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Objective: History of cesarean section (CS) can affect future hysterectomy; however most studies on this include all routes of hysterectomy. This study aimed to evaluate the effect of history of CS on laparoscopic and robotic hysterectomies by minimally invasive gynecologic surgery (MIGS) fellowship-trained surgeons. Materials and Methods: This retrospective, cross-sectional study was of patients who had laparoscopic hysterectomy at a single tertiary-care center in the southeastern United States. A convenience sample was collected of all patients who underwent laparoscopic hysterectomy with a MIGS-trained surgeon from 2016 to 2019. Primary outcomes were estimated blood loss (EBL), operative time, and intra- and postoperative complication rates, including blood transfusions, conversion to laparotomy, vascular or visceral injury, surgical-site complications, and emergency-room visits. Measures were compared between patients with a history of CS and those without a history of CS, using χ2 and Student's t-tests. Log-linear models with constant coefficient of variation and logistic-regression models adjusted for body mass index (BMI) were used to estimate the association between history of CS and surgical outcomes. Results: A total of 484 hysterectomies were included. 152 patients had at least 1 CS and 332 did not have any CS. There were no significant demographic differences between the groups. In patients with a history of CS, 69 (45%) had 1, 52 (34%) had 2, and 30 (21%) had 3 or more prior CS. When comparing the cohort with a history of CS and the cohort without a history of CS, log-linear and logistic regression models adjusted for BMI did not show any difference between EBL (mean 62 mL versus 57 mL), operative time (mean 152 minutes versus 148 minutes), or total complication rate (27% versus 25%). There was no relationship between number of prior CS and operative outcomes. Conclusions: Neither a history of any CS nor the total number of prior CS affected EBL, operative time, or intraoperative or postoperative complications of laparoscopic hysterectomies performed by MIGS-trained surgeons. This can be helpful for counseling patients and setting expectations of surgical complexity and complication risks. (J GYNECOL SURG 40:156) [ABSTRACT FROM AUTHOR]

Objective: This study evaluated the 1-year outcome of laparoscopic high uterosacral-ligament suspension (HULS) of the apical vault following total laparoscopic hysterectomy (TLH) in women with uterine prolapse stage 2 or higher. Methods: Women (N = 11) with pelvic organ prolapse (POP) underwent TLH and laparoscopic HULS between 2018 and 2021. (HULS is shown in a supplementary video.) POP degree was assessed preoperatively via the Pelvic Organ Prolapse Quantification (POP-Q) tool. Successful surgery was: (1) anatomical cure with POP-Q points Aa, Ba, C, Ap, or Bp, less than stage 2 (< 1 cm above the hymen ([–1]) (2) improvement in subjective satisfaction scores on the Pelvic Floor Impact Questionnaire-7 (PFIQ-7). Follow-up time was 12 months with assessment of anatomical outcomes via the POP-Q, and patient satisfaction measured with the PFIQ-7. Results: Mean POP-Q point C improved from 0 to −8.6 cm at 1 year post-laparoscopic HULS. There were no major intraoperative or postoperative complications (e.g., ureteric or rectal injuries, or massive blood losses needing transfusions). PFI-Q-7 scores improved (mean preoperative 135 versus mean 1 year postoperative 0; p = 0.003); this was statistically significant. Conclusions: Laparoscopic HULS of the apical vault following TLH seems to be a highly successful procedure for treating uterine prolapse, although further evaluation with higher-powered studies are needed. Prerequisites to perform laparoscopic HULS safely include familiarity with anatomy of the ureterosacral ligament and its proximity to vital structures as well as surgical expertise in ureterolysis. (J GYNECOL SURG 39:240) [ABSTRACT FROM AUTHOR]

Objective: This study evaluated outcomes following hysterectomies performed for benign indications in surgeries that meet criteria for complexity, compared to those that did not. Materials and Methods: This retrospective study of hysterectomies performed for benign indications compared outcomes in surgeries deemed complex versus noncomplex. Surgery was defined as complex if one or more of the following factors were present: uterine weight >250 g; surgical history of 2 prior cesarean deliveries; or prior laparoscopy or laparotomy for abdominal myomectomy, endometriosis resection, lysis of adhesions, or other surgery on a pelvic organ. Surgeon-level factors were evaluated, including minimally invasive hysterectomy (MIH) use, postoperative length of stay (LOS), and complication rates. Results: From January 2017 to August 2021, 833 women had hysterectomies for benign indications; 603 hysterectomies were complex. These hysterectomies by low-volume surgeons were more likely to have complications than by high-volume surgeons (15.6% versus 5.4%; p < 0.001). These operations by high-volume surgeons were more-frequently MIH (83.4% versus 48.7%; p = 0.009), had fewer blood losses ≥500 mL (1.2% versus 8.0%; p < 0.001), and were less likely to need overnight admissions (74.9% versus 94.5%; p < 0.001). Conclusions: Complex hysterectomies performed for benign indications by high-volume gynecologic surgeons lead to fewer complications and shorter LOS, and are more likely to be performed with a minimally invasive approach. (J GYNECOL SURG 39:229) [ABSTRACT FROM AUTHOR]

Objective: This study quantified the COVID-19 pandemic's impact on same-day discharges for minimally invasive hysterectomy and evaluated the effect on postoperative morbidity and health care use. Materials and Methods: This retrospective cohort study, from March 2018 to October 2021 at a single institution, included women older than age 18 who had laparoscopic, vaginal, or robotic-assisted hysterectomy by any gynecologic surgeon. Primary outcome was rate of same-day hospital discharge. Secondary measures were length of stay and rates of 30-day postoperative morbidity and health care use. Univariate and multivariable logistic regression analyses were conducted to evaluate associations between patients' characteristics and likelihood of same-day discharge. Results: There were 1608 women included, 896 in a prepandemic cohort and 712 in a postpandemic cohort. Surgeon subspecialty rates were similar between groups, but surgical approaches differed, with more laparoscopic procedures in the postpandemic cohort (p = 0.007). Case order and lengths, and concurrent procedures were not different between groups. Postpandemic patients were more likely to be discharged on the same day even after controlling for confounders in a multivariable regression (32% versus 54%, respectively; odds ratio: 2.78; p < 0.001). Rates of 30-day postoperative complications, transfusions, emergency department visits, readmissions, reoperations, and mortality were not significantly different. Conclusions: The COVID-19 pandemic was associated with increased same-day discharges without increases in 30-day postoperative complications. The data confirmed that same-day discharge following minimally invasive hysterectomy was safe for managing hospital constraints caused by the COVID-19 pandemic. (J GYNECOL SURG 39:170) [ABSTRACT FROM AUTHOR]

This article discusses mesh biology and known issues with mesh kits. The current mesh recommendations of national and international societies, as well as the impact of hysterectomy on mesh exposure during sacrocolpopexy are also discussed. (J GYNECOL SURG 39:30) [ABSTRACT FROM AUTHOR]

A decline in surgical training and skill acquisition in gynecology has been widely recognized and has been receiving much attention during the past 5 years. Potential solutions have been discussed in a number of publications and forums. A system of tracking is 1 such proposal, with the idea being to provide residents opportunities to direct their training into more-specialized areas after basic training. Gynecologic surgical training, as it relates to obstetrical practice has received little attention. This article discusses the importance of gynecologic surgical training for the practicing obstetrician. (J GYNECOL SURG 38:379) [ABSTRACT FROM AUTHOR]

Objective: This research was conducted to evaluate the incidence and predictors of appropriate antibiotic prophylaxis prior to hysterectomy performed for benign indications in patients with penicillin allergy. Materials and Methods: This was a retrospective cohort study of patients with self-reported penicillin allergy undergoing hysterectomy for benign indications at an academic medical center in 2018. The primary outcome was appropriate preoperative antibiotic administration based on the American College of Obstetricians and Gynecologists guidelines. Secondary outcomes included predictors of receiving appropriate antibiotic prophylaxis and incidence of preoperative allergy testing. Standard analysis for descriptive data was performed, and a multivariable logistic regression was fit to explore predictors for receiving appropriate preoperative antibiotics. Results: For this research, 230 patients met the inclusion criteria. Appropriate antibiotics were administered to 42.6% (n = 98) of patients. There were no significant differences in demographic factors between the groups. Preoperative allergy testing was performed in 3.9% of patients (n = 9). On multivariable logistic regression, the odds of receiving appropriate antibiotics were 0.16 times lower among methicillin-resistant Staphylococcus aureus carriers (confidence interval [CI]: 0.03, 0.91; p = 0.04), 2.50 times higher among those with 3 or more antibiotic allergies (CI: 1.15, 5.42; p = 0.02), 1.97 times higher among those with at least 1 comorbidity (CI: 1.06, 3.67; p = 0.03), 8.94 times higher if anaphylaxis was the reported allergy (CI: 3.53, 22.63; p < 0.001), and 6.24 times higher if the reported allergy was hives (CI: 3.17, 12.29; p < 0.001). Conclusions: More than half of patients with penicillin allergy undergoing hysterectomy received inappropriate prophylactic antibiotics. Patients with more medical comorbidities, greater number of antibiotic allergies, and immunoglobulin E–mediated hypersensitivity reactions to penicillin had higher odds of receiving appropriate prophylaxis. (J GYNECOL SURG 38:287) [ABSTRACT FROM AUTHOR]

Objective: Given the increasing prevalence of obesity, the incidence of endometrial cancer and endometrial intraepithelial neoplasia (EIN) could increase twofold within the next 2 decades. Although hysterectomy is the preferred treatment, increasing body mass indices (BMIs) pose technical challenges to surgeons and are associated with adverse surgical outcomes. This study evaluated perioperative outcomes of superobese (BMI of ≥50 kg/m2) patients who underwent total vaginal hysterectomy (TVH), compared to total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH) for endometrial cancer or EIN. Materials and Methods: This was a retrospective cohort study of 84 patients with BMIs ≥50 kg/m2 who underwent hysterectomy for treatment of endometrial cancer or EIN from July 1, 2007, to May 1, 2017, at a tertiary academic medical center. Demographic data, intraoperative parameters, and postoperative data were collected via a retrospective chart review. The primary outcome was a composite of intraoperative injury, Clavien–Dindo post-operative morbidity score, 30-day readmission rate, estimated blood loss >1000 cc, and transfusion. The secondary outcome was survival. Results: There was no difference in the combined perioperative primary outcome or survival for patients with BMIs ≥50 kg/m2 undergoing TVH for EIN or endometrial cancer, compared to patients undergoing TAH or TLH. Conclusions: TVH is a viable surgical route for superobese patients with endometrial cancer or EIN. Further evaluation of the role of TVH in the setting of EIN and endometrial cancer is needed as the superobese population rapidly increases. (J GYNECOL SURG 37:470) [ABSTRACT FROM AUTHOR]

Objective: The present prospective randomized study compared the effects of a minimal-residue low fiber diet for 3 days preoperatively with fasting alone on surgical vision and efficiency during laparoscopic hysterectomy and myomectomy, as well as patient outcomes after these procedures were completed. Materials and Methods: The present study included 281 patients who underwent surgery between April 2012 and June 2015. Prior to surgery, the patients were assigned to 1 of 2 groups: (1) a fasting-alone group or (2) a minimal-residue diet group. The primary outcome was the visual quality of the surgical field. Results: Overall exposure of the surgical field was evaluated as "good" or "excellent" in 100 of 139 (71.9%) patients of the fasting-alone group and in 108 of 142 (76.0%) patients of the minimal-residue diet group, which was not statistically significant (p = 0.79). Conclusions: A preoperative minimal-residual diet does not improve the quality of surgical vision, compared to fasting alone. Accordingly, it may be reported that fasting alone is a safe and preferable alternative with no added complications in minimally invasive gynecologic surgery, such as laparoscopic hysterectomy and myomectomy. (J GYNECOL SURG 37:485) [ABSTRACT FROM AUTHOR]

Objective: The aim of this systematic review and meta-analysis was to obtain an estimate of the prevalence of occult uterine malignancies of any subtype found at surgery for uterine fibroids. Methods: MEDLINE® was searched for peer-reviewed articles about uterine surgeries, including morcellated or nonmorcellated hysterectomies, with occult uterine malignancies. Articles selected had data on occult malignancy found during hysterectomies specifically for uterine fibroids. One author screened and extracted data, and another author resolved study-suitability questions. Search terms included occult malignancy or occult uterine pathology, AND morcellation OR hysterectomy. A Freeman–Tukey double-arcsine transformation was used to compute the weighted pooled estimate of the occult uterine malignancy prevalence and to perform back-transformation on the pooled estimate. Results: Of 233 articles, 53 met review criteria; 8 studies with specific data were used for meta-analysis. Of 105,890 patients, 578 had occult uterine malignancies. The pooled prevalence of uterine cancer was 0.17% (95% confidence interval [CI]: 0.00%–0.49%). With substantial heterogeneity across the studies (I2 = 93.94%; Q χ2 [7] = 115.50; p < 0.001), there were pooled prevalences of 0.54% for population-based studies and 0.12% for retrospective case series. Conclusions: The prevalence of occult uterine cancer of all subtypes combined found during surgery for fibroids is likely higher than estimates from previous studies that focused exclusively on leiomyosarcomas. [ABSTRACT FROM AUTHOR]

Objective: To assess the volume and temporal trends in utilization of gynecologic surgery codes between 2010 and 2015. Study design: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to determine the frequency of individual gynecologic surgical procedures from 2010 to 2015. The National Inpatient Sample was used to further define the frequency of minimally invasive hysterectomies from 2012 to 2016. Data were analyzed using linear regression and chi-squared tests. Results: Gynecologic procedures represented 6.8% (95% confidence interval 6.8–6.9) of all surgical procedures included in the NSQIP database from 2010 through 2015 and this percentage was stable during the study period. The top 10% of procedures make up ∼70% (66.5%–71.2%) of all procedures performed. The top 40% of procedures make up ∼97% (96.8%–97.5%) of all procedures. Although hysterectomy codes were consistently among the top 10 most utilized codes, significant trends were observed in utilization related to the route of hysterectomy with rise of total laparoscopic hysterectomy (TLH). This was correlated with increasing adoption of robotic-assisted laparoscopy and decline of total vaginal hysterectomy (TVH) and abdominal hysterectomy (p < 0.001). There was also a large increase in concomitant adnexal surgery at the time of TLH, which potentially mirrors the recent rise in opportunistic salpingectomy. Conclusion: In this analysis, we highlight changes in the utilization of different gynecologic procedures to inform policy makers of challenges to appropriate reimbursement for laparoscopic procedures and a potential skills loss in open and vaginal procedures. (J GYNECOL SURG 37:323) [ABSTRACT FROM AUTHOR]

Objective: This research assessed if attending surgical volume impacted the relationship between resident participation and operative time in robotic surgery for benign gynecologic conditions. Materials and Methods: This retrospective cohort study included 1 academic and 1 community hospital, where a total of 329 patients underwent robotic surgery for benign gynecologic conditions from January 2018 to March 2019. The primary outcome was total operative time. The primary exposure was resident participation versus nonparticipation in robotic cases. The patients were operated on by 3 surgeons from the same group. The lifetime robotic hysterectomy volumes were 1250 (over 11 years), 146 (over 8 years), and 107 (over 8 years), respectively for the 3 surgeons. Results: The unadjusted mean total operative time was longer for cases involving residents (130.3 minutes [95% confidence interval (CI): 122.8–137.7 minutes] versus 109.6 minutes [95% CI: 104.0–115.3 minutes]; p < 0.001). Among hysterectomy cases, the adjusted mean total operative time was 22.3 minutes longer for cases with resident participation versus no participation (95% CI: 11.9–32.7 minutes longer; p < 0.001). Among hysterectomy cases, the mean total operative time for the high-volume surgeon increased by 14.9 minutes with resident participation, compared to an increase of 45.3 minutes for his 2 low-volume partners. Conclusions: This retrospective chart review's results suggest that attending surgeon robotic volume and surgery type appear to mediate the relationship between resident participation in robotic surgery and total operative time. More research is needed to confirm these findings. (J GYNECOL SURG 37:303) [ABSTRACT FROM AUTHOR]

Objective: To compare the quantity in morphine milligram equivalent (MME) of opioids prescribed at hospital discharge after gynecologic surgery before and after passage of comprehensive New Hampshire state legislation (HB 1423) regulating opioid prescribing. Design: A retrospective chart review was performed on all patients undergoing gynecologic surgery between January 1, 2016 and June 30, 2016 (before legislation) and between April 1, 2017 and September 30, 2017 (after legislation) at a single tertiary care center. Materials and Methods: The primary outcome was MME prescribed at hospital discharge. Secondary outcomes included discharge without opioids, prescriptions ≤37.5 and ≥200 MME. Type of gynecologic surgery and benign versus oncologic diagnoses were analyzed. A logistic regression model was conducted to determine variables associated with a prescription of ≥200 MME. Results: Seven hundred seventy-four patients underwent gynecologic procedures during the identified time periods; 349 patients before legislation and 423 patients after legislation. Significantly fewer mean MME were prescribed after legislation (173 MME vs. 78.5 MME, p < 0.001). This was true for laparotomy with hysterectomy (231 MME vs. 111 MME; p < 0.001), laparotomy without hysterectomy (275 MME vs. 141 MME; p = 0.04), laparoscopic hysterectomy (143 MME vs. 62 MME; p < 0.001), other laparoscopy (133 MME vs. 59 MME; p < 0.001), and vaginal hysterectomy (232 MME vs. 89 MME; p = 0.002) and among those with a cancer diagnosis (178.5 vs. 67.9; p < 0.001). The number of patients discharged without a prescription for opioids significantly increased after legislation (4.4% vs. 9.8%; p = 0.005). In multivariate analysis, surgery before legislation (odds ratio [OR] 14.56 [95% confidence interval 8.22–25.82]), having a laparotomy with hysterectomy (OR 5.85 [2.47–13.85]) or laparotomy without hysterectomy (OR 6.35 [2.35–17.13]) were predictive of a prescription ≥200 MME. Conclusion: After opioid prescribing legislation in New Hampshire, significantly fewer opioids were prescribed on hospital discharge after gynecologic surgery. This reduction was seen regardless of type of gynecologic surgery or cancer diagnosis. (J GYNECOL SURG 37:291) [ABSTRACT FROM AUTHOR]

Objective: There are limited studies on laparoscopy for benign hysterectomy in low- and middle-income countries. This article describes national trends in modes of hysterectomy in Brazil and compares outcomes by regions and health sectors. Materials and Methods: This was a cross sectional retrospective analysis of benign hysterectomies from open-access national databases (public sector: 2008–2017; private sector: 2016) in Brazil. Variables examined included the modes (vaginal, abdominal, and laparoscopic) of hysterectomies, geographic regions, mortality rates, and lengths of stay (LOS). Results: Benign hysterectomies decreased by 19.2% over 10 years. The proportion of abdominal surgeries increased from 85% to 88%. Despite an increase in laparoscopic surgeries (0.2–0.9%), minimally invasive surgery (vaginal and laparoscopic) decreased (14.7%–12.6%), largely driven by a drop in vaginal cases (14.5%–11.7%). More laparoscopic hysterectomies were performed in the private sector compared to the public sector (11% versus 1%; p < 0.001). There were significant geographic disparities, with 17% of hysterectomies in the private sector performed laparoscopically in the south compared to 9% in the northeast (p < 0.001). Conclusions: Trends in modes of hysterectomies have changed. There are regional inequities, with wealthier regions accessing more laparoscopic surgery. Understanding the trends and factors affecting access to laparoscopy is essential for ensuring equitable access to high-quality gynecologic care. (J GYNECOL SURG 37:337) [ABSTRACT FROM AUTHOR]

Background: Although uterine leiomyoma causes many problems, including infertility, there are few studies that have investigated the epidemiologic characteristics of uterine leiomyoma in South Korea. The aim of this study is to estimate the prevalence and incidence of uterine leiomyoma in South Korea and analyze the treatment trends. Materials and Methods: Women of reproductive age (15–54 years) were selected from the Korean National Health Insurance Service (NHIS) sample cohort dataset, which was collected from 2002 to 2013. Patients with uterine leiomyoma were identified by ICD-10 (International Codes of Disease, 10th Edition) and intervention codes. Prevalence and incidence were calculated from the NHIS cohort dataset and the treatment trends were analyzed for diagnosed patients. Results: The prevalence in overall age groups increased from 0.96% in 2002 to 2.43% in 2013, and the 1-year incidences of all age groups increased. The 26–30 age group showed the highest rate of 1-year incidence increase (2.14-folds, 0.33% in 2003 to 0.70% in 2013). The proportion of myomectomy increased from 22% in 2002 to 49% in 2013, whereas the proportion of hysterectomy decreased from 78% to 45%. Conclusions: The prevalence and incidence of uterine leiomyoma are increasing in South Korea as time progresses, and the rate of incidence increase is higher in younger reproductive women. Overall trends in uterine leiomyoma treatment are shifting to the methods of the saving uterus. [ABSTRACT FROM AUTHOR]

Vascular injury is a rare but potentially fatal complication of gynecologic surgery. Reported risk factors for vascular injury during abdominal surgery include obesity, adhesions, vascular aberrations, and surgery at low-volume surgical centers. Oncologic procedures pose inherent additional risk of injury related to operating in proximity to major vascular structures or tumor involving the pelvic sidewall. Here we review major vascular injuries that may occur during hysterectomy and other types of gynecologic surgeries, with a focus on risk factors, prevention, recognition, and intraoperative management. All pelvic vasculature is at risk. Efforts to prevent injury include gentle and directional opening of avascular planes, cautious dissection of tumor and adherent lymph nodes from vascular structures, prophylactic ligation when indicated, and careful placement of initial and subsequent laparoscopic trocars. Recognition and control of injury must be immediate. Venous injuries manifest as nonpulsatile but potentially torrential hemorrhage, whereas an arterial injury typically presents with pulsatile bleeding from an obvious source. Repair of a major vascular injury is accomplished with pressure with or without hemostatic agents, suturing, clipping, or cautery depending on the clinical situation. (J GYNECOL SURG 37:200) [ABSTRACT FROM AUTHOR]

Objectives: The goals of this research were to identify the incidence of, and risk factors for, postoperative urinary retention in patients who underwent outpatient hysterectomy, and to evaluate the incidence of urinary retention among those patients, according to variable requirements for urinary function in the immediate postoperative time period. Materials and Measurements: This retrospective cohort study was conducted in an academic-affiliated community hospital. The subjects were patients who underwent planned outpatient hysterectomies for benign disease from January 2013 to April 2016 at Lahey Hospital and Medical Center, in Burlington, MA. Results: A total of 197 patients who underwent outpatient hysterectomy were identified. The average age of the patients was 45.7 ± 6.8 years, and most patients underwent hysterectomy for leiomyomas. Of these cases, 21 (10.6%) had unplanned hospital admissions. The most-common reasons for admission included nausea (3.1%), pain (1.6%), and dizziness (1.0%). Only 1 patient was admitted for urinary retention (0.5%). Six patients (3.0%) were diagnosed with urinary retention, defined as a bladder scan ≥300cc or a postvoid residual ≥200 cc. All patients with urinary retention were identified either immediately postoperatively or during their admissions. No other patients returned to the clinic or were readmitted to the hospital for urinary retention. Patients identified with urinary retention were more likely to have been admitted overnight for other reasons (83.3%). Of the 197 patients, 8 were required to void prior to same-day discharge, based on provider preference. There was no significant difference in patients' characteristics for patients required to void and those who were not required to do so. No patients in the group required to void were diagnosed with urinary retention. There was no difference between the groups with regard to readmissions or return visits for urinary symptoms. Conclusions: The incidence of urinary retention after outpatient minimally invasive surgery is low, and, when present, can be identified in the immediate postoperative timeperiod regardless of whether or not the patient is required to void prior to discharge. Therefore, it is safe to discharge patients after minimally invasive hysterectomy without a requirement to void postoperatively. (J GYNECOL SURG 37:252) [ABSTRACT FROM AUTHOR]

The role of abdominal hysterectomy for benign disease has decreased with time, given the broad application of minimally invasive hysterectomy. Abdominal hysterectomy is indicated when minimally invasive surgery is not feasible due to patient-, disease-, or technical-factors, including uterine size, risk of malignancy, or extensive endometriosis and adhesive disease. Conversion from minimally invasive hysterectomy might also be required when unexpected adhesive disease or intraoperative complications are encountered. Attention to preoperative preparation; surgical planning; and intraoperative setup, exposure, and use of available surgical assistance optimize the success of planned or emergent conversion to abdominal hysterectomy. Finally, intraoperative and advanced pelvic surgical techniques, as well as consultation with colleagues across subspecialties, can be utilized to facilitate safe surgery in patients with complex pelvic diseases or inadvertent intraoperative injuries. [ABSTRACT FROM AUTHOR]

Objective: Complication rates during laparoscopic hysterectomy performed at high-volume surgical centers have not been reviewed recently; rather, reliance is placed on older data when counseling patients. This study reviewed patient demographics and surgical complications occurring during laparoscopic hysterectomy for benign gynecologic disease at a major academic teaching institution. The relationship between surgeon experience and perioperative outcomes were also assessed. Materials and Methods: This was a retrospective chart review of consecutive women who underwent hysterectomy for benign gynecologic disease from September 2014 to August 2016. Clinical, demographic, and surgical characteristics were ascertained. Complications and readmission rates were assessed. Primary outcomes were surgical complications, estimated blood loss (EBL), operative times, and blood transfusions. The patients were treated at a single, high-volume tertiary-care teaching hospital. They were divided into 5 groups. In groups 1–4, surgeries were performed by 4 individual experts. Group 5 had surgeries performed by minimally invasive gynecologic-surgery fellows. Numeric data were expressed as medians and ranges, unless stated otherwise. Statistical analyses were performed with SPSS version 21.0 for Windows. Results: A total of 1095 hysterectomies were included: 1040 (94.98%) were performed laparoscopically; 33 (3.01%) were performed via laparotomy; and 22 (2.01%) via vaginal procedures. Median operative time was 117 minutes (range: 23–499 minutes). Median EBL was 100 mL (range: 10–1000 mL). Only 1 surgery was converted to laparotomy (0.10%). Intraoperative injuries occurred 6 times—3 ureteral (0.29%), 2 bladder (0.19%), and 1 bowel (0.10%). All injuries were noted during the procedures with intraoperative repair performed in each case and subsequent postoperative complications avoided. Blood transfusions were required in 4 patients (0.38%). No ureteral and vesical fistulae occurred. Laparoscopic hysterectomy rates of 100% without conversions were achieved by Surgeons #1 and #3. Compared to other groups, Surgeons #1 and #2 had lower EBLs and shorter mean surgical times. Surgeon #1 had more frequent pelvic adhesions than other groups. Surgeon #4 had the largest uterine weights, while fellows operated on uteri weighing >500 g or >1000 g less frequently. Rates of bowel occlusions were higher for Surgeon #4 and the fellows. Fellows had more-frequent skin infections. Other postoperative complications and readmission rates were similar among the groups. Conclusions: Laparoscopic hysterectomy is a safe, feasible option for benign gynecologic surgery. This procedure is safe even during the initial learning-curves of fellows with low and reasonable complication rates, but with longer associated operative times. An increase in experience is associated with a higher rate of laparoscopic hysterectomies, shorter operating times, less blood loss, and a low incidence of complications. [ABSTRACT FROM AUTHOR]

Background: Uterine arteriovenous fistula (UAVF), a rare condition, usually occurs in females of reproductive age and is commonly diagnosed in those with histories of myometrial traumas. UAVF is generally associated with severe bleeding. Treatment choices are usually limited to selective embolization or hysterectomy; however, other treatment options—such as surgical occlusion of the pelvic vessels, and, less frequently, en bloc resection of the lesion adjacent to the surrounding myometrium with uterine reconstruction—have also been reported. This article presents a case of conservative surgical management (CSM) of the condition, with details about a simple surgical technique and a literature review on this topic. Case: A 25-year-old female (gravida 1, molar 1), with a history of curettage 11 months before consultation, presented with severe vaginal bleeding and severe anemia. UAVF was diagnosed based on findings of Doppler ultrasound and magnetic resonance angiography. This patient was managed with complete surgical resection of the UAVF and uterine reconstruction. Results: Remarkably, this patient had a spontaneous pregnancy 15 months' postoperatively. Conclusions: A review of the literature identified only 5 reports on CSM, with the most frequently used treatments being hysterectomy and arterial embolization for UAVF. The former method eliminates all possibilities of future pregnancies, whereas the latter has a high failure rate for the first attempt. In cases of UAVF in which fertility preservation is preferred and expectant management is not possible, surgical resection of the affected area followed by uterine reconstruction represents a valid option for health care centers with experienced interdisciplinary teams. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to examine feasibility, safety, and efficacy, in the first postmarket case series in gynecologic surgery, using an integrated table motion (ITM) device, which is a new surgical device including a unique operating table that connects wirelessly with the da Vinci® Xi surgical platform. This new feature is expected to advance robotic surgery and the field of minimally invasive gynecologic surgery. Materials and Methods: This was a prospective postmarket study, performed with ITM in 11 women who underwent gynecologic surgery. Primary endpoints were ITM feasibility, safety, and efficacy. Results: During the 11 gynecologic surgeries, there were 35 instances of table moves. The ITM length was <1 minute per movement in 25 of 35 moves (71%). During total robotic hysterectomy (TRH), the mean number of ITM movements was 3.1, resulting in 28 instances of table movements. During pelvic organ prolapse (POP) surgery, the mean number of ITM moves was 3.5, resulting in 7 instances of table moves. The mean duration of each table motion was 30 seconds during TRH, compared with 94 seconds during POP surgery. Of 35 ITM moves, 32 were performed to achieve internal exposure in the pelvis. The endoscope as well as the instruments remained inserted during 88% of table movements. No adverse events and no ITM safety-related remarks were noted in the medical records. Conclusions: Preliminary analysis of the early experience with using an ITM device as a new operating table, which communicates with da Vinci Xi platform, indicated the feasibility, safety, and efficacy of the ITM for different gynecologic surgeries. The small number of subjects in the first worldwide series of gynecologic surgeries as well the diversity of surgical procedures are not yet enough to provide definitive scientific evidence about the use of this device. However, the present study on humans concerning the use of ITM, highlighted the development of this new tool for robotic surgery performed for both benign and malignant gynecologic diseases. (J GYNECOL SURG 34:144) [ABSTRACT FROM AUTHOR]

Background: The study objective was to analyze and compare patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) after hysterectomy in women with and without a preoperative complaint of pelvic pain associated with and without a confirmed diagnosis of endometriosis. Methods: Retrospective nationwide register study. Data on 28,776 hysterectomies performed on benign indication between 2004 and 2016 were retrieved from the Swedish National Register for Gynecological Surgery. Multivariable logistic regression models were used to compare the PREMs and PROMs items. The results are presented as adjusted odds ratios (aORs) and 95% confidence intervals (CI). Results: Regardless of the occurrence of pelvic pain preoperatively and a diagnosis of endometriosis, 1 year after surgery, the women were satisfied or very satisfied (>90%) with the hysterectomy, and their medical condition was improved or much improved (>95%). The women with a preoperative complaint of pelvic pain and endometriosis more often reported excessively short hospital stays (aOR 1.45, 95% CI 1.17–1.79), more severe complications after discharge (aOR 2.02, 95% CI 1.59–2.66) at the 8-week follow-up and at the 1-year follow-up (aOR 2.31, 95% CI 1.57–3.39), and more dissatisfaction with the operation (aOR 1.83, 95% CI 1.35–2.48) than preoperative pelvic pain-free women without endometriosis at the 1-year follow-up. Conclusions: The majority of the women were satisfied after their hysterectomy. The women with pelvic pain and endometriosis were at a higher risk of being dissatisfied. Pelvic pain per se seemed to be the main factor affecting the rating in the PREMs and PROMs, and the endometriosis was a significant contributing factor. [ABSTRACT FROM AUTHOR]

The primary objective of this study was to describe surgical treatment patterns among women with newly diagnosed uterine fibroids (UF). A secondary objective was to estimate the medical costs associated with other common surgical interventions for UF. Claims-based commercial and Medicare data (2011-2016) were used to identify women aged ≥30 years with continuous enrollment for at least 12 months before and after a new diagnosis of UF. Receipt of a surgical or radiologic procedure (hysterectomy, myomectomy, endometrial ablation, uterine artery embolization, and curettage) was the primary outcome. Health care resource utilization and costs were calculated for women with at least 12 months of continuous enrollment following a UF surgical procedure. Among women who met selection criteria, 31.7% of patients underwent a surgical procedure; 20.9% of these underwent hysterectomy. An increase was observed over time in the percentage of women undergoing outpatient hysterectomy (from 27.0% to 40.2%) and hysteroscopic myomectomy (from 8.0% to 11.5%). The cost analysis revealed that total health care costs for hysteroscopic myomectomy ($17,324) were significantly lower ( P < 0.001) than those for women who underwent inpatient hysterectomy ($24,027) and those for women undergoing the 3 comparison procedures. Hysterectomy was the most common surgical intervention. Patients undergoing inpatient hysterectomy had the highest health care costs. Although less expensive, minimally invasive approaches are becoming more common; they are performed infrequently in patients with newly diagnosed UF. The results of this study may be useful in guiding decisions regarding the most appropriate and cost-effective surgical treatment for UF. [ABSTRACT FROM AUTHOR]

Objective: The goal of this research was to evaluate the risk associated with dissemination in laparoscopic procedures with power morcellation for benign gynecologic indications. Materials and Methods: This was a retrospective cohort study. A retrospective analysis was completed for cases of consecutive women who underwent laparoscopic myomectomy or supracervical hysterectomy with morcellation at a single academic institution between 2002 and 2014. The demographics and clinical characteristics of the patients were abstracted from the electronic medical records. Results: There were 456 women who underwent power morcellation during the study period. The majority (78%) was premenopausal with a median body mass index of 26 (range: 19-50). The most common preoperative diagnoses were fibroids, abnormal uterine bleeding, and pelvic organ prolapse. Eighteen percent of patients underwent myomectomy and 82% underwent supracervical hysterectomy. General gynecologists performed 58% of the surgeries, followed by urogynecologists (22%). Sixty-six percent of patients underwent preoperative uterine evaluation with at least an ultrasound or endometrial sampling, with 21% having undergone more than one modality. Patients with a diagnosis of fibroids were more likely to undergo preoperative endometrial sampling than patients with other diagnoses (32% versus 16%; p < 0.05). One uterine specimen (0.2%) had an undiagnosed atypical leiomyoma with moderate-to-severe cytologic atypia. Conclusions: The incidence of occult malignancy discovered on pathology following power morcellation of the uterus and/or fibroids is low in women. These data can be used to counsel patients prior to consideration of power morcellation. Given the limitations in preoperative diagnosis of sarcoma and potential complications of morcellation even of benign pathology, controlled morcellation should be a goal with established guidelines. (J GYNECOL SURG 34:27) [ABSTRACT FROM AUTHOR]

Objective: The goal of this research was to explore physicians' perceptions of uterine morcellation and minimally invasive hysterectomy in the setting of new hospital regulations, comparing gynecologists and internal medicine providers, geographic locations, and levels of training. Design: This was a multicenter cross-sectional study. Materials and Methods: A 17-question, anonymous, electronic survey was administered to resident, fellow, and attending gynecologists, and internal medicine physicians at three institutions. Results: Two hundred and twenty-two gynecologists responded for a response rate of 46%. Most gynecologists believe morcellation is safe and acceptable, and the benefits of minimally invasive surgery outweigh the potential risk of cancer dissemination as a result of morcellation. The majority reported that the incidence of occult leiomyosarcoma is rarer than 1 in 350. Physicians from Boston, MA, responded less favorably toward morcellation than providers in Pittsburgh, PA, and Chapel Hill, NC ( p < 0.001). Trainees were not significantly different from attending gynecologists. One hundred and forty-seven internal medicine physicians responded for a response rate of 40%. Compared to internal medicine providers, significantly more gynecologists believe minimally invasive approaches, as opposed to laparotomy, yield the best overall outcome ( p < 0.001), and the benefits of morcellation outweigh its potential risks ( p < 0.001). Compared to gynecologists, more internal medicine physicians felt morcellation should be banned ( p < 0.001). Conclusions: Most gynecologists highly value morcellation as a means of tissue extraction to facilitate minimally invasive approaches in order to provide the most optimal patient outcomes. Gynecologists' opinions regarding morcellation differ by geographical location but not by level of training. Gynecologists responded more favorably toward minimally invasive hysterectomy and morcellation, compared to internal medicine physicians. (J GYNECOL SURG 33:12) [ABSTRACT FROM AUTHOR]

Objective: The aim of this research was to compare two new hysterectomy techniques by robotic vaginal natural orifice transluminal endoscopic surgery and to demonstrate that transvaginal robotic hysterectomy can be performed in nulliparous patients by natural orifice transluminal endoscopic surgery (NOTES). Materials and Methods: This research was conducted in a case series format. Previous experience with total vaginal NOTES hysterectomy (TVNH) and with transvaginal robotic surgery for robotic vaginally assisted NOTES hysterectomy (RVANH), led to the decision to combine these techniques to perform robotic TVNH (RTVNH) in nulliparous patients. Twenty patients were included in this study. In 10 nulliparous patients, RTVNH was performed. A gloveport was inserted into the vagina to create a pneumovagina. A Da Vinci Xi surgical robot was side-docked between the legs of each patient. The hysterectomy was performed via transvaginal NOTES using the surgical robot. Once the hysterectomy was completed, the robot and gloveport were removed. The colpotomy was closed as in classical vaginal surgery. The data of these patients were compared to that of 10 parous patients who underwent RVANH. Results: All procedures were completed without conversion to transabdominal laparoscopy or laparotomy. Mean patient data and results for RTVNH/RVANH were: age, 49-63; body mass index, 26.4-27.8; total operating time, 90-118 minutes; hemoglobin drop, 1.2-1.3 g/dL; uterus weight, 149-213 g; pain scores at day 1, 2-2, and at day 2, 2-2. There was one complication in the RVANH group: superficial thrombophlebitis. Conclusions: This cohort study confirmed that robotic transvaginal surgery is feasible and can be used to perform total hysterectomy. RTVNH enabled hysterectomies to be performed without any abdominal incisions in nulliparous patients, who had been determined as unsuitable candidates for classical vaginal hysterectomy. RTVNH and RVANH are novel techniques and require further validation. Further developments in robotic technology will help overcome the practical problem of arm collision and will increase the time efficiency of the procedure. (J GYNECOL SURG 32:270) [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to assess if the GelPOINT advanced-access platform and the GelPOINT mini-advanced-access platform (both from Applied Medical, Rancho Santa Margarita, CA) are suitable ports for performing vNOTES (transvaginal natural orifice transluminal endoscopic surgery) procedures. Materials and Methods: Between March and October 2015, 110 procedures by vNOTES using the aforementioned GelPOINT ports were performed by a single surgeon (B.J.). Patients and perioperative data were analyzed. Results: Seventy-seven patients underwent vaginally assisted NOTES hysterectomy (VANH), and 33 patients underwent vNOTES adnexal surgery, including 4 salpingectomies, 25 adnexectomies, and 4 ovarian cystectomies. There were no conversions to standard laparoscopy or laparotomy, and all procedures were completed using a GelPOINT port. The mean operation times were: for VANH, 56 minutes; and for adnexal surgery, 25.5 minutes. There were no intraoperative complications and the patients' postoperative pain scores were low. Conclusions: The GelPOINT port is suitable for VANH, and the GelPOINT mini-port is suitable for vNOTES adnexal procedures. The main advantages of using a GelPOINT port, compared to self-constructed gloveports, are shorter setup time, easier instrument transfers through the trocars, better ergonomics, and a less-fragile port. The greatest disadvantage is the higher cost. (J GYNECOL SURG 32:257) [ABSTRACT FROM AUTHOR]

Objective: The aim of this research was to demonstrate the feasibility and safety of laparoendoscopic single-site surgery (LESS) for total laparoscopic hysterectomy (TLH). A laparoscope was used with a work channel and modified conventional laparoscopic instruments. Design: This was a prospective study. Materials and Methods: Between April 2010 and December 2014, LESS-TLH was performed in 80 patients with benign gynecologic conditions at the department of laparoscopic and endoscopic surgery, at the National Center for Minimal Access Surgery, in Havana, Cuba. Results: The mean age of the patients was 45 years (range 30-76 years), mean uterus weight was 225 g (100-482 g), mean operative time was 82 minutes (50-200 minutes), and mean blood loss 54 mL (10-400 mL). The postoperative hospital stay was <1 day. One patient experienced an intraoperative complication (bladder injury). There were two postoperative complications: 1 patient with a vault abscess 2 weeks after surgery and 1 patient with endometriosis had a ureter injury. No patients required transfusion during or after the laparoscopic procedure and there were two conversions to conventional TLH. Conclusions: This LESS-TLH technique proposed in this article seems to be a feasible and safe approach, with similar operative time, and without the disadvantages of loss of triangulation and clashing of instruments, compared with other LESS hysterectomy techniques. (J GYNECOL SURG 32:91) [ABSTRACT FROM AUTHOR]

Objective: The United States Food and Drug Administration (FDA) Manufacture and User Device Experience (MAUDE) Database houses reports of deaths, injuries, and malfunctions related to FDA-approved devices. This article evaluates the 10-year statistics from MAUDE related to robotic gynecologic surgery. Materials and Methods: This study is a database analysis. The MAUDE database was queried for events occurring between 2003 and 2012. The following information was abstracted: date of surgery; report date; type of surgery; indication; injury sustained; interventions required; device malfunction; and involvement in legal proceedings. Results: During the 10 years studied, 455 injuries and 177 malfunctions were reported. Reporting increased over time. Gynecologic cases represented 61% of all reported robotic injuries; 81% of these led to legal proceedings. The most common gynecologic procedure resulting in injury was hysterectomy ( n=399, 87%). Common complications included ureteral injuries (19%), infections (18%), and small-bowel injuries (16%). This resulted in 435 interventions, most commonly ureteral reimplantation (14%), bowel resection or repair (10%), and vaginal cuff closure (13%). Ninety-three device-related deaths were reported; 30 were associated with gynecologic surgeries. The most common cause of gynecologic procedure-related death was sepsis with or without bowel injury (28%) followed by hemorrhage (18%). Fifty adverse events resulted from 177 robot malfunctions. Conclusions: Reporting of robotic injuries, deaths, and malfunctions to the FDA is steadily increasing; however, as reporting in the MAUDE system is voluntary, the true incidence is unknown. Compulsory reporting would allow identification of absolute risks associated with robotic surgery and lead to improved root-cause analyses. (J GYNECOL SURG 31:331) [ABSTRACT FROM AUTHOR]

Background: The aims of this work were to introduce a two-port access (TPA) staging laparoscopy in gynecologic cancers and evaluate the feasibility and surgical outcomes of this operation. Materials and Methods: We performed 12 cases of TPA staging laparoscopy. The TPA system consisted of a single multichannel port at the umbilicus and an ancillary 5-mm port in the suprapubic area. Patient status was estimated in terms of operative morbidity and surgical outcomes. Results: All operations were completed laparoscopically, with no conversions to conventional laparoscopy or laparotomy. Procedures included endometrial cancer staging ( n = 6), ovarian cancer staging ( n = 3), 2 cases of type III radical hysterectomy, and 1 type II radical hysterectomy. Median patient age and body mass index were 48 years and 20.4 kg/m2, respectively. Median operation duration was 241 minutes (range, 188–360). Median estimated blood loss was 175 mL. Median number of lymph nodes obtained was 30 (range, 14–49). Median postoperative hospital stay was 8 days. There were no perioperative complications. Conclusions: TPA staging laparoscopy, using the single multichannel port system, could be a feasible procedure in selected gynecologic cancer patients, with only minimal skin incisions. Prospective, randomized trials will permit the evaluation of potential benefits of this minimally invasive surgical technique. [ABSTRACT FROM AUTHOR]