC, Sandberg EM, Frank GPGM, Ansink K, Pelger RCM, de Kroon CD, Jansen FW. Towards spill-free in-bag morcellation: a health failure mode and effects analysis. Surg Endosc 2018; 32:4357-4362. [PMID: 29987561 PMCID: PMC6132883 DOI: 10.1007/s00464-018-6284-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 06/18/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND To assess potential risks of new surgical procedures and devices before their introduction into daily practice, a prospective risk inventory (PRI) is a required step. This study assesses the applicability of the Health Failure Mode and Effects Analysis (HFMEA) as part of a PRI of new technology in minimally invasive gynecologic surgery. METHODS A reference case was defined of a patient with presumed benign leiomyoma undergoing a laparoscopic hysterectomy or myomectomy including in-bag power morcellation; however, pathology defined a stage I uterine leiomyosarcoma. Using in-bag morcellation as a template, a HFMEA was performed. All steps of the in-bag morcellation technique were identified. Next, the possible hazards of these steps were explored and possible measures to control these hazards were discussed. RESULTS Five main steps of the morcellation process were identified. For retrieval bags without openings to accommodate instruments inside the bag, 120 risks were identified. Of these risks, 67 should be eliminated. For containment bags with openings 131 risks were identified of which 68 should be eliminated. Of the 10 causes most at risk to cause spillage, two can be eliminated by using appropriate bag materials. Myomectomy appears to be more at risk for residual tissue spillage compared to total hysterectomy. CONCLUSION The HFMEA has provided important new insights regarding potential weaknesses of the in-bag morcellation technique, particularly with respect to hazardous steps in the morcellation process as well as requirements that bags should meet. As such, this study has shown HFMEA to be a valuable method that identifies and quantifies potential hazards of new technology.
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Affiliation(s)
- Lukas van den Haak
- Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Anne C van der Eijk
- Central Sterile Supply Department, Leiden University Medica Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Evelien M Sandberg
- Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Gerard Peter G M Frank
- Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Karin Ansink
- Operating Room Center, Leiden University Medica Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Rob C M Pelger
- Department of Urology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Cor D de Kroon
- Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of BioMechanical Engineering, Delft University of Technology, PO Box 5, 2600 AA, Delft, The Netherlands.
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Yu SP, Lee BB, Han MN, Chan C, Rao J, Levin M, Fung PC, Parker W. Irrigation after Laparoscopic Power Morcellation and the Dispersal of Leiomyoma Cells: A Pilot Study. J Minim Invasive Gynecol 2018; 25:632-637. [DOI: 10.1016/j.jmig.2018.01.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/22/2018] [Accepted: 01/26/2018] [Indexed: 12/14/2022]
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17
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Regarding “Incidence of Occult Uterine Malignancy Following Vaginal Hysterectomy with Morcellation”. J Minim Invasive Gynecol 2018; 25:187-188. [DOI: 10.1016/j.jmig.2017.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 12/16/2022]
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Tissue Extraction Techniques for Leiomyomas and Uteri During Minimally Invasive Surgery. Obstet Gynecol 2017; 130:1251-1260. [DOI: 10.1097/aog.0000000000002334] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Petrozza JC. Value of versatility in fibroid surgery. Fertil Steril 2017; 108:453-454. [PMID: 28865545 DOI: 10.1016/j.fertnstert.2017.07.1162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/28/2017] [Indexed: 10/18/2022]
Affiliation(s)
- John C Petrozza
- Department of Obstetrics and Gynecology, Division of Reproductive Medicine and IVF, Massachusetts General Hospital, Boston, Massachusetts
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Clark NV, Cohen SL. Tissue Extraction Techniques During Laparoscopic Uterine Surgery. J Minim Invasive Gynecol 2017; 25:251-256. [PMID: 28866098 DOI: 10.1016/j.jmig.2017.07.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 10/18/2022]
Abstract
Morcellation allows minimally invasive approaches to surgery even in the presence of large uteri or myomas. Recent restrictions in the use of power morcellation, as well as concerns regarding the potential for morcellation to disseminate malignant tissue, have initiated investigation and innovation to find safer methods. This review examines current techniques for tissue extraction during uterine surgery, with a focus on contained power morcellation and contained manual morcellation via mini-laparotomy or colpotomy. Videos are included to demonstrate these methods.
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Affiliation(s)
- Nisse V Clark
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah L Cohen
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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Mynbaev OA, Malvasi A, Simakov SS, Tinelli A. Comment on "Oestrogen-induced angiogenesis and implantation contribute to the development of parasitic myomas after laparoscopic morcellation". Reprod Biol Endocrinol 2017; 15:54. [PMID: 28732545 PMCID: PMC5521111 DOI: 10.1186/s12958-017-0268-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 03/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The cause of contamination and dissemination of leiomyoma tissue particles and cells in the peritoneal cavity during myomectomy is a challenging issue for both clinicians and researchers. Therefore, the article by Huang et al. recently published in your journal is the subject of this letter. MAIN BODY We comment on the role of laparoscopic condition in xenograft implantation and also highlighted the shortcomings of this study. The surgical technique of intramural fibroid enucleation, cell spillage during morcellation and postsurgical hormonal impact on the development of parasitic myomas become evident, while the contribution of CO2 insufflation, the fibroid's nature, mutations and pseudocapsule impacts on angiogenesis are not clear. In addition, an exploration of the exact origin of implanted fragments harvested from the fibroid tissue and their nature might play a significant role in the implantation and the angiogenesis induction ability of xenografts. CONCLUSION Taking into account the current literature in the scope of this study, we suggest that the factors involved in development of parasitic myomas can be classified as confirmed and doubtful contributions.
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Affiliation(s)
- Ospan A. Mynbaev
- 0000 0000 9559 0613grid.78028.35Division of Molecular Technologies, Research Institute of Translational Medicine, N.I.Pirogov Russian National Research Medical University, Ostrovitianova str. 1, Moscow, 117997 Russia
- 0000 0001 2192 9124grid.4886.2Institute of Numerical Mathematics, RAS, Moscow, Russia
| | - Antonio Malvasi
- 0000 0004 1785 3878grid.415208.aDepartment of Obstetrics and Gynecology, Santa Maria Hospital. G.V.M. Care and Research, Bari, Italy
| | - Sergei S. Simakov
- 0000 0001 2192 9124grid.4886.2Institute of Numerical Mathematics, RAS, Moscow, Russia
| | - Andrea Tinelli
- 0000 0004 1769 6825grid.417011.2Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Piazza Muratore, Lecce, Italy
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22
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Changes in Myomectomy Practice After the U.S. Food and Drug Administration Safety Communication on Power Morcellation. Obstet Gynecol 2017; 129:1007-1013. [PMID: 28486366 DOI: 10.1097/aog.0000000000002035] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine the association between the 2014 U.S. Food and Drug Administration (FDA) safety communication on power morcellation and surgical approach and morbidity after myomectomy. METHODS In this retrospective cohort study, data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program database on 3,160 myomectomies between April 2012 and December 2013 (pre-FDA) and 4,378 between April 2014 and December 2015 (post-FDA). Aims were to 1) compare rates of abdominal and laparoscopic myomectomy pre-FDA and post-FDA (primary outcome), 2) directly compare the morbidity of abdominal and laparoscopic myomectomy during each time period (secondary outcome 1), and 3) compare the morbidity after all myomectomies performed pre-FDA and post-FDA (secondary outcome 2). Adjusted means, odds ratios, and rate ratios with 95% confidence intervals were calculated using linear, logistic, and Poisson regression, respectively, adjusting for age, race, ethnicity, body mass index, and myoma burden. RESULTS Myomectomies performed post-FDA were more likely to be abdominal (60.0%, 95% confidence interval [CI] 58.6-61.5%) than laparoscopic (40.0%, 95% CI 38.5-41.4%) as compared with myomectomies pre-FDA, which were equally divided between surgical approaches (49.1% abdominal, 95% CI 47.4-50.9% compared with 50.9% laparoscopic, 95% CI 49.1-52.6%; P<.001). When directly compared with laparoscopic myomectomy, abdominal myomectomy was associated with longer hospitalizations, higher readmission rates, and greater morbidity both pre-FDA and post-FDA (P<.05, all comparisons). Adjusted models demonstrated shorter operative times post-FDA for all myomectomies (P<.001), although composite morbidity was similar between myomectomies performed pre-FDA and post-FDA (P=.809). CONCLUSIONS The FDA safety communication on power morcellation was associated with an 11% absolute increase in the use of abdominal myomectomy. Although morbidity is consistently higher after abdominal as compared with laparoscopic myomectomy, the increased reliance on abdominal myomectomy post-FDA did not result in clinically significant changes in morbidity in this cohort.
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23
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Ghezzi F, Casarin J, De Francesco G, Puggina P, Uccella S, Serati M, Cromi A. Transvaginal contained tissue extraction after laparoscopic myomectomy: a cohort study. BJOG 2017; 125:367-373. [PMID: 28467660 DOI: 10.1111/1471-0528.14720] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2017] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- F Ghezzi
- Department of Obstetrics and Gynaecology, Del Ponte Hospital, University of Insubria, Varese, Italy
| | - J Casarin
- Department of Obstetrics and Gynaecology, Del Ponte Hospital, University of Insubria, Varese, Italy
| | - G De Francesco
- Department of Obstetrics and Gynaecology, Evangelical Hospital, 'Villa Betania', Naples, Italy
| | - P Puggina
- Department of Obstetrics and Gynaecology, Evangelical Hospital, 'Villa Betania', Naples, Italy
| | - S Uccella
- Department of Obstetrics and Gynaecology, Del Ponte Hospital, University of Insubria, Varese, Italy
| | - M Serati
- Department of Obstetrics and Gynaecology, Del Ponte Hospital, University of Insubria, Varese, Italy
| | - A Cromi
- Department of Obstetrics and Gynaecology, Del Ponte Hospital, University of Insubria, Varese, Italy
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24
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Bortoletto P, Hariton E, Salas S, Cohen SL. Update on Fibroid Morcellation. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0197-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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25
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Is Laparoscopic Power Morcellation of Fibroids a Cardinal Sin in 2017? J Obstet Gynaecol India 2017; 67:1-6. [PMID: 28242959 DOI: 10.1007/s13224-017-0970-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 12/21/2022] Open
Abstract
The diagnosis of an unsuspected leiomyosarcoma after hysterectomy for the treatment of a presumed benign leiomyoma is a rare but highly clinically significant event. In order to facilitate removal of large uterine specimens using a minimally invasive surgical approach, morcellation with extraction in pieces is often performed. In the event of unsuspected malignancy, this may result in abdominal dispersion of the tumor and contribute to poorer survival. Modern surgical innovations always work toward improving minimally invasive strategies. Laparoscopy, rooted in practices for years, supplanted laparotomy for many indications. For extraction of large uteri, morcellation is currently the only way to externalize surgical specimens (myomas, uteri), without increasing the skin opening while allowing to reduce postoperative complications when compared to laparotomy. However, in 2014, the Food and Drug Administration warned against the use of uterine morcellation because of an oncological risk. Some practicing academicians have challenged this recommendation. The incidence of uterine sarcomas is still poorly identified and preoperative diagnostic facilities remain inadequate. The small number of retrospective studies currently available do not reinforce any recommendation. The evaluation of morcellation devices and the improvement of preoperative diagnostic modalities (Imaging, preoperative Biopsy) are being improvised continually so as to minimize the oncological risks. Even during conventional myomectomy, tissue spillage occurs during resection of leiomyoma(s). Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. Preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is recommended.
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