Hysterectomy Procedures Research Articles

Contained and uncontained morcellation in hysterectomy and myomectomy: A systematic review and meta-analysis

We sought to analyze all high-quality studies available regarding the possible differences in contained and uncontained techniques for morcellation of fibroids and uteri. We systematically searched PubMed, Cochrane Central, Scopus, ClinicalTrials.Gov, MEDLINE and Web of Science from September 2010 to September 2020 for our search terms. We included studies that specifically enrolled patients undergoing power morcellation myomectomy or power morcellation hysterectomy procedures. In our search, we had no restriction to age, country, or publication date.We extracted data related to study design, baseline characteristics of patients, and perioperative outcomes such as total operative time, total blood loss, and duration of hospital stay. We found no substantial difference in total operative time between contained power morcellation and uncontained manual morcellation myomectomy (p=0.52), but contained power morcellation had a significantly longer total operative time than uncontained power morcellation for hysterectomy and myomectomy [135.50 vs. 93.33 minutes, (p=0.003)]. Total blood loss was comparable for contained power morcellation versus uncontained manual morcellation myomectomy (p=0.32) and contained power morcellation versus uncontained power morcellation myomectomy or hysterectomy (p=0.91). Contained power morcellation and uncontained manual morcellation myomectomy had comparable hospital stay periods (p=0.5). Contained power morcellation leads to a longer operating time than uncontained power morcellation for both hysterectomy and myomectomy. No differences were found in comparisons of blood loss, operative time, or comparison to manual methods of morcellation.

Temperature-dependent dielectric properties of human uterine fibroids over microwave frequencies

Microwave ablation is under investigation as a minimally-invasive treatment for uterine fibroids. Computational models play a vital role in the development, evaluation and characterization of candidate ablation devices. The temperature-dependent dielectric properties of fibroid tissue are essential for accurate computational modeling. Objective: To measure the broadband temperature-dependent dielectric properties of uterine fibroids excised during hysterectomy procedures. Methods: The open-ended coaxial probe method was employed for measuring the broadband dielectric properties of freshly excised human uterine fibroid samples (n = 6) obtained from an IRB-approved tissue bank. The dielectric properties (relative permittivity, ε r, and effective electrical conductivity, σ eff) were evaluated at temperatures ranging from 23 °C–150 °C, over the frequency range of 0.5–6 GHz. Linear piecewise parametrization with respect to temperature and quadratic parametrization with respect to frequency was applied to characterize broadband temperature-dependent dielectric properties of fibroid tissue. Results: The baseline room temperature values of ε r vary from 57.5 ± 5.29 to 44.5 ± 5.77 units and σ eff changes from 0.91 ± 0.19 to 6.02 ± 0.7 S m−1 over the frequency range of 0.5–6 GHz. At temperatures close to the water vaporization point, ε r, drops considerably i.e. to 12%–14% of its baseline value for all measured frequencies. σ eff values initially rise till 98 °C and then fall to 11%–13% of their baseline values at 125 °C for frequencies ≤2.45 GHz. The σ eff follows a decreasing trend for frequencies >2.45 GHz and drops to ∼6 % of their baseline room temperature values. Conclusion: The temperature dependent dielectric properties of uterine fibroid tissues over microwave frequency range are reported for the first time in this study. Parametric models of uterine fibroid dielectric properties are also presented for incorporation within computational models of microwave ablation of fibroids.

Assessing the Effectiveness of a Hysterectomy Patient Education Video Narrated in Spanish: A Feasibility Study

<h3>Study Objective</h3> Hysterectomy is the most common gynecological surgical procedure, and yet, studies show women have a poor understanding of the procedure. The objective of this study was to assess the feasibility of testing the effectiveness of a video we developed in Spanish, about hysterectomy, in improving knowledge among Spanish speaking women. <h3>Design</h3> Pre-test, post-test study design using a web-based learning management system (LMS) to fully digitize the study. The knowledge instrument used was previously validated. <h3>Setting</h3> A women's health clinic at a large teaching hospital in Texas. <h3>Patients or Participants</h3> Patients were female patients who spoke Spanish and who were being evaluated for conditions for which hysterectomy is a potential treatment. <h3>Interventions</h3> An empirically developed, focus group tested patient education video on the hysterectomy procedure narrated in Spanish. <h3>Measurements and Main Results</h3> We had 6 Spanish speaking women participate in this feasibility study. Our study consisted of a demographic survey followed by a pre-test followed by our hysterectomy education video followed by a post-test. All these components were combined in electronic form, using a web-based LMS, as if the study were an online course. Mean time taken to complete the pre-test was 393 seconds (range from 303 to 603 seconds). Mean score on the pre-test was 51.2% with a range from 25.9 to 66.7%. Mean time taken to complete the post-test was 365 seconds (range from 297 to 526 seconds). Mean score on the post-test was 60.5% with a range from 37 to 81.5%. <h3>Conclusion</h3> This small study demonstrated the feasibility of doing a health literacy study among Spanish speaking women focused on the hysterectomy procedure by using an online learning management system typically used for online courses. Using a learning management system allowed us to fully digitize this study that consisted of both questions to be answered as well as a video to be watched.

Benefit of Routine Cystoscopy at Time Uncomplicated Total Laparoscopic Hysterectomy

<h3>Study Objective</h3> To demonstrate the value of routine cystoscopy for evaluation of bladder injury at time of laparoscopic hysterectomy. <h3>Design</h3> Video abstract. <h3>Setting</h3> Minimally invasive gynecologic surgery department at an academic community hospital. <h3>Patients or Participants</h3> Patients who underwent an uncomplicated total laparoscopic hysterectomy with bilateral salpingectomy for abnormal uterine bleeding and fibroids. <h3>Interventions</h3> Routine cystoscopy following a seemingly uncomplicated total laparoscopic hysterectomy with primary repair of bladder after unanticipated thermal bladder injury noted. <h3>Measurements and Main Results</h3> Following total laparoscopic hysterectomy, visual inspection of the pelvis did not reveal any injuries to the bladder or ureters. At time of routine cystoscopy, a <1cm thermal injury was noted at the dome of the bladder, which was treated with primary repair. We also present a companion case with finding of 1.5cm thermal bladder dome injury following laparoscopic hysterectomy, bilateral salpingectomy and laparoscopic Burch procedure. Again, no evidence of injury was noted at completion of laparoscopy by visual inspection. The injured bladder mucosa was excised and the iatrogenic cystotomy repaired in two layers. <h3>Conclusion</h3> Recommendation for routine cystoscopy following laparoscopic hysterectomies to adequately assess for possible thermal bladder injury that otherwise would be undetected with visual inspection.

The Valero Tip and Attachment for Cooper Surgical Rumi Uterine Manipulator

<h3>Study Objective</h3> To produce a Stainless-Steel surgical degree tip and attachment that works with uterine manipulator and allows the use of cervical cup for different types of surgeries. - Plastic pollution continue to be a serious problem for human health and environment, it's estimate that for 2030, 53 million tonnes of plastic could end up in rivers, lakes and oceans. One example of how changing consumption patterns can improve the environment is the use and disposal of plastics. The global theme of World Environment Day is "Beat Plastic Pollution". It aims to change consumer behaviour with the challenge, "If you can't reuse it, refuse it." In OR we don't have exception, for reducing Medical Waste and optimizing our ORs for the future, we design a stainless-steel surgical degree tip and attachment for the uterine manipulator. <h3>Design</h3> We produce a 3-D Model plastic tip as a prototype, subsequently a stainless-steel tip and attachment <h3>Setting</h3> Like it adapts to a uterine manipulator, patient position is lithotomy, the Tip attaches by a "ring" then allows the use of a cervical cup that adapts to the ring. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> The design patent pending through the School of Medicine and Engineer, attach to the three types of uterine manipulator also it allows to use the cervical cup and provides the ability to use it in hysterectomy or other procedures without the cervical cup. Base on this we present the prototype guide and assemble. <h3>Conclusion</h3> The reestirilization of the tip allows us not promote the use of plastic waste.

Post-Operative Opioid Use with a Modified ERAS Protocol: A before-and-after Comparison

<h3>Study Objective</h3> To determine if limited, post-operative changes to patient care in the model of enhanced recovery after surgery are sufficient to decrease post-operative opioid prescriptions. <h3>Design</h3> A pre- and post-implementation study of a modified Enhanced Recovery protocol. <h3>Setting</h3> Post-operative setting in a tertiary academic medical center. <h3>Patients or Participants</h3> Included women undergoing scheduled gynecologic surgery at one hospital system where minimally-invasive procedures are predominant, aged 18-95 years. Procedures included hysterectomy or urogynecologic procedures performed by physicians involved in the study. The cohorts were broken up into a year prior to implementation of the intervention (n=175), and a year after (n=149). Excluded were patients discharged on the same calendar day. <h3>Interventions</h3> A post-operative order set including scheduled non-opioid analgesics and anti-emetics, expedited diet advancement, and standardized order sets for post-operative prescriptions. <h3>Measurements and Main Results</h3> The primary outcome was the amount of opioid prescribed through post-discharge day 14. Opioids were converted today's supply and morphine milligram equivalents (MME). Baseline demographics were similar between the two groups, with exceptions being race (White race 96% in the first cohort vs. 89% in the second, p=0.0369) and tobacco use (19% use in the first cohort vs. 10% in the second, p=0.0288). Percent of patients with baseline chronic opioid use was similar between the two groups (15 vs. 10, p=0.5318). Mean pain scores before and after the intervention were not significantly different. There was a significant decrease in both day's supply (3.23 vs. 2.43, p=0.0311) and MME prescribed following the intervention (47.98 vs. 41.42, p=0.0022). There was a non-significant decrease in cumulative MME through post-discharge day 14 (210.8 vs. 143.2, p=0.3631), as well as total day's supply through post-discharge day 14 (3.45 vs. 3.15, p=0.4604). <h3>Conclusion</h3> Simple changes to the post-operative experience in line with an enhanced recovery protocol are sufficient to decrease post-operative opioid use in a population including patients with baseline chronic opioid use.

Variation of Chargemaster Price Listings for Hysterectomy Procedures across Five States

<h3>Study Objective</h3> A 2018 Executive Order calling for price transparency required hospitals to provide their chargemaster (list of prices) on their public websites in order to drive competition and lower prices. Our goal was to compare chargemaster prices listed for hysterectomy procedures from hospitals in five states. <h3>Design</h3> Hospital chargemasters were obtained between February to April 2020, across 5 states chosen to represent a range of demographics and health systems. Current Procedural Terminology (CPT) codes for abdominal hysterectomy (58150, 58152, 58180), vaginal hysterectomy (58260, 58262, 58290, 58291, 58263, 58267, 58270, 58292, 58293, 58294), and laparoscopic hysterectomy (58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573) as well as procedure names were searched and pricing extracted. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> 837 hospitals in 5 states were included. 105 chargemasters (12.5%) listed prices for abdominal, 106 (12.7%) vaginal, and 114 (13.6%) laparoscopic hysterectomies. Mean prices listed were significantly different for all types of hysterectomy across states (Table 1). Each type of hysterectomy had a wide range of prices listed (laparoscopic $49.00-$43,491.00, abdominal $61.45-$34,849.20, vaginal $6.00-$22,651.00). <h3>Conclusion</h3> Overall, few hospitals made price listings available for abdominal, vaginal, or laparoscopic hysterectomies and price listings varied widely for these procedures across states. Despite previous literature reporting vaginal hysterectomy to have the lowest direct cost and abdominal hysterectomy the highest (Kaaki et al 2020), this is not what these public chargemasters reflect to patients. Currently, chargemasters do not seem to be a reliable option for patients to shop for healthcare. Further investigation of chargemaster prices with hospital characteristics and quality metrics is imperative.

The Okabayashi Radical Hysterectomy: Basic Principle and Step-by-Step Procedure.

Abdominal radical hysterectomy is the standard operation for stage IB–IIB cervical cancer in the world, which was established by Professor Hidekazu Okabayashi in 1921. In this article, the basic principle and step-by-step procedure of Okabayashi radical hysterectomy are presented, especially for young doctors to understand clearly the important points of this surgery and to realize its radicality and safety for better survival and quality of life of patients with cervical cancer.

Total Laparoscopic Nerve-Sparing Radical Hysterectomy Using the No-look No-touch Technique.

Radical hysterectomy is a standard operation for patients with early-stage cervical cancer. Over the recent decades, laparoscopic radical hysterectomy has been considered an alternative treatment. In 2018, the results of the laparoscopic approach to cervical cancer trial suggested that women with early-stage cervical cancer who underwent minimally invasive surgery for radical hysterectomy had poorer prognosis than those who underwent open surgery. This finding was unexpected, and direct evidence supporting poor prognosis related to minimally invasive radical hysterectomy was not available because the trial was not designed to evaluate the cause of the inferior outcomes. Tumor spillage caused by surgeon-related factors, including squeezing of the uterine cervix and tumor exposure to circulating CO 2 gas, is considered to be associated with the poor prognosis of patients who underwent minimally invasive radical hysterectomy. We believe that protective maneuver to avoid tumor spillage is the key to improve oncologic outcomes of cervical cancer. Here, we present a procedure of total laparoscopic nerve-sparing radical hysterectomy for early-stage cervical cancer in which techniques, such as the “no-look no-touch technique,” were used to prevent tumor spillage.

1387 Audit of Pregnancy Status Documentation in Emergency Admissions to A Tertiary Colorectal Surgery Unit

Abstract Aim Documenting pregnancy status (PS) is an important component of the medical assessment of all females of reproductive age (FRA), defined as age 16-55 years old when admitted to hospital. This audit aims to determine the rate of documentation of PS amongst FRA admitted to a tertiary colorectal surgical unit via the surgical admissions unit (SAU) or transfer from other departments between 01/10/20 – 13/11/20. Method A complete documentation of PS comprises of results of urine or serum (β-hCG) and relevant gynaecological history (i.e., last menstrual period and any contraceptive use) clearly reported in the admission clerk-in. Patients with presenting complaint excluding abdominal pain, current pregnancy, history of hysterectomy or sterilisation procedures were excluded. Results During the audit duration, 29 FRA were admitted of which 13 (44.8%) were included for analysis. Of patients included, 4/9 (44.4%) and 1/4 (25.0%) admitted via SAU or transferred from other departments respectively had a past colorectal history. 4 (30.8%) had complete documentation of PS of which, 3 (75.0%) were patients transferred from other departments. Conclusions Low rates of documentation of PS especially amongst emergency admissions via SAU, is possibly associated with a narrow differential diagnosis influenced by pre-existing colorectal history. This audit did not look at PS documentation prior to any subsequent surgical intervention. A re-audit following the implementation of a guidance poster in SAU is currently underway.

Racial Differences in Planned Hysterectomy Procedure Route.

Background: Hysterectomies can be performed with a minimally invasive surgical (MIS) approach or a laparotomic (abdominal) approach. The objective of this study was to assess any racial differences in the likelihood of having a planned MIS hysterectomy. Materials and Methods: A prospective cohort study of women undergoing hysterectomy at Henry Ford Health System was conducted where laparotomic and MIS approaches are available to all patients. All procedures were performed between October, 2015, and August, 2017. For this study, women were asked to report demographic and insurance information and complete validated questionnaires from 2 weeks before hysterectomy and up to six additional times in the year after hysterectomy. Clinical and operative characteristics were collected from electronic health records. Logistic regression and multinomial logistic regression models were applied to assess the association between race and the surgical approach. Results: Analyses included 235 White women and 196 Black women. Black women were less likely to have any MIS planned for their hysterectomy (odds ratio [OR] = 0.46, 95% confidence interval [CI] 0.3-0.71, p < 0.05), a laparoscopic hysterectomy (relative risk ratio [RRR] = 0.46, 95% CI 0.29-0.73, p < 0.05), or a vaginal hysterectomy (RRR = 0.45, 95% CI 0.25-0.81, p = 0.01) compared with White women. After adjusting for confounders, uterine weight and indication for surgery was fibroids, these racial differences did not remain statistically significant (MIS vs. abdominal [adjusted odds ratio {aOR} = 0.93, 95% CI 0.55-1.57, p = 0.79], laparoscopic vs. abdominal [adjusted relative risk ratio {aRRR} = 0.89, 95% CI 0.52-1.51, p = 0.54], and vaginal vs. abdominal [aRRR = 1.22, 95% CI 0.61-2.45, p = 0.58]). The associations were not confounded by the baseline survey data from standardized questionnaires on depression, financial distress, and satisfaction with their decision. Conclusions: Black women were not less likely than White women to have planned an MIS hysterectomy after controlling for important confounding variables. These results emphasize the importance of considering all important confounders when examining racial differences.

Trends and Perioperative Outcomes across Elective Benign Hysterectomy Procedures from the ACS-NSQIP 2007–2017

In this study, we describe trends of all 3 routes of hysterectomy, patient demographics, and perioperative morbidity among women undergoing surgery for benign indications between 2007 and 2017. We also sought to compare the rates of extended length of stay (ELOS) and readmission rates among the laparoscopic, abdominal, and transvaginal routes. A retrospective cohort study. National database study. The American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent an elective hysterectomy for benign indication between 2007 and 2017. Patients were identified using Current Procedural Terminology codes and excluded if their indication for surgery included cancer and pelvic organ prolapse diagnoses based on International Classification of Diseases codes. The collected variables of interest included age, body mass index, American Society of Anesthesiologists classification, uterine weight of >250 grams, and operative time. Our outcomes of interest included ELOS and readmission within 30 days. ELOS was defined as a hospital admission of 2 days or more after laparoscopic and transvaginal hysterectomy and greater than 3 days for an abdominal hysterectomy. Summary statistics were used to evaluate shifts in patient characteristics and postoperative outcomes by hysterectomy route and year of surgery. Multivariable logistic regression analysis, stratified by year, comparing laparoscopic with transvaginal and abdominal hysterectomies was performed. There were 224357 patients who met the inclusion and exclusion criteria. Of those, 132567 (59.1%) underwent a laparoscopic hysterectomy, 30105 (13.4%) a vaginal hysterectomy, and 61685 (27.5%) an abdominal hysterectomy. The rate of laparoscopic hysterectomy increased by >200% between 2007 and 2017, whereas the rates of transvaginal and abdominal hysterectomies steadily decreased (-58% and -42%, respectively) The mean age, median obesity, and American Society of Anesthesiologists classification increased among women undergoing hysterectomy across all routes with the sharpest increase within the laparoscopic hysterectomy group (% increase in mean age [2.1%, 1.3%, 0.7%] and mean body mass index [9.1%, 4.3%, 3.7%] for laparoscopic, transvaginal, and abdominal routes, respectively). In 2017, the odds of ELOS were 29% lower for those who received laparoscopic than those who received abdominal hysterectomy (p <.001). Comparing the rates of readmission between the laparoscopic and abdominal hysterectomy groups shows that the odds of readmission are significantly lower for patients who receive a laparoscopic hysterectomy across all 11 years (p <.001). The rates of laparoscopic hysterectomy have been steadily increasing over the past 11 years. This large retrospective study confirms the lowest rates of readmission and ELOS within the laparoscopic hysterectomy group despite the rising medical complexity of the patients.

Stepwise Treatment for Abnormally Invasive Placenta with Placenta Previa

Placenta accreta spectrum (PAS) disorder often causes a large amount of intraoperative bleeding in a short period which makes maternal circulation unstable and threatens life. As a countermeasure, two-stage surgery combined with selective uterine arterial embolization (UAE), named “stepwise treatment” was introduced in 2003. At a cesarean section (CS), only the baby is delivered and the placenta is left in situ. The transcatheter angiographic UAE is performed on the operation day, followed by the total hysterectomy on 5 to 7 days after CS. The difficulty in the operative procedures for hysterectomy and the amount of bleeding can be reduced by the added effect of the blood flow interruption by UAE and the uterine involution. Although there are not many indication cases, this is the prudent operation that should be considered for the most severe PAS case such as total placenta increta/percreta with placenta previa.In this article, the practical procedures and tips of stepwise treatment are described.

Retrospective analysis of secondary resection of the cervical stump after subtotal hysterectomy: why and when?

PurposeThe rates of hysterectomy are falling worldwide, and the surgical approach is undergoing a major change. To avoid abdominal hysterectomy, a minimally invasive approach has been implemented. Due to the increasing rates of subtotal hysterectomy, we are faced with the following questions: how often does the cervical stump have to be removed secondarily, and what are the indications?MethodsThis was a retrospective, single-centre analysis of secondary resection of the cervical stump conducted from 2004 to 2018.ResultsSecondary resection of the cervical stump was performed in 137 women. Seventy-four percent of the previous subtotal hysterectomy procedures were performed in our hospital, and 26% were performed in an external hospital. During the study period, 5209 subtotal hysterectomy procedures were performed at our hospital. The three main indications for secondary resection of the cervical stump were prolapse (31.4%), spotting (19.0%) and cervical dysplasia (18.2%). Unexpected histological findings (premalignant and malignant) after subtotal hysterectomy resulted in immediate (median time, 1 month) secondary resection of the cervical stump in 11 cases. In four patients, the indication was a secondary malignant gynaecological disease that occurred more than 5 years after subtotal hysterectomy. The median time between subtotal hysterectomy and secondary resection of the cervical stump was 40 months. Secondary resection of the cervical stump was performed vaginally in 75.2% of cases, laparoscopically in 20.4% of cases and abdominally in 4.4% of cases. The overall complication rate was 5%.ConclusionSecondary resection of the cervical stump is a rare surgery with a low complication rate and can be performed via the vaginal or laparoscopic approach in most cases. The most common indications are prolapse, spotting and cervical dysplasia. If a secondary resection of the cervical stump is necessary due to symptoms, 66.6% will be performed within the first 6 years after subtotal hysterectomy.

"The Characteristics of Patients who have Undergone Total Vaginal Hysterectomy Procedure at Dr. Sardjito Hospital Yogyakarta"

Since ancient times, human beings considered that the climate has influence on the origin and nature of diseases. The relation between climate and health was first attributed to supernatural forces, till Hippocrates in 460 BC refused all these superstitions, legends, and beliefs.

Post-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?

ObjectiveTo compare and evaluate the results and suitability of two different approaches to the treatment of post-conization International Federation of Gynaecology and Obstetrics (FIGO) stage IA1 cervical carcinoma: a more radical approach, directly scheduling a second surgery versus a more conservative one, which consists of performing a cotest (PAP plus HPV-test) in a follow-up visit and deciding whether to apply a second surgery on the basis of the results. Study DesignRetrospective descriptive study including 144 cases of stage IA1 cervical carcinoma diagnosed after a loop electrosurgical excisional procedure (conization), between 1987 and 2019 in the Mother-and-Child University Hospital of Gran Canaria (Spain). Selected patients were split into two groups for analysis: patients directly undergoing a second surgical intervention (hysterectomy or re-conization) after diagnosis and patients who were followed-up before making a decision whether to schedule a second surgery or continue to follow-up. Results75% of women directly receiving a second surgical intervention (no post-conization follow-up) underwent hysterectomy, while 25% underwent re-conization. Histological outcomes from hysterectomized patients showed 65% negative results for intraepithelial lesions, 9% low-grade squamous intraepithelial lesions (LSIL), 16% high-grade squamous intraepithelial lesions (HSIL) and only 10.5% confirmed invasive lesions: hysterectomy complication rate was 7%. Histological studies from women subjected to re-conization showed 32% negative results, 37% LSIL, 5% HSIL and 26% malignancy. In the group of patients who were followed-up after diagnosis, 8.8% needed a second intervention; none of them showed negative histological results, while 100% hysterectomized and 25% patients with re-conization showed HSIL. No unnecessary hysterectomy procedures were conducted in this group. HPV-16 was the most common genotype in both groups. ConclusionConization proved to be a suitable alternative to hysterectomy as a treatment for post-conization stage IA1 cervical cancer. Our results showed that 65% hysterectomy procedures conducted without previously monitoring for residual disease corresponded to negative results and were therefore, unnecessary. We conclude that confirmation of the presence of residual disease by using cotest is essential to make a decision on further treatment and that a conservative management is often possible and, in our opinion, preferable.

Morbid obesity increases the failure rate of sentinel lymph node mapping for endometrial carcinoma

<h3>Objectives:</h3> Sentinel Lymph Node (SLN) mapping is recommended for patients with endometrial carcinoma to reduce the rate of full lymphadenectomy and its associated morbidity such as lymphedema. Obesity is a risk factor for endometrial carcinoma, and many patients are morbidly obese at the time of diagnosis. The goal of this study is to examine the impact of body mass index (BMI) on the success rate of SLN mapping using indocyanine green (ICG) and near-infrared imaging. <h3>Methods:</h3> A retrospective cohort study was performed of women with endometrial carcinoma undergoing robotic hysterectomy and SLN mapping with ICG between March 2016 and August 2019. Robotic surgery cases were identified from the hospital financial system that were coded with a primary diagnosis of Endometrial Cancer, a procedure of hysterectomy, and a cost code for indocyanine green. A total of 369 cases were identified. A total of 28 cases were excluded because no dye was used or SLN mapping was not attempted due to extent of disease. Preoperative patient characteristics and surgical outcomes including SLN mapping success rate were compared across World Health Organization BMI groups. <h3>Results:</h3> BMI was categorized as normal weight (BMI 18.5 - 24.9, 41 patients), pre-obesity (BMI 25.0 - 29.9, 48 patients), obesity class I (BMI 30.0 - 34.9, 71 patients), obesity class II (BMI 35.0 - 39.9, 70 patients), and obesity class III (BMI ≥40, 111 patients). Across BMI groups, patient age and ASA category were significantly different, with younger ages and higher ASA scores in the higher BMI groups. BMI groups did not differ in the number of prior abdominal surgeries or FIGO Grade. Uterine weight, diameter and procedure time were all significantly different across BMI groups, with higher weights, diameters and procedure times in the higher BMI groups. Estimated blood loss and depth of myometrial invasion were not significantly different. In the cohort, 85% had FIGO Stage 1 disease. For procedures with successful unilateral or bilateral SLN detection, the mean number of lymph nodes removed per side was not significantly different across BMI groups. The overall bilateral SLN mapping success rate for the cohort was 68.9%. However, the bilateral SLN mapping success rate was significantly lower in patients with obesity class III (54.1%) compared with patients who were less obese (76.1%, p<0.01). There was no difference in success rate between lower BMI categories. <h3>Conclusions:</h3> Patients with class III obesity (BMI > 40) have a significantly lower success rate for SLN mapping when compared with all other BMI categories (54.1% vs 76.1%, respectively, p<0.01).

Wide local excision of the vulva for premalignant or benign lesions: do antibiotics decrease the risk of postoperative wound complication?

Objectives: To investigate determinants of wound complication following wide local excision (WLE) of the vulva for suspected premalignant or benign disease at a tertiary care center over the years 2016 to 2020. To determine factors associated with perioperative antibiotic use for WLE of the vulva and whether preoperative intravenous (IV) antibiotics or postoperative topical antimicrobial agents are associated with a decreased risk of wound complication. Methods: Consecutive patients were identified who underwent wide local excision of the vulva for suspected premalignant or benign lesions between June 1, 2016 and February 28, 2020. IRB approval was obtained and surgical records were reviewed; patients undergoing ‘wide local excision, vulva,’ ‘simple partial vulvectomy,’ or ‘destruction of vulvar lesion with excision’ were considered for inclusion. Demographic, peri- and postoperative, and pathologic data were recorded. Dimensions of specimen and elliptical surface areas were recorded. Patient follow up was documented at least through the postoperative appointment. Patients were separated by receipt of preoperative IV antibiotics or postoperative antimicrobial agents and by postoperative wound complications. Fisher's exact tests and Chi squared tests were used to compare categorical variables between groups and logistic regression models were used for continuous variables. P-values Results: Three-hundred thirty-five patients met inclusion criteria over the study period. One-hundred forty-one patients developed a wound complication (42%); this included 134 wound separations (40%), 22 infections (6.6%), and 4 hematomas (1.2%). Thirty-two patients (9.6%) received preoperative IV antibiotics and 42 (12.5%) received postoperative topical antimicrobial agents. Neither IV nor topical antimicrobial agents were associated with a decreased risk of wound complication (RR 0.96, 95% CI 0.62-1.49; RR 0.99, 95% CI 0.66-1.48). Demographics and preoperative characteristics were similar between those who received and did not receive antibiotics. Antibiotic administration was not associated with the maximum length or total surface area of excisions, number of vulvar excisions per surgery, or indication for WLE. Preoperative antibiotic use was similar between the gynecologic oncology and general gynecology divisions (RR 1.23, 95% CI 0.59-2.59). Patients who received IV antibiotics were more likely to be undergoing concurrent hysterectomy or other laparoscopic procedure (RR 12.8, 95% CI 7.87-20.75). Conclusions: WLE of the vulva is a common procedure among gynecologic oncologists and general gynecologists and carries a high rate of wound complication. Recent ERAS guidelines report low-level evidence to consider preoperative antibiotics for WLE and do not comment on topical antimicrobials.[1] In our study neither preoperative antibiotics nor postoperative topical antimicrobials were associated with improved outcomes. Prospective data on this topic is lacking and should be an area of future research. Antibiotic use for WLE-in the absence of concurrent clean-contaminated procedures-appears to be guided by surgeon preference.

Comparison of Surgical Outcomes of Total Laparoscopic Hysterectomy and vNOTES Hysterectomy for Undescended-Enlarged Uteri

Aim This study aimed to compare the surgical outcomes of laparoscopic hysterectomy (LH) and vaginally assisted natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy procedures in women with undescended-enlarged uteri. Materials and methods This cross-sectional study was conducted with 78 women who underwent LH (48 patients) or vNOTES hysterectomy (30 patients) for benign gynecological pathologies. The dimension of the uterus, operation time, intraoperative blood loss, the presence of peri-, postoperative complications, conversion to laparotomy, pre-, postoperative hemoglobin (Hb), and hematocrit (Hct) levels, postoperative hospital stay, total dose of postoperative analgesics, VAS scores at the postoperative 6th and 24th hours, and the final pathology reports were recorded. Results There was no significant difference between LH and vNOTES hysterectomy groups regarding age (47 vs. 47.5 years, p = 0.92), parity (2 vs. 2, p = 0.74), and BMI (30.8 vs. 28.2 kg/m2, p = 0.31). The patients in the vNOTES hysterectomy group had significantly shorter durations of surgery (45 vs. 160 min) and hospitalization (48 vs. 72 h) than the LH group (p < 0.001, p < 0.001, respectively). The 24th hour VAS score was lower (VAS score 2 vs. 3, p = 0.003) in favor of the vNOTES hysterectomy group. In matched group analysis, the 24th hour VAS score (2 vs. 3, p = 0.008), operation time (45 vs. 157, p < 0.001), and hospitalization (48 vs. 72, p < 0.001) were lower in the vNOTES hysterectomy group than the LH group. Conclusion vNOTES hysterectomy provides favorable outcomes compared to conventional LH considering the shorter operation time, hospitalization, and lower 24th h VAS score.

Robotic or laparoscopic approach for hysterectomy: comparison of operative outcomes and cost

Purpose: The present study aimed to compare surgical outcomes and cost analysis of robotic-assisted surgery (RAS) and conventional laparoscopic surgery (CLS) hysterectomy procedures.&#x0D; Materials and Methods: The patients who underwent total robotic hysterectomy or total conventional laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy due to benign gynecological disorders such as uterine fibroid, abnormal uterine bleeding, endometrial hyperplasia, adenomyosis, persistent ovarian cysts, chronic pelvic pain were retrospectively evaluated. &#x0D; Results: A total of 80 women underwent RAS or CLS hysterectomy during the study period. The mean total operative time was 187 ±10 min. in RAS and 133 ±24 min. in CLS groups, respectively. The mean total cost of the RAS hysterectomy group was 17.710 TL, and CLS hysterectomy group was 7000 TL. &#x0D; Conclusion: Both CLS and RAS hysterectomies for benign gynecological indications are safe surgical procedures with negligible complication rates. RAS is a more expensive procedure compared to CLS.