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Frontiers in Surgery 2021To provide updated evidence on comparative efficacy for clinical outcomes of radical trachelectomy and radical hysterectomy in patients with early-stage cervical...
To provide updated evidence on comparative efficacy for clinical outcomes of radical trachelectomy and radical hysterectomy in patients with early-stage cervical cancer. A systematic search was conducted in the PubMed, Scopus, Cochrane Database of Systematic Reviews, and Google scholar databases. Studies were done in patients with early-stage cervical cancer that compared the outcomes between radical trachelectomy (RT) and hysterectomy (RH) were considered for inclusion in the review. The outcomes of interest were operative time, the volume of blood loss, need for blood transfusion, any complications, length of hospital stay, risk of recurrence, and survival. The strength of association was presented in the form of pooled relative risk (RR), hazards risk (HR), and weighted mean difference (WMD). Statistical analysis was done using STATA version 16.0. A total of 12 articles were included in the meta-analysis. The majority were retrospective cohort-based studies. Compared to RH, the operative time (in min) was comparatively higher in RT (WMD 23.43, 95% CI: 5.63, 41.24). Patients undergoing RT had blood loss (in ml) similar to those undergoing RT (WMD -81.34, 95% CI: -170.36, 7.68). There were no significant differences in the risk of intra-operative (RR 1.61, 95% CI: 0.49, 5.28) and post-operative complications (RR 1.13, 95% CI: 0.54, 2.40) between the two groups. Patients in the RT group had lesser duration of post-operative hospital stay (in days) (WMD -1.65, 95% CI: -3.22, -0.09). There was no statistically significant difference in the risk of recurrence (HR 1.21, 95% CI: 0.68, 2.18), 5-year overall survival (HR 1.00, 95% CI: 0.99, 1.02), and recurrence-free survival (HR 0.99, 95% CI: 0.96, 1.01) between the two groups. Among the patients with early-stage cervical cancer, RT is similar to RH in safety and clinical outcomes. Future studies with a randomized design and larger sample sizes are needed to further substantiate these findings.
PubMed: 34859038
DOI: 10.3389/fsurg.2021.735944 -
Archives of Gynecology and Obstetrics Sep 2021Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome... (Meta-Analysis)
Meta-Analysis Review
Protective operative techniques in radical hysterectomy in early cervical carcinoma and their influence on disease-free and overall survival: a systematic review and meta-analysis of risk groups.
PURPOSE
Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome for open versus minimal invasive surgery, however, the reasons remain to be speculated. This meta-analysis evaluates the outcomes of robotic and laparoscopic hysterectomy compared to open hysterectomy. Risk groups including the use of uterine manipulators or colpotomy were created.
METHODS
Ovid-Medline and Embase databases were systematically searched in June 2020. No limitation in date of publication or country was made. Subgroup analyses were performed regarding the surgical approach and the endpoints OS and DFS.
RESULTS
30 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Patients were analyzed concerning the surgical approach [open surgery (AH), laparoscopic surgery (LH), robotic surgery (RH)]. Additionally, three subgroups were created from the LH group: the LH high-risk group (manipulator), intermediate-risk group (no manipulator, intracorporal colpotomy) and LH low-risk group (no manipulator, vaginal colpotomy). Regarding OS, the meta-analysis showed inferiority of LH in total over AH (0.97 [0.96; 0.98]). The OS was significantly higher in LH low risk (0.96 [0.94; 0.98) compared to LH intermediate risk (0.93 [0.91; 0.94]). OS rates were comparable in AH and LH Low-risk group. DFS was higher in the AH group compared to the LH group in general (0.92 [95%-CI 0.88; 0.95] vs. 0.87 [0.82; 0.91]), whereas the application of protective measures (no uterine manipulator in combination with vaginal colpotomy) was associated with increased DFS in laparoscopy (0.91 [0.91; 0.95]).
CONCLUSION
DFS and OS in laparoscopy appear to be depending on surgical technique. Protective operating techniques in laparoscopy result in improved minimal invasive survival.
Topics: Carcinoma, Squamous Cell; Colpotomy; Early Detection of Cancer; Female; Humans; Hysterectomy; Laparoscopy; Minimally Invasive Surgical Procedures; Pregnancy; Uterine Cervical Neoplasms
PubMed: 34021804
DOI: 10.1007/s00404-021-06082-y -
Journal of Minimally Invasive Gynecology 2019Hysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify... (Meta-Analysis)
Meta-Analysis Review
STUDY OBJECTIVE
Hysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify nonhormonal interventions, perioperative surgical interventions, and devices to minimize blood loss at the time of hysterectomy for leiomyoma.
DATA SOURCES
Librarian-led search of Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases from 1946 to 2018 with hand-guided updates.
METHODS OF STUDY SELECTION
Included studies reported on keywords of hysterectomy, leiomyoma, and operative blood loss/postoperative hemorrhage/uterine bleeding/metrorrhagia/hematoma. The review excluded a comparison of route of hysterectomy, morcellation, vaginal cuff closure, hormonal medications, vessel sealing devices for vaginal hysterectomy, and case series with <10 patients.
TABULATION, INTEGRATION, AND RESULTS
Surgical blood loss, postoperative hemoglobin (Hb) drop, hemorrhage, transfusion, and major and minor complications were analyzed and aggregated in meta-analyses for comparable studies in each category. A total of 2016 unique studies were identified, 33 of which met the inclusion criteria, and 22 were used for quantitative synthesis. The perioperative use of misoprostol in abdominal hysterectomy (AH) was associated with a lower postoperative Hb drop (0.59 g/dL; 95% confidence interval [CI], 0.39-0.79; p < .01) and blood loss (-96.43 mL; 95% CI, -153.52 to -39.34; p < .01) compared with placebo. Securing the uterine vessels at their origin in laparoscopic hysterectomy (LH) was associated with decreased intraoperative blood loss (-69.07 mL; 95% CI, -135.20 to -2.95; p = .04) but no significant change in postoperative Hb (0.24 g/dL; 95% CI, -0.31 to 0.78; p = .39) compared with securing them by the uterine isthmus. Uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with standard ligation (-27.72 mL; 95% CI, -35.07 to -20.38; p < .01). The postoperative Hb drop was not significantly different with a bipolar electrosurgical device versus suturing in AH (0.26 g/dL; 95% CI, -0.19 to 0.71; p = .26). There was no significant difference between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the Hb drop (0.02 g/dL; 95% CI, -0.15 to 0.20; p = .79) or blood loss (-50.88 mL; 95% CI, -106.44 to 4.68; p = .07) in LH. Blood loss in LH was not decreased with the LigaSure (Medtronic, Minneapolis, MN) impedance monitoring EBVS compared with competing EBVS systems monitoring impedance or temperature (2.00 mL; 95% CI, -8.09 to 12.09; p = .70). No significant differences in hemorrhage, transfusion, or major complications were noted for all interventions.
CONCLUSION
Perioperative misoprostol in AH led to a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines) although the clinical benefit is likely limited. Remaining interventions, although promising, had at best low-quality evidence to support their use at this time. Larger and rigorously designed randomized trials are needed to establish the optimal set of perioperative interventions for use in hysterectomy for leiomyomas.
Topics: Blood Loss, Surgical; Female; Humans; Hysterectomy; Leiomyoma; Perioperative Care; Treatment Outcome; Uterine Neoplasms
PubMed: 31039407
DOI: 10.1016/j.jmig.2019.04.021 -
Urogynecology (Philadelphia, Pa.) Oct 2022Vaginal hysterectomy (VH) is the preferred route of choice for women desiring hysterectomy to treat uterine pathology, including premalignant conditions and fibroids. (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Vaginal hysterectomy (VH) is the preferred route of choice for women desiring hysterectomy to treat uterine pathology, including premalignant conditions and fibroids.
OBJECTIVE
The aim of this study was to evaluate the impact of the use of preemptive local analgesia (LA) on postoperative pain and perioperative outcomes for women undergoing VH.
STUDY DESIGN
A systematic search of 4 electronic databases (MEDLINE, Scopus, Cochrane CENTRAL Register of Controlled Trials, and Clinicaltrials.gov ) was performed for articles published up to January 2021. All randomized controlled trials that presented outcomes of patients who underwent VH due to pelvic floor disorders or other benign gynecological disorders and received local infiltration analgesia were finally included.
RESULTS
A total of 5 studies with 277 women (138 LA group vs 199 no-LA group) who underwent a VH were included in the present meta-analysis. Mean pain scores at both 30 minutes to 2 hours and 3 to 6 hours postoperatively were significantly lower in the LA group compared with the non-LA group (220 patients: mean difference [MD], -1.75; 95% confidence interval [CI], -2.77 to -0.74; P = 0.0007; and 220 patients: MD, -1.68; 95% CI, -2.28 to 1.09; P < 0.00001, respectively). Morphine/narcotic opioid-based consumption up to 24 hours postoperatively was significantly reduced in the LA group compared with the non-LA group (197 patients MD, -9.47 mg; 95% CI, -16.51 to -2.43; P = 0.008).
CONCLUSIONS
The use of preemptive LA during VH seems to be beneficial especially with regard to short-term postoperative pain and opioid use. However, further studies are needed to identify the optimal anesthetic regimen, the dosage, and sites of application aiming to achieve the optimal benefit in the postoperative management.
Topics: Humans; Female; Anesthetics, Local; Hysterectomy, Vaginal; Analgesics, Opioid; Randomized Controlled Trials as Topic; Pain, Postoperative; Morphine Derivatives
PubMed: 35759786
DOI: 10.1097/SPV.0000000000001221 -
Biology Mar 2023Primary malignant melanoma (MM) of the cervix uteri is a rare and aggressive malignancy of the female reproductive tract. Considering that clinical data on this cancer... (Review)
Review
Primary malignant melanoma (MM) of the cervix uteri is a rare and aggressive malignancy of the female reproductive tract. Considering that clinical data on this cancer are scarce, we aimed to comprehensively examine the currently available literature and provide an overview of the reported cases of cervical MM focusing on the clinical characteristics, diagnosis and therapeutic management. We conducted a systematic review of the literature by screening three electronic databases until June 2022. The critical appraisal checklist provided by the Joanna Briggs Institute was employed to evaluate the overall quality of the studies. We included 96 reports, which comprised 137 patients diagnosed with MM of the cervix. The mean age of the patients was 56.5 (median: 58, age range: 33-88). Data regarding menopausal status were provided for 98 patients with 15 being premenopausal and 83 being postmenopausal. The most common presenting symptom was vaginal bleeding (83%, 100/121). Biopsy (either excisional or punch biopsy) was used as the first diagnostic modality in most of the patients (67%, 64/95), followed by cytology (18%, 17/95). In 74 cases, the FIGO staging system for cervical cancer was used with the most common stage being FIGO stage I (38%, 28/74), followed by FIGO stage II (36%, 27/74), FIGO stage III (19%, 14/74) and FIGO stage IV (7%, 5/74). Most of the patients were managed surgically (90%, 119/131) with a hysterectomy (either radical or total), and a salpingo-oophorectomy with/without lymphadenectomy was the most common approach utilized (40%, 48/119). The data of clinical outcomes were provided for 105 patients, of whom 61 died (58%, 61/105) and 44 survived (42%, 44/105). Knowledge regarding the rare occurrence of MM in the cervix and the increased awareness of clinicians can prevent clinical misdiagnosis and ultimately improve further the clinical outcomes of patients developing this rare malignancy.
PubMed: 36979090
DOI: 10.3390/biology12030398 -
Obstetrical & Gynecological Survey Jun 2021The aim of this study was to estimate the efficacy of preemptive paracervical block or uterosacral ligament infiltration in reducing postoperative pain and opioid... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of this study was to estimate the efficacy of preemptive paracervical block or uterosacral ligament infiltration in reducing postoperative pain and opioid consumption after benign minimally invasive hysterectomy.
DATA SOURCES
We searched MEDLINE, Cochrane Library, Embase, ClinicalTrials.gov, and Google Scholar from inception until February 2020.
METHODS OF STUDY SELECTION
We identified randomized placebo-controlled trials assessing the primary outcome of pain and opioid consumption after paracervical block or uterosacral infiltration in benign laparoscopic, vaginal, or robotic hysterectomy. Two investigators evaluated studies for risk of bias and quality of evidence.
TABULATION, INTEGRATION, AND RESULTS
We reviewed 219 abstracts; 6 studies met the inclusion criteria: 3 using paracervical block (2 vaginal and 1 laparoscopic) and 3 using uterosacral ligament infiltration (all vaginal). Two studies were included in the meta-analysis (both vaginal hysterectomy). Because of lack of numerical data, or comparison, the other 4 studies are reported in narrative form. Three controlled trials reported a moderate benefit from paracervical block up to 8 hours after vaginal and 4 hours after laparoscopic surgery. Meta-analysis could not be performed because of the lack of numerical data for pooling results or the lack of a laparoscopic hysterectomy comparison group. Three trials reported that uterosacral infiltration decreases pain up to 6 hours after vaginal hysterectomy, and meta-analysis pooling the results of 2 of these studies demonstrated improvement in pain up to 4 hours on a 0- to 100-mm visual analog scale for pain (-19.97 mm; 95% confidence interval, -29.02 to -10.91; < 0.000). Five trials reported a moderate reduction in cumulative opioid use within 24 hours after vaginal surgery for both paracervical block and uterosacral infiltration. Meta-analysis was not performed for paracervical block because only 1 trial provided suitable data for pooling. Meta-analysis pooling the results of 2 trials of uterosacral infiltration demonstrated opioid consumption of 20.73 morphine milligram equivalents less compared with controls (95% confidence interval, -23.54 to -17.91; < 0.000).
CONCLUSIONS
There were a total of 6 randomized placebo-controlled studies evaluated in this study. Although a meta-analysis was unable to be performed for all studies because of lack of comparison groups or numerical data, there is evidence that preemptive uterosacral ligament infiltration may reduce postoperative pain and opioid consumption after vaginal hysterectomy. Our study does not allow us to make any substantive conclusions on the use of paracervical block in vaginal hysterectomy or the use of either type of injection in laparoscopic or robotic hysterectomy.
Topics: Anesthesia; Anesthesia, Obstetrical; Female; Humans; Hysterectomy; Ligaments; Minimally Invasive Surgical Procedures; Pain Measurement; Pain, Postoperative; Uterus; Visual Analog Scale
PubMed: 34192340
DOI: 10.1097/OGX.0000000000000901 -
Journal of Obstetrics and Gynaecology... Nov 2021To review all high quality available evidence regarding the effect of intraoperative bupivacaine 24 hours (or 8.9 half-lives) after intraoperative administration at time... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To review all high quality available evidence regarding the effect of intraoperative bupivacaine 24 hours (or 8.9 half-lives) after intraoperative administration at time of gynaecologic surgery and to ascertain whether a second mechanism of action, beyond the initial prevention of sodium channel depolarization and blockade of nerve impulses, may be occurring.
DATA SOURCES
We searched all major databases with an algorithm designed to include all randomized trials that used any form of local bupivacaine, regardless of dose or route of administration, at the time of any gynaecologic surgery and compared its use with saline placebo.
RESULTS
As expected, we found that bupivacaine showed a significant improvement for all gynaecologic surgeries with respect to pain intensity at 6 hours after surgery when compared with a saline group (mean difference [MD] -1.28; 95% CI -1.96 to -0.61], P = 0.07). We also found a significant difference at 24 hours after surgery, giving evidence to the possibility of a second mechanism of action (MD -0.57; 95% CI -1.10 to -0.05], P = 0.01). Further subgroup analysis for pain levels at 24 hours showed significant decreases in pain for the laparoscopy (MD -0.74; 95% CI -0.93 to -0.54, P < 0.01) and laparotomy (MD -2.60; 95% CI -2.93 to -2.27, P < 0.01)) subgroups but not for the vaginal hysterectomy (MD 0.20; 95% CI -0.69 to 1.09, P = 0.66) or prolapse surgery (MD -0.11; 95% CI -0.41 to 0.19, P = 0.48) subgroups. There was no significant difference with respect to the length of hospital stay (MD -0.11; 95% CI -0.59 to 0.38, P = 0.67).
CONCLUSION
As expected, bupivacaine significantly reduced visual analog pain scores when compared with placebo at 6 hours after surgery, but also showed a significant difference at 24 hours after surgery, giving evidence of a second mechanism of action following the initial sodium channel blockade.
Topics: Anesthetics, Local; Bupivacaine; Female; Gynecologic Surgical Procedures; Humans; Length of Stay; Pain, Postoperative
PubMed: 34293514
DOI: 10.1016/j.jogc.2021.06.010 -
Updates in Surgery Dec 2020The aim of this review is to evaluate the effectiveness and safety of uterine manipulators in facilitating total laparoscopic hysterectomy (TLH). A literature search in...
The aim of this review is to evaluate the effectiveness and safety of uterine manipulators in facilitating total laparoscopic hysterectomy (TLH). A literature search in MEDLINE, EMBASE, Cochrane Library, UpToDate, SpringerLink, ClinicalKey and Elsevier ScienceDirect databases was performed, and articles describing TLH with or without the use of uterine manipulators were retrieved. Complications related to the use of uterine manipulators are numerous, and although uterine manipulator seems to facilitate TLH, the procedure without a uterine manipulator seems to have a comparable safety and effectiveness, although evidence based on a direct comparison of the two approaches is limited without available controlled trials. Uterine manipulator may provide support in cases of large uteri, severe endometriosis, recto vaginal adhesions and regional anesthesia, while its use may increase complications in cases of vaginal stenosis and nulliparity. Therefore, to perform TLH, the surgeon should individualize for each case if uterine manipulator is needed and which manipulator best suits the surgical procedure requirements and case characteristics. Further studies comparing the two approaches are mandatory.
Topics: Blood Loss, Surgical; Female; Humans; Hysterectomy; Laparoscopy; Operative Time; Postoperative Complications; Safety; Surgical Instruments; Uterine Neoplasms; Uterus
PubMed: 31606857
DOI: 10.1007/s13304-019-00681-w -
Journal of Minimally Invasive Gynecology Aug 2021The purpose of this systematic review was to evaluate surgical treatment for malformations of the cervix in terms of short- and long-term postoperative function and... (Review)
Review
OBJECTIVE
The purpose of this systematic review was to evaluate surgical treatment for malformations of the cervix in terms of short- and long-term postoperative function and relevant reproductive outcomes.
DATA SOURCES
International Prospective Register of Systematic Reviews (ID No CRD42019128899). Electronic databases were searched for eligible studies up to October 2019 on Medline/PubMed (1966-2019), Scopus/Elsevier (1950-2019), and Google Scholar (up to 2019). Search terms included "congenital cervical malformations/anomalies," "uterocervical aplasia/dysgenesis/agenesis," "cervical aplasia/dysgenesis/ agenesis," "müllerian anomalies/dysgenesis/agenesis," "utero-vaginal anastomosis," "cervical reconstruction," "uterocervical reconstruction/canalization," "cervical canalization," "reproductive/pregnancy/functional outcome," "menstruation," "pregnancy," and "regular periods."
METHODS OF STUDY SELECTION
Studies were chosen and included with clear description of preoperative diagnosis via sonography, magnetic resonance imaging, and surgical confirmation; assessment and clear description of gynecologic anatomy and any concomitant anomalies; meticulous description of the operative technique; follow-up of at least 6 weeks postoperatively; and postoperative end points including menstrual and reproductive outcomes. We included randomized controlled trials, case-control studies (both prospective and retrospective), and case reports. Data registries, studies without clearly described primary or secondary outcomes, and studies not in the English language were excluded from the analyses.
TABULATION, INTEGRATION, AND RESULTS
The literature search returned 745 studies; 546 records were initially excluded (397 not related to the topic, 15 not related to humans, 134 non-English language); 111 full-text articles were further excluded (patients underwent hysterectomy or no surgery); 88 studies with a total of 249 patients were suitable for analysis. Almost all patients had preoperative amenorrhea (248/249, 99.6%). Postoperatively, of 249 patients, resolution of menstruation occurred in 228 patients (91.6%), and hysterectomy was performed in 22 patients (8.8%); overall, there were 30 (12.0%) conceptions that resulted in 27 (10.8%) viable and 24 (9.6%) term pregnancies. Indications for hysterectomy were stenosis of the genital tract and sepsis. Coexisting vaginal agenesis and use of full thickness skin graft for creation of neocervix was associated with negative surgical outcomes.
CONCLUSION
This review suggests that conservative surgical approaches result in better clinical and reproductive outcomes than more aggressive reconstructive surgeries for patients with malformations of the cervix.
Topics: Cervix Uteri; Female; Humans; Pregnancy; Retrospective Studies; Urogenital Abnormalities; Uterus
PubMed: 34058406
DOI: 10.1016/j.jmig.2020.10.030 -
Journal of Personalized Medicine Jun 2023Forty percent of women will experience prolapse in their lifetime. Vaginal pessaries are considered the first line of treatment in selected patients. Major complications... (Review)
Review
BACKGROUND
Forty percent of women will experience prolapse in their lifetime. Vaginal pessaries are considered the first line of treatment in selected patients. Major complications of vaginal pessaries rarely occur.
METHODS
PubMed and Embase were searched from 1961 to 2022 for major complications of vaginal pessaries using Medical Subject Headings (MeSH) and free-text terms. The keywords were pessary or pessaries and: vaginal discharge, incontinence, entrapment, urinary infections, fistula, complications, and vaginal infection. The exclusion criteria were other languages than English, pregnancy, complications without a prior history of pessary placement, pessaries unregistered for clinical practice (herbal pessaries), or male patients. The extracted data included symptoms, findings upon examination, infection, type of complication, extragenital symptoms, and treatment.
RESULTS
We identified 1874 abstracts and full text articles; 54 were assessed for eligibility and 49 met the inclusion criteria. These 49 studies included data from 66 patients with pessary complications amenable to surgical correction. Clavien-Dindo classification was used to grade the complications. Most patients presented with vaginal symptoms such as bleeding, discharge, or ulceration. The most frequent complications were pessary incarceration and fistulas. Surgical treatment included removal of the pessary under local or general anesthesia, fistula repair, hysterectomy and vaginal repair, and the management of bleeding.
CONCLUSIONS
Pessaries are a reasonable and durable treatment for pelvic organ prolapse. Complications are rare. Routine follow-ups are necessary. The ideal patient candidate must be able to remove and reintroduce their pessary on a regular basis; if not, this must be performed by a healthcare worker at regular intervals.
PubMed: 37511669
DOI: 10.3390/jpm13071056