Surgical morbidity of total laparoscopic hysterectomy for benign disease: Predictors of major postoperative complications

OBJECTIVE

To estimate rate of perioperative complications and to define risk factors of 30-day major (Clavien-Dindo ≥ 2) postoperative complications of total laparoscopic hysterectomy (TLH) for benign disease.

STUDY DESIGN

An uncontrolled single-center single-arm retrospective study. Data of consecutive patients who have undergone TLH for pathologically confirmed benign disease between January 2000 and December 2019 have been analyzed. Perioperative surgical outcomes, occurrence of postoperative complications, readmissions, and reoperations within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major (Clavien-Dindo ≥ 2) postoperative complications.

RESULTS

Over the study period 3090 patients were included in the study. Conversion to open surgery occurred in 54 (1.7%) cases. Mean operative time for TLH was 87.7 (±1.7) minutes while mean estimated blood loss was 119.5 (+7.4) mL. Overall, postoperative complications were registered in 430 (13.9%) patients, and major events were observed in 208 (6.7%) of the cases. Same-hospital readmissions and reoperations within 30-day from surgery occurred in 78 (2.5%) and 28 (0.9%) patients, respectively. At multivariable analysis, endometriosis (odds ratio: 3.51, 95%CI:1.54-8.30, p = 0.02), the need for conversion to open surgery (odds ratio: 1.26, 98%CI:1.03-12.64, p < 0.001), and the occurrence of any intraoperative complication (odds ratio: 3.10, 95%CI: 1.45-21.61, p < 0.001) were found as independent risk factors for major postoperative complications.

CONCLUSIONS

Total hysterectomy performed via laparoscopy is associated with acceptable major postoperative complications rate. A huge effort should be made to minimize the occurrence of intraoperative complications and the need for conversion to open surgery. Patients undergoing TLH for endometriosis should be counselled about the increased risk of major postoperative events.

Cervical re-injection of indocyanine green to improve sentinel lymph node detection in endometrial cancer

OBJECTIVES

To evaluate the role of cervical re-injection of indocyanine green (ICG) to increase the detection rate of sentinel lymph node (SLN) in patients with endometrial cancer (EC) who underwent robotic-assisted surgical staging.

METHODS

We retrospectively identified consecutive EC patients undergoing robotic-assisted staging with SLN biopsy at our Institution between June 2016 and April 2020. Patients were excluded if they had open abdominal surgical approach, neoadjuvant chemotherapy, and advanced stage [International Federation of Gynecology and Obstetrics (FIGO) stage III-IV] at diagnosis. According to our SLN protocol, in case of either unilateral or no SLN detection, we performed an ipsilateral or bilateral cervical re-injection of ICG.

RESULTS

In total, 251 patients meeting inclusion criteria were included in the analysis. At first injection, bilateral detection was achieved in 184 (73.3%), unilateral detection in 57 (22.7%), and no detection in 10 (4.0%) patients. Cervical re-injection was performed in 51 of 67 patients with failed bilateral mapping. After cervical re-injection, bilateral detection rate increased to 94.5% (222/235), while unilateral and no detection were 5.1% (12/235) and 0.4% (1/235), respectively.

CONCLUSIONS

Our results suggest that cervical re-injection of ICG, in case of failed bilateral mapping of SLN, brings about a significant improvement in SLN detection rates, therefore reducing the number of side-specific required lymphadenectomies.

Vaginal vs. robotic hysterectomy for patients with endometrial cancer: A comparison of outcomes and cost of care

OBJECTIVE

To compare outcomes and cost for patients with endometrial cancer undergoing vaginal hysterectomy (VH) or robotic hysterectomy (RH), with or without lymphadenectomy (LND).

METHODS

Patients undergoing planned VH (and laparoscopic LND) or RH (and robotic LND) between January 2007 and November 2012 were reviewed. Patients with stage IV disease, synchronous cancer, synchronous surgery, or treated with palliative intent were excluded. Patients were objectively triaged to LND per institutional protocol based on frozen section. Outcomes were compared between VH and RH groups matched 1:1 on propensity scores.

RESULTS

VH was planned in 153 patients; 60 (39%) had concurrent LND while 93 (61%) were low risk and did not require LND. RH was planned in 398 patients; 225 (56%) required concurrent LND and 173 (44%) did not. Among 50 PS-matched pairs without LND, there was no significant difference in complications, length of stay, readmission, or progression free survival. However, median operative time was 1.3h longer and median 30-day cost $3150 higher for RH compared to VH (both p<0.001). Among patients requiring LND, 42 PS-matched pairs were identified. Median operative time was not different when pelvic and para-aortic LND was performed, and 12min longer in the VH group for pelvic LND alone (p=0.03). Median 30-day cost was $921 higher for RH compared to VH when LND was required (p=0.08).

CONCLUSION

Utilization of vaginal hysterectomy for endometrial cancer results in similar surgical and oncologic outcomes and lower costs compared to RH and should be considered for appropriate patients with a low risk of requiring LND.

Management of bladder endometriosis with combined transurethral and laparoscopic approach. Follow-up of pain control, quality of life, and sexual function at 12 months after surgery

To describe the pre-surgical and post-surgical outcomes at one year in terms of recurrence of lower urinary tract symptoms, quality of life, and sexual function of a transurethral and laparoscopic combined approach in the treatment of bladder endometriosis. The au- thors performed a prospective observational study of 16 women affected by symptomatic bladder endometriosis at the University Hos- pitals of Cagliari, Padua, and Foggia. In all patients bladder nodule was excised with a transurethral and laparoscopic combined approach technique. Intensity of lower urinary tract symptoms (VAS score) were assessed pre- and post-operatively at one, six, and 12 months after surgery; quality of life (SF-36) and sexual functions (FSFI) were collected preoperatively and one year postoperatively. Operative time was 120.18 ± 15.77 minutes and mean blood loss was 65.12 ± 44.74. No intraoperative and postoperative complications and conversion laparotomy occurred. Intensity of lower urinary tract symptoms evaluated with VAS score were significantly lower after one, six, and 12 months postsurgery vs. presurgery (p < 0.001). The authors observed a significantly improvement in the quality of life and sexual functions in all patients at one year after surgery. This surgical approach is safe and simple in the treatment of bladder en- dometriosis, with low risks and optimal resolution of symptoms, and improvement of quality of life and sexual function.

Monopolar versus bipolar device: safety, feasibility, limits and perioperative complications in performing hysteroscopic myomectomy

PURPOSE OF INVESTIGATION

The authors' aim is to compare surgical outcome of hysteroscopic G1 and G2 submucous myomectomy using bipolar resectoscope to those performed by monopolar device.

MATERIALS AND METHODS

a multicenter-observational-case-control study was conducted on premenopausal women affected by menorrhagia, pelvic pain or infertility because of submucous uterine myoma. The authors considered eligible: single G1 or G2 submucous uterine myoma, at least 0.5 cm ultrasound 'myometrial-free-margin' and two months GnRH pre-surgical treatment (myoma > three cm). Goup A patients were treated b y bipolar resectoscope and Group B by monopolar resectoscope. Primary endpoint was to compare the groups in term of complete or incomplete myomas resection ("second-step-procedure" rate). Secondary endpoint was to compare two treatments in term of surgical time and intraoperative complications rate.

RESULTS

Group A (60 patients) and Group B (216 patients) were homogeneous for general features and myomas location but they differed for G2 type prevalence (73.3% vs 50.5%), mean myomas diameter (33.17 +/- 11.93 vs 29.45 +/- 9.63), and surgical time (29.43 +/- 12.6 vs 23.2 +/- 8.2 minutes). In Group A patients both G1 and G2 myomas were completely removed in single step without intraoperative/postoperative complications; in Group B surgical outcomes of G1 myomas were similar to those of Group A, while G2 myomas required procedure termination in 12% of cases because of light electrolyte disturbance (22 cases) and severe iponatremia in four cases. All intraoperative complications occurred when procedure time exceeded 30 minutes and when myomas diameter was greater than 37.5 millimeters.

CONCLUSION

in the era ofmini-invasive surgery, hysteroscopic approach by bipolar device should be considered as a useful, safe, and large scale feasible procedure for submucosal myoma treatment, particularly when G2.