Benign Gynecology Research Articles

Approaches for hysterectomy and implementation of robot-assisted surgery in benign gynaecological disease: A cost analysis study in a large university hospital

BackgroundAs a minimally invasive technique, robot-assisted hysterectomy (RAH) offers surgical advantages and significant reduction in morbidity compared to open surgery. Despite the increasing use of RAH in benign gynaecology, there is limited data on its cost-effectiveness, especially in a European context. Our goal is to assess the costs of the different hysterectomy approaches, to describe their clinical outcomes, and to evaluate the impact of introduction of RAH on the rates of different types of hysterectomy. MethodsA retrospective single-centre cost-analysis was performed for patients undergoing a hysterectomy for benign indications. Abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), laparoscopically assisted vaginal hysterectomy (LAVH) and RAH were included. We considered the costs of operating room and hospital stay for the different hysterectomy techniques using the “Activity Centre–Care program model”. We report on intra- and postoperative complications for the different approaches as well as their cost relationship. ResultsBetween January 2014 and December 2021, 830 patients were operated; 67 underwent VH (8%), 108 LAVH (13%), 351 LH (42%), 148 RAH (18%) and 156 AH (19%).After the implementation and learning curve of a dedicated program for RAH in 2018, AH declined from 27.3% in 2014–2017, to 22.1% in 2018 and 6.9 % in 2019–2021.The reintervention rate was 3–4% for all surgical techniques. Pharmacological interventions and blood transfusions were performed after AH in 28%, and in 17–22% of the other approaches.AH had the highest hospital stay cost with an average of €2236.40. Mean cost of the hospital stay ranged from €1136.77-€1560.66 for minimally invasive techniques.The average total costs for RAH were €6528.10 compared to €4400.95 for AH. ConclusionImplementation of RAH resulted in a substantial decrease of open surgery rate. However, RAH remains the most expensive technique in our cohort, mainly due to high material and depreciation costs. Therefore, RAH should not be considered for every patient, but for those who would otherwise need more invasive surgery, with higher risk of complications. Future prospective studies should focus on the societal costs and patient reported outcomes, in order to do cost-benefit analysis and further evaluate the exact value of RAH in the current healthcare setting.

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study

Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste. This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries. This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital. A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01). Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.

Ultrasound Elastography in Benign Gynecology: A Scoping Review.

To perform a scoping review of the literature in which ultrasound elastography (UE) has been used in benign gynecology and identify avenues for its use in future research and clinical implementations. A structured search of EMBASE, Medline and Cochrane databases was conducted (last search date April 15th, 2022). Eligible studies included adult participants with female pelvic anatomy. English language papers focusing on the utility of ultrasound elastography applied to benign gynecology were included. Narrative reviews, conference abstracts, and letters to the editor were excluded. Two independent reviewers screened titles and abstracts for inclusion, a third reviewer was consulted in cases of disagreement. Study quality was assessed by a checklist for study implementation and elastography technique. Extracted data included elastography technology, gynecologic application, opportunities for clinical implementation, and strengths and limitations. The search returned 2026 studies. A total of 40 studies, published between 2013 and 2022, were retained for data extraction. Studies most frequently used shear wave elastography as the method of UE (n = 23), followed by strain elastography (n = 13) and acoustic radiation force impulse (n = 4). Most common clinical applications for UE were the diagnosis of adenomyosis and uterine fibroids (27.5%), assessment of pelvic floor muscle function (22.5%), and describing the elastic properties of polycystic ovaries (17.5%) and the uterine cervix (15.0%). Limitations of the technology were identified as the lack of published reference values for gynecologic organs and difficulties in assessing tissues deep to the transducer. Future research is needed to validate the use of ultrasound elastography in gynecology under both normal and pathologic conditions.

Impact of Health Literacy on Patient-Reported Outcomes in Benign Gynecology: A Systematic Review.

The objective of this study was to systematically review the relationship between low health literacy and patient-reported outcomes in patients with benign gynecologic conditions. In this specific population, we also sought to determine the current reported prevalence of low health literacy, examine demographic characteristics that may be related to low health literacy, and collate any health literacy interventions described in the literature. A systematic search of MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, The Cochrane Library, Web of Science, PubMed, and clinicaltrials.gov was performed on July 12, 2021, and repeated on October 13, 2023, for terms related to health literacy, specific health literacy measures, and benign gynecologic conditions. There were language or publication period restrictions. Inclusion required primary literature to report associations between health literacy and patient-reported outcomes, using validated tools to quantitatively measure each, in adult women with benign gynecologic conditions. Title screening, abstract screening, and full-text review were conducted with Covidence software (Melbourne, Australia) assisting with the review process. Of the 18,701 studies returned using our search strategy, 25 were selected for full-text review. Of these, no studies met inclusion criteria and reported an association between health literacy and patient-reported outcomes. This study identified a large gap in the literature. Future work should be directed at evaluating the association between health literacy and patient-reported outcomes in benign gynecology to inform patient-centered interventions and care provision.

Robotic-assisted Versus Conventional Laparoscopic Hysterectomy for Benign Gynecological Conditions: A Systematic Review and Meta-analysis.

Minimally invasive gynecologic surgery is safe and feasible procedure for benign gynaecological conditions with less morbidity. To determine the best approach in benign gynecology and establish superiority of robotic over conventional laparoscopic hysterectomy in terms of safety and effectiveness. Search strategy: Electronic databases: MEDLINE, Embase, CENTRAL (the Registry of Controlled Clinical Studies of the Cochrane Collaboration), Google scholar, Pubmed and Scopus were searched from 2010-2022. Selection criteria: All randomized controlled trials and quasi-randomised trials which compared robotic versus conventional laparoscopic hysterectomy were included to conduct this systematic review and meta-analysis to investigate compared to traditional approaches. Only five RCTs (326 patients in total) comparing robotic and conventional laparoscopic hysterectomy were included after a comprehensive literature search. Results of our analysis showed no clear benefit in any of the two techniques in operating time, estimated blood loss, length of hospital stay and overall complications. This systematic review suggests no statistical difference in surgical and patient outcomes between robotic and conventional laparoscopic hysterectomy relating to OT, EBL, LOHS, overall complications, and survival.

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study

Socioeconomic factors influence surgical wait times for non-emergent gynecologic surgical procedures: a retrospective analysis

BackgroundIn various disciplines, an association between surgical wait times and patient outcomes has been identified. This study is among the first to investigate whether practice setting influences wait times for elective surgeries in benign gynecology.MethodsThis retrospective study of patients at three New York hospitals from 10/2019–2/2020 compared surgical wait times among patients seen in federally-qualified health centers (FQHC’s) and private practice settings. Emergent surgeries, oncology cases, abortions, urogynecology procedures, and cases concurrently booked with another specialty were excluded. Surgical wait time was defined as the time (days) from the decision to operate to the day of the procedure. A multivariable mixed model was used to model surgical wait time by setting of care, adjusting for age, BMI, race, ethnicity, insurance, need for medical clearance, and scheduled block time. A univariable analysis was then utilized to assess surgical wait times by clinical setting for each insurance type.ResultsFive hundred forty patients were identified with a median age of 45.6 years (range 16–87). Average surgical wait time was 27 days (range 1–288 days). In multivariable analysis, longer surgical wait times were associated with being seen preoperatively in a FQHC compared to the private practice setting (102% longer, 59.5 days vs. 22 days, p < 0.0001), and with needing medical clearance (56.4% longer, 45 days vs. 22 days. p = 0.0001).ConclusionsThese results suggest that in benign gynecology, surgical wait times are significantly influenced by the practice setting in which a patient gets care, with notable delays in care among patients who are seen in a federally qualified health center preoperatively.

Attitudes About the Human Papillomavirus Vaccine Among Patients With and Without Cervical Dysplasia.

The aims of the study are to examine the perception of the human papillomavirus (HPV) vaccine among those with and without a history of cervical dysplasia and to examine perceptions of the vaccine for their children. Patients were recruited to complete a survey about the HPV vaccine for both themselves and their children. Patients in a colposcopy clinic with a history of abnormal cervical cytology and patients in a benign gynecology clinic without a history of abnormal cervical cytology were recruited. Participants' medical records were reviewed. Demographics and survey answers were described, and Fisher exact test was used to compare the groups. One hundred eighty-three patients participated: 73 in colposcopy clinic and 110 in benign clinic. The majority self-identified as Black (74% colposcopy, 71% benign, p = .588) and reported an income less than $39,000 a year (77% colposcopy, 65% benign, p = .089). Fifty-six percent in benign clinic agreed the HPV vaccine is a good way to protect oneself from disease compared with 48% in colposcopy clinic ( p = .022). When examining results based on cytology, fewer patients in the highest-grade cytology group agreed the vaccine was effective (30% high-grade, 48% normal, 57% low-grade, p = .027) or a good way to protect themselves from disease (29% high-grade, 53% normal, 62% low-grade, p = .002). There was otherwise no statistically significant difference between the groups on questions regarding self or child vaccination. In a majority Black, low-income population, patients without a history of abnormal cervical cytology have more favorable perceptions of the HPV vaccine's effectiveness in preventing disease. Those with the highest-grade cytology had more negative perceptions of the vaccine's effectiveness and protectability.

9756 Excess Use of Surgical Supplies in Minimally Invasive Benign Gynecology Surgery: An Observational Study

9756 Excess Use of Surgical Supplies in Minimally Invasive Benign Gynecology Surgery: An Observational Study

New Role of Indocyanine Green (ICG) in Benign Gynecology Surgery

New Role of Indocyanine Green (ICG) in Benign Gynecology Surgery

Strategies and factors to maximize cost-effectiveness of robotic surgery in benign gynecological disease.

Operating room procedures account for half of the gross hospital cost in the United States per annum. Hysterectomy is the eighth most common surgery nationally, with more than 300,000 cases every year. Since the introduction of robotic surgery in benign gynecology, concern has been raised regarding the increased cost without significant improvements in outcomes or practice. Surgeon volume, complication rates, length of hospital stay, and selected intraoperative instrumentation are all factors that have a direct effect on cost in robotic surgery. Cost is indirectly influenced by the OR team workflow, postoperative processes to expedite discharge, and converting surgery to the ambulatory setting. More research is needed to develop evidence-based practices for cost containment in robotic surgery.

Robotic surgery in obstetrics and gynecology: a bibliometric study.

We aimed to identify the trends and patterns of robotic surgery research in obstetrics and gynecology since its implementation. We used data from Clarivate's Web of Science platform to identify all articles published on robotic surgery in obstetrics and gynecology. A total of 838 publications were included in the analysis. Of these, 485 (57.9%) were from North America and 281 (26.0%) from Europe. 788 (94.0%) articles originated in high-income countries and none from low-income countries. The number of publications per year reached a peak of 69 articles in 2014. The subject of 344 (41.1%) of articles was gynecologic oncology, followed by benign gynecology (n = 176, 21.0%) and urogynecology (n = 156, 18.6%). Articles discussing gynecologic oncology had lower representation in low- and middle-income countries (LMIC) (32.0% vs. 41.6%, p < 0.001) compared with high income countries. After 2015 there has been a higher representation of publications from Asia (19.7% vs. 7.7%) and from LMIC (8.4% vs. 2.6%), compared to the preceding years. In a multivariable regression analysis, journal's impact factor [aOR 95% CI 1.30 (1.16-1.41)], gynecologic oncology subject [aOR 95% CI 1.73 (1.06-2.81)] and randomized controlled trials [aOR 95% CI 3.67 (1.47-9.16)] were associated with higher number of citations per year. In conclusion, robotic surgery research in obstetrics & gynecology is dominated by research in gynecologic oncology and reached a peak nearly a decade ago. The disparity in the quantity and quality of robotic research between high income countries and LMIC raises concerns regarding the access of the latter to high quality healthcare resources such as robotic surgery.

Surgical outcomes and cost analysis of a multi-specialty robotic-assisted surgery caseload in the Australian public health system.

This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches.

Artificial intelligence: Friend or foe?

Artificial intelligence: Friend or foe?

Definition and Criteria for Diagnosing Cesarean Scar Disorder

Approximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms. To achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition. A consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022. Definition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche. In total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis. In this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.

Individualized medicine using 3D printing technology in gynecology: a scoping review

ObjectiveDevelopments in 3-dimensional (3D) printing technology has made it possible to produce high quality, affordable 3D printed models for use in medicine. As a result, there is a growing assessment of this approach being published in the medical literature. The objective of this study was to outline the clinical applications of individualized 3D printing in gynecology through a scoping review.Data sourcesFour medical databases (Medline, Embase, Cochrane CENTRAL, Scopus) and grey literature were searched for publications meeting eligibility criteria up to 31 May 2021.Study eligibility criteriaPublications were included if they were published in English, had a gynecologic context, and involved production of patient specific 3D printed product(s).Study appraisal and synthesis methodsStudies were manually screened and assessed for eligibility by two independent reviewers and data were extracted using pre-established criteria using Covidence software.ResultsOverall, 32 studies (15 abstracts,17 full text articles) were included in the scoping review. Most studies were either case reports (12/32,38%) or case series (15/32,47%). Gynecologic sub-specialties in which the 3D printed models were intended for use included: gynecologic oncology (21/32,66%), benign gynecology (6/32,19%), pediatrics (2/32,6%), urogynecology (2/32,6%) and reproductive endocrinology and infertility (1/32,3%). Twenty studies (63%) printed 5 or less models, 6/32 studies (19%) printed greater than 5 (up to 50 models). Types of 3D models printed included: anatomical models (11/32,34%), medical devices, (2/32,6%) and template/guide/cylindrical applicators for brachytherapy (19/32,59%).ConclusionsOur scoping review has outlined novel clinical applications for individualized 3D printed models in gynecology. To date, they have mainly been used for production of patient specific 3D printed brachytherapy guides/applicators in patients with gynecologic cancer. However, individualized 3D printing shows great promise for utility in surgical planning, surgical education, and production of patient specific devices, across gynecologic subspecialties. Evidence supporting the clinical value of individualized 3D printing in gynecology is limited by studies with small sample size and non-standardized reporting, which should be the focus of future studies.

Benign Gynecology

Benign Gynecology

Uses of indocyanine green in benign gynecology

Uses of indocyanine green in benign gynecology

Indocyanine Green tattooing for marking the caudal excision margin of a full-thickness vaginal endometriotic nodule

The use of Indocyanine Green (ICG) is well-described in oncology and more recently in benign gynaecological surgery. In this article we describe submucosal transvaginal ICG infiltration caudal to a vaginal endometriotic nodule to visualise the lower margin of excision laparoscopically. To demonstrates the use of submucosal ICG tattooing to mark and delineate the caudal margin of an ultra-low full thickness vaginal nodule and aid its excision laparoscopically. A stepwise approach highlighting the "SOSURE" surgical technique for the excision of endometriosis and the practical use of the ICG to delineate the lowest margin of the full thickness vaginal nodule. Laparoscopic complete excision of a 5 cm full-thickness vaginal nodule invading the right parametrium and involving the superficial muscularis layer of the rectum. ICG tattooing was helpful in identifying the lower margin of dissection of the rectovaginal space. ICG tattooing of the margins of full-thickness vaginal nodules could be another use of ICG in benign gynaecology to complement the surgeon's tactile and visual identification of the lower edge of dissection.

Factors Associated With Increased Estimated Blood Loss and Factors Associated With Utilization of Type and Screen in Benign Gynecology: A Retrospective Chart Review.

There is minimal literature discussing factors associated with increased estimated blood loss (EBL) or transfusion in gynecologic surgery in tertiary academic centers. The aim of the study was to determine factors associated with transfusion and increased blood loss during gynecologic surgery. This retrospective cohort investigated patients undergoing benign gynecologic procedures at a tertiary medical center. We excluded women undergoing surgery for known or suspected malignancy, emergent surgery, obstetrical procedures, or cases with another surgical specialty. Patient age, body mass index, American Society of Anesthesiologists class, medical history, EBL, arterial line placement, preoperative laboratory studies, and transfusion receipt for up to 6 weeks postoperatively were extracted. The primary outcome was transfusion within 6 weeks of surgery; risk factors for high blood loss (EBL >500 mL) and transfusion were explored. Nine hundred seventy-five surgical procedures were included (59% vaginal, 36% laparoscopic, 4% robotic). Median EBL was 50 mL (interquartile range, 10-100 mL). Estimated blood loss increased with duration of surgery (P < 0.01). Transfusions were more likely to occur during open procedures (13%) compared with vaginal (2%), laparoscopic (2%), or robotic (3%). Arterial line placement (relative risk [RR], 11.8; 95% confidence interval [CI], 5.3-26.1) and additional intravenous placement (RR, 6.0; 95% CI, 2.6 to 13.7) were associated with transfusion. Vaginal surgery (RR, 0.13; 95% CI, 0.05 to 0.32) and urogynecologic procedures (RR, 0.1; CI, 0.01-0.7) were associated with reduced risk of needing transfusion. Most benign gynecologic surgical procedures have minimal blood loss. Patients undergoing surgery through minimally invasive routes or urogynecologic procedures are at further decreased risk of transfusion.