Large Uterus Research Articles

11826 Tips and Tricks for Minimally Invasive Hysterectomy for the Large Uterus

11826 Tips and Tricks for Minimally Invasive Hysterectomy for the Large Uterus

Very pronounced bowel sparing during radiation therapy for anal carcinoma using a natural spacer (Myoma) – a case report

BackgroundUsing dose-painted intensity-modulated radiation therapy, specific dose volume constraints or implantation of tissue expanders prior to radiotherapy are validated options for reducing radiation dose on the bowel and therefore minimizing acute gastrointestinal toxicity during chemoradiation for anorectal malignancies. We describe the rare case of a female patient with a locally advanced anal carcinoma where a large myomatous uterus served as a natural spacer to protect the bowel during radiation therapy.Case presentationInitially the patient presented with anal pain, proctoscopy followed by an excisional biopsy confirmed the diagnosis of a squamous cell carcinoma of the anus. Imaging examination showed a locally advanced tumor and in addition a large uterus with typical leiomyomas up to 11.5 cm in diameter. The patient underwent chemoradiation; because of the large leiomyomas there was almost no dose burden for the small intestine and therefore practically no gastrointestinal toxicity.ConclusionAs we know, this report describes the situation that a large myomatous uterus served as a natural spacer during radiation therapy in a way that is unique to date.

Evaluation of Latrogenic Genitourinary Fistula after Major Gynaecological Operation in Patient Group Admitted in BSMMU

Introduction: Close proximity of urinary tract and genital systems in females poses potential risk of fistulas formation during surgical interventions. Gynaecological malignancy, bleeding, prolonged surgery, the presence of active infection during operation, endometriosis, large uterus, previous pelvic operation, pelvic adhesions and myoma uteri are major predisposing factors that may increase the risk of urological injuries & genitourinary fistulas. Genitourinary fistulas result in continuous or intermittent urinary incontinence and a significant public health issue with negative physical, emotional and social impacts on individuals. Materials and Methods: This cross sectional observational study was conducted in Department of Obstetrics &Gynaecology, Bangabandhu Sheikh Mujib Medical University, Dhaka, from 27th March 2017 to 26th September 2017. The sample was collected by purposive sampling technique. The study subjects were women with iatrogenic fistula (diagnosed after a clinical examination and investigations) attended in out-patients or in-patients department. Result: Mean age of patients was 32.5 ± 9.54 years. Vesicovaginal fistula was commonest cause for iatrogenic genitourinary fistula, present in 34 patients. Ureterovaginal fistula was 10 patients and 6 patients detected urethrovaginal. Aetiological factors revealed that, 46.0% occurred during vaginal hysterectomy, 18.0% due to abdominal hysterectomy, 20.0% due to laparotomy with salphingoophorectmy and 16.0% during laparotomy with cystectomy. Conclusion: The commonest urogenital fistula is the vesicovaginal fistula. Urinary leakage following gynaecological surgery is a dreaded complication due to the formation of urogenital fistula. Thorough evaluation, using all diagnostic tools for complete diagnosis, understanding the pathophysiology and choosing the best surgical procedure are mandatory to obtain good outcomes after the surgical procedures. Medicine Today 2024, Vol.36 (2): 110-113

Charting Proficiency: The Learning Curve in Robotic Hysterectomy for Large Uteri Exceeding 1000 g.

Background/Objectives: This study evaluates the safety and surgical outcomes of performing robotic hysterectomy on uteri weighing over 1000 g, with a focus on the surgeon's learning curve. Methods: A retrospective analysis was conducted on 44 patients who underwent hysterectomy by a single surgeon from January 2020 to February 2024 using the DaVinci Xi System. Surgical procedures included total hysterectomy with bilateral salpingectomy, and specimens were removed via transvaginal manual morcellation. Operative times were segmented into docking, console, morcellation, and conversion times. Results: Results indicated an inflection point in the 20th case, suggesting proficiency after 20 surgeries. Comparison between early (Group A, cases 1-20) and later cases (Group B, cases 21-44) showed significant reductions in console time (CT) and morcellation time (MT) in Group B, leading to a shorter overall operative time (OT). Although estimated blood loss was higher in Group A, it was not statistically significant. Hemoglobin differences were significantly higher in Group B. No significant differences were observed in transfusion rates, postoperative analgesic usage, or complications between the groups. Conclusions: The study concludes that robotic hysterectomy for large uteri is safe and that surgical proficiency improves significantly after 20 cases, enhancing overall outcomes.

O-024 Age affects ultrasound markers of endometrial receptivity in artificial cycles

Abstract Study question Are ultrasound markers of endometrial receptivity affected by patient age in artificial cycles? Summary answer Maternal age is linked to certain ultrasound markers such as a larger uterus, reduced endometrial compaction and lower uterine peristalsis. What is known already The decline in fertility in advanced age women has traditionally been linked to low oocyte quantity and quality. However, recent studies indicate that age may also affect endometrial aspects, influencing implantation and live birth rates. Advanced age can lead to impaired decidualization, increased fibrosis and decreased expression of progesterone and estradiol receptors. This study aims to investigate the influence of age on ultrasound factors related to implantation in patients undergoing embryo transfer in artificial cycles. Study design, size, duration Retrospective study of 452 patients undergoing frozen embryo transfer with artificial cycle, between January 2017 and December 2023. Participants/materials, setting, methods Ultrasound markers were evaluated, including assessment of uterine pathology, endometrial thickness before and after the onset of progesterone and uterine peristalsis. Serum progesterone level was also analysed. Spearman correlation and multivariate linear regression were used for analysis, adjusting for uterine factors. Subgroup analysis was performed for patients aged ≥45 years. Main results and the role of chance Age correlated inversely with endometrial compaction (S range: 0.3–0.2; p = 0.01) and uterine peristalsis (S range: −0.3–0.1; p < 0.001) and positively with uterus length (S range: 0.2–0.3; p < 0.001) and fibroids. Multivariate linear regression confirmed independent associations (R=.45; p < 0.001). Logistic regression in patients aged ≥45 revealed associations with uterine peristalsis (OR 0.7, 95%CI 0.5–0.9; p = 0.04) and uterus length (OR 1.03; 95%CI 1.01-1.06) but not with endometrial compaction (p = 0.103). Limitations, reasons for caution The main limitation of the study is its retrospective nature. Being a study based on daily clinical practice, the group of patients can be heterogeneous, which may have influenced the results. Studies with a homogeneous control group are needed to corroborate our findings. Wider implications of the findings Our findings indicate that advanced maternal age affects uterine ultrasound factors, potentially influencing endometrial receptivity in artificial treatments. This may be useful to inform patients of their prognosis and to perform better clinical counseling, as well as to explore different therapeutic strategies in older patients. Trial registration number not applicable

Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review.

To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint. PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible. This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy. The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss. Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time. PROSPERO, CRD42021233300.

Fetal external features and morphology of the umbilical cord of wild boars.

This study aimed to describe the gestational and morphological aspects of the fetuses and their respective umbilical cords from two pregnant wild boars (Sus scrofa). Morphological descriptions were provided for 23 fetuses and the gestational ages were estimated through fetal characteristics and formula application. The specimens were fixed in 10% formalin for subsequent macroscopic and microscopic examination. Histological characterization was performed using haematoxylin-eosin (H&E), Masson's trichrome (MT) and Verhöeff's staining techniques. The wild boar fetuses exhibited an estimated gestational age of 55 days (in the larger uterus) and 45 days (in the smaller uterus). They displayed well-developed features consistent with domestic pig fetuses, except for the presence of five pairs of mammae. Additionally, the umbilical cord consisted of two arteries, one vein, an allantoic duct, and a vitelline duct (the latter two identified only microscopically), located in the juxtafetal, intermediate and juxtaplacental portions. The arteries and veins were comprised of endothelium, smooth muscle and collagen fibres, with no elastic fibres observed in the vessel walls. The allantoic duct was lined with simple cuboidal epithelium, while the vitelline duct featured a simple squamous epithelium. In conclusion, the morphological characteristics observed in the examined structures align with the expected patterns for species of the Suidae family. Furthermore, these findings contribute substantially to the morphological characterization of the wild boar, yielding valuable insights into the fetal morphology and the structure of the umbilical cord.

Non-descent vaginal hysterectomies: a brief report

Non-descent vaginal hysterectomies: a brief report

Assessing perioperative risk with hysterectomy in very large uteri by surgical route

Assessing perioperative risk with hysterectomy in very large uteri by surgical route

VNOTES hysterectomy of the large fibroid uterus - tips and tricks

vNOTES hysterectomy of the large fibroid uterus - tips and tricks

Robotic-assisted total laparoscopy hysterectomy for the large uterus: size does not matter

Robotic-assisted total laparoscopy hysterectomy for the large uterus: size does not matter

The feasibility and benefits of minimally invasive hysterectomy for large uterus

The feasibility and benefits of minimally invasive hysterectomy for large uterus

Procrastinating necessary evolution awaiting a calamity: The journey post the morcellation saga

Abstract This review article highlights the need for the timely adoption of various containment devices for tissue retrieval of large specimens, especially myomas and large uteri, irrespective of the minimally invasive surgical route or modality used for debulking, principally focusing on morcellation. This article aims to share the feasibility and safety profile of laparoscopic contained power morcellation and also to provide a basic comparative overview of various other tissue retrieval techniques currently employed. The authors share their technical experience of nearly 3000 cases of laparoscopic contained in-bag morcellation of fibroids or large uteri, which required debulking for retrieval and also the possible limitations. The authors found this technique viable, safe, and effective in reducing potential hazards of uncontained morcellation such as parasitic fibroids, leiomyomatosis peritonei and also reducing possible up-staging of cancers, but believe there is a pivotal role of preoperative diagnostic differentiation of any malignant conditions, which may be lacking in some cancers such as leiomyosarcoma. In conclusion, the authors urge to make this necessary evolution in tissue retrieval techniques rather than procrastinating for other multiple calamities to strike again.

Hysterectomy for Large Uterus by Minimally Invasive Surgery (MIS).

When the uterus is or more than 18 to 20 weeks in size, laparotomy but not minimally invasive surgery (MIS) is commonly performed for hysterectomy. It is, however, acknowledged that MIS carries numerous benefits to patients compared to laparotomy. The uterine size should therefore not be an excluding factor for MIS. This study aims to demonstrate the feasibility and benefits of MIS for hysterectomy for large uterus and explain specific techniques employed. Data from 73 laparoscopic and robotic hysterectomy cases were collected. Cases were divided in two groups based on uterine weight (≥500 g vs <500 g). Estimated blood loss (EBL), operative time, length of hospital stays, and perioperative complications were compared between the groups. The average specimen weight in two groups was 244 ± 102.75 g vs 903 ± 438.18 g (P < .01). There was no statistically significant difference in length of hospital stay between the two groups. Only 3 patients were hospitalized for more than one day. There were no instances of conversion to laparotomy, intraoperative or postoperative blood transfusion. There was a statistically significant difference in the EBL (78.19 ± 43.8 ml vs 127.88 ± 69.76 ml, P < .01) and operative time (180.68 ± 48.36 vs 228.85 ± 53.04 minutes, P < .01) between the two groups. There were two cases of bladder laceration in the group with uterine weight exceeding 500 g. With advanced surgical skills and the adoption of specific techniques, hysterectomy for large uterus can be performed safely and efficiently by MIS.

Computed tomographic findings in a canine ovarian teratoma.

A 2-year-old, intact female, Labrador Retriever was referred for progressive abdominal distension, assessed by emergency clinicians as being extrauterine in origin on AFAST. Abdominal radiographs and ultrasound identified a large, lobulated, partially mineralized, soft tissue, mid-abdominal mass and gravid uterus. Contrast-enhanced CT identified a mixed fat to soft tissue attenuating mass with a complex internal mineralized matrix, heterogeneous contrast enhancement, receiving blood from the left ovarian artery. Histology confirmed a left ovarian teratoma, diffuse endometrial hyperplasia, and fetal implantation. The patient had a good post-operative outcome for 2 years, but was later diagnosed with primary cranial mediastinal neuroendocrine carcinoma.

A new knotless parametrial tissue ligation technique for safe total laparoscopic hysterectomy.

Parametrial tissue ligation during total laparoscopic hysterectomy (TLH) is important in large uteri with large vessels. A retrospective study was performed at Asan Medical Center for comparing TLH performed with a new knotless parametrial tissue ligation method and conventional laparoscopic-assisted vaginal hysterectomy (LAVH) from March 2019 to August 2021. For TLH, after anterior colpotomy, the parametrial tissue was ligated by anchoring the suture and making a loop in one direction three times using 1-0 V-LocTM 180 (Covidien, Mansfield, MA, USA) suture. Subsequently, the cranial part of the loop was cut using an endoscopic device. A total of 119 and 178 patients were included in the TLH and LAVH groups, respectively. The maximal diameter of the uterus was larger in the TLH group (106.29±27.16 cm) than in the LAVH group (99.00±18.92 cm, P=0.01). The change in hemoglobin (Hb) level was greater in the LAVH group than in the TLH group (P<0.001). The weight of the removed uterus was greater in the TLH group than in the LAVH group (431.95±394.97 vs. 354.94±209.52 g; P=0.03). However, when the uterine weight was >1,000 g, the operative times and change in Hb levels were similar between the two groups. In both groups, no ureteral complications occurred during or after surgery. Knotless parametrial tissue ligation using 1-0 V-LocTM 180 suture in TLH can be safely applied, even in cases with large uteri, without increased risks of ureteral injury or uterine bleeding.

Racial disparities between measures of area deprivation and financial toxicity, and uterine volume in myomectomy patients

BackgroundAt time of myomectomy, a surgical procedure to remove uterine fibroids, Black women tend to have larger uteri than White women. This makes Black patients less likely to undergo a minimally invasive myomectomy which has been shown to have less postoperative pain, less frequent postoperative fever and shorter length of stay compared to abdominal myomectomies. The associations between individual financial toxicity and community area deprivation and uterine volume at the time of myomectomy have not been investigated.MethodsWe conducted a secondary data analysis of patients with fibroids scheduled for myomectomy using data from a fibroid treatment registry in [location]. We used validated measures of individual-level Financial Toxicity (higher scores = better financial status) and community-level Area Deprivation (ADI, high scores = worse deprivation). To examine associations with log transformed uterine volume, we used linear regression clustered on race (Black vs. White).ResultsBlack participants had worse financial toxicity, greater deprivation and larger uterine volumes compared with White participants. A greater Financial Toxicity score (better financial status) was associated with lower uterine volume. For every 10 unit increase in Financial Toxicity, the mean total uterine volume decreased by 9.95% (Confidence Interval [CI]: -9.95%, -3.99%). ADI was also associated with uterine volume. A single unit increase in ADI (worse deprivation) was associated with a 5.13% (CI: 2.02%, 7.25%) increase in mean uterine volume.ConclusionDisproportionately worse Financial Toxicity and ADI among Black patients is likely due to structural racism – which now must be considered in gynecologic research and practice.Trial RegistrationNot applicable.

9875 Approaching the Large Uterus: Early Colpotomy and Other Tips.

9875 Approaching the Large Uterus: Early Colpotomy and Other Tips.

Cost-effectiveness of two treatments for excessive menstrual bleeding in large uteri

Introduction: Excessive menstrual bleeding is menstrual loss that interferes with the woman's quality of life, regardless of the absolute amount. Drug treatment is preferred to avoid surgical risks and preserve fertility. Anti-inflammatory, antifibrinolytic, oral contraceptive and progestogen are prescribed. These therapies result in 40 to 50% reduction in menstrual loss. The intrauterine levonorgestrel system (SIU-LNG) is the most effective long-term clinical treatment. On the other hand, hysterectomy is the most widely performed gynecological surgical procedure in the world and, although it offers complete control of symptoms, it is the most invasive, morbidly, irreversible and costly method of treatment. Objective: To compare the results and costs of clinical treatment with SIU-LNG and hysterectomy in women with large uteri and excessive menstrual bleeding. Method: It is a retrospective cohort study with 62 patients who performed two treatments: SIU-LNG insertion or videolaparoscopic hysterectomy (HVLP) and followed for four years. Results: The groups were homogeneous regarding age, parity, body mass index, schooling and uterine volume. SIU-LNG failed in 32.3% of patients, while the efficacy of hysterectomy was 100%. Complications occurred 22.6% after UIS insertion and 19.4% in the surgical group, the most serious. The cost of clinical treatment, including its complications, was nearly five times lower than the cost of surgical treatment with its complications. Conclusion: Compared to hysterectomy, treatment with SIU-LNG had lower efficacy, but simpler complications and lower costs.

Successful myomectomy in a 36 weeks size fibroid uterus through a supra pubic transverse incision

Uterine fibroids are the commonest Gynecological benign tumor which affect reproductive age women. Surgical management of large fibroid uterus create multiple challenges to both surgeon and the patient. This is a case of large fibroid uterus in an unmarried lady, grown up to the level of xiphisternum which treated with successful myomectomy through a suprapubic transverse incision.