Benign Gynecology Research Articles

Simplified Laparoscopic Sacrohysteropexy

Study ObjectiveTo demonstrate a simplified technique of performing laparoscopic sacrohysteropexy for uterine prolapse. DesignA technical video demonstrating a simplified method of laparoscopic sacrohysteropexy (Canadian Task force classification level III). SettingThe benign gynecology department at a university hospital. InterventionsA 38-year old woman with grade 3 uterine descent presented requesting surgical management for symptomatic prolapse. ConclusionLaparoscopic sacrohysteropexy is becoming an increasingly popular alternative to hysterectomy to treat uterine prolapse in women. We present a novel approach of performing laparoscopic sacrohysteropexy that differs from previously described methods [1,2]; it is shorter, simpler, and reduces possible complications. Key differences include the mesh type, site of attachment, and dissection of the peritoneum while creating the possibility of future vaginal delivery after pregnancy. Our simplified technique uses a polyvinylidene fluoride mesh woven with a square weave secured to the posterior aspect of the cervix under a layer of visceral peritoneum. Because there is no longitudinal give of the mesh, unlike polypropylene meshes with a diamond weave, a wrap method [2] is not required. No dissection of the broad ligament and bladder is needed, eliminating the risk of bladder perforation and anterior mesh erosion with fewer adhesions and simplifying hysterectomy if required in the future. We also uniquely “tunnel” the peritoneum, reducing the size of defect for suture closure, and reperitonize the mesh. Previous methods restrict cervical dilatation and require women to have cesarean sections. The method described in the video allows women to deliver vaginally and, in the event of late miscarriage, avoid the need for hysterotomy. We have performed 25 cases with 1 mild cystocoele recurrence requiring no surgery, 1 reoperation for posterior compartment repair, and 1 case of cervical elongation requiring Manchester repair. No cases of recurrent uterine prolapse have occurred.

Nurse Led Follow Up: Is It The Best Way Forward for Post-Operative Endometriosis Patients?

The benefits of nurse led follow-up are well documented in the wider literature and include higher patient satisfaction rates, improved information delivery and quicker discharge rates. Unfortunately there is a paucity of data when it comes to benign gynaecology and the aim of this study was to establish the efficacy of outpatient services offered by an endometriosis specialist nurse compared to standard medical follow up in women undergoing operative laparoscopy for severe endometriosis. Outcome measures included both patient satisfaction and the duration of follow-up until discharge. Our findings highlight that a nurse led service is highly acceptable to patients and leads not only to higher satisfaction rates, but also a reduced duration of follow-up resulting in a significantly more cost effective service without any detriment to the patient.

69 - One Institute Experience of Robotic Single-Site Surgery: 500 Cases in Benign Gynecology

69 - One Institute Experience of Robotic Single-Site Surgery: 500 Cases in Benign Gynecology

Core outcome sets in women's and newborn health: a systematic review.

Variation in outcome collection and reporting is a serious hindrance to progress in our specialty; therefore, over 80 journals have come together to support the development, dissemination, and implementation of core outcome sets. This study systematically reviewed and characterised registered, progressing, or completed core outcome sets relevant to women's and newborn health. Systematic search using the Core Outcome Measures in Effectiveness Trial initiative and the Core Outcomes in Women's and Newborn Health initiative databases. Registry entries, protocols, systematic reviews, and core outcome sets. Descriptive statistics to describe characteristics and results. There were 49 core outcome sets registered in maternal and newborn health, with the majority registered in 2015 (n=22; 48%) or 2016 (n=16; 32%). Benign gynaecology (n=8; 16%) and newborn health (n=3; 6%) are currently under-represented. Twenty-four (52%) core outcome sets were funded by international (n=1; <1%), national (n=18; 38%), and regional (n=4; 8%) bodies. Seven protocols were published. Twenty systematic reviews have characterised the inconsistency in outcome reporting across a broad range of relevant healthcare conditions. Four core outcome sets were completed: reconstructive breast surgery (11 outcomes), preterm birth (13 outcomes), epilepsy in pregnancy (29 outcomes), and maternity care (48 outcomes). The quantitative, qualitative, and consensus methods used to develop core outcome sets varied considerably. Core outcome sets are currently being developed across women's and newborn health, although coverage of topics is variable. Development of further infrastructure to develop, disseminate, and implement core outcome sets is urgently required. Forty-nine women's and newborn core outcome sets registered. 50% funded. 7 protocols, 20 systematic reviews, and 4 core outcome sets published. @coreoutcomes @jamesmnduffy.

Reducing research waste in benign gynaecology and fertility research.

Reducing research waste in benign gynaecology and fertility research.

Risk Factors and Outcomes for Conversion to Laparotomy of Laparoscopic Hysterectomy in Benign Gynecology.

To estimate the incidence and factors for conversion to laparotomy in women scheduled for laparoscopic hysterectomy for benign gynecologic indications and to examine the effect of conversion on patient outcomes. A retrospective cohort study of a Michigan multicenter prospective database was abstracted from January 1, 2013, through July 2, 2014. Participants were collected from an all-payer quality and safety database maintained by the Michigan Surgical Quality Collaborative. Women with a preoperative indication of cancer or obstetric indications were excluded. A logistic regression model was used to calculate odds of conversion using patient preoperative and intraoperative attributes. During the study period, 6,992 women underwent an attempted laparoscopic hysterectomy with 3.93% (n=275) converted to laparotomy. After adjusting for socioeconomic differences, hysterectomy indication, and intraoperative factors, there were decreased odds of conversion to laparotomy with use of robotic-assisted laparoscopy compared with traditional laparoscopy (adjusted odds ratio [OR] 0.14, 95% confidence interval [CI] 0.07-0.25) with a predicted risk of conversion of 0.8% compared with 5.4% (P<.001). High-volume surgeons were less likely to convert to laparotomy compared with low- and medium-volume surgeons (adjusted OR 0.66, 95% CI 0.47-0.92) with a predicted risk of conversion of 1.4% compared with 2.25% (P=.015). Conversion was associated with moderate or severe adhesive disease and increasing specimen weight. Conversion was associated with increased rates of surgical site infection, blood transfusion, severe sepsis, and reoperation. This analysis demonstrates that conversion to laparotomy is associated with increased odds of postoperative morbidity, and robotic assistance and surgeon volume are strongly associated with decreased odds of conversion.

Postoperative Pain Management in Benign Laparoscopic Gynecologic Surgery: A Systematic Review

Our primary objective was to determine if there is enough evidence within the benign gynecology literature to make recommendations for postoperative pain control that can be used specifically in patients undergoing minimally invasive benign hysterectomies.

Exploring the Benefits of Robotic Surgery in the Management of Severe Endometriosis

Robotic surgery has not been shown to be superior to laparoscopy in benign gynaecology conditions, including in endometriosis, which is often an underdiagnosed or a misdiagnosed condition. Our patient is a 41 yo G3P2 woman with persistent pelvic pain despite vaginal hysterectomy, who presented with an endometrioma and severe endometriosis. This video demonstrates the application of robotic surgery in severe and deep infiltrating endometriosis, in terms of its specific characteristics and benefits. There may be many additional advantages to using robotic-assisted laparoscopy in the surgical management of severe endometriosis, compared to traditional laparoscopy.

Advantages of robotics in benign gynecologic surgery.

The purpose of this article is to review the literature and discuss the advantages of robotics in benign gynecologic surgery. Minimally invasive surgery has become the preferred route over abdominal surgery. The laparoscopic or robotic approach is recommended when vaginal surgery is not feasible. Thus far, robotic gynecologic surgery data have demonstrated feasibility, safety, and equivalent clinical outcomes in comparison with laparoscopy and better clinical outcomes compared with laparotomy. Robotics was developed to overcome challenges of laparoscopy and has led to technological advantages such as improved ergonomics, visualization with three-dimensional capabilities, dexterity and range of motion with instrument articulation, and tremor filtration. To date, applications of robotics in benign gynecology include hysterectomy, myomectomy, endometriosis surgery, sacrocolpopexy, adnexal surgery, tubal reanastomosis, and cerclage. Though further data are needed, robotics may provide additional benefits over other approaches in the obese patient population and in higher complexity cases. Challenges that arose in the earlier adoption stage such as the steep learning curve, costs, and operative times are becoming more optimized with greater experience, with implementation of robotics in high-volume centers and with improved training of surgeons and robotic teams. Robotic laparoendoscopic single-site surgery, albeit still in its infancy where technical advantages compared with laparoscopic single-site surgery are still unclear, may provide a cost-reducing option compared with multiport robotics. The cost may even approach that of laparoscopy while still conferring similar perioperative outcomes. Advances in robotic technology such as the single-site platform and telesurgery, have the potential to revolutionize the field of minimally invasive gynecologic surgery. Higher quality evidence is needed to determine the advantages and disadvantages of robotic surgery in benign gynecologic surgery. Conclusions on the benefits and risks of robotic surgery should be made with caution given limited data, especially when compared with other routes. Route of surgery selection should take into consideration the surgeons' skill and comfort level that allows for the highest level of safety and efficiency. Ultimately, the robotic device is an additional minimally invasive surgical tool that can further the goal of minimizing laparotomy in gynecology.

Centres that do not offer TLH as their primary method of hysterectomy should be considered outdated and not Fit for Purpose: AGAINST: To allow one their informed choice may mean others have no choice at all.

The delivery of a laparoscopic hysterectomy service presents many challenges, not all of which can be met by every centre. The availability of appropriately trained doctors is limited by access to Advanced Training Skills Modules (ATSMs) in Benign Gynaecology and Advanced Laparoscopy, which not all consultants have yet undertaken. In addition to the doctors, theatre personnel who know how to use and maintain the equipment are also essential. Affordability is another factor given that laparoscopic hysterectomies use more consumables and operative time. Training has a long learning curve and time taken to complete surgery can be many hours per case. Most health economic arguments that support this approach assume that all operators are equally skilled and take similar operative time, when we know that not to be true. Operative time is a finite and expensive resource, and targets from referral to definitive management currently drive the service more than quality-of-life outcomes. They also assume that all patients who have laparoscopic surgery only stay for 1 day. Remuneration is not the same across all institutions. Currently the tariff for laparoscopic hysterectomy is lower than for open hysterectomy. They also do not account for the cost of acquisition, amortisation, and maintenance, nor for the cost of higher complication rates, both in terms of re-operations and prolonged stays in hospital. As the surgical techniques are refined, the cases for which they are advocated increase in both number and complexity, with a commensurate increase in the equipment required delivering it. With time the cost of delivery can only rise. All these factors make affordability a major issue in most centres. The patient's anatomy, performance status, and pathology of the condition to be managed also have an influence. Treatments such as the intrauterine system (IUS), endometrial ablation, and hysteroscopic surgery means that hysterectomy is reserved for more challenging pathology, such as fibroids and endometriosis. Sometimes an open approach is intrinsically safer. It is no longer acceptable to reduce a fibroid in size in order to aid its removal because of the risk of disseminating previously unrecognised cancer. The US Food and Drug Administration (FDA) estimates this risk to be 1/350, and although this figure is debated, it would be a foolhardy surgeon that ignores it. Thus a fibroid that obstructs safe access to the uterine vessels, pelvic sidewall or cannot be removed intact is not suitable. Only surgeons trained in advanced laparoscopic techniques can manage rectosigmoid disease and dense adhesions safely. Advanced ovarian cancer will usually require an open approach. The needs and priorities of health care vary widely in resource-rich and resource-poor countries. The quality-of-life outcomes have little relevance when maternal and perinatal mortality is high. Training in these countries is quite appropriately focused on the improvement of maternity care. The supply of basics such as sutures, swabs, and an electrical supply are more pressing matters than the ability to deliver complex minimal-access surgery. In a state-provided service, the needs of the population supersede those of the individual. Thus an individual patient's ‘rights’ should be seen within the context of safety and affordability. To allow one their informed choice may mean others have no choice at all. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Cancer, Benign Gynecology, and Sexual Function--Issues and Answers.

The diagnosis, treatment, and survivorship of cancer have a profound effect on the quality of lifeand psychological well-being of men and women. Indeed, the perturbation of sexual function because of neoplasm has far-reaching implications. To explore the prevalence, pathophysiology, and treatment of sexual issues in persons with cancer and offer evidence-based recommendations regarding optimal prevention and treatment strategies. A committee of multidisciplinary specialists was formed as part of the larger International Sexual Medicine Consultation working with urologic and sexual medicine societies over a 1-year period to review the result of chronic-illness management on sexual function and satisfaction. The aims, goals, data collection techniques, and report format were defined by a central committee. Expert consensus was based on evidence-based medical and psychosocial literature review, extensive group discussion, and an open presentation with a substantial discussion period. This summary evaluates contemporary literature concerning the prevalence, pathophysiology, and psychological impact of cancer diagnosis and treatment on sexual dysfunction. Evidence-based recommendations and guidelines for evaluation and management are presented. The diagnosis and treatment of cancer have a significant negative impact on sexual function and satisfaction. Comprehension of baseline sexual function, role of psychological supports, and available treatment options could attenuate the heavy burden of decreased sexual function.

Association Between Patient's BMI and Uterine Weight With Feasibility of Single-Port Robotic-Assisted Surgery in Benign Gynecology.

Association Between Patient's BMI and Uterine Weight With Feasibility of Single-Port Robotic-Assisted Surgery in Benign Gynecology.

Increased Continuity Improves Medical Student Clerkship Evaluations and Enhances Recruitment

Methods: In 2012, the OBGYN clerkship was restructured such that all students spent two weeks on labor and delivery, and two weeks on two of the other specialty services of benign gynecology, gynecologic oncology, MFM, minimally invasive surgery, REI, and urogynecology. Each student was also assigned two continuity generalist providers clinics for 1⁄2 day per week. Prior to 2012, each student had spent one week on each of the specialty services, and was assigned one continuity generalist provider for 1⁄2 day per week. Student performance on the National Board of Medical Examiners (NMBE) exam, and response on the clerkship evaluation questions “overall quality of clerkship” and “quality of ambulatory care experiences” for the two years prior and after the restructuring were compared using paired t-tests. The percent of the medical school class who matched in OBGYN for the two years prior and after were compared using chai square analysis.

Minimally Invasive Surgery in Gynecology: Underutilized?

Minimally invasive gynecologic surgery encompasses vaginal, laparoscopic, and robotic-assisted surgery. In this review, we highlight the current use of laparoscopic and robotic-assisted surgery in benign and oncologic gynecology and explore whether utilization is optimal. Given the many benefits associated with minimally invasive surgery, including fewer perioperative complications, less blood loss, and faster recovery times, it is critical to offer as many gynecologic surgery patients as possible a minimally invasive approach.

To morcellate or not to morcellate – is that the question?

The row over morcellation of apparently benign tissue has generated understandable concern from patients whose previously undiagnosed sarcomas have been upstaged to Stage 4 as a result of being spread about the peritoneum to facilitate the removal of their fibroids (www.change.org/petitions/women-s-health-alert-deadly). The concern of the oncological establishment to defend minimally invasive surgery is also understandable (Goff BA, Lancet Oncol 2014;15:e148), but how should they deal with the proposition that “Guidelines should err on the side of caution where hazards are reported”? (Editorial, Lancet Oncol 2014;15:123). The problem facing patients is that large fibroids and ovarian cysts cannot be removed through 1 cm incisions. If they opt for open surgery their funder must pay more, they must accept longer recovery, larger scars and greater risks of adhesion-related pain. In the present state of the art, doctors cannot confidently exclude sarcomas pre-operatively. They may be more suspicious where the fibroid first presents perimenopausally (Reed N, Curr Oncol Rep 2013;15:581–7) and expands rapidly, causing pain or abnormal bleeding, especially with cystic spaces on imaging. In the hands of sub-specialists the risk must be much less than the headline figures based on simple incidence suggest, but it cannot be excluded. The properly counselled woman has no easy options. If the problem is presented in overly cautious terms, some women under 30 with no risk factors will sensibly decide that their symptoms are not so severe that they wish to accept the adhesion pain and the scar associated with open surgery and will choose to grin and bear it. Most benign gynaecology is carried out to relieve symptoms. A very few of women will thereby avoid the morcellator upstaging of their leiomyosarcoma. Unfortunately, most of them will re-present when their malignant condition has progressed due to the natural history of the disease. If the advice they were given erred on the side of caution, they may have cause for complaint, as will their sisters presenting for repeated unsuccessful adhesiolysis. Some may be offered treatment by embolisation or MRI-focused ultrasound. Is that good therapy for fibroids with lurking sarcomas? Nobody knows: some sarcomas have presented after such treatment, but how many have been infarcted and cured? I have three suggestions: None.

Global women's health: current clinical trials in low- and middle-income countries.

Clinical trials in low- and middle-income countries (LMICs) are necessary to develop evidence-based approaches to improve women's health. Understanding what research is currently being conducted will allow the identification of research gaps, avoidance of duplication, planning of future studies, collaboration amongst research groups, and geographical targeting for research investments. To provide an overview of active women's health trials in LMICs. The World Health Organization's International Clinical Trials Registry Platform was searched for trials registered between 1 April 2012 and 31 March 2014. Selected trials were randomised, conducted in LMICs, active, and with a women's health intervention or a significant outcome for the woman. Two reviewers extracted data. Analysis included geographical spread, speciality areas, pre-enrolment registration, study size, and funders. Of the 8966 records, 509 were eligible for inclusion. Gynaecology trials made up 57% of the research, whereas the remaining 43% of trials were in obstetrics. Research activity focused on fertility (17%), the antenatal period (15%), benign gynaecology (14%), intrapartum care (9%), and pre-invasive disease and cancers (8%). The majority of trials (84%) took place in middle-income countries (MICs). In low-income countries (LICs) 83% of research investigated obstetrics, and in MICs 60% of research investigated gynaecology. Most trials (80%) had a sample size of 500 or fewer participants. The median size of trials in LICs was 815 compared with 128 in MICs. Pre-enrolment registration occurred in 54% of trials. The majority (62%) of trials were funded locally. Many LMICs are active in women's health research. The majority of registered trials are located in MICs; however, the trials in LICs are often larger. The focus of research in MICs may be driven by local priorities and funding, with fertility being highly researched. In LICs, pregnancy is the focus, perhaps reflecting the international prioritisation of maternal health.

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

The emergency room at the Rotunda Hospital: evidence of an improving service over the past 3 years.

This is a retrospective review of the Rotunda Hospital Emergency Room (ER) documentation with respect to attendances for a 4-month period (August-November) in both 2009 and 2012. The aim was to quantify the workload and assess the quality of care offered to patients attending the ER over the two time periods and to highlight any improvements in care after changes were implemented following the initial 2009 review. This study was done comparing the ER patient attendances over two time periods (1st August 2009 to 30th November 2009 and same period in 2012). SPSS version 20 was used to make statistical analysis along with simple percentage calculation. Comparing the two time frames, a decrease in the number of antenatal patients attending ER was seen (p < 0.001) [7,128 (91.0 %) in 2009 and 6,890 (89.4 %) in 2012], waiting times fell (p < 0.001) [4,351 (55.5 %) in 2009 seen within 2 h and 5,855 (76.2 %) in 2012], less women left ER without being seen (p < 0.001) [151 (1.9 %) in 2009 and 119 (1.5 %) in 2012] and record keeping regarding outcome of attendances improved (p < 0.001) [465 cases (5.9 %) in 2009 not recorded and 259 (3.3 %) in 2012]. The improvements noted may be due to establishment of an early pregnancy assessment unit facility and changes in ER staffing. Two registrars being on-call rather than one registrar. Increased numbers of gynaecology patients (p < 0.001) [334 (4.3 %) in 2009 and 463 (6 %) in 2012] were seen, most likely due to changes in benign gynaecology services in north Dublin. All the comparisons were statistically significant.

Cytological follow-up after hysterectomy: is vaginal vault cytology sampling a clinical governance problem? The University Hospital of North Staffordshire approach.

Vaginal vault cytology sampling following hysterectomy is recommended for specific indications in national guidelines. However, clinical governance issues surround compliance with guidance. Our first study objective was to quantify how many patients undergoing hysterectomy at the University Hospital of North Staffordshire (UHNS) had vault cytology advice in their histology report and, if indicated, whether it was arranged. The second was to devise a vault cytology protocol based on local experience and national guidance. The local cancer registry was searched. Clinical, clerical and histological data for all patients undergoing hysterectomy were collected. In total, 271 patients were identified from both the gynae-oncology and benign gynaecology teams. Of these, 24% (65/271) were gynae-oncology patients with a mean age of 69years. The benign gynaecology team had 76% (206/271) of patients with a mean age of 55years. Subsequently, 94% (256/271) had cytology follow-up advice in their histopathology report. Ultimately, from both cohorts, 39% (18/46) had follow-up cytology performed when indicated. A high proportion of cases complied with national guidance. However, a disappointingly high number did not have vault cytology sampling when this was indicated. This is probably a result of the complex guidance that is misunderstood in both primary and secondary care. Vault follow-up of patients after hysterectomy rests with the team performing the surgery. Vault cytology, if indicated, should be performed in secondary care and follow-up should be planned. The protocol set out in this article should be followed to avoid unnecessary clinical governance failings.

The debate over robotics in benign gynecology

The debate over the role of the da Vinci surgical robotic platform in benign gynecology is raging with increasing fervor and, as product liability issues arise, greater financial stakes. Although the best currently available science suggests that, in the hands of experts, robotics offers little in surgical advantage over laparoscopy, at increased expense, the observed decrease in laparotomy for hysterectomy is almost certainly, at least in part, attributable to the availability of the robot. In this author's opinion, the issue is not whether the robot has any role but rather to define the role in an institutional environment that also supports the safe use of vaginal and laparoscopic approaches in an integrated minimally invasive surgery program. Programs engaging robotic surgery should have a clear and self-determined regulatory process and should resist pressures in place that may preferentially support robotics over other forms of minimally invasive surgery.