-
Journal of Minimally Invasive Gynecology Nov 2023To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route...
STUDY OBJECTIVE
To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population.
DESIGN
Retrospective cohort study (Canadian Task Force Classification II2) of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States.
SETTING
National Surgical Quality Improvement Program Database.
PATIENTS
Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into 4 groups according to uterine weight: <100 g, 100-249 g, 250 g-499 g, and specimens ≥500 g.
INTERVENTIONS
Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index, smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight.
MEASUREMENTS AND MAIN RESULTS
A total of 122,418 hysterectomies occurring between 2014 and 2019 were included in our study, of which 28,407 (23.2%) patients underwent abdominal, 75,490 (61.7%) laparoscopic, and 18,521 (15.1%) vaginal hysterectomy. The overall rate of VTE in patients with large specimen hysterectomies (≥500 g) was 0.64%. After multivariable adjustment, there was no significant difference in the odds of VTE between uterine weight groups. Only 30% of the surgeries with uterine weight above 500 g were performed with minimally invasive surgical routes. Patients who underwent minimally invasive hysterectomy had lower odds of VTE via laparoscopic (adjusted odds ratio [aOR] 0.62; confidence interval [CI]: 0.48-0.81) and vaginal (aOR 0.46; CI: 0.31-0.69) routes compared to laparotomy. Prolonged operative time (>120 min) was associated with increased odds of VTE (aOR 1.86; CI:1.51-2.29).
CONCLUSION
The occurrence of VTE after a benign large specimen hysterectomy is rare. The odds of VTE is higher with longer operative times and lower with minimally invasive approaches, even for markedly enlarged uteri.
Topics: Humans; Female; United States; Venous Thromboembolism; Retrospective Studies; Postoperative Complications; Hysterectomy; Hysterectomy, Vaginal
PubMed: 37422052
DOI: 10.1016/j.jmig.2023.06.017 -
Archives of Gynecology and Obstetrics Jan 2024Uterine leiomyomas are benign uterine tumors. The choice of surgical treatment is guided by patient's age, desire to preserve fertility or avoid "radical" surgical...
PURPOSE
Uterine leiomyomas are benign uterine tumors. The choice of surgical treatment is guided by patient's age, desire to preserve fertility or avoid "radical" surgical interventions such as hysterectomy. In laparotomy, the issue of extracting the fibroid from the cavity does not arise. However, in laparoscopy and robotic surgery, this becomes a challenge. The aim of the present study was to determine the optimal surgical approach for fibroid extraction following laparoscopic or robotic myomectomy in terms of postoperative pain, extraction time, overall surgical time, scar size, and patient satisfaction.
METHODS
A total of 51 patients met the inclusion criteria and were considered in our analysis: 33 patients who had undergone the "ExCITE technique" (Group A), and 18 patients a minilaparotomy procedure (Group B), after either simple myomectomy, multiple myomectomy, supracervical hysterectomy, or total hysterectomy. The diagnosis of myoma was histologically confirmed in all cases.
RESULTS
Regarding the postoperative pain evaluation, at 6 h, patients reported 4 [3-4] vs 6 [5.3-7] on the VAS in Group A and B, as well as at 12 h, 2 [0-2] vs 3.5 [2.3-4] in Group A and B, respectively: both differences were statistically significant (p < 0.001). No statistically significant difference at 24 h from surgery was found. All patients in Group A were satisfied with the ExCITE technique, while in Group B only 67% of them. The length of the hospital stay was significantly shorter in Group A as compared to Group B (p = 0.007). In terms of the operative time for the extraction of the surgical specimen, overall operative time, and the scar size after the surgery, there was a statistically significant difference for those in Group A.
CONCLUSION
The ExCITE technique does not require specific training and allows the surgeon to offer a minimally invasive surgical option for patients, with also an aesthetic result. It is a safe and standardized approach that ensures tissue extraction without the need for mechanical morcellation.
Topics: Female; Humans; Laparotomy; Retrospective Studies; Cicatrix; Leiomyoma; Uterine Neoplasms; Uterine Myomectomy; Minimally Invasive Surgical Procedures; Laparoscopy; Hysterectomy; Pain, Postoperative
PubMed: 37796281
DOI: 10.1007/s00404-023-07239-7 -
Revista Da Associacao Medica Brasileira... 2023The aim of this study was to analyze the surgical content of the 50 most-viewed laparoscopic myomectomy videos on YouTube while evaluating the educational quality and...
OBJECTIVE
The aim of this study was to analyze the surgical content of the 50 most-viewed laparoscopic myomectomy videos on YouTube while evaluating the educational quality and accuracy of the videos.
METHODS
In this cross-sectional study, the keyword "laparoscopic myomectomy" was searched in publicly available content on YouTube, and the videos were sorted by view count using YouTube's advanced search options. Out of the first 66 videos, only 50 were eligible according to our selection criteria. One associate professor of gynecology and one gynecology resident watched these videos independently and evaluated the quality and surgical aspects. Our primary outcome was the scores of the Quality Criteria for Consumer Health Information and Global Quality Score and the features of the surgical technique.
RESULTS
The 50 most-viewed laparoscopic myomectomy videos were uploaded between 2010 and 2021. They had a mean of 66636.6±103772.2 views. According to the Quality Criteria for Consumer Health Information criteria, 78% of the videos were categorized as "poor," 12% of them were "fair," and 10% of them were "very poor." The indication of the surgery was not specified in 27 (54%) of them. The surgeons in 39 (79.6%) of the videos did not use any containment system for the power morcellation, even though it was restricted by the United States Food and Drug Administration. The preoperative and perioperative precautions to minimize blood loss were underemphasized. There was no scientific evidence in 49 (98%) of the videos.
CONCLUSION
Laparoscopic myomectomy videos on YouTube are limited in terms of providing evidence-based and well-organized scientific knowledge.
Topics: United States; Humans; Female; Cross-Sectional Studies; Uterine Myomectomy; Educational Status; Cell Movement; Laparoscopy; Video Recording; Reproducibility of Results
PubMed: 37971128
DOI: 10.1590/1806-9282.20230736 -
Revista Da Associacao Medica Brasileira... 2023The aim of this study was to reveal the learning curve of early apical release en bloc laser prostatectomy using a high-power thulium (200 W) laser device.
OBJECTIVE
The aim of this study was to reveal the learning curve of early apical release en bloc laser prostatectomy using a high-power thulium (200 W) laser device.
METHODS
We obtained data on the initial 60 patients who had thulium laser enucleation of the prostate by a single surgeon between October 2021 and August 2022 to treat the signs and symptoms of benign prostatic hyperplasia at our clinic. The cases were split into three groups, each consisting of 20 patients. Prostate volumes, prostate-specific antigen and hemoglobin levels, the International Prostate Symptom Score, Quality of Life scores, the International Index of Erectile Function-5 scores, and uroflowmetry parameters were documented preoperatively. The enucleation weight, the enucleation and morcellation times, as well as the efficiency, hospitalization, and catheterization durations were calculated. The patients were re-evaluated at 6 months postoperatively, examined for functional results, and compared to baseline conditions.
RESULTS
Enucleation times, morcellation times, enucleation weight, and enucleation efficiency were significantly different among the groups. However, there was no statistically significant difference in total operative time and morcellation efficiency. In terms of postoperative statistics, the reduction in hemoglobin was significantly greater in Group 1 compared to Group 2. Six months after surgery, all groups had comparable validated ratings (International Prostate Symptom Score, Quality of Life, and the International Index of Erectile Function-5) on postoperative examinations. There were no long-term complications in either group throughout the perioperative period.
CONCLUSION
Completing 40 first cases would be sufficient for managing the learning curve for early apical release en bloc thulium laser enucleation of the prostate.
Topics: Male; Humans; Prostate; Learning Curve; Thulium; Erectile Dysfunction; Quality of Life
PubMed: 37729364
DOI: 10.1590/1806-9282.20230325 -
Journal of Clinical Medicine Dec 2023The aim of this study is to investigate the prevalence of occult malignant mesenchymal tumors in patients operated on for uterine fibroids in relation to the surgical...
The aim of this study is to investigate the prevalence of occult malignant mesenchymal tumors in patients operated on for uterine fibroids in relation to the surgical approach and type of operation. A retrospective review of all patients that underwent surgery for uterine fibroids (January 2011-December 2018) at the 1st Department of Obstetrics & Gynecology at "Papageorgiou" Hospital. The surgical approach and clinicopathological characteristics were analyzed. A total of 803 patients were operated on: 603 (75.1%) with laparotomy, 187 (23.3%) laparoscopically, and 13 (1.6%) vaginally. Furthermore, 423 (52.7%) patients underwent hysterectomy and 380 (47.3%) myomectomies. Laparoscopy and myomectomy were offered to younger patients with fewer smaller uterine fibroids and were associated with statistically significant shorter hospitalization. The pathological reports revealed: 690 (86%) benign leiomyomas, 32 (4%) cellular leiomyomas, 29 (3.6%) degenerated leiomyomas, 22 (2.7%) adenomyomas, 18 (2.2%) atypical-bizarre leiomyomas, 1 (0.1%) STUMP, 5 (0.65%) endometrial stromal sarcomas, and 6 (0.75%) cases of leiomyosarcomas (LMS). All LMS were preoperatively characterized as suspicious and underwent abdominal hysterectomy. Morcellation was offered in two cases of atypical leiomyomas, with no morcellation-associated complication. Laparoscopy as a valuable surgical approach for young patients with fewer in number and smaller in size fibroids is associated with shorter hospitalization. The risk of unintended morcellation of LMS seems to be very low and can be reduced with careful preoperative work-up but not eliminated.
PubMed: 38137623
DOI: 10.3390/jcm12247555 -
Bulletin Du Cancer 2023Low-grade endometrial stromal sarcoma (LG-ESS) accounts for approximately 15% of all uterine sarcomas. Median age of patients is around 50 years and half of the patients... (Review)
Review
Low-grade endometrial stromal sarcoma (LG-ESS) accounts for approximately 15% of all uterine sarcomas. Median age of patients is around 50 years and half of the patients are premenopausal. In all, 60% of cases present with FIGO stage I disease. Preoperatively radiologic findings of ESS are not specific. Pathological diagnosis remains essential. This review aimed to present the French guidelines for low grade ESS treatment within the Groupe sarcome français - Groupe d'étude des tumeurs osseuse (GSF-GETO)/NETSARC+ and tumeur maligne rare gynécologique (TMRG) networks. Treatments should be validated in multidisciplinary team involved in sarcomas or rare gynecologic tumors. Hysterectomy is the cornerstone of treatment for localized ESS, and morcellation should be avoided. Systematic lymphadenectomy in ESS does not improve the outcome and is not recommended. Leaving the ovaries in situ in stage I tumors could be discussed for young women. Adjuvant hormonal treatment could be considered, for two years for stage I with morcellation or stage II and livelong for stages III or IV. Nevertheless, several questions remain, such as optimal doses, regimens (progestins or aromatase inhibitors) and duration of therapy. Tamoxifen is contraindicated. Secondary cytoreductive surgery if feasible for recurrent disease, appears to be an acceptable approach. Systemic treatment for recurrent or metastatic disease is mainly hormonal, with or without surgery.
Topics: Female; Humans; Middle Aged; Sarcoma, Endometrial Stromal; Endometrial Neoplasms; Genital Neoplasms, Female; Uterine Neoplasms; Sarcoma
PubMed: 36990895
DOI: 10.1016/j.bulcan.2023.03.003 -
PLoS Medicine Dec 2023Hysteroscopic resection is the first-choice treatment for symptomatic type 0 and 1 fibroids. Traditionally, this was performed under general anesthesia. Over the last... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Hysteroscopic resection is the first-choice treatment for symptomatic type 0 and 1 fibroids. Traditionally, this was performed under general anesthesia. Over the last decade, surgical procedures are increasingly being performed in an outpatient setting under procedural sedation and analgesia. However, studies evaluating safety and effectiveness of hysteroscopic myomectomy under procedural sedation are lacking. This study aims to investigate whether hysteroscopic myomectomy under procedural sedation and analgesia with propofol is noninferior to hysteroscopic myomectomy under general anesthesia.
METHODS AND FINDINGS
This was a multicenter, randomized controlled noninferiority trial conducted in 14 university and teaching hospitals in the Netherlands between 2016 and 2021. Inclusion criteria were age ≥18 years, maximum number of 3 type 0 or 1 fibroids, maximum fibroid diameter 3.5 cm, American Society of Anesthesiologists class 1 or 2, and having sufficient knowledge of the Dutch or English language. Women with clotting disorders or with severe anemia (Hb < 5.0 mmol/L) were excluded. Women were randomized using block randomization with variable block sizes of 2, 4, and 6, between hysteroscopic myomectomy under procedural sedation and analgesia (PSA) with propofol or under general anesthesia (GA). Primary outcome was the percentage of complete resections, assessed on transvaginal ultrasonography 6 weeks postoperatively by a sonographer blinded for the treatment arm and surgical outcome. Secondary outcomes were the surgeon's judgment of completeness of procedure, menstrual blood loss, uterine fibroid related and general quality of life, pain, recovery, hospitalization, complications, and surgical reinterventions. Follow-up period was 1 year. The risk difference between both treatment arms was estimated, and a Farrington-Manning test was used to determine the p-value for noninferiority (noninferiority margin 7.5% of incomplete resections). Data were analyzed according to the intention-to-treat principle, including a per-protocol analysis for the primary outcome. A total of 209 women participated in the study and underwent hysteroscopic myomectomy with PSA (n = 106) or GA (n = 103). Mean age was 45.1 [SD 6.4] years in the PSA group versus 45.0 [7.7] years in the GA group. For 98/106 women in the PSA group and 89/103 women in the GA group, data were available for analysis of the primary outcome. Hysteroscopic resection was complete in 86/98 women (87.8%) in the PSA group and 79/89 women (88.8%) in the GA group (risk difference -1.01%; 95% confidence interval (CI) -10.36 to 8.34; noninferiority, P = 0.09). No serious anesthesiologic complications occurred, and conversion from PSA to GA was not required. During the follow-up period, 15 serious adverse events occurred (overnight admissions). All were unrelated to the intervention studied. Main limitations were the choice of primary outcome and the fact that our study proved to be underpowered.
CONCLUSIONS
Noninferiority of PSA for completeness of resection was not shown, though there were no significant differences in clinical outcomes and quality of life. In this study, hysteroscopic myomectomy for type 0 and 1 fibroids with PSA compared to GA was safe and led to shorter hospitalization. These results can be used for counseling patients by gynecologists and anesthesiologists. Based on these findings, we suggest that hysteroscopic myomectomies can be performed under PSA in an outpatient setting.
TRIAL REGISTRATION
The study was registered prospectively in the Dutch Trial Register (NTR 5357; registration date: 11 August 2015; Date of initial participant enrollment: 18 February 2016).
Topics: Humans; Female; Middle Aged; Adolescent; Uterine Myomectomy; Uterine Neoplasms; Propofol; Quality of Life; Leiomyoma; Analgesia; Anesthesia, General; Pain
PubMed: 38153958
DOI: 10.1371/journal.pmed.1004323 -
Lasers in Medical Science May 2024Thulium laser enucleation of the prostate (ThuLEP) is a highly effective approach to the treatment of benign prostatic hyperplasia. We present here a description of the...
Thulium laser enucleation of the prostate (ThuLEP) is a highly effective approach to the treatment of benign prostatic hyperplasia. We present here a description of the "ARTh Technique" and the benefits it offers in terms of improved visualization, short operation times, and easy recognition of the dissection plane, describing specifically the anterior release (AR) technique using ThuLEP(Th). Included in this retrospective study were 32 consecutive patients operated on between January 2022-November 2022. Parameters were measured before and after the procedure: the International Prostate Symptom Score(IPSS), maximum flow rate(Qmax), post-void residual urine(PVR) prostate-specific antigen(PSA), prostate volume, operation-time, morcellation-time, catheterization-time and presence of transient urinary incontinence, and compared. The median age of patients undergoing enucleation of the prostate using the ARTh technique was 64 years (range: 44-83). The median prostate volume of the patients was 83.5 ml(50-128 ml), preoperative-IPSS was 24.8(15-33), postoperative-IPSS was 7(5-11), preoperative-Qmax was 8.1 ml/Sects. (5-11.5 ml/sec), postoperative-Qmax was 26.9 ml/Sect. (20.8-34 ml/sec), preoperative-PVR was 145 ml(75-258 ml), postoperative-PVR was 36.2 ml(0-66 ml), total operation time was 51.4 min(28-82 min), enucleation time was 36.9 min(19-51 min) and morcellation time was 15.3 min(8-27 min). The ARTh technique is a safe procedure that allows the surgeon to easily recognize and adhere to the defined dissection plane, thus decreasing operation times, significantly reducing the rate of postoperative transient urinary incontinence (TUI).
Topics: Humans; Male; Prostatic Hyperplasia; Thulium; Aged; Retrospective Studies; Middle Aged; Aged, 80 and over; Lasers, Solid-State; Adult; Laser Therapy; Prostate; Prostatectomy; Operative Time; Treatment Outcome
PubMed: 38714553
DOI: 10.1007/s10103-024-04071-6 -
BMC Surgery Jul 2023Laparoscopic surgery has been a milestone for minimally invasive surgeries. But safe removal of large uterine tissue is a challenge for minimally invasive procedures,...
BACKGROUND
Laparoscopic surgery has been a milestone for minimally invasive surgeries. But safe removal of large uterine tissue is a challenge for minimally invasive procedures, and there still exists concern about the dissemination of benign or occult malignant uterine tissue during the use of the morcellator. Different tissue containment systems have been used in laparoscopic power morcellation. However, a risk of leakage still exists in clinical practice. In this study, we aimed to evaluate leakage and tissue dissemination associated with a new detachable multi-hard-port containment system for tissue removal during laparoscopic myomectomy morcellation.
METHODS
Beef tongue specimens were stained with methylene blue solution and morcellated in a plastic trainer box under laparoscopic guidance. The morcellation test in vitro conditions comprised two different containment systems to simulate laparoscopic power morcellation, specifically a polyurethane bag with two pipes (control group) and a detachable multi-hard-port containment system (experimental group). Insufflation pressure was set at 14 mmHg. Three methods are used to detect the leakage The procedure times were recorded. Thirty trials were performed using a multi-port approach and the two tissue containment systems.
RESULTS
The leakage rate was 0.03% (n = 30) for the experimental group and 26.6% (n = 30) for the control group (p < 0.005). Morcellation time was significantly shorter in the experimental group than in the control group (p < 0.001). Median bag introduction time was shorter in the experimental group than in the control group; however, removal time differences were not significant.
CONCLUSIONS
This study quantified the low leakage rate during morcellation and the improved convenience of operation provided by a new tissue containment system.
Topics: Animals; Cattle; Female; Humans; Leiomyoma; Uterine Neoplasms; Morcellation; Laparoscopy; Uterine Myomectomy; Hysterectomy
PubMed: 37525186
DOI: 10.1186/s12893-023-02124-1 -
World Journal of Urology Mar 2024To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV).
Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients.
PURPOSE
To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV).
METHODS
We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with different energy sources in 14 centers (January 2019-January 2023).
INCLUSION CRITERIA
prostate volume ≥ 80 ml.
EXCLUSION CRITERIA
prostate cancer, previous prostate/urethral surgery, pelvic radiotherapy.
PRIMARY OUTCOME
complication rate.
SECONDARY OUTCOMES
incidence of and factors affecting postoperative UI. Patients were divided into 3 groups. Group 1: PV = 80-100 ml; Group 2 PV = 101-200 ml; Group 3 PV > 200 ml. Multivariable logistic regression analysis was performed to evaluate independent predictors of overall incontinence.
RESULTS
There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2. There was no significant difference in overall 30-day complications and readmission rates. Incontinence incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p = 0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (OR 1.019 95% CI 1.003-1.035) was the only factor significantly associated with higher odds of incontinence.
CONCLUSIONS
PV has no influence on complication and UI rates following EEP. Age is risk factor of postoperative UI.
Topics: Male; Humans; Prostate; Retrospective Studies; Incidence; Laser Therapy; Urinary Incontinence; Prostatic Hyperplasia; Transurethral Resection of Prostate; Lasers, Solid-State; Treatment Outcome
PubMed: 38507108
DOI: 10.1007/s00345-024-04886-6