Estimation of uterine volume: A comparison between Viewpoint and 3D ultrasound estimation in women undergoing laparoscopic hysterectomy

Anterior Quadratus Lumborum Block for Total Laparoscopic Hysterectomy: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVES

This study aimed to investigate the perioperative analgesic effects of anterior quadratus lumborum block (QLB) for total laparoscopic hysterectomy (TLH).

MATERIALS AND METHODS

One hundred patients undergoing TLH were randomized to receive an anterior QLB or placebo before general anesthesia. The primary and secondary outcomes were postoperative sufentanil consumption, intraoperative remifentanil demand, time to first opioid demand, numeric rating scale (NRS) pain scores, heart rate, mean arterial pressure, and complications within 24 hours after surgery.

RESULTS

No significant intergroup differences were observed in sufentanil consumption within 24 hours after surgery. Remifentanil consumption during surgery was lower in the QLB group than in the placebo group. At 1 hour after surgery, the NRS scores of abdominal visceral pain at rest and during activity were 1.26 and 1.41 points lower than those in the placebo group. In other time points, the differences in abdominal visceral pain were neither statistically significant nor clinically significant (pain difference <1) or both. No significant differences in NRS scores of shoulder pain, abdominal incisional pain, and perineal pain were observed between the 2 groups, at rest or during activity. There were no significant differences in other secondary outcome variables between the 2 groups.

DISCUSSION

Preoperative bilateral anterior QLB only reduced intraoperative opioid demand and postoperative abdominal visceral pain scores at 1 hour after surgery. Thus, the clinical significance of anterior QLB in TLH may be limited.

Ultrasound Control of Cervical Regeneration after Large Loop Excision of the Transformation Zone: Results of an Innovative Measurement Technique

The objective of this research is to evaluate cervical regeneration after large loop excision of the transformation zone (LLETZ) through the identification of a new sonographic reference point at the level of the uterine margins. In the period March 2021-January 2022, a total of 42 patients affected by CIN 2-3 were treated with LLETZ at the University Hospital of Bari (Italy). Before performing LLETZ, cervical length and volume were measured with trans-vaginal 3D ultrasound. From the multiplanar images, the cervical volume was obtained using the Virtual Organ Computer-aided AnaLysis (VOCAL™) program with manual contour mode. The line that connects the points where the common trunk of the uterine arteries reaches the uterus splitting into the ascending major branch and the cervical branch was considered as the upper limit of the cervical canal. From the acquired 3D volume, the length and the volume of the cervix were measured between this line and the external uterine os. Immediately after LLETZ, the removed cone was measured using Vernier's caliper, and before fixation in formalin, the volume of the excised tissue was evaluated by the fluid displacement technique based on the Archimedes principle. The proportion of excised cervical volume was 25.50 ± 17.43%. The volume and the height of the excised cone were 1.61 ± 0.82 mL and 9.65 ± 2.49 mm corresponding to 14.74 ± 11.91% and 36.26 ± 15.49% of baseline values, respectively. The volume and length of the residual cervix were also assessed using 3D ultrasound up to the sixth month after excision. At 6 weeks, about 50% of cases reported an unchanged or lower cervical volume compared to the baseline pre-LLETZ values. The average percentage of volume regeneration in examined patients was equal to 9.77 ± 55.33%. In the same period, the cervical length regeneration rate was 69.41 ± 14.8%. Three months after LLETZ, a volume regeneration rate of 41.36 ± 28.31% was found. For the length, an average regeneration rate of 82.48 ± 15.25% was calculated. Finally, at 6 months, the percentage of regeneration of the excised volume was 90.99 ± 34.91%. The regrowth percentage of the cervical length was 91.07 ± 8.03%. The cervix measurement technique that we have proposed has the advantage of identifying an unequivocal reference point in 3D cervical measurement. Ultrasound 3D evaluation could be useful in the clinical practice to evaluate the cervical tissue deficit and express the "potential of cervical regeneration" as well as provide the surgeon useful information about the cervical length.

Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study

BACKGROUND

atypical endometrial hyperplasia (AEH) is a precancerous condition implying a high risk of concurrent endometrial cancer (EC), which might be occult and only diagnosed at postoperative histopathological examination after hysterectomy. Our study aimed to investigate potential differences in preoperative clinical, sonographic, and hysteroscopic characteristics in patients with AEH and postoperative diagnosis of EC.

METHODS

a retrospective single-center study was carried out on a case series of 80 women with AEH undergoing diagnostic workup, including ultrasonography and hysteroscopy, with subsequent hysterectomy. Women with AEH confirmed at the histopathological examination were compared with patients with a postoperative diagnosis of EC.

RESULTS

in our population, EC was diagnosed in 53 women, whereas the preoperative diagnosis of AEH was confirmed in 27 cases. At ultrasonography, women with occult EC showed greater endometrial thickness (20.3 mm vs. 10.3 mm, p 0.001) and size of the endocavitary lesion (maximum diameter 25.2 mm vs. 10.6 mm, p 0.001), and a higher prevalence of irregular endometrial-myometrial junction (40.5% vs. 6.7%, p 0.022) and endouterine vascularization at color Doppler (64.2% vs. 34.6%, p 0.017). At hysteroscopy, patients with occult EC showed a higher prevalence of necrosis (44.2% vs. 4.2%, p 0.001) and atypical vessels (70.6% vs. 33.3%, p 0.003), whereas true AEH mainly presented as a protruding intracavitary lesion (77.8% vs. 50.9%, p 0.029). In EC, subjective assessment by the operator was more frequently indicative of cancer (80.0% vs. 12.5%). No difference was found for clinical variables.

CONCLUSIONS

occult EC in AEH may exhibit some differences in ultrasonographic and hysteroscopic patterns of presentation compared with real AEH, which could prompt a more significant suspect for the possible presence of concurrent EC at preoperative diagnostic workup.

Is Vaginal Hysterectomy Safe for an Enlarged Uterus?

Objective

The purpose of this study was to compare the surgical outcomes between two sets of women undergoing vaginal hysterectomy (VH) for benign gynecological conditions: those with moderately enlarged ( ≥12 weeks') uteruses and those with normal-sized uteruses.

Materials and Methods

The medical records of 84 women who underwent vaginal hysterectomies for benign gynecological conditions at Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey between 2013 and 2015 were reviewed. Age, uterine sizes, indications, duration of hospitalization, operation time, hematocrit (HCT) levels, and complications were analyzed.

Results

The most common indications for VH were uterine descensus. However, most women had presented with more than one indication. The mean age of the patients who underwent VH was 56.12. The maximum volume of the uterus was found to be 1244.74 ml, and the smallest volume was found to be 18.83 ml. The mean volume of the uterus was found as 122.6629 ml. The mean duration of operation was 159.70 minutes, whereas the mean duration of hospital stay was 3.79 days. The mean preoperative HCT and hemoglobin (Hgb) values were 37.098 (±3.64) gr/dl and 12.365 (±1.35) gr/dl respectively. Postoperative HCT and Hgb values were 31.363 (±3.94) gr/dl and 10.52 (±1.38) respectively.

Conclusion

VH is usually a simple procedure with low morbidity. It is important to choose the appropriate patient when deciding on the operation. In addition, having experienced surgeons in the field of VH increases the success of surgery.

Three-dimensional transvaginal sonographic assessment of uterine volume as preoperative predictor of need to morcellate in women undergoing laparoscopic hysterectomy

OBJECTIVE

In light of recent statements from the United States Food and Drug Administration warning against the use of power morcellation of uterine leiomyomas during laparoscopy, we sought to evaluate the use of preoperative two- (2D) and three- (3D) dimensional transvaginal ultrasound (US) assessment of uterine volume to predict the need for morcellation in women undergoing laparoscopic hysterectomy (LH).

METHODS

This was a prospective observational study performed between October 2008 and November 2011 in a tertiary referral laparoscopic unit. All women scheduled to undergo LH were included and underwent detailed preoperative transvaginal US. Uterine volumes were calculated using 2D-US measurements (ellipsoid formula), and using Virtual Organ Computer-aided AnaLysis (VOCAL™) having acquired 3D-US volumes of the uterus. Age, parity, need to morcellate and final uterine dry weight at histology were recorded. The estimated uterine volumes were then incorporated into a previously published logistic regression model to predict the need to morcellate for both nulliparous and parous women. The probability threshold cut-off of 0.14 (95% sensitivity) was evaluated in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios (LRs). The performance of the models incorporating 2D- and 3D-US calculations were compared with 2D- and 3D-US-generated volumes alone, using receiver-operating characteristics (ROC) curves.

RESULTS

Of 76 women who underwent LH during the study period, 79% (n = 60) had complete background and 3D-US data. Their mean age was 43.7 years, 91.7% were parous and 35% underwent morcellation. The greatest uterine volume that did not require morcellation was 404 mL estimated using 3D-US, which corresponded to a uterine volume of 688.8 mL using 2D-US. The smallest uterine volume that required morcellation was 118.9 mL using 3D-US, which corresponded to a uterine volume of 123.4 mL using 2D-US. The 3D-US uterine volume for parous women with a sensitivity of 95% based on ROC-curve analysis was approximately 120 mL, which equated to a predicted probability of morcellation cut-off of 0.14. For this cut-off, specificity was 55.00%, PPV was 51.35%, NPV was 95.65%, LR+ was 2.11 and LR- was 0.09. Areas under the ROC curves for the morcellation logistic regression model were 0.769 (95% CI, 0.653-0.886) and 0.586 (95% CI, 0.419-0.753) using uterine volumes obtained by 3D-US and by 2D-US, respectively, and they were 0.938 (95% CI, 0.879-0.996) and 0.815 (95% CI, 0.681-0.948) using 3D-US and 2D-US volumes alone.

CONCLUSIONS

The need to morcellate can be predicted preoperatively using 3D-US uterine volumes obtained by transvaginal US with a fair degree of accuracy. Uteri with volumes smaller than 120 mL at 3D-US are very unlikely to require morcellation. The incorporation of 3D-US-estimated uterine volume into the previously published logistic regression model does not seem to confer any significant improvement when compared with 3D-US uterine volume alone to predict the need to morcellate in women undergoing total LH. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.