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Journal of the Turkish German... Feb 2019In the last 5 years there has been much discussion about the surgical procedure for uterine fibroids, and essentially, also uterine sarcoma. Still there exists no...
OBJECTIVE
In the last 5 years there has been much discussion about the surgical procedure for uterine fibroids, and essentially, also uterine sarcoma. Still there exists no reliable presurgical diagnostic tool to differentiate between benign fibroids and uterine sarcomas. The aim of this study was to confirm the suspected association between intraoperative spread of tumor by morcellation and impaired outcomes in patients with sarcoma.
MATERIAL AND METHODS
After the local ethics commission positively reviewed the study protocol, the oncologic database of our university hospital was retrospectively reviewed for patients with uterine sarcomas over a time period of 13 years (2002-2015). Data was extracted from the medical files and survival information was collected by contacting the patient’s general practitioners if last follow-up-status was older than 6 months. For the analysis, patients were split into two groups with either intrasurgical morcellation (M+) or no morcellation (M-) regarding information provided by the surgical report.
RESULTS
Data on 57 patients with uterine sarcoma were available for further analysis. The median age and body mass index of the patients was 63 years and 27 kg/m², respectively. The sarcoma subtypes were 25 leiomyosarcoma, 19 carcinosarcoma, 9 endometrioid stroma sarcoma, 3 adenosarcoma, and one case without further differentiation. In the majority, no morcellation was performed (M- group, n=44) and 51 patients received open surgery (3 laparoscopic, 1 vaginal, and 2 incomplete surgeries). The median time of follow-up was 31 months. The disease-free survival was 50.5 months and the Cox regression analysis showed a hazard ratio of 3.06 [no significant difference between the two subgroups (p=0.079; 95% confidence interval (CI): 0.9-10.6)]. The overall survival was found as 62.2 months and the Cox regression analysis showed a hazard ratio of 3.216 with a statistically significant difference between the two subgroups (p=0.013; 95% CI: 1.3-8.1).
CONCLUSION
Despite the efforts to find a pre-surgical diagnostic tool, the clinical situation remains unsatisfactory. Overall sarcoma prevalence is low during the last 13 years at our university center, but morcellation occurred in a relevant portion of patients (13 of 57). If sarcoma is suspected or diagnosed then en-bloc resection of the uterus can prolong survival. Thus, morcellation of the uterus and not the surgical technique (en-bloc resection) is the prognostic factor and should be avoided in any suspicious case.
PubMed: 30299262
DOI: 10.4274/jtgga.galenos.2018.2018.0083 -
Urology Jan 2020To demonstrate how bladder ultrasound can be useful in completing morcellation during difficult Holmium Laser Enucleation of the Prostate (HoLEP). As HoLEP has emerged...
OBJECTIVE
To demonstrate how bladder ultrasound can be useful in completing morcellation during difficult Holmium Laser Enucleation of the Prostate (HoLEP). As HoLEP has emerged as a standard of care for the treatment of benign prostatic hyperplasia, multiple studies have reported the potentially catastrophic complication of bladder injury during morcellation. This video aims to assist any urologist performing HoLEP by providing step-by-step instruction for using ultrasound to complete morcellation safely.
METHODS
Enucleation is performed using a 26-French continuous flow scope, off-set laser bridge with a laser stabilization catheter, and a 550 µm holmium laser fiber. Once the median and lateral lobes have been enucleated, the outer sheath is removed and the nephroscope is inserted to facilitate morcellation. Under dual inflow irrigation, the Piranha morcellator (Richard Wolf, Knittlingen, Germany) is introduced and set to the manufacturer's recommended settings of 1500 rpm. A 3.5-MHz convex abdominal ultrasound transducer (Hitachi Prosound Alpha 7; Hitachi Aloka Medical America, Wallingford, CT) under B-mode is used to visualize the bladder, predominantly in the sagittal orientation. Morcellation proceeds under simultaneous ultrasound and direct cystoscopic guidance.
RESULTS
The distended bladder is visualized concurrently with the ultrasound and via the nephroscope as the Piranha engages the adenoma and begins morcellation. Once the adenoma is engaged, the operator then drops their hands to place the morcellator in the center of the bladder. Ultrasound provides real-time feedback as to the location of the morcellator in relation to the adenoma and bladder.
CONCLUSION
This video highlights the use of intraoperative bladder ultrasound as a visual aid to assist during the morcellation portion of HoLEP. This proof of concept demonstrates that ultrasound can be an additional tool to utilize during difficult cases when cystoscopic visualization during morcellation is limited.
Topics: Humans; Intraoperative Complications; Laser Therapy; Lasers, Solid-State; Male; Morcellation; Proof of Concept Study; Prostate; Prostatectomy; Prostatic Hyperplasia; Ultrasonography; Urinary Bladder
PubMed: 31589882
DOI: 10.1016/j.urology.2019.09.027 -
Obstetrics & Gynecology Science May 2019Scarce literature about myoma removal without anesthesia has been published. The aim of this paper is to evaluate the feasibility of a new alternative for a...
OBJECTIVE
Scarce literature about myoma removal without anesthesia has been published. The aim of this paper is to evaluate the feasibility of a new alternative for a hysteroscopic myomectomy in a conventional office setting, without need for anesthesia.
METHODS
Step-by-step description of the surgical technique has been provided, based on video images. An office hysteroscopy was performed in a Gynecological Endoscopy Department of a tertiary European hospital.
RESULTS
A 49-year-old woman was referred for management of severe hypermenorrhea. Consent and approval were received from the patient and the institutional review board, respectively. The introduction of a Truclear hysteroscopic polyp morcellator of 5.5 mm with optic of 0 degrees into the uterine cavity did not require any kind of anesthesia or cervical dilatation. The use of saline flow helped distend the cavity and identify a submucosal myoma. Under direct vision, a full myomectomy was performed via mechanical energy with continuous cutting movements, without any complication. After the procedure was completed, the excised material was aspirated through the device into a collecting pouch. A successful complete morcellation of a Type-0 submucosal leiomyoma with a polyp morcellator device was performed in an outpatient setting. Good medical results, good tolerance by the patient besides lower surgical risks due to mechanical instead of electrical energy are shown.
CONCLUSION
In conclusion, this video demonstrates that a hysteroscopic myomectomy can be performed successfully in office with lower risk of complications from the procedure and without use of general anesthesia besides good tolerance by the patient.
PubMed: 31139595
DOI: 10.5468/ogs.2019.62.3.183 -
Annals of Translational Medicine Jan 2022This study sought to analyze the risk of morcellation in patients who underwent surgery for leiomyoma and had a final pathological diagnosis of uterine leiomyosarcoma...
BACKGROUND
This study sought to analyze the risk of morcellation in patients who underwent surgery for leiomyoma and had a final pathological diagnosis of uterine leiomyosarcoma (uLMS), and evaluate the survival benefits of second-look surgery and chemotherapy in patients with stage I occult uLMS.
METHODS
A retrospective analysis of the data of patients with occult stage I uLMS in the Peking Union Medical College Hospital database between 2005 and 2018 was conducted. The recurrence rate and progression-free survival (PFS) were compared between patients who underwent morcellation or not. Univariate analyses were used to evaluate the survival impact of lymphadenectomy, oophorectomy and adjuvant chemotherapy. Propensity-score matching methods were used to evaluate the effect of morcellation on recurrence while adjusting for baseline confounding factors using Poisson regression fitted by inverse probability weighting (IPW) estimation.
RESULTS
A total of 96 patients with uLMS were identified among the 31,679 surgeries performed for leiomyomas (incidence: 0.303%). Hysterectomy was performed in 60 patients, and myomectomy was performed in 36 patients (power morcellation n=20). There were 36 (37.5%) patients underwent lymphadenectomy, and 76 (79.2%) patients underwent oophorectomy. Among them, 47 (52.8%) patients received postoperative chemotherapy. The median follow-up time was 40 months (range, 12-146 months), and there were 43 cases of recurrence (44.7%). No differences in recurrence were found between the hysterectomy and myomectomy groups (hazard ratio 0.839, P=0.701). The 3-year PFS rates for patients with hysterectomy, power morcellation, and non-power morcellation were 64.3%, 53.8%, and 59.8%, respectively. No survival differences were identified between patients with/without lymphadenectomy [PFS: P=0.513; overall survival (OS): P=0.413] and oophorectomy (PFS: P=0.162; OS: P=0.815). Postoperative chemotherapy was associated with better PFS (P=0.047), but not OS (P=0.36).
CONCLUSIONS
No survival differences were observed among the initial surgical procedures in stage I patients with occult uLMS. No survival benefits were observed between lymphadenectomy and oophorectomy patients. Compared to continued observation, postoperative chemotherapy was associated with improved PFS, but not OS.
PubMed: 35282058
DOI: 10.21037/atm-21-6424 -
International Journal of Applied &... 2021A giant uterine fibroid is a rare tumor of the uterus. Uterine leiomyomas are the most common type of a benign tumor that arises from the female pelvis. Uterine...
A giant uterine fibroid is a rare tumor of the uterus. Uterine leiomyomas are the most common type of a benign tumor that arises from the female pelvis. Uterine leiomyoma is a smooth muscle tumor. Its prevalence is more in reproductive age group and decreases after menopause. They are rare in adolescents. In reproductive age group, the preferred mode of management of fibroid is myomectomy. For large myomas, the role of laparoscopic myomectomy is still controversial. Laparoscopic myomectomy for giant myoma is technically challenging and should be performed by an experienced surgeon. We herein report the case of a 32-year-old unmarried girl who visited our hospital with the complaint of progressive abdominal distension and discomfort from the past 4-5 months. Ultrasonography was done, and it showed a markedly enlarged uterus containing a 16 cm × 17 cm subserosal fibroid and 3 cm × 4 cm intramural fibroid. Magnetic resonance imaging suggestive of three myoma, one sub serosal myoma at fundal region of 11.2 cm × 9.6 cm × 14.2 cm, second intramural fibroid in the lateral wall of the uterus of 3 cm × 3 cm and a small submucosal fibroid of dimension 1.1 cm × 0.9 cm × 0.8 cm. Laparoscopic myomectomy was planned and completed successfully with no intra- and postoperative complications. Intraoperative finding was suggestive of 20 cm × 20 cm × 18 cm fundal fibroid and 2 cm × 3 cm lateral wall fibroid. The defect was closed using V-lock suture in two layers. The myoma was removed by tissue morcellator. In the literature, only a few cases reported of successful removal of giant myoma by laparoscopy.
PubMed: 33912432
DOI: 10.4103/ijabmr.IJABMR_382_19 -
Journal of Clinical Medicine May 2023Contained electromechanical morcellation has emerged as a safety approach for laparoscopic myomatous tissue retrieval. This retrospective single-center analysis...
Contained electromechanical morcellation has emerged as a safety approach for laparoscopic myomatous tissue retrieval. This retrospective single-center analysis evaluated the bag deployment practicability and safety of electromechanical in-bag morcellation when used for big surgical benign specimens. The main age of patients was 39.3 years (range 21 to 71); 804 myomectomies, 242 supracervical hysterectomies, 73 total hysterectomies, and 1 retroperitoneal tumor extirpation were performed. A total of 78.7% of specimens weighed more than 250 g (n = 881) and 9% more than 1000 g. The largest specimens, weighing 2933 g, 3183 g, and 4780 g, required two bags for complete morcellation. Neither difficulties nor complications related to bag manipulation were recorded. Small bag puncture was detected in two cases, but peritoneal washing cytology was free of debris. One retroperitoneal angioleiomyomatosis and three malignancies were detected in histology (leiomyosarcoma = 2; sarcoma = 1); therefore, patients underwent radical surgery. All patients were disease-free at 3 years follow-up, but one patient presented multiple abdominal metastases of the leiomyosarcoma in the third year; she refused subsequent surgery and was lost from follow-up. This large series demonstrates that laparoscopic bag morcellation is a safe and comfortable method to remove large and giant uterine tumors. Bag manipulation takes only a few minutes, and perforations rarely occur and are easy to detect intraoperatively. This technique did not result in the spread of debris during myoma surgery, potentially avoiding the additional risk of parasitic fibroma or peritoneal sarcoma.
PubMed: 37297823
DOI: 10.3390/jcm12113628 -
Journal of Minimally Invasive Gynecology 2019Conventional laparoscopic myomectomy (CLM) and robotic-assisted myomectomy (RAM) are limited in the number and size of myomas that can be removed, whereas abdominal...
STUDY OBJECTIVE
Conventional laparoscopic myomectomy (CLM) and robotic-assisted myomectomy (RAM) are limited in the number and size of myomas that can be removed, whereas abdominal myomectomy (AM) is associated with increased complications and morbidity. Here we evaluated the surgical outcomes of these myomectomy techniques compared with those of laparoscopic-assisted myomectomy (LAM), a hybrid approach that combines laparoscopy and minilaparotomy with bilateral uterine artery occlusion or ligation to control blood loss.
DESIGN
Retrospective chart review (Canadian Task Force classification II-1).
SETTING
Suburban community hospital.
PATIENTS
Women age ≥18 years with nonmalignant indications.
INTERVENTION
A total of 1313 consecutive CLMs, RAMs, AMs, and LAMs performed between January 2011 and December 2013.
MEASUREMENTS AND MAIN RESULTS
Our review included 163 CLMs (12%), 156 RAMs (12%), 686 AMs (52%), and 308 LAMs (23%). Although the average number, size, and total weight of leiomyomas removed were comparable in the LAM and AM groups (9.1, 8.13 cm, and 391 g, respectively, vs 9.0, 7.5 cm, and 424 g; p < .0001), the number and weight of myomas were significantly greater in those 2 groups compared with the CLM and RAM groups (2.9 and 217 g, respectively, and 2.9 and 269 g; p < .0001). The intraoperative complication rate was highest in the RAM group, and the postoperative complication rate was highest in the AM group, both of which were approximately 3 times greater than the rates in the LAM group. There was no statistically significant difference in postoperative complication rates between the CLM and LAM groups.
CONCLUSION
LAM with uterine artery occlusion/ligation is a viable approach for removing large tumor loads while minimizing blood loss and precluding the need for power morcellation.
Topics: Adult; Electronic Health Records; Female; Humans; Intraoperative Complications; Laparoscopy; Laparotomy; Leiomyoma; Ligation; Middle Aged; Morcellation; Myoma; Postoperative Complications; Reproducibility of Results; Retrospective Studies; Therapeutic Occlusion; Uterine Artery; Uterine Myomectomy; Uterine Neoplasms
PubMed: 30170179
DOI: 10.1016/j.jmig.2018.08.016 -
In Vivo (Athens, Greece) 2019Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least... (Review)
Review
Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.
Topics: Animals; Disease Management; Evidence-Based Practice; Female; Humans; Incidence; Leiomyoma; Leiomyosarcoma; Minimally Invasive Surgical Procedures; Morcellation; Quality Improvement; Undiagnosed Diseases
PubMed: 31471384
DOI: 10.21873/invivo.11616 -
Ginekologia Polska 2018To estimate the incidence of occult uterine malignancies during laparoscopic supracervical hysterectomy (LSH).
OBJECTIVES
To estimate the incidence of occult uterine malignancies during laparoscopic supracervical hysterectomy (LSH).
MATERIAL AND METHODS
Retrospective cohort study based on archival data (2010-2016) of the Department of Gynecology and Oncology, Jagiellonian University.
RESULTS
Medical records of 696 women, who underwent LSH were analyzed. Two occult sarcomas (2/696; 0.29%, 0.003, 95% CI: 0.001 to 0.01), including one case of low-grade endometrial stromal sarcoma (ESS) with co-occurring atypical endometrial hyperplasia (AH) and one case of high-grade ESS were found postoperatively. One case of invasive primary fallopian tube cancer (1/696; 0.14%, 0.001, 95% CI: 0.00 to 0.008) and additional three cases of AH (3/696; 0.57%, 0.004, 95% CI: 0.001 to 0.013) were also identified. No case of EC was documented. One hundred sixty nine (24.3%) women of 696 had an endometrial sampling prior LSH including these with ESS. We did not observe worsening of the prognosis and all patients with confirmed malignancy are still alive and free from recurrence in 2-5 years of observations.
CONCLUSIONS
Most commonly the occult malignancy would have not been recognized if the surgery had not been conducted. When appropriate diagnostics is conducted, rare incidents of malignant tissue morcellation should not be considered as a professional misconduct but as a possible adverse event. Patients should be informed about the risk of malignancy according to available estimations and that endometrial sampling cannot eliminate such a risk. A consensus regarding safe indications, required diagnostics, and justifiability of mandatory use of contained morcellation for LSH should be developed.
Topics: Adult; Aged; Aged, 80 and over; Databases, Factual; Female; Humans; Hysterectomy; Incidence; Incidental Findings; Laparoscopy; Middle Aged; Poland; Prevalence; Prognosis; Retrospective Studies; Risk Factors; Time Factors; Uterine Neoplasms
PubMed: 30318572
DOI: 10.5603/GP.a2018.0080 -
Research and Reports in Urology 2016Multiple endoscopic surgical options exist to treat benign prostatic hyperplasia (BPH), including holmium laser enucleation of the prostate (HoLEP). HoLEP alleviates... (Review)
Review
BACKGROUND
Multiple endoscopic surgical options exist to treat benign prostatic hyperplasia (BPH), including holmium laser enucleation of the prostate (HoLEP). HoLEP alleviates obstructive prostatic tissue via enucleation, both bluntly with a resectoscope and by cutting tissue with the holmium laser, and removal of adenoma via morcellation. This article reviews patient selection for HoLEP in order to optimize outcomes, costs, and patient satisfaction.
METHODS
A literature review of all studies on HoLEP was conducted. Studies that focused on outcomes in regard to patient and procedural factors were closely reviewed and discussed.
RESULTS
Various studies found that men with large or small prostates, on antithrombotic therapy, in urinary retention, with bladder hypocontractility, with prostate cancer, undergoing retreatment for BPH, or in need of concomitant surgery for bladder stones and other pathologies do well with HoLEP, as demonstrated by excellent functional and symptomatic outcomes as well as low complication rates. There is a 74-78% rate of retrograde ejaculation following HoLEP. Techniques to preserve ejaculatory function following enucleative techniques have not been able to demonstrate a significant improvement.
CONCLUSION
Patient selection for HoLEP can include most men with bothersome BPH who have evidence of bladder outlet obstruction and are healthy enough to undergo surgery. The ability to safely perform concomitant surgery with HoLEP benefits the patient by sparing them an additional anesthetic and also decreases costs. Patients should be made aware of the risk of retrograde ejaculation following HoLEP and counseled on treatment alternatives if maintaining ejaculatory function is desired.
PubMed: 27800470
DOI: 10.2147/RRU.S100245