Gynecologic Surgeons Research Articles

The role of gender bias in patient ratings of minimally invasive gynecologic surgeons

The role of gender bias in patient ratings of minimally invasive gynecologic surgeons

Consensus on surgical technique for sentinel lymph node dissection in cervical cancer

ObjectiveThe purpose of this study was to establish a consensus on the surgical technique for sentinel lymph node (SLN) dissection in cervical cancer.MethodsA 26 question survey was emailed to international...

The Visual Effect of a Down-Regulation With Dienogest and GnRH Analogues in Endometriosis: Lessons Learned From Two-Step Surgical Approach

ObjectiveTo evaluate the intraoperative visual effect of treatment with GnRH-analogues and Dienogest in endometriosis. DesignRetrospective observational study. SettingEvery laparoscopy from all the different disciplines in our hospital is documented on video and stored in a database. The study was approved by the local ethics committee. A total of 193 patients with histological proven endometriosis from 2007 to 2021 were included, who underwent 2-step surgical procedure. Indications were endometrioma before CO2-Laser therapy, missing consent because of emergencies or other surgeries from other disciplines, or high active and extended disease. When endometriosis was suspected in a surgery conducted by other disciplines, a gynecological surgeon was called during the surgery. Data and intraoperative videos were reviewed by 2 independent reviewers at one referral center. Only cases with available video of first and second look laparoscopy were included. We excluded patient who had prior hormonal treatment in the last 6 months. Lesions were classified according to the description of Khan et al. Statistical analysis was performed using SPSS (Version 27.0, IBM). Mann-Whitney U test (nonparametric analysis) and χ2 tests were applied. Percentages were calculated for categorical variables and mean and standard deviation were calculated for continuous variables. Significance level was set to p <.05. InterventionsSeventy-seven received GnRH-analogues and 116 Dienogest for preoperative hormone down-regulation. The median duration of down-regulation with GnRH-analogues or Dienogest was 3 months. The mean age was 32.3 (SD 6.3) years for GnRH-analogues and 32.6 (SD 6.3) years for Dienogest, p = .619 respectively. The visible intraoperative effect will be demonstrated in the video. ConclusionThe effect of a hormonal treatment can be observed macroscopically in endometriosis. This can help to understand the in vivo response to the administrated treatment. This video is showing our past experience, as performing second-look laparoscopy is not state of the art anymore.

Validation of a Simulation Model for Robotic Myomectomy

Study ObjectiveSeveral simulation models have been evaluated for gynecologic procedures such as hysterectomy, but there are limited published data for myomectomy. This study aimed to assess the validity of a low-cost robotic myomectomy model for surgical simulation training. DesignProspective cohort simulation study. SettingSurgical simulation lab. ParticipantsTwelve obstetrics and gynecology residents and four fellowship-trained minimally invasive gynecologic surgeons were recruited for a 3:1 novice-to-expert ratio. InterventionsA robotic myomectomy simulation model was constructed using <$5 worth of materials: a foam cylinder, felt, a stress ball, bandage wrap, and multipurpose sealing wrap. Participants performed a simulation task involving two steps: fibroid enucleation and hysterotomy repair. Video recorded performances were timed and scored by two blinded reviewers using the validated Global Evaluative Assessment of Robotic Skills (GEARS) scale (5-25 points) and a modified GEARS scale (5-40 points), which adds three novel domains specific to robotic myomectomy. Performance was also scored using predefined task errors. Participants completed a post-task questionnaire assessing the model's realism and utility. Measurements and Main ResultsMedian task completion time was shorter for experts compared to novices (9.7 vs. 24.6 minutes, P=.001). Experts scored higher than novices on both the GEARS scale (median 23 vs. 12, P=.004) and modified GEARS scale (36 vs. 20, P=.004). Experts made fewer task errors than novices (median 15.5 vs. 37.5, P=.034). For interrater reliability of scoring, the intraclass correlation coefficient was calculated to be 0.91 for the GEARS assessment, 0.93 for the modified GEARS assessment, and 0.60 for task errors. Using the contrasting groups method, the passing mark for the simulation task was set to a minimum modified GEARS score of 28 and a maximum of 28 errors. Most participants agreed that the model was realistic (62.5%) and useful for training (93.8%). ConclusionWe have demonstrated evidence supporting the validity of a low-cost robotic myomectomy model. This simulation model and the performance assessments developed in this study provide further educational tools for robotic myomectomy training.

Adenomyosis and fertility-sparing surgery: A literature appraisal.

Adenomyosis is an intricate pathological condition that negatively impacts the uterus. It is closely related to the more well-known endometriosis, with which it shares parallels in terms of diagnosis, therapy, and both microscopic and macroscopic features. The purpose of this narrative review is to give a clear univocal definition and outlook on the different, patient-adapted, surgical treatments. MEDLINE and PubMed searches on these topics were conducted from 1990 to 2022 using a mix of selected keywords. Papers and articles were identified and included in this narrative review after authors' revision and evaluation. From the literature analysis, authors reported the following surgical techniques: laparoscopic double/triple-flap method, laparotomic wedge resection of the uterine wall, laparotomic transverse H-incision of the uterine wall, laparotomic wedge-shaped excision, and laparotomic complete debulking excision by asymmetric dissection technique. Each of these techniques has strengths and weaknesses, but the literature data on the pregnancy rate are somewhat limited. The only certain information is the risk of uterine rupture up to 6.0% after surgical treatment for uterine adenomyosis. Over the years, the surgical approach continued to reach a positive result by minimally invasive treatment, with less hospitalization, less postoperative pain, and less blood loss. Over the years, the gynecological surgeon has gained the skills, training and increasingly sophisticated surgical techniques to target effective therapy. That's why a hysterectomy is no longer the only surgical resource to treat adenomyosis, but in patients who wish to preserve the fertility, there is a wide variety of surgical alternatives.

Partial Epididymal Obstruction as a Cause of Idiopathic Oligozoospermia: A Reproductive Urologist's Perspective following 35 Years of Surgical and Clinical Experience.

The role of partial epididymal obstruction as contributing to the development of oligozoospermia has been neglected for decades. In the early 1970s, however, Robert Schoysman, a gynecological surgeon devoted to the surgical and medical management of male factor infertility, dedicated many efforts to study such a pathology and its possible effects on male fertility. Following the studies of this pioneer in the field, we concentrated our attention to the patterns of partial and complete epididymal obstruction during surgical scrotal exploration, once made possible even in oligozoospermic men by diagnostic and therapeutic interventions, such as vasovesciculography or seminal tract washout test, at present considered obsolete and no longer feasible in light of the current guidelines. Interestingly, we found signs of partial epididymal obstruction in about 30% of oligozoospermic men with normal testicular volume and serum FSH level as well as normal spermatogenesis at testis biopsy. We, then, compared the findings of scrotal ultrasound with those of scrotal exploration and found that the ultrasound abnormalities of the epididymis were highly predictive of anatomic alteration of the gland. In the present study, we report our experience, together with a historical review of the literature, on this topic.

Hysterectomy and Oophorectomy for Transgender Patients: Preoperative and Intraoperative Considerations

ObjectiveTo review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender patients. DesignStepwise demonstration of techniques with narrated video footage. SettingApproximately 0.3% of hysterectomies performed annually in the United States are for transgender men. While some transgender men choose hysterectomy for the same indications as cisgender women, the most prevalent diagnosis for the performed surgeries is gender dysphoria.1 Hysterectomy with or without oophorectomy can be offered to patients who have met the World Professional Association for Transgender Health (WPATH) criteria.2 InterventionsImportant perioperative counseling points for transgender patients include: establishing terminology for relevant anatomy as well as the patient's name and pronouns; if applicable, discussing options for fertility preservation if the patient desires biological children3,4 and discussing the use of hormone therapy post-oophorectomy to reduce the loss of bone density;5,6 and reviewing intraoperative and postoperative expectations.When performing an oophorectomy on a transgender patient for gender affirmation, it is especially important to minimize the risk for ovarian remnant syndrome and the need for additional surgery, such as due to persistent menstruation. The performance of a two-layer vaginal cuff closure should be considered to reduce the risk of vaginal cuff complications, which is preferable for patients whose pelvic organs cause gender dysphoria.7,8 ConclusionSpecial considerations outlined in this video and the WPATH guidelines should be reviewed by gynecologic surgeons to minimize transgender patients’ experiences of gender dysphoria before, during, and after surgery.

Real-time auto-segmentation of the ureter in video sequences of gynaecological laparoscopic surgery.

Ureteral injury is common during gynaecological laparoscopic surgery. Real-time auto-segmentation can assist gynaecologists in identifying the ureter and reduce intraoperative injury risk. A deep learning segmentation model was crafted for ureter recognition in surgical videos, utilising 3368 frames from 11 laparoscopic surgeries. Class activation maps enhanced the model's interpretability, showing its areas. The model's clinical relevance was validated through an End-User Turing test and verified by three gynaecological surgeons. The model registered a Dice score of 0.86, a Hausdorff 95 distance of 22.60, and processed images in 0.008s on average. In complex surgeries, it pinpointed the ureter's position in real-time. Fifty five surgeons across eight institutions found the model's accuracy, specificity, and sensitivity comparable to human performance. Yet, artificial intelligence experience influenced some subjective ratings. The model offers precise real-time ureter segmentation in laparoscopic surgery and can be a significant tool for gynaecologists to mitigate ureteral injuries.

Utility of Routine Postoperative Examination for Detecting Vaginal Cuff Dehiscence After Total Laparoscopic Hysterectomy

To determine the utility of routine postoperative vaginal cuff examination for detection of vaginal cuff dehiscence (VCD) after total laparoscopic hysterectomy (TLH). Retrospective cohort study. Quaternary care academic hospital in the United States. All patients who underwent TLH with a minimally invasive gynecologic surgeon at our institution from 2016 to 2022. Laparoscopic hysterectomy with routine vaginal cuff check 6 to 8 weeks postoperatively and laparoscopic hysterectomy without routine vaginal cuff check. We identified 703 patients who underwent TLH, 216 (30.7%) with routine cuff checks and 487 (69.3%) without. Within the no cuff check group, 287 (58.9%) had entirely virtual follow-up. There was no difference in VCD between the routine cuff check (1.28%, n=2) and no cuff check groups (0.93%, n=7, p=.73). Median time to VCD was 70.0 days (27.5-114.0). No VCDs were identified in asymptomatic patients on routine examination, and both patients in the cuff check group with VCD had appropriately healing cuffs on routine examination. In the cuff check group, 7 patients (3.2%) had findings of incomplete healing requiring intervention (silver nitrate, extended pelvic rest), all of whom were asymptomatic at the time of examination. Eight patients (3.7%) in the routine cuff check group and 21 (4.3%) in the no examination group required a nonroutine cuff check owing to symptoms. There was no difference in points of contact for postoperative symptoms between the groups (median 0 [0-1.0] for both groups, p=.778). Routine postoperative vaginal cuff examination does not seem to affect or negate the risk of future VCD. Virtual follow-up for asymptomatic patients may be appropriate after TLH.

Can a Society Elevate the Quality of Research: A Look at the Proceedings of the Society of Gynecologic Surgeons' (SGS) Annual Conference Over the Years. An SGS Collaborative Research in Pelvic Surgery Consortium Study

Can a Society Elevate the Quality of Research: A Look at the Proceedings of the Society of Gynecologic Surgeons' (SGS) Annual Conference Over the Years. An SGS Collaborative Research in Pelvic Surgery Consortium Study

10162 Association between Gynecologic Surgeon Year of Experience and Peri-Operative Complications for Hysterectomies

10162 Association between Gynecologic Surgeon Year of Experience and Peri-Operative Complications for Hysterectomies

9767 Stepwise Approach to Rectovaginal Space Dissection for the Minimally Invasive Gynecologic Surgeon

9767 Stepwise Approach to Rectovaginal Space Dissection for the Minimally Invasive Gynecologic Surgeon

Synoptic Reporting for Pretreatment CT Examination in Patients With Advanced Ovarian Cancer: Impact on Documentation of Disease Sites and Physician Satisfaction.

BACKGROUND. Imaging reports that consistently document all disease sites with a potential to increase surgical complexity or morbidity can facilitate ovarian cancer treatment planning. OBJECTIVE. The aims of this study were to compare simple structured reports and synoptic reports from pretreatment CT examinations in patients with advanced ovarian cancer in terms of completeness of documenting involvement of clinically relevant anatomic sites as well as to evaluate physician satisfaction with synoptic reports. METHODS. This retrospective study included 205 patients (median age, 65 years) who underwent contrast-enhanced abdominopelvic CT before primary treatment of advanced ovarian cancer from June 1, 2018, to January 31, 2022. A total of 128 reports generated on or before March 31, 2020, used a simple structured report (free text organized into sections); 77 reports generated on or after April 1, 2020, used a synoptic report (a list of 45 anatomic sites relevant to ovarian cancer management, each of which was classified in terms of disease absence versus presence). Reports were reviewed for completeness of documentation of involvement of the 45 sites. For patients who underwent neoadjuvant chemotherapy based on diagnostic laparoscopy findings or underwent primary debulking surgery with suboptimal resection, the EMR was reviewed to identify surgically established sites of disease that were unresectable or challenging to resect. Gynecologic oncology surgeons were electronically surveyed. RESULTS. The mean report turnaround time was 29.8 minutes for simple structured reports versus 54.5 minutes for synoptic reports (p < .001). A mean of 17.6 of 45 sites (range, four to 43 sites) were mentioned by simple structured reports versus 44.5 of 45 sites (range, 39-45) for synoptic reports (p < .001). Forty-three patients had surgically established unresectable or challenging-to-resect disease; involvement of anatomic site(s) with such disease was mentioned in 37% (11/30) of simple structured reports versus 100% (13/13) of synoptic reports (p < .001). All eight surveyed gynecologic oncology surgeons completed the survey. CONCLUSION. A synoptic report improved completeness of pretreatment CT reports in patients with advanced ovarian cancer, including for established sites of unresectable or challenging-to-resect disease. CLINICAL IMPACT. The findings indicate the role of disease-specific synoptic reports in facilitating referrer communication and potentially guiding clinical decision-making.

Current Clinical Practice Patterns in Total Vaginal Hysterectomy.

There are no data on current surgical practice patterns for benign total vaginal hysterectomy (TVH) despite recently published guidelines. The objective was to determine gynecologic surgeon practice patterns regarding TVH perioperative interventions and to assess adherence to clinical practice guidelines. A survey to assess TVH practice patterns was distributed to gynecologic surgical society members for completion. The primary outcome was to compare adherence to practice guidelines between fellowship-trained and non-fellowship-trained gynecologic surgeons. Secondary outcomes included comparing adherence based on age, practice location, and hysterectomy volume. Of the 204 respondents, there were 163 (80%) fellowship-trained and 41 (20%) non-fellowship-trained gynecologic surgeons. Fellowship-trained surgeons were more likely than non-fellowship-trained surgeons to use vaginal packing (34% vs 15%, P = 0.028), which is contrary to the recommendations. No cohort followed the guideline recommending a circular cervicovaginal incision. Fellowship-trained surgeons also were more likely than non-fellowship-trained surgeons to use the clamp and suture technique for vessel ligation (88% vs 68%, P = 0.004); otherwise, there were no significant differences between cohorts for adherence to any of the other guidelines. Although fellowship-trained surgeons were adherent to fewer of the guidelines as compared with surgeons without fellowship training, both groups generally adhered to a majority of the clinical practice guidelines for benign TVH. This information demonstrates a need for the development of targeted education and interventions to increase the use of evidence-based clinical practice guidelines during TVH for both fellowship-trained and non-fellowship-trained gynecologic surgeons.

Microsurgical training curriculum in a gynecological breast cancer center: a benefit for patients and surgeons?

PurposeAutologous breast reconstruction improves patient satisfaction and quality of life after mastectomy. In Germany, free flap surgery and implant-based reconstruction is usually separate between reconstructive surgery and gynecology. Cooperation between the specialist disciplines and implementation of microsurgery into breast surgeon training could enhance surgical treatment for breast cancer patients. This evaluation is intended to demonstrate the learning progress within a microsurgical training program and the complication rate in relation to microsurgical experience.MethodsAt the breast cancer center at Klinikum rechts der Isar, TU Munich, a three-stage training program for autologous breast reconstruction and microsurgery for gynecological breast surgeons was developed. Between 2019 and 2022, 74 women received autologous free flap breast reconstruction by a consistent team consisting of a gynecological surgeon in training and an expert microsurgeon. Peri- and postoperative data were collected to analyze the feasibility and safety of a microsurgical training in gynecology.ResultsWithin the training, operative steps of free autologous breast reconstruction were increasingly taken over by the gynecological surgeon in training. The analysis showed a decrease in operating times with consistently low complication rates during the training.ConclusionThis study demonstrated that a training in free autologous breast reconstruction for gynecological surgeons is safely feasible through close cooperation between gynecological and reconstructive surgery.

A multicenter noninferior randomized controlled study comparing the efficacy of laparoscopic versus abdominal radical hysterectomy for cervical cancer (stage IB3 and IIA2): study protocol of the LAUNCH 3 trial

BackgroundCervical cancer is and will remain to be an important health problem in China, especially with an increasing proportion of younger patients who has more specific needs. In China, surgery to remove tumor burden followed by postoperative treatment with radiotherapy and chemotherapy based on clinicopathologic factors may be the best choice for stages IB3 and IIA2 patients. Radical hysterectomy in cervical cancer has been a classic landmark surgery in gynecology. The current trial is designed to evaluate whether there is a difference between laparoscopic RH and abdominal RH in cervical cancer (stages IB3 and IIA2) patient survival under stringent operation standards and consistent surgical oncologic principles. This paper reports the rationale, design, and implementation of the trial.Methods/designThis is an investigator-initiated, prospective, randomized, open, blinded endpoint (PROBE) controlled trial. A total of 1104 patients with stage IB3 and IIA2 cervical cancer will be enrolled over a period of 3 years. Patients are randomized (1:1) to either the laparoscopic RH or the abdominal RH group. Patients will then be followed up for at least 5 years. The primary end point will be 5-year overall survival, and secondary endpoints include 5-year progression-free survival, recurrence, and quality of life measurements.DiscussionThe study results will provide more convincing evidence-based information for stages IB3 and IIA2 cervical cancer patients and their gynecologic cancer surgeons in their choice of surgical method.Trial registrationClinicalTrials.gov, NCT04939831, retrospectively registered on 25 June 2021.

Exploring international differences in ovarian cancer care: a survey report on global patterns of care, current practices, and barriers

ObjectiveAlthough global disparities in survival rates for patients with ovarian cancer have been described, variation in care has not been assessed globally. This study aimed to evaluate global ovarian cancer...

Robot-assisted Laparoscopic Excision of Abdominal Wall Endometrioma Utilizing Intraoperative Ultrasound and Transabdominal Needle Placement

In patients with endometriosis, extra pelvic endometriosis is estimated to have an incidence of 11% and a rare subset of extra pelvic lesions include abdominal wall endometriosis with an incidence of 0.03-3.5%1,3. Evaluation for and surgical management of abdominal wall endometriosis is an essential skillset for the advanced gynecologic surgeon. In this video, we demonstrate a surgical technique for robot-assisted laparoscopic excision of abdominal wall endometriosis with intraoperative ultrasound-guided needle placement. Description and demonstration of surgical technique. Patient with previous history of 2 cesarean sections and right lower quadrant cyclic abdominal wall pain. Tertiary care, academic center INTERVENTIONS: Intraoperative ultrasound-guided needle placement to map location and boundaries of the lesion followed by minimally invasive resection of the lesion with the intermittent advancement and withdrawal of needles to confirm clear margins. Minimally invasive resection of abdominal wall endometriosis using intraoperative ultrasound guided needle placement is an effective technique to guide surgical dissection and allow for clear surgical margins and successful treatment of this rare condition.

Robotic-assisted vaginal natural orifice transluminal endoscopic surgery versus robotic-assisted single-site port for benign hysterectomy: a comparison of surgical outcomes.

The objective of this study is to evaluate the surgical outcomes for robotic-assisted vaginal natural orifice transluminal endoscopic surgery (R-VNOTES) hysterectomy versus robotic-assisted single-site port (RSSP) hysterectomy when performed for benign indications. This is a retrospective chart review in an academic tertiary setting. 404 patients underwent hysterectomy for benign indications. R-VNOTES hysterectomy and RSSP hysterectomy were performed by a single minimally invasive gynecologic surgeon from January 2015 to August 2022. The primary outcome of our study was total operative time (minutes). Secondary outcomes included estimated blood loss (mL), length of hospital stay (days), and postoperative pain score. Other intraoperative and postoperative surgical complications were also compared. 159 patients underwent R-VNOTES hysterectomy, and 269 patients underwent RSSP hysterectomy. Median length of surgery (minutes) demonstrated a statistically significant shorter operative time in the R-VNOTES hysterectomy group when compared to the RSSP hysterectomy group, (132min versus 146min, respectively, p = 0.0001). Additionally, patients in the R-VNOTES hysterectomy group experienced decreased postoperative pain levels at week 1 (6 versus 7, respectively, p = 0.01) and week 3 (1.5 versus 2.5, respectively, p = 0.01) after surgery. There were no statistically significant differences between the two groups when comparing length of hospital stay, estimated blood loss, and weight of the uterus. There was no difference in rates of urinary tract infection, blood transfusion, bowel injury, readmission, reoperation, conversion, deep surgical site infection, and venous thromboembolism between both groups. However, there was a higher rate of superficial SSI in the RSSP hysterectomy group (0.6% versus 4.5%, respectively, p = 0.03). When compared to RSSP hysterectomy, R-VNOTES hysterectomy is safe and feasible, as both approaches have comparable surgical outcomes. Patients undergoing R-VNOTES hysterectomy had shorter length of surgery, decreased postoperative pain, and lower rates of superficial surgical site infections.

Evaluation of the Preoperative Slide Test in the Prediction of Intra-Abdominal Adhesions: A Single-Center, Double-Blinded, Prospective Observational Study.

To evaluate the efficacy of the preoperative ultrasonographic sliding sign in predicting intra-abdominal adhesions. This was a single-center, double-blinded, prospective observational study undertaken from March and September 2021 on 110 patients with a history of previous abdominal surgery. All patients who were scheduled for laparoscopy underwent slide test in 5 zones of abdomen: right lower quadrant, left lower quadrant, previous operation site, vesicouterine pouch, and rectovaginal pouch. Adhesions were assessed by the same gynecologic surgeon using ultrasonography before the surgery and by gynecological surgeons during surgery, and by a third gynecologic surgeon to compare the preoperative slide test findings and laparoscopic findings after the surgery. Seventy-three (66.4%) patients underwent laparoscopic surgery, and 37 (33.6%) patients underwent laparotomy. The mean age of patients was 46.9 ± 1.0years. Sensitivity, specificity, and positive and negative predictive values of preoperative ultrasonography in predicting adhesions were 89.5%, 91.7%, 97.5%, and 71.0%, respectively. The accuracy of the slide test was calculated as 90.0%. It was found that as the total number of cesarean sections increased the estimates of vesicouterine adhesions and actual adhesions increased (P = .008). Also, the prediction of intra-abdominal adhesions and actual adhesions significantly increased as the total number of surgical operations increased (P = .002). Intra-abdominal adhesions can be detected with the slide test, which is a non-invasive and well-tolerated procedure. Slide test can guide the physician before the elective operation in patients with previous abdominal surgery and may assist in counseling patients.