Laparoscopic Subtotal Hysterectomy Research Articles

Advanced cervical stump cancer after laparoscopic subtotal hysterectomy: a case report of imaging, laparoscopic staging and treatment approach

BackgroundAdvanced cancer of the cervical stump, occurring years after a laparoscopic supracervical hysterectomy (LASH), is a rare but serious clinical condition. Many patients who undergo a LASH are unaware of this possible complication. Upon diagnosis of advanced cervical stump cancer, a holistic approach including imaging, laparoscopic surgery and multimodal oncological therapy is required.Case presentationA 58-year-old patient presented to our department with the suspicion of advanced cervical stump cancer eight years after LASH. She reported pelvic pain, irregular vaginal bleedings and irregular discharge. Gynaecological examination revealed a locally advanced tumor of the uterine cervix with suspicion of infiltration of the left parametria and bladder. After thorough diagnostic imaging and laparoscopic staging, the tumor stage was determined as FIGO IIIB and the patient was treated with combined radiochemotherapy. The patient presented with tumor recurrence 5 months after the completion of therapy and she is currently being treated with multichemotherapy and immunotherapy regimens as palliative treatment.ConclusionPatients should be made aware about the risk of cervical stump carcinoma after LASH and the necessity for regular screening. Cervical cancer after LASH is often diagnosed at advanced stages and the treatment requires an interdisciplinary approach.

Special Focus on Subtotal Laparoscopic Hysterectomy

Today 80 percent of hysterectomies in patients with benigne and malignant disease are done by endoscopic procedures. Clear indications for Laparoscopic Subtotal Hysterectomy include a cervix free of any disturbances, a multifibroid uterus and the wish of the patient to reserve the normal function of her pelvic organs. Laparoscopically this procedure can be easily performed without any side effects. Recently in China Li, Zi-Jun et al. [25] 2020 described a new technique called Anterograde Vaginal Subtotal Hysterectomy (AVSH) which appears to be much more complicated than our Kiel based LSH initiated by Kurt Semm in 1991 [13]. It is the aim of this chapter to line out the easiness and beauty of Laparoscopic Subtotal Hysterectomy (LSH). This is not intended to be a research paper but a historical development presentation for LSH.

Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series

ObjectivesLaparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH. Study designWe report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients’ characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery. ResultsPatients’ median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34–143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1–3) and no postoperative complications within 30 days from surgery were recorded. ConclusionsLSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.

Two-port method for laparoscopic subtotal hysterectomy: approach and outcomes

Two-port method for laparoscopic subtotal hysterectomy: approach and outcomes

Laparoscopic Sacrocervicopexy for Uterovaginal Prolapse: Step by Step for Safety and Efficiency

<h3>Study Objective</h3> The purpose of this video is to demonstrate the step by step of laparoscopic sacrocervicopexy for uterovaginal prolapse using a Y-shaped monofilament polypropylene mesh. <h3>Design</h3> Laparoscopic Subtotal hysterectomy is performed. After that, opening of the posterior peritoneum took place on the sacral promontory and was extended under the right uterosacral ligament. The Douglas pouch was then opened, and the rectovaginal plane was exposed. This maneuver was facilitated by the introduction and the relevant movements of a vaginal malleable valve. Dissecting the inter vesicovaginal space, the anterior mesh is on the anterior vaginal apex with two other sutures and the anterior mesh was fixed on the anterior vaginal wall just before the trigone and at the isthmus of the uterus. After that, the posterior mesh was fixed on the posterior vaginal apex with two other sutures and on the posterior vaginal wall. Both sutures with a 2/0 polygalactin suture. Mesh were anchored on the sacral promontory using a 0 polypropylene non absorbable suture on the longitudinal ligament. At the end, full peritonization of the mesh with a 2–0 polyglactin running suture. <h3>Setting</h3> Patient positioned in a Trendelenburg lithotomy position with legs slightly bent. A 10-mm trocar was placed at the umbilicus, two 5-mm trocars were positioned 2 cm above and medially to the anterior superior iliac spine and a third was positioned midway between the umbilicus and the pubic symphysis. <h3>Patients or Participants</h3> One 56 years old female patient with uterovaginal prolapse stage IV. <h3>Interventions</h3> laparoscopic sacrocervicopexy for uterovaginal prolapse with Y-shaped monofilament macroporous polypropylene mesh. <h3>Measurements and Main Results</h3> The laparoscopic sacrocervicopexy can be performed in patient at stage IV uterovaginal prolapse after partial hysterectomy in an efficient way. After the laparoscopic sacrocervicopexy surgery, the patient evolved with correction of the prolapse to stage I. <h3>Conclusion</h3> Laparoscopic surgery allows a good view of the vaginal walls performing this procedure safely and efficiently

Learning curve analysis of applying Seprafilm hyaluronic acid/carboxymethylcellulose membrane during laparoscopic hysterectomy

This study was designed to evaluate the learning curve of applying Seprafilm (modified hyaluronic acid and carboxymethylcellulose; Genzyme, Cambridge, MA, USA) during laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy. In this retrospective cohort study, 35 patients who underwent laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy were enrolled. The Seprafilm was cut into 4 pieces, rolled up with a trimmed plastic sleeve and delivered through an incision wound made for the 5-mm ancillary trocar. The membrane was unrolled and placed on the rough surface after hysterectomy or subtotal hysterectomy with or without adnexectomy. The time from the insertion of the first piece of membrane into the abdominal cavity to the complete removal of the trimmed plastic sleeve was recorded. The median time for Seprafilm placement was 3 min. The learning curve was analyzed using the power-law method and suggested that 10 cases were required to achieve proficiency in the procedure. The presence of adnexectomy was significantly associated with the time required for Seprafilm placement (P < 0.001). Although Seprafilm placement is more complicated compared to the liquid and gel forms of anti-adhesion barriers, surgical proficiency seemed to be attained after 10 cases for an experienced surgeon.

2032 Laparoscopic Pectopexy for Prolapse Repair

Video Objective To study the efficacy and safety of Laparoscopic Pectopexy Setting Tertiary care center Interventions Since October 2015 till March 2019 – 50 cases of pectopexy have been done. Most of the cases have been of Hysteropexy in age group of 27-36 years (mean age 32 years) and 7 cases of Laparoscopic Subtotal Hysterectomy in age group of 42- 67 years (average age 54.5). And 4 cases of vault prolapse. Our technique combines site specific repair with mesh augmented repair. Anterior pelvic support is pubocervical fascia which is dissected after pushing the bladder down, and plicated with 1-0 polyester suture. After plication of Pubocervical fascia a 15 cm by 3 cm size mesh is applied over the cervical stump / lower uterine segment / vaginal vault in the center. The lateral attachments of the mesh are fixed over to the iliopectineal ligament on both the sides. Iliopectineal ligament is the posterior prolongation of the Cooper's ligament. For a global repair and long term good results plication of the uterosacral ligaments is done. Conclusion Pectopexy appears to be a new, useful tool in the armamentarium of gynecological endoscopists for hysteropexy in patients desirous of further child bearing as it gives bilateral support at level of pericervical ring. It is also applicable for vault prolapse repair and after Laparoscopic Subtotal Hysterectomy for vault suspension.

Clear cell carcinoma arising from abdominal wall endometriosis with lymph node metastasis – a rare case report and review of the literature

Abdominal wall endometriosis represents 1-2% of all endometriotic lesions. The malignant transformation of abdominal wall endometriosis is rare, though it can occur. Herein the authors report a rare case of clear cell adenocarcinoma arising from abdominal wall endometriosis with extensive lymph node metastasis. In this case, a 51-year-old woman presented with a growing mass in the right periumbilical area. Computed tomography scan revealed a 5-cm solid mass located on the right rectus muscle. A punch biopsy of the abdominal lesion was performed and histology showed metastatic adenocarcinoma of unknown origin. She had a surgical history of laparoscopic subtotal hysterectomy with right salpingo-oophorectomy. The patient underwent radical excision of the mass, trachelectomy, left salpingo-oophorectomy, and lymph node dissection. The abdominal wall mass showed clear cell adenocarcinoma arising from endometriosis on histology. There were extensive lymph node metastases. The patient underwent adjuvant chemotherapy. Both lymphatic and local invasion are key routes of clear cell adenocarcinoma arising from abdominal wall endometriosis. Extensive lymph node metastasis could be associated with poor prognosis.

Laparoscopic specimen retrieval and attitudes towards morcellation: a questionnaire survey of gynaecology consultants in the United Kingdom

The aim of this study was to evaluate the practices of laparoscopic specimen retrieval among Gynaecologists in the United Kingdom and to determine any variation in practice. A survey of Consultant Gynaecologist members of the British Society of Gynaecological Endoscopy (BSGE) was conducted using Survey Monkey™. Of the 460 registered consultants, 187 (40%) responded to the questionnaire. Sixty-two percent (62%) of the respondents considered themselves to be advanced laparoscopic surgeons whilst 34% considered themselves to be intermediate laparoscopic surgeons. The umbilical port was the most commonly used port for specimen retrieval and it was used to remove 49% of ectopic pregnancies, 43% of ovarian cysts and 43% of endometrioma. Most respondents would not insert an extra port or extend the existing port just for the retrieval of a specimen. The level of laparoscopic experience and the gender did not affect the method of specimen retrieval in cases of ectopic pregnancies, endometrioma and ovarian cysts (p value >.05, not significant). The majority of respondents used power morcellation for a laparoscopic myomectomy (85% of respondents) and laparoscopic subtotal hysterectomy (93% of respondents), despite the recent concerns surrounding power morcellation. Impact statement What is already known on this subject? There is a paucity of literature regarding laparoscopic specimen retrieval in gynaecology. In view of recent controversy pertaining to the potential upstaging of leiomyosarcoma with morcellation, other methods of specimen retrieval are gaining an importance. What do the results of this study add? This study shows that the umbilical port is the most commonly used port for specimen retrieval among UK gynaecologists and that most gynaecologists would not insert an additional port purely for specimen retrieval. Most respondents would still use power morcellation for a laparoscopic myomectomy and subtotal hysterectomy, despite the recent concerns over morcellation and its safety. What are the implications of these findings for clinical practice and/or further research? This paper demonstrates the need for development of a database of morcellation practices to enable analysis of both benefits and potential adverse outcomes. This paper will also encourage future research and the audit of specimen retrieval.

Laparoscopic Subtotal Hysterectomy: Does It Still have a Stand?

Laparoscopic Subtotal Hysterectomy: Does It Still have a Stand?

Single port access laparoscopic subtotal hysterectomy using contained manual morcellation: Experience from a tertiary referral center in Taiwan

ObjectiveTo describe the surgical outcomes of single port access laparoscopic subtotal hysterectomy (LSH) using in-bag manual morcellation and evaluate the feasibility of this procedure. Materials and MethodsThirty patients with symptomatic leiomyoma or adenomyosis were enrolled. A 2-cm transverse incision was made at the umbilicus and single port apparatus (LagiPort) was applied. After dissection of vesicouterine peritoneum from the uterus, the uterine ligaments and vessels were secured and transected by Gyrus PK cutting forceps. Cervical amputation at the level of internal os was made by SupraLoop (Karl Storz). The uterine corpus was put into an Endobag before morcellation. The opening of Endobag was exteriorized from the umbilical incision and the uterine corpus was removed in a contained manner by manual morcellation with a scalpel. ResultsThis procedure was successfully performed on all patients. Neither laparotomic conversion nor additional port was needed. The mean age and mean BMI of the patients were 43.63 years and 24.02 kg/㎡. The mean operative time was 148 min and the estimated blood loss in most patients was less than 150 ml. The median weight of uterine corpus was 214 g. No intraoperative complications occurred in any patient. One patient was diagnosed with unexpected endometrioid adenocarcinoma FIGO grade 1 postoperatively. One patient reported cyclic bleeding and underwent a transvaginal trachelectomy 17 months later. ConclusionSingle port access LSH using contained manual morcellation represents a safe and feasible alternative to conventional LSH using open power morcellation.

The Power Law of Learning in Transumbilical Single-Port Laparoscopic Subtotal Hysterectomy

Study ObjectiveTo analyze the surgical outcomes and learning curve of transumbilical single-port laparoscopic subtotal hysterectomy, which requires sutures of the cervical stump. DesignA prospective observational study (Canadian Task Force classification II-2). SettingA university-affiliated center. PatientsFrom the first (July 2012) and consecutive patients of benign uterine disease scheduled for subtotal hysterectomy until October 2013. InterventionsAll single-port laparoscopies were performed using straight instruments by 1 gynecologist. An ancillary port was added whenever technical difficulties could endanger surgical quality. Measurement and Main ResultsSeventy-five patients were recruited for intention-to-treat analysis with a mean (±SD) age of 44.7 ± 3.8 years and a body mass index of 24.2 ± 3.7 kg/m2. No major complication was noted. The mean uterine weight was 432.5 ± 344.0 g with 24 (32%) uteri ≧500 g. The patients' sequential order, or gradually increasing experience, was the determining factor in progressively decreasing operative time. Furthermore, most cases that required an additional ancillary port (67%) were clustered in the first 20 cases, whereas 4 were scattered after the 47th patient because of severe pelvic adhesion. The mean operative time decreased in the power law function of the patients' sequential order with a plateau achieved at the 20th patient. ConclusionThe patients' sequential order was identified as an independent factor of achieving purely single-port access, and the trend of decreasing operative time delineated the existence of a learning curve. Approximately 20 patients were needed for an experienced multiport laparoscopist to reach technical competency in the current series.

Complication Rate of Laparoscopic Hysterectomies in Denmark, 2011-2016.

Background and Objectives:After the U. S. Food and Drug Administration's recommendation against the use of power morcellation for tissue extraction in minimally invasive hysterectomy, the number of procedures completed laparoscopically declined in favor of open surgery laparotomy. We conducted a retrospective cohort study comparing perioperative and long-term outcomes, including complications associated with laparoscopic hysterectomy before and after the FDA recommendation.Methods:We included procedures performed in Danish government hospitals (GHs) and a hospital specializing in minimally invasive gynecological surgery (MIGS). Different types of hysterectomy over the period from January 2011 through May 2016 were examined.Results:Hysterectomies were analyzed from GHs (n = 21,495) and from a hospital specializing in MIGS (n = 749). In the GHs, we found a decrease in open hysterectomy from 40% in 2011 to 20% in 2016. In the MIGS hospital, 4 of 749 (0.05%) open hysterectomies were performed during the 6 years; however, there was a change in operative technique. After the FDA recommendation, there was a shift from laparoscopic subtotal hysterectomy (LSH) to total laparoscopic hysterectomy (TLH) from 32% in 2011 to 82% by May 2016. Containment bags were used in LSH and large-uterus TLH after the 2014 advisory. Significantly more complications occurred in the GHs than in the MIGS hospital: 3224/21,495 (15%) vs 53/749 (7.0%), respectively.Conclusion:The rate of minimally invasive hysterectomies continues to increase. However, after 2014, many of the morcellation techniques have been replaced by a minilaparotomy to extract the uterus at the end of surgery, compared to the use of the contained morcellation in 100% of cases in the MIGS hospital. There was a major difference in complication rates between the hospitals that is partly explainable by the challenge in training residents and the low operative volume of surgeons in GHs.

Survey among ESGE members on leiomyosarcoma morcellation incidence

BackgroundIncreased awareness of leiomyosarcoma (LMS) risk during myomectomy or hysterectomy is essential. Objective and correct reasoning should prevail on any decision regarding the extent and type of surgery to employ. The anticipated risk of a sarcoma after myoma or uterus morcellation is low, and the frequency of leiomyosarcoma especially in women below the age of 40 is very rare. The prevalence data has a wide range and is therefore not reliable. The European Society of Gynaecological Endoscopy (ESGE) initiated a survey among its members looking into the frequency of morcellated leiomyosarcoma after endoscopic surgery.The ESGE Central office sent 3422 members a structured electronic questionnaire with multiple answer choices for each question. After 3 months, the answers were classified with a unique number in the EXCEL spread sheet. Statistical analysis was done using the SPSS v.18.ResultsOut of 3422 members, 294 (8.6%) gynaecologists replied to the questionnaire; however, only 240 perform myomectomies by laparoscopy and hysteroscopy and hysterectomies by laparoscopy. The reported experience in performing laparoscopic myomectomy, hysteroscopic myomectomy, laparoscopic hysterectomy (LH), and laparoscopic subtotal hysterectomy (LSH) on an average was 10.8 (1–32) years. The vast majority of 67.1% had over 5 years of practice in laparoscopic surgery. The total number of 221 leiomyosarcoma was reported among 429,777 minimally invasive surgeries (laparoscopic and hysteroscopic myomectomies and LH and LSH), performed by all doctors in their lifetime. The overall reported sarcoma risk of all types of endoscopic myoma surgeries has been estimated to be 1.5% of operations which is very rare. Categorizing by type, 57 (0.06%) LMS were operated by laparoscopic myomectomy and 54 (0.07%) by hysteroscopic myomectomy, while 38 (0.13%) leiomyosarcoma operated by laparoscopic subtotal hysterectomy and 72 (0.31%) by laparoscopic hysterectomy. The probability of a sarcoma after morcellation to be falsely diagnosed by histopathology as a benign tumour and later identified as a sarcoma in a later examination has been reported and calculated to be 0.2%. The low risk of a sarcoma is also reflected by the small number of surgeries, where only 32 doctors reported that they operated once, 29 twice, and 18 operated on 3–10 sarcomas by laparoscopy during their lifetime.ConclusionThe survey demonstrated that myomectomy by hysteroscopy or laparoscopy has similar risks of sarcoma with an estimated incidence of 0.07%, much lower than that by laparoscopic hysterectomy and subtotal hysterectomy. Hence, for young patients with myoma infertility problem and low risk for LMS, myomectomy by MIS can be the first option of treatment. The fact that only 12.5% (216/1728) of uterine sarcoma cases are operated laparoscopically demonstrates the surgeons’ awareness and alertness about LMS and the potential of spreading sarcomatous cells after myoma/uterus power morcellation.

Effect of surgeon's experience on complications from laparoscopic hysterectomy

ObjectiveTo analyze the effect of learning in two surgeons on complications and conversion to laparotomy during total and subtotal laparoscopic hysterectomy. Material and methodsWe analyzed retrospectively 236 total and subtotal laparoscopic hysterectomies done by two surgeons from the time they first performed the procedure. The interventions were classified in three groups based on the surgeon's experience: the first 75 hysterectomies (“novice period”), the subsequent 75 hysterectomies (“intermediate”), and the subsequent 86 hysterectomies (“routine period”). ResultsPatient's characteristics changed as surgeons gained experience, with more complex operations (greater obesity, previous surgery and malignant disease) becoming more frequent. During the second group of operations when surgeons had an intermediate level of experience, the risk of major complications decreased (adjusted odds ratio: 0.28, 95% confidence interval: 0.10–0.85), as did the risk of type III complications of Clavien–Dindo classification (adjusted odds ratio 0.15, 95% confidence interval: 0.03–0.93). However, the percent rate of conversion to laparotomy remained stable in the second (intermediate experience) group. In the third group, after the surgeons had performed 150 procedures and when the risk of any type of complication was lowest, the risk of conversion to laparotomy decreased compared to the routine group. ConclusionsThe surgeon's experience in performing laparoscopic hysterectomy plays an essential role in the decrease in the risk of complications, and this finding supports the importance of providing appropriate training for residents and gynecologists to enable them to perform this procedure with an optimal degree of competence and safety.

Does fibroids surgery by endoscopy or laparotomy represent a malignancy threat?

The aim of this study was to 1) estimate the incidence of unsuspected uterine sarcoma in patients after myomectomies and hysterectomies for benign uterine fibroids; 2) to assess the incidence of uterine sarcomas among patient who had uterine fibroids or a suspicion of uterine sarcoma before undergoing the surgical procedures. Retrospective study in single center university hospital. Patient's records with uterine fibroids and uterine sarcoma from 2003 to 2015 collected. Data presented as mean and standard deviation for continuous variable and percentage for categorical variables. The exact Clopper-Pearson interval was used to calculate 95% confidence interval. The total number of women with uterine fibroids was 2269 and uterine sarcomas 7. Of these seven, four were uterine leiomyosarcomas (ULMS), one endometrial sarcoma (ESS), one high-grade undifferentiated uterine sarcoma (HGUS) and one embryonal rhabdomyosarcoma (ERMS). Six of these patients underwent direct open conventional cancer treatment. The mean age of the patients with ULMS was 73.7±3.9 years. Immunohistochemistry results indicated SMA(+), CD 10(+), desmin(+) and h-caldesmon(+). The two patients with HGUS and ERMS were also preoperatively diagnosed with suspected malignancy and operated upon according. However, only one woman 48 years old primarily diagnosed with benign uterine fibroids underwent a laparoscopic subtotal hysterectomy (LSH) procedure; however, the histological results detected an ESS. Immunohistochemistry showed CD10(+), desmin(+), smooth muscle actin (SMA)(-), Aktin(-) and 5% Ki67(+).Two weeks after the initial surgery, an open cervical stump resection with bilateral sapping-oophorectomy and an omentectomy was performed. The frequency of unsuspected ESS was 1/2269 among the women who underwent myomectomies and hysterectomies for the treatment of benign uterine fibroids. The total incidence of uterine sarcoma was 7/2275 among the patients who had presumed uterine fibroids or a suspicion of uterine sarcoma prior to undergoing the surgical procedures.

Postoperative sexual functioning in total versus subtotal laparoscopic hysterectomy: what do women expect?

To evaluate sexual functioning and expected changes in sexual functioning in women with planned total versus subtotal laparoscopic hysterectomy. A total of 120 women undergoing laparoscopic hysterectomy were preoperatively enrolled in this study with a cross-sectional design. Full data sets were available for 112 patients, so that 56 patients with planned total laparoscopic hysterectomy (TLH) and 56 women with planned laparoscopic supracervical hysterectomy (LASH) were preoperatively assessed. Sexual functioning was evaluated using the female sexual function index (FSFI). Additionally, participants filled in a standardised questionnaire concerning expected changes on sexual function after the procedure. Demographic parameters, expectations concerning postoperative sexuality and FSFI scores were analysed and compared in women undergoing TLH and LASH. There were no significant differences concerning demographic parameters and FSFI scores comparing collectives. Sexuality in general was considered more important in women undergoing LASH (2.88±0.83 vs. 2.48±0.89; p=0.011). Also, in 29 patients (52%) opting for LASH and 8 (14%) patients undergoing TLH a potential change in postoperative sexuality had an impact on their choice for a subtotal/total hysterectomy, respectively (p<0.001). Patients' expectations concerning preservation of the cervix and postoperative sexuality appear to have the potential to bias investigations comparing total with subtotal hysterectomy. Hence, future research focusing on this issue should be accomplished incorporating patients' expectations stratified by mode of intervention.

Frequency of uterine sarcomas in patients admitted for uterine fibroid surgery.

Objective:To estimate the frequency of unsuspected uterine sarcoma identified postoperatively in women undergoing surgery for presumed benign uterine fibroids at a single university hospital.Material and Methods:This was a retrospective single-center study; the records of all 2275 patients with uterine fibroids and uterine sarcomas from 2003 to 2015 were reviewed. Descriptive statistics were used to analyze demographic and clinical characteristics. To calculate confidence intervals (CIs), the Clopper-Pearson Exact method was applied.Results:Preoperatively, 2269 patients had presumed benign uterine fibroids, and six patients had suspected uterine sarcoma. Among the 2269 patients who underwent surgery for presumed uterine fibroids, endometrial stromal sarcoma was histopathologically revealed in only one patient [0.044%, 95% CI: (0.001-0.25)] after laparoscopic subtotal hysterectomy with morcellation. All six patients who were preoperatively diagnosed having uterine sarcoma underwent direct conventional cancer treatment. Histopathologic analyses confirmed four cases of uterine leiomyosarcoma, one high-grade undifferentiated uterine sarcoma, and one embryonal rhabdomyosarcoma. Altogether, seven women were diagnosed as having uterine sarcomas over this twelve-year period.Conclusion:In our institution, the frequency of unsuspected uterine sarcomas was 1/2269 (0.044%) among women who underwent myomectomies and hysterectomies to treat presumed benign uterine fibroids.

Subtotal hysterectomy by natural orifice transluminal endoscopic surgery.

Study objective:To introduce the innovative surgical procedure of treating benign uterine pathology with subtotal hysterectomy by natural orifice transluminal endoscopic surgery (NOTES).Design:Prospective observational study.Setting:Tertiary referral medical center.Methods:From June 2014 to May 2016, three patients with benign uterine diseases who were eligible for laparoscopic subtotal hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured.Results:Subtotal hysterectomy by transvaginal NOTES was successfully completed in all patients without any conversion to conventional laparoscopy. The operative time was 144 ± 4.5 (138–149) minutes with an average estimated blood loss of 133 ± 62 (50–200) mL. None of the patients required an intraoperative blood transfusion. The mean specimen weight was 140 ± 59 (56–188) g. The final histology reports were uterine leiomyoma and adenomyosis in these three cases. There were no intraoperative or postoperative complications. No case required intraoperative or postoperative blood transfusion. No cases were converted to traditional laparoscopy or laparotomy.Conclusion:Our preliminary results showed the safety and feasibility of subtotal hysterectomy by transvaginal NOTES in selected patients. It is one of the most minimally invasive surgeries and results in invisible scars.

Highlights of Morcellation and Sarcoma Incidence in German Patients Admitted for Uterine Fibroid Surgery [12B

INTRODUCTION: To assess the incidence and frequency of unsuspected cases of uterine sarcomas among patients undergoing surgery for benign uterine fibroids in Germany. METHODS: This was a retrospective single-center study at a university hospital. The records of patients with uterine fibroids and uterine sarcoma from 2003 to 2015 were reviewed. RESULTS: A total of 2,275 patients were included. Preoperatively, 2,269 patients had presumed benign uterine fibroids, and 6 patients had suspected uterine sarcoma. Among the 2,269 patients who underwent surgery for presumed uterine fibroids, only one patient (0.044%, 95% CI: 0.001%-0.25%) histopathologically revealed endometrial stromal sarcoma (ESS) after laparoscopic subtotal hysterectomy (LSH) with morcellation(48 years old). Six patients were diagnosed with uterine sarcoma preoperatively and underwent a direct open conventional cancer treatment. Histopathological analyses confirmed four cases of uterine leiomyosarcoma (ULMS) mean age 73.7 ± 3.9, one high-grade undifferentiated uterine sarcoma (HGUS), and one embryonal rhabdomyosarcoma (ERMS). Altogether, seven of the 2,275 women (0.31%, 95% CI: 0.12%-0. 63%) were diagnosed with uterine sarcomas over this twelve-year period. CONCLUSION: The frequency of unsuspected uterine sarcoma was 1/2,269 (0.044%) among the women who underwent myomectomies and hysterectomies to treat presumed benign uterine fibroids. The total incidence of uterine sarcoma was 7/2,275 (0.31%) among the women who had presumed uterine fibroids or a suspected uterine sarcoma before undergoing the surgical procedures. Shall we continue with unprotected morcellation.