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Objective: The objective of this study was to evaluate the effect of an Enhanced Recovery After Surgery (ERAS) protocol on patient experience after discharge from laparoscopic hysterectomy. Materials and Methods: Patients having laparoscopic hysterectomies by high-volume surgeons (>10 hysterectomies per year) at an urban tertiary-care hospital were divided into 2 cohorts: (1) a perioperative ERAS protocol adopted by the institution or (2) standard perioperative care according to the patient's surgeon. At the postoperative visit, each patient completed a validated questionnaire of self-reported recovery scores in domains of daily functional activities Results: There were 40 patients in the ERAS group and 44 in the standard perioperative care group, and 100% follow-up through the 2-week postoperative visits. Patients in both groups had similar rates of same-day discharges (88% versus 73%; p = 0.09). Both groups reported similar physical activity scores (1.38 versus 1.33; p = 0.79), days of first bowel movements (2.69 versus 2.71; p = 0.94), and days of opioid use after surgery (3.13 versus 2.64; p = 0.48). ERAS patients had fewer unplanned patient contacts than the standard care group (15% versus 50%; p < 0.01). There were no readmissions. Patients took few opioids, with 90% of all patients using <10 opioid tablets post surgery (5-mg oxycodone equivalents). Conclusions: Same-day discharge, patient-reported recovery experience, and opioid requirements did not differ between the ERAS protocol versus standard perioperative care. The ERAS protocol decreased unplanned patient contacts. [ABSTRACT FROM AUTHOR]

Study Objective: Compare odds of postoperative urinary symptoms in women who had cystoscopy after benign laparoscopic hysterectomy with 50% dextrose and with normal saline solution with intravenous indigo carmine.Design: Retrospective cohort study.Setting: Two tertiary care centers.Patients: All women who underwent benign laparoscopic hysterectomy and intraoperative cystoscopy carried out by a single surgeon.Interventions: We compared postoperative urinary symptoms in patients who received 50% dextrose cystoscopy fluid (January 2016-June 2017) with those who received saline cystoscopy with intravenous indigo carmine (November 2013-April 2014).Measurements and Main Results: A total of 96 patients had cystoscopy with 50% dextrose and 104 with normal saline with intravenous indigo carmine. Differences in baseline characteristics of the two groups of participants mainly reflected institutional population diversity: age (45.2 vs 41.9, p = .01), body mass index (26.9 vs 33.4, p <.01), race, current smoking status (1% vs 7.8%, p = .04), diabetes (2.1% vs 11.5%, p = .01), history of abdominal surgery (53.1% vs 74%, p <.01), hysterectomy type, receipt of intraoperative antibiotics (92.7% vs 100%, p <.01), recatheterization (10.4% vs 0%, p <.01), and removal of catheter on postoperative day 0 (66.7% vs 12.5%, p <.01). Urinary symptoms were similar for 50% dextrose and saline (12.5% vs 7.7%, p = .19). After adjusting for age, body mass index, race, diabetes, and day of catheter removal, there remained no significant differences in urinary symptoms between the groups (odds ratio 3.19 [95% confidence interval, 0.82-12.35], p = .09). One immediate bladder injury was detected in the saline group and 1 delayed lower urinary tract injury in the 50% dextrose group.Conclusion: Overall, most women experienced no urinary symptoms after benign laparoscopic hysterectomy. There were no significant differences in postoperative urinary symptoms or empiric treatment of urinary tract infection after the use of 50% dextrose cystoscopy fluid as compared with normal saline. The previous finding of increased odds of urinary tract infection after dextrose cystoscopy may be due to use in a high-risk population. [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]

Study Objective: Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH.Design: Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III).Setting: U.S. hospitals.Patients: Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata.Interventions: We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature.Measurements and Main Results: Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of $2193 ($24 181 vs $26 374). Over 5 years, women in the LH group experienced 4.99 QALY versus women in the AH group with 4.91 QALY (incremental gain of .085 QALYs). LH dominated AH in base-case estimates: LH was both less expensive and yielded greater QALY gains. The ICER was sensitive to operative costs for LH and AH. Varying operative costs of AH yielded an ICER of $87 651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time; 17.4% of simulations fell above the willingness-to-pay threshold of $50 000/QALY gained.Conclusion: When considering total direct hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. Driven by the rarity of occult LMS and the reduced incidence of intra- and postoperative complications, LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata. [ABSTRACT FROM AUTHOR]

Abstract: The patient presented here delivered at 32 weeks' gestation after expectant management of spontaneous preterm membrane rupture. She had an unusually located placenta accreta at the left cornu that required a hysterectomy for treatment. The type of abnormal placentation and the laparoscopic approach to her surgery were unique features of her care. [Copyright &y& Elsevier]

Abstract: Study Objective: To estimate whether a new surgical technique is associated with lower incidence of postoperative breakdown of the vaginal cuff after laparoscopic hysterectomy or trachelectomy, compared with previous methods of closure. Design: Retrospective cohort study, Canadian Task Force Classification II-3. Setting: Tertiary-care university-based teaching hospital. Patients: Patients who underwent laparoscopic vaginal closure after removal of the uterus and/or cervix by members of a subspecialty gynecologic laparoscopy division from January 2007 to January 2010 (n = 387). Interventions: Use of bidirectional barbed suture for laparoscopic vaginal cuff closure. Measurements and Main Results: A total of 387 patient records were reviewed. The incidence of vaginal cuff dehiscence among those with other methods of closure was 4.2%, while there were no cases of dehiscence among those who had closure with bidirectional barbed suture (p = .008). Postoperative bleeding (OR 2.3, 95% C.I. 1.3–3.9), presence of granulation tissue (OR 1.9, 95% C.I. 0.92–3.9), and cellulitis (OR 4.6, 95% C.I. 1.0–21.1) all occurred more frequently in patients without barbed suture closure. Conclusion: Dehiscence of the vaginal cuff after laparoscopic closure is a rare but important complication in gynecologic surgery. Use of bidirectional barbed suture eliminated the problem in our first year of experience with the technique. We also observed a decreased incidence of other common problems of the vaginal cuff. This method is easy to learn and inexpensive and does not require advanced skills such as laparoscopic knot-tying. [Copyright &y& Elsevier]

Objective The purpose of this study was to model outcomes in laparoscopic hysterectomy with morcellation compared with abdominal hysterectomy for the presumed fibroid uterus and to examine short- and long-term complications and death. Study Design A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women who underwent hysterectomy for presumed fibroid tumors over a 5-year time horizon. Parameter and quality-of-life utility estimates were determined from published literature for postoperative complications, leiomyosarcoma incidence, death related to leiomyosarcoma, and procedure-related death. Results The decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy compared with abdominal hysterectomy (98 vs 103 per 100,000). Although there were more deaths from leiomyosarcoma after laparoscopic hysterectomy (86 vs 71 per 100,000), there were more hysterectomy-related deaths with abdominal hysterectomy (32 vs 12 per 100,000). The laparoscopic group had lower rates of transfusion (2400 vs 4700 per 100,000), wound infection (1500 vs 6300 per 100,000), venous thromboembolism (690 vs 840 per 100,000) and incisional hernia (710 vs 8800 per 100,000), but a higher rate of vaginal cuff dehiscence (640 vs 290 per 100,000). Laparoscopic hysterectomy resulted in more quality-adjusted life years (499,171 vs 490,711 over 5 years). Conclusion The risk of leiomyosarcoma morcellation is balanced by procedure-related complications that are associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit on which patient-centered decisions can be made. [ABSTRACT FROM AUTHOR]