Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review

OBJECTIVE

To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures.

DATA SOURCES

We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022.

METHODS OF STUDY SELECTION

Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity.

CONCLUSION

Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022327490.

Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review

OBJECTIVE

To conduct a systematic review to evaluate the effect of procedural interventions for leiomyomas on pelvic floor symptoms.

DATA SOURCES

PubMed, EMBASE, and ClinicalTrials.gov were searched from inception to January 12, 2023, searching for leiomyoma procedures and pelvic floor disorders and symptoms, restricted to primary study designs in humans.

METHODS OF STUDY SELECTION

Double independent screening for studies of any study design in all languages that reported pelvic floor symptoms before and after surgical (hysterectomy, myomectomy, radiofrequency volumetric thermal ablation) or radiologic (uterine artery embolization, magnetic resonance-guided focused ultrasonography, high-intensity focused ultrasonography) procedures for management of uterine leiomyomas. Data were extracted, with risk-of-bias assessment and review by a second researcher. Random effects model meta-analyses were conducted, as feasible.

TABULATION, INTEGRATION, AND RESULTS

Six randomized controlled trials, one nonrandomized comparative study, and 25 single-group studies met criteria. The overall quality of the studies was moderate. Only six studies, reporting various outcomes, directly compared two procedures for leiomyomas. Across studies, leiomyoma procedures were associated with decreased symptom distress per the UDI-6 (Urinary Distress Inventory, Short Form) (summary mean change -18.7, 95% CI -25.9 to -11.5; six studies) and improved quality of life per the IIQ-7 (Incontinence Impact Questionnaire, Short Form) (summary mean change -10.7, 95% CI -15.8 to -5.6; six studies). There was a wide range of resolution of urinary symptoms after procedural interventions (7.6-100%), and this varied over time. Urinary symptoms improved in 19.0-87.5% of patients, and the definitions for improvement varied between studies. Bowel symptoms were inconsistently reported in the literature.

CONCLUSION

Urinary symptoms improved after procedural interventions for uterine leiomyomas, although there is high heterogeneity among studies and few data on long-term outcomes or comparing different procedures.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272678.

Twitter Gynecologic Surgery Journal Club: Impact on Citation Scores and Social Media Attention

STUDY OBJECTIVE

To study the impact of a Twitter-based gynecologic surgery journal club of articles published in the Journal of Minimally Invasive Gynecology (JMIG) on their social media attention and citation scores.

DESIGN

A cross-sectional study.

SETTING

N/A.

PATIENTS

N/A.

INTERVENTIONS

Comparison of citation and social media attention scores was conducted for all articles presented in the JMIG Twitter Journal Club (#JMIGjc), a monthly scientific discussion on Twitter of JMIG selected articles, between March 2018 and September 2021 (group A), with 2 matched control groups of other JMIG articles: group B, articles mentioned on social media but not promoted in any JMIG social media account, and group C, articles with no social media mentions and not presented in #JMIGjc. Matching was performed for publication year, design, and topic in a 1:1:1 ratio. Citation metrics included number of citations per year (CPY) and relative citation ratio (RCR). Altmetric Attention Score (AAS) was used to measure social media attention. This score tracks research articles' online activity from different sources such as social media platforms, blogs, and websites. We further compared group A with all JMIG articles published during the same period (group D).

MEASUREMENTS AND MAIN RESULTS

Thirty-nine articles were presented in the #JMIGjc (group A) and were matched to 39 articles in groups B and C. Median AAS was higher in group A than groups B and C (10.00 vs 3.00 vs 0, respectively, p <.001). CPY and RCR were similar among groups. Median AAS was higher in group A than group D (10.00 vs 1.00, p <.001), as were median CPY and RCR (3.00 vs 1.67, p = .001; 1.37 vs 0.89, p = .001, respectively).

CONCLUSION

Although citation metrics were similar among groups, #JMIGjc articles had higher social media attention metrics than matched controls. Compared with all publications within the same journal, #JMIGjc articles resulted in higher citation metrics.

Single port robotic assisted sacrocolpopexy: technique and tips

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy is the most durable surgical procedure for the treatment of symptomatic pelvic organ prolapse (Maher et al. Cochrane Database Syst Rev. 2013;(4):CD004014). The single port robotic platform has recently been approved in the USA for use in urological surgery. Innovation in robotic surgery continues to evolve, minimizing abdominal wall trauma while improving instrumentation and technical feasibility. Identifying the appropriate procedures to utilize novel technology is important to understand the role of new surgical tools. Sacrocolpopexy procedure, when performed with supracervical hysterectomy, requires extension of an incision for specimen retrieval, making it ideal for single port surgery. The technique and adaptation to new instrumentation is demonstrated in this video.

METHOD

A surgical demonstration of single port robotic sacrocolpopexy is shown.

RESULTS

Sacrocolpopexy was successfully completed using the single port robotic platform.

CONCLUSIONS

Sacrocolpopexy is technically feasible with use of the single port robotic platform.

Barriers to Referral to Fellowship-trained Minimally Invasive Gynecologic Surgery Subspecialists

STUDY OBJECTIVE

To determine patterns and barriers for referral to fellowship-trained minimally invasive gynecologic surgeons.

DESIGN

Questionnaire.

SETTING

United States and its territories and Canada.

PARTICIPANTS

Actively practicing general obstetrician/gynecologists (OB/GYNs).

INTERVENTIONS

Internet-based survey.

MEASUREMENTS AND MAIN RESULTS

Of 157 respondents, 144 (91.7%) general OB/GYNs were included. Subspecialty fellowship training resulted in the exclusion of 13 (8.3%) respondents. A total of 86 respondents (59.7%) considered referral to fellowship-trained minimally invasive gynecologic surgery (MIGS) subspecialists. The top 3 cited reasons for nonreferral were adequate residency training (n = 84, 58.3%), preference for continuity of care (n = 48, 33.3%), and preference for referral to other subspecialists (n = 46, 31.9%). The top 3 cited reasons for referral to MIGS subspecialists were complex pathology (n = 92, 63.9%), complex medical and/or surgical history (n = 76, 52.8%), and out of scope of practice (n = 53, 36.8%). If providers required intraoperative assistance, respondents consulted an OB/GYN colleague with comparable training (n = 50, 34.7%), gynecologic oncologist (n = 48, 33.3%), or non-OB/GYN surgical subspecialist (n = 33, 22.9%). Factors that were not associated with the decision to refer to MIGS subspecialists included years in practice (p = .13), additional training experiences beyond residency (p = .45), and number of hysterectomies performed by laparotomy (p = .69). Self-reported high-volume surgeons (p <.01) were less likely to refer. In contrast, providers who self-reported as low-volume surgeons (p = .02) and were aware of MIGS subspecialists in the community (p <.01) were more likely to consider referral. Respondents reported using a laparoscopic approach to hysterectomy most frequently (n = 79, 54.9%). In contrast, 36.8% preferred the laparoscopic route for themselves or their partner, whereas 48.6% preferred the vaginal approach.

CONCLUSION

Most of the general OB/GYNs would consider referral to fellowship-trained MIGS subspecialists. Providers who reported adequate residency training and those who preferred continuity of care or referral to other surgical subspecialists were less likely to refer to MIGS subspecialists.