Surgery For Benign Gynecologic Disease Research Articles

Effect of A118G (rs1799971) single-nucleotide polymorphism of the μ-opioid receptor OPRM1 gene on intraoperative remifentanil requirements in Japanese women undergoing laparoscopic gynecological surgery.

Abundant data are available on the effect of the A118G (rs1799971) single-nucleotide polymorphism (SNP) of the μ-opioid receptor OPRM1 gene on morphine and fentanyl requirements for pain control. However, data on the effect of this SNP on intraoperative remifentanil requirements remain limited. We investigated the effect of this SNP on intraoperative remifentanil requirements. We investigated 333 Japanese women, aged 21-69 years, who underwent laparoscopic gynecological surgery for benign gynecological disease under total intravenous anesthesia at Juntendo University Hospital. Average infusion rates of propofol and remifentanil during anesthesia and the average bispectral index (BIS) during surgery were recorded. Associations among genotypes of the A118G and phenotypes were examined with the Mann-Whitney U test. The average propofol infusion rate was not different between patients with different genotypes. The average remifentanil infusion rate was significantly higher in patients with the AG or GG genotype than the AA genotype (p = 0.028). The average intraoperative BIS was significantly higher in patients with the GG genotype than the AA or AG genotype (p = 0.039). The G allele of the A118G SNP was associated with higher intraoperative remifentanil requirements and higher intraoperative BIS values but was not associated with propofol requirements. Given that remifentanil and propofol act synergistically on the BIS, these results suggest that the G allele of the A118G SNP is associated with lower effects of remifentanil in achieving adequate intraoperative analgesia and in potentiating the sedative effect of propofol on the BIS.

Insight on the intracrinology of menopause: androgen production within the human vagina

ABSTRACT Introduction The human vagina is extremely sensitive to hormonal changes occurring during the woman's lifetime, in particular the decline in estrogens that characterizes the menopause is known to induce a range of genital and sexual symptoms (dryness, burning, irritation, lack of lubrication, discomfort, pain), known as “genitourinary syndrome of menopause” (GSM). However, this reduction in estrogen levels is also accompanied by a progressive ageing-dependent decline in androgens for which the role of androgens in the development and treatment of GSM has received more attention. It is known that peripheral tissues compensate for circulating hormonal imbalances through the in-situ production of small quantities of sex hormones deriving from inactive precursors metabolized by specific cellular enzymes. This non-classical production and local activity of hormones is defined as “intracrinology”. Objective The aim of the study was to investigate whether the human vagina possesses the specific enzymatic machinery to convert weak androgen precursors, such as DHEA, into active androgens [Δ4-androstenedione (A), testosterone (T) and dihydrotestosterone (DHT)] as already described in other species. Methods In this study, a well established model of human smooth muscle cells (hSMCs), isolated from vagina tissues of women undergoing surgery for benign gynecological diseases, was used. Semi-quantitative RT-PCR was employed in order to evaluate the mRNA expression of the steroidogenic markers in hSMCs and corrispective tissue. The production of androgens was quantified in hSMCs medium by liquid chromatography tandem-mass spectrometry (LC-MS/MS). Results In vaginal tissues, AR mRNA was significantly less expressed than estrogen receptor α (ERα), whereas in hvSMCs, its mRNA expression was higher than progestin and both estrogen receptors. In hvSMCs and in vaginal tissue, when compared to ovaries, the mRNA expression of pro-androgenic steroidogenic enzymes (HSD3β1/β2, HSD17β3/β5), along with 5α-reductase isoforms and sulfo-transferase, resulted as being more abundant. In addition, enzymes involved in androgen inactivation were less expressed than in the ovaries. The LC-MS/MS analysis revealed that, in hvSMCs, short term DHEA supplementation increased Δ4-androstenedione levels in spent medium, while increasing testosterone (T) and dihydrotestosterone (DHT) secretion after longer incubation. Finally, androgenic signaling activation was evaluated through AR-dependent marker mRNA expression, after DHEA and T stimulation. Conclusions This study provides evidence for the presence of steroidogenic machinery in the human vagina, supporting, for the first time, the construct of intracrinology in this organ, emphasizing that the vagina is an androgen-dependent organ. These observations suggest the potential mechanism and resulting action of intravaginally administered DHEA, recently indicated for the treatment of GSM and open new perspectives for the treatment of this common and bothersome condition. Disclosure Work supported by industry: no.

Expression of lnc-MyD88 and its relationship with the prognosis of patients with epithelial ovarian cancer

Objective: To explore the expression of long non-coding RNA-myeloid differentiation factor 88 (lnc-MyD88) and its relationship with the prognosis of patients with epithelial ovarian cancer (EOC). Methods: A total of 70 EOC patients who underwent initial cytoreductive surgery and platinum-based drugs combined with paclitaxel for 6 to 8 courses were selected at Sichuan Cancer Hospital from January 2016 to January 2019. The fresh cancer tissue specimens were collected. In addition, 28 fresh normal ovarian tissues from patients who underwent surgery for benign gynecological diseases during the same period were collected as control group. Reverse transcription (RT) and real-time quantitative polymerase chain reaction (qPCR) were used to detect the expression of lnc-MyD88 and myeloid differentiation factor 88 (MyD88) mRNA in EOC tissues and normal ovarian tissues. The correlation between the expression of lnc-MyD88 and MyD88 mRNA in EOC was analyzed by Pearson's correlation coefficient. The relationship between lnc-MyD88 expression and clinicopathological characteristics of patients with EOC was analyzed. Kaplan-Meier method was used to calculate the survival rate of patients. The log-rank test was used for univariate survival analysis, and Cox proportional hazard model was used for multivariate survival analysis. Results: (1) RT-qPCR showed that the relative expression level of lnc-MyD88 and MyD88 mRNA in EOC were 0.009 (0.000-0.049) and 0.001 (0.000-0.006), respectively, which were significantly higher than those of normal ovarian tissues (all P<0.01); Pearson's correlation coefficient showed that the expression of lnc-MyD88 and MyD88 mRNA in EOC was positively correlated (r2=0.610, P<0.01). (2) The high expression rate of lnc-MyD88 in EOC patients with lymph node metastasis, distant metastasis and chemotherapy resistance (71%, 64% and 70%, respectively) were significantly higher than the patients in control group (41%, 40% and 35%, respectively; all P<0.05). There were no statistically significant in the high expression rate of lnc-MyD88 in EOC patients with different ages, pathological types, pathological grades, surgical pathological stages, postoperative residual lesion size, and ascites cancer cells (all P>0.05). (3) Univariate analysis showed that surgical pathological staging, lymph node metastasis, distant metastasis, postoperative residual tumor size, and high expression of lnc-MyD88 and MyD88 mRNA significantly affected the progression-free survival (PFS) and overall survival (OS) of EOC patients (all P<0.05), ascites cancer cells were the risk factors that significantly affected PFS in EOC patients (P=0.040); multivariate analysis showed that surgical pathological staging and high expression of lnc-MyD88 and MyD88 mRNA were independent factors affecting PFS and OS in EOC patients (all P<0.05), the size of residual lesions after surgery was an independent factor affecting PFS in EOC patients (P=0.001). Conclusions: The level of lnc-MyD88 expression in ovarian cancer tissues was significantly increased. Lnc-MyD88, as a molecular marker for the poor prognosis of EOC, is related to the expression of MyD88 in EOC, and may be involved in its expression regulation, thereby affecting the survival and prognosis of EOC patients.

Cosmetic Outcome of Robotic Surgery Compared to Laparoscopic Surgery for Benign Gynecologic Disease.

Background and Objectives:This study was designed to compare patients who have undergone conventional laparoscopic surgery with those who undergone multiport robot-assisted laparoscopic surgery for benign gynecological diseases regarding cosmetic results, patient satisfaction, and quality of life.Methods:Sixty-four patients who underwent either robot-assisted or conventional laparoscopic surgery for benign gynecological diseases from July 1, 2019 to March 31, 2020 at Acibadem Mehmet Ali Aydinlar University Hospital were enrolled. Patients were evaluated using the Patient and Observer Scar Assessment Scale, visual analog scale for cosmetic satisfaction, body image questionnaire, and 12-item Short Form Survey six months postoperatively.Results:The median patient assessment scale and observer assessment scale (general) values were significantly higher in the robotic group than in the laparoscopic group. The mean body image questionnaire (cosmetic section) and visual analog scale values were significantly higher in the laparoscopic group than in the robotic group. No significant differences in body image scale, body image questionnaire 9–10, and 12-item Short Form Survey values were observed between the groups. The number of patients with previous surgical history was significantly higher in the laparoscopic group than in the robotic group.Conclusion:Although esthetic concerns are not a priority consideration when deciding an appropriate surgical method, the higher cosmetic satisfaction rate in the laparoscopic group than in the robotic group suggests that cosmetic results should be discussed with patients after evaluating other factors.

P–699 Multi-scale study of the architecture, topography and mechanics of the human ovary from prepuberty to menopause: a blueprint for next-generation bioengineering and diagnosis

Abstract Study question Does the ovarian ECM have a precise and unique biophysical phenotype, specific to each age, from prepuberty to menopause? Summary answer Differences between healthy prepubertal, reproductive-age, and menopausal ovarian tissue, unravel and elucidate a unique biophysical phenotype of reproductive-age tissue, bridging biophysics and female fertility. What is known already Ovarian engineering has recently emerged to respond to patient needs and offer reliable models for basic research. It has relied on synthetic and natural biomaterials and microfluidics. However, these techniques were designed based on knowledge acquired from 2D cell culture and animal models. Our lack of information on the human ovary hampers our ability to mimic the main features of this organ, for clinical applications. The complex composition and hierarchical structure of its ECM complicates the design of truly biomimetic constructs, notably: fiber morphology, interstitial and perifollicular fiber orientation, porosity, topography, and viscoelasticity, which all play a role in mechanotransduction. Study design, size, duration Ovarian biopsies were taken from prepubertal (mean age [±SD]=7±3 years, n = 21), reproductive age (mean age [±SD]=27±5, n = 26 ) and menopausal (mean age [±SD]=61±6 years, n = 29) patients after obtaining their informed consent. All participating adult subjects were undergoing laparoscopic surgery for benign gynecological diseases not affecting the ovaries. Prepubertal tissue was derived from young cancer patients scheduled for ovarian cortex cryopreservation as a fertility preservation strategy, before being subjected to acute gonadotoxic cancer treatments. Participants/materials, setting, methods All samples were cryopreserved by slow freezing and kept frozen until the day of their analysis. Tissues provided from the same patients (n = 5 per age group) were investigated by scanning electron microscopy (SEM) (fiber, pore and topography analyses) and atomic force microscopy (AFM). A larger number of paraffin-fixed biopsies (prepubertal, n = 16, reproductive-age, n = 21, and menopausal, n = 24) obtained from the biobank of St-Luc’s Hospital were used to conduct computed fiber orientation analysis. Main results and the role of chance Our results revealed a unique ECM architecture at reproductive age, where fibers of intermediate diameter are assembled into thickest bundles compared to prepubertal and menopausal tissues(p &amp;lt; 0.0001). Indeed, during prepuberty the bundles assemble into a tight network with high number of small pores while reproductive-age ovary gain more porosity(p &amp;lt; 0.0001). However, at menopause tissue pore number and area change significantly(p &amp;lt; 0.001). These pore geometry and distribution changes contribute to diffusion and access of key molecules to/from cells, which can be translated into changes in permeability and molecule selectivity with age. Fiber directionality around follicle borders at preantral stages revealed that before and after puberty, secondary follicles appear to modify their microenvironment arrangement locally compared to follicles at earlier stages of development (p &amp;lt; 0.01), by reorienting the majority of collagen fibers below 50°.This could indicate that follicles at this stage require higher fiber contact and adhesion signaling to complete their development and maturation towards ovulation. AFM evidenced a relatively rigid ovarian tissue at prepuberty, softening significantly at reproductive age, then stiffening considerably upon menopause. These differences(p &amp;lt; 0.01) are not only structure-dependent, but also related to biochemical differences in ECM composition, as previously demonstrated in our follow-up of variations in elastic matrisome components from prepuberty to menopause. Limitations, reasons for caution The samples represent single time points from each age group which could present limitations, since following ovary dynamics from prepuberty to menopause in the same patient is not feasible. Wider implications of the findings: Our study provides the first conclusive proof of a link between ECM biophysics and fertility by comparing different stages of ovarian transformation related to a woman’s reproductive life, which will oriente new strategies for infertility prognoses based on ECM biophysics and may become a blueprint for designing functional engineered ovaries. Trial registration number Not applicable

Pregnancy and childbirth after transvaginal natural orifice transluminal endoscopic surgery for benign gynecological diseases.

In recent years, natural orifice transluminal endoscopic surgery (NOTES) has been utilized as an extended innovation of conventional laparoscopy. Due to its natural advantages, such as easy access to the peritoneal cavity and safe closure of the incision, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has become a popular surgical treatment method.

Analysis of the operative factors related to anal exhaust time after laparoscopic surgery for benign gynecological diseases

PurposeThe study seeks to determine surgical factors related to anal exhaust in patients treated with laparoscopic surgery for benign gynecological diseases and to explore measures that effectively promote the rapid recovery of intestinal function in these patients. MethodsFrom June 2017 to August 2018, 155 patients with benign gynecological diseases who underwent laparoscopic surgery in our hospital were selected as study subjects. Patients were divided into two groups based on anal exhaust time: the ≤ 24-hour group and > 24-hour group. Factors related to the operation were statistically analyzed for all patients. Chi-squared tests and logistic regression were used for univariate and multivariable analyses. ResultsOf 155 gynecological patients, 57 (36.8%) underwent laparoscopic ovarian cyst stripping, 48 (30.9%) underwent laparoscopic salpingectomy with/without oophorectomy, and 50 (32.3%) underwent laparoscopic myomectomy. Among all patients, 62 (40.0%) and 93 (60.0%) had anal exhaust within and after 24 h, respectively. Univariate analysis results revealed differences in the operation method (P = 0.040), intraoperative blood loss (P = 0.037), operation duration (P = 0.007), whether an abdominal drainage tube was placed (P = 0.012) and whether warm saline was used (37 °C) for abdominal washing (P = 0.013) between groups. Logistic regression analysis showed that the duration of the operation (P = 0.027) and whether warm saline was used for abdominal washing (P = 0.040) were the main factors affecting anal exhaust time. ConclusionDuring laparoscopy for patients with benign gynecological diseases, abdominal washing with warm water is an important factor that promotes early postoperative anal exhaust and is worthy of use in clinical practice.

Insight on the Intracrinology of Menopause: Androgen Production within the Human Vagina.

In this study, we investigated steroidogenic gene mRNA expression in human vaginas and verified the ability of human vagina smooth muscle cells (hvSMCs) to synthesize androgens from upstream precursor dehydroepiandrosterone (DHEA). As a readout for androgen receptor (AR) activation, we evaluated the mRNA expression of various androgen-dependent markers. hvSMCs were isolated from vagina tissues of women undergoing surgery for benign gynecological diseases. In these cells, we evaluated mRNA expression of several steroidogenic enzymes and sex steroid receptors using real time reverse transcription-polymerase chain reaction. Androgen production was quantified with liquid chromatography tandem-mass spectrometry (LC-MS/MS). In vaginal tissues, AR mRNA was significantly less expressed than estrogen receptor α, whereas in hvSMCs, its mRNA expression was higher than progestin and both estrogen receptors. In hvSMCs and in vaginal tissue, when compared to ovaries, the mRNA expression of proandrogenic steroidogenic enzymes (HSD3β1/β2, HSD17β3/β5), along with 5α-reductase isoforms and sulfotransferase, resulted as being more abundant. In addition, enzymes involved in androgen inactivation were less expressed than in the ovaries. The LC-MS/MS analysis revealed that, in hvSMCs, short-term DHEA supplementation increased Δ4-androstenedione levels in spent medium, while increasing testosterone and DHT secretion after longer incubation. Finally, androgenic signaling activation was evaluated through AR-dependent marker mRNA expression, after DHEA and T stimulation. This study confirmed that the human vagina is an androgen-target organ with the ability to synthesize androgens, thus providing support for the use of androgens for local symptoms of genitourinary syndrome in menopause.

Potential Effect of Celecoxib on Pain Reduction and Gene Expression Related with Prostaglandins after Single Port Laparoscopic Surgery

Study Objective To evaluate the potential effect of celecoxib on pain reduction and identify change of expression of relevant genes after laparoscopic surgery for benign gynecologic diseases. Design A randomized, double-blind, placebo-controlled pilot trial Setting Under general anesthesia single port laparoscopic surgery was done in lithotomy position. Patients or Participants Patients who received single port laparoscopic surgery for benign gynecologic disease from October 2017 to April 2018. Interventions All patients were randomly assigned according to preoperative medication as follows: celecoxib 400 mg; placebo 400 mg. Two peritoneal tissues were obtained before and after capnoperitoneum, and all patients received patient-controlled analgesia (PCA) after surgery. Thereafter, we evaluated numeric rating scale (NRS), and the numbers of intravenous ketorolac used as a rescue drug. Moreover, we compared expression of genes which activate PG such as PG I2 synthase (PSGIS), PG E synthase (PTGES), PTGES3, and genes which inactivate PG including 15-hydroxyprostaglandin dehydrogenase (HDPG) and aldo-keto reductase family 1 member C3 (AKR1C3) in the two peritoneal tissues between the two groups by reverse transcription polymerase chain reaction. Measurements and Main Results A total of 62 patients received celecoxib (n=30) and placebo (n=32), and there were no differences in characteristics between the two groups. Pain reduction by celecoxib was observed in only patients whose capnoperitoneum maintained 60 min or more, and the effect was more definite in those under PCA. When we compared the five genes between the two groups, an increase of HDPG expression was also identified in only those whose capnoperitoneum maintained 60 min or more. Conclusion The potential effect of celecoxib may be related with an increase of HDPG expression in patients whose capnoperitoneum maintained 60 min or more (No. of trial; NCT03391570).

A Randomized Controlled Trial of Thermo-Sensitive Sol-Gel Anti-Adhesion Agent after Gynecologic Surgery.

Postoperative abdominal adhesions can lead to several adverse consequences such as pelvic pain, bowel obstruction, and infertility. We aimed to explore the anti-adhesion efficacy and safety of a thermo-sensitive sol–gel agent in patients who receive abdominopelvic surgery for benign gynecologic disease. This study was a randomized, controlled, single-blind clinical trial of women undergoing benign gynecologic surgery between January 2017 and December 2017. The patients were randomly assigned to three groups with a 1:1:1 ratio: experimental group (received the thermo-sensitive sol–gel agent), control group (untreated), and comparator group (received 4% icodextrin). Patients were followed for 4 weeks postoperatively, and efficacy was evaluated by performing the visceral slide test to identify adhesion formation. In total, 183 patients were enrolled in the study, and 178 (97.3%) completed the trial. The incidence rate of abdominal adhesion formation was significantly lower in the experimental group than in the control group (7.9% vs. 21.1%, p = 0.040); however, it was similar between the experimental and comparator groups (7.9% vs. 13.8%. p = 0.299). At 4 weeks, no differences in adhesion-related symptoms were observed between the experimental and control groups. Adverse events were mostly mild and did not differ significantly among the three groups (p = 0.375). In conclusion, use of a thermo-sensitive sol–gel agent was safe and effective to prevent abdominal adhesions after benign gynecologic surgeries.

Isoflavone increases the mRNA expression levels of IL-6 signal transducer glycoprotein 130 in human endometrial glandular cells

Purpose of investigation: The authors examined whether isoflavone can effectively increase the secretion of cytokines associated with implantation from endometrial glandular cells. Material and Methods: Endometrial tissue was collected from 14 patients who underwent surgery for benign gynecological diseases in this hospital. The endometrial tissue was separated into stromal and glandular cells, and isoflavone was added to the glandular cells at a concentration of 0, 0.05, 0.5, and 5 &#x03BC;g/ml. In another group, an estrogen receptor antagonist was added together with isoflavone. After 24 hours, the expression levels of leukemia inhibitory factor, interleukin (IL)-6, IL-11, and IL-6 signal transducer glycoprotein 130 (IL-6/gp130) were measured by quantitative polymerase chain reaction. Results: A significant increase in the expression of IL-6/gp130 was found in glandular cells treated with isoflavone (0.5 &#x03BC;g/ml). The significant differences were not observed among the groups upon treatment with isoflavone and an estrogen receptor antagonist, indicating that isoflavone acted via the estrogen receptor. Conclusion: Isoflavone increases the mRNA expression levels of IL-6/gp130 in human endometrial glandular cells of early to mid secretary phase.

Assessment of Cervicovaginal Cancer Antigen 125 Levels: A Preliminary Study for Endometrial Cancer Screening

Aim: We primarily aimed to compare the levels of serum and cervicovaginal cancer antigen 125 (CA 125) in women with and without endometrial carcinoma in order to reveal whether cervicovaginal CA 125 could be used as a non-invasive method. Methods: A preliminary case-control study was designed. The study group consisted of patients who were operated for endometrial adenocarcinoma or endometrial intraepithelial neoplasia. The control group consisted of patients who underwent surgery for benign gynecological diseases. Serum and cervicovaginal secretions were immediately collected before surgery to compare levels of CA 125. Results: The mean cervicovaginal CA 125 levels in patients with endometrial cancer and controls were 1,598.1 ± 1,691.1 versus 947.0 ± 1,282.7 U/ml, respectively (p = 0.016). Whereas area under receiver operating characteristic curve was 0.62 for serum CA 125, it was 0.68 for cervicovaginal CA 125. The optimal threshold of CA 125 in cervicovaginal secretion was calculated to be 575 U/ml, which detected endometrial precancer or cancer with sensitivity of 78% and specificity of 57%. The positive and negative predictive values for this threshold were 38.7 and 88.2%, respectively. Conclusion: In conclusion, detection of CA 125 in cervicovaginal secretion has a potential role for the non-invasive screening of endometrial precancers and cancers.

Comparative Effectiveness of Robotically Assisted Compared With Laparoscopic Adnexal Surgery for Benign Gynecologic Disease

Laparoscopic adnexal surgery emerged as an alternative to laparotomy in the mid-1990s. It is associated with less morbidity and pain, reduced length of hospital stay, and reduced costs compared with laparotomy. For these reasons, laparoscopy has become the standard of care for benign adnexal surgery. Over the last 2 decades, robotically assisted surgery has been used for many procedures, but little is known about robotically assisted adnexal surgery. Outcome data for robotically assisted adnexal surgery are limited and based on single-center experiences. This population-based study compared the complications and cost of laparoscopic and robotically assisted adnexal surgery. A nationwide database was used to analyze outcomes of robotically assisted adnexal surgery from 2009 to 2012. Participants underwent either laparoscopic oophorectomy (with or without salpingectomy) or laparoscopic ovarian cystectomy. Predictors of use of robotic surgery were examined using multivariable mixed-effects regression models. After propensity score matching, complications and cost of robotically assisted and laparoscopic surgery were compared. A total of 87,514 women were identified; of these, 52,999 underwent oophorectomy, and 34,915 underwent cystectomy. During the study period, use of robotic-assisted oophorectomy increased yearly from 3.5% (95% confidence interval [CI], 3.2%–3.8%) to 15.0% (95% CI, 14.4%–15.6%), and robotically assisted cystectomy increased annually from 2.4% (95% CI, 2.0%–2.7%) to 12.9% (95% CI, 12.2%–13.5%) (both comparisons, P < 0.001). The overall complication rate for robotically assisted oophorectomy was 7.1% (95% CI, 4.0%–10.2%) compared with 6.0% (95% CI, 2.9%–9.1%) for laparoscopic oophorectomy; the odds ratio (OR) was 1.20, with a 95% CI of 1.00–1.45, P = 0.052. Robotic-assisted oophorectomy was also associated with a higher rate of intraoperative complications (3.4% vs 2.1%; OR, 1.60; 95% CI, 1.21–2.13; P < 0.001). With respect to cystectomy, the overall complication rate after the robotically assisted procedure was 3.7% (95% CI, −0.8% to 8.2%) and 2.7% (95% CI, −1.8% to 7.2%) for the laparoscopic technique (OR, 1.38; 95% CI, 0.95–1.99). Robotically assisted cystectomy was associated with a higher rate of intraoperative complications compared with laparoscopy (2.0% vs 0.9%; the OR was 2.40, with a 95% CI of 1.31 to 4.38. Robotically assisted oophorectomy was associated with $2504 (95% CI, $2356–$2652) more total costs and robotically assisted cystectomy $3310 (95% CI, $3082–$3581) more total costs than laparoscopy. These findings show that use of robotically assisted adnexal surgery increased rapidly from 2009 to 2012. Robotically assisted adnexal surgery was associated with substantially greater costs and a small, but statistically significant, increase in intraoperative complications compared with laparoscopic surgery.

WITHDRAWN: Robotic surgery for benign gynaecological disease.

Background Robotic surgery is the latest innovation in the field of minimally invasive surgery. In the case of robotic surgery, instead of directly moving the instruments the surgeon uses a robotic system to control the instruments for surgical procedures. Robotic surgical systems have been used in various gynaecological surgeries for benign disease, such as hysterectomy (removal of the uterus), myomectomy (removal of uterine leiomyomas) and tubal reanastomosis (the reuniting of a divided tube). The mounting evidence demonstrates the feasibility and safety of robotic surgery in benign gynaecological disease. Robotic surgery is advertised as having promising advantages including more precise vision and procedures, improved ergonomics and shorter length of hospital stay. However, the main disadvantages of the robotic surgical system should not be overlooked, including the high cost of disposable instruments and retraining for both surgeons and nurses. Objectives To assess the effectiveness and safety of robot‐assisted surgery in the treatment of benign gynaecological disease. Search methods We searched the Cochrane Menstrual Disorders and Subfertility Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2011), MEDLINE and EMBASE up to November 2011 and citation lists of relevant publications. Selection criteria All randomised controlled trials (RCTs) comparing robotic surgery for benign gynaecological disease to laparoscopic or open surgical procedures. RCTs comparing different types of robotic assistants were also included. We contacted study authors for unpublished information, but failed in obtaining a response. Data collection and analysis Two review authors independently screened studies for inclusion. The domains assessed for risk of bias were allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Odds ratios (OR) were used for reporting dichotomous data with 95% confidence intervals (CI), whilst mean differences (MD) were determined for continuous data. Statistical heterogeneity was assessed using the I2 statistic. We contacted the primary authors for missing data but failed in obtaining a response. Main results Two trials involving 158 participants were included. Since one included trial was published in conference proceedings, limited usable data were available for further analysis. The only analysis in this trial showed comparable rates of conversions to open surgery between the robotic group and the laparoscopic group (OR 1.41, 95% CI 0.22 to 9.01; P = 0.72). One RCT showed longer operation time (MD 66.00, 95% CI 40.93 to 91.07; P Authors' conclusions Currently, the limited evidence showed that robotic surgery did not benefit women with benign gynaecological disease in effectiveness or in safety. Further well‐designed RCTs with complete reported data are required to confirm or refute this conclusion.

Is gynaecological laparoscopic surgery safe for elderly women? A comparison study

The aim of this study was to evaluate the efficacy and safety of gynaecological laparoscopic surgery in an elderly group, by comparing the operative outcomes of the elderly group with those of the younger group. We analysed retrospective data of 121 women who underwent laparoscopic surgery for benign gynaecological disease. Women aged > 60 years were compared with women aged between 30 and 50 years who had the same operation. We evaluated body mass index, comorbidities, number of previous abdominal surgeries, operating time, haemoglobin change, postoperative complications, hospital stay and return of bowel activity. There were no significant differences between the elderly and a matched younger group in number of previous abdominal surgeries, operating time, ASA score distribution, changes in haemoglobin level, hospital stay and postoperative complications (p > 0.05). Laparoscopic surgery can be safely performed in elderly patients with benign gynaecological disease, and surgeons should not hesitate to perform laparoscopic surgery in elderly patients.

The prepped vaginal canal may be a sterile conduit for ventral hernia mesh insertion: a prospective comparative study

Although still experimental, natural orifice translumenal endoscopic surgery (NOTES) aims to use the natural orifices for intraabdominal surgery. Pure transvaginal umbilical hernia repair has been reported. However, mesh protection devices were used to minimize mesh contamination during mesh insertion. The authors believe that before widespread implementation of this technique, more foundational research is indicated to establish the sterility of hernia mesh insertion through this route. This prospective study aimed to compare transvaginal ventral hernia mesh insertion sterility with laparoscopic trocar-site insertion sterility to establish baseline data to help promote the safety of NOTES tranvaginal hernia repair. This was a prospective descriptive study (Canadian Task Force classification 2A). With institutional review board approval, 10 patients undergoing laparoscopic surgery for benign gynecologic disease were enrolled in the study. Atrium Prolite mesh (polypropylene monofilament) was inserted into the vagina before and after standard surgical preparation with 10 % povidone–iodine. As a control, mesh also was inserted through a prepped laparoscopic port site. The mesh was cultured for bacterial, fungal, and viral contamination. All patients received standard infection prophylaxis that included preoperative intravenous cefazolin and metronidazole. The unprepped vaginal canal was cultured and demonstrated normal multiorganism vaginal flora in all 10 cases. Of the 10 skin incision mesh samples, 3 (30 %) grew bacteria, including Staphylococcus lugdunensis, a potentially pathogenic organism. In contrast, none of the prepped vaginal mesh specimens yielded any growth of microorganisms or potential pathogens. This study showed that a surgically prepped vaginal canal can be a sterile conduit for insertion of polypropylene mesh for transvaginal ventral hernia repair without the use of additional mesh protection. Surprisingly, the prepped vaginal conduit in our patients was more sterile than a prepped skin incision.

Robotically Assisted vs Laparoscopic Hysterectomy Among Women With Benign Gynecologic Disease

There has been increasing enthusiasm for robotic gynecologic surgery in recent years. Most data supporting robotically assisted hysterectomy for benign gynecologic disease were from small studies conducted in single institutions or centers with surgery performed by highly experienced surgeons. The results of these studies may not be applicable to the practice of gynecology in a community setting. A meta-analysis of randomized trials comparing robotic and laparoscopic surgery for benign gynecologic disease concluded that both procedures were associated with similar outcomes and complications; however, the robotic procedure was considerably more expensive. At present, benefits of robotically assisted hysterectomy for women with benign gynecologic disease are unclear. The aims of this population-based study were to determine rates of uptake of robotically assisted hysterectomy over a 3-year period and to compare the association between use of robotic surgery and rates of abdominal and laparoscopic hysterectomy during this period. In-hospital complications and costs were also compared. The cohort was composed of 264,758 women who underwent hysterectomy for benign gynecologic disorders at 441 hospitals in the United States from 2007 to 2010. The primary outcome measures were uptake of robotic-assisted hysterectomy and factors associated with its utilization. Factors evaluated in the participants included complications, transfusion, reoperation, length of stay, death, and cost. A propensity score–matched analysis was performed to analyze outcomes and minimize selection bias and to estimate the propensity to undergo a robotic-assisted hysterectomy. Uptake of robotically assisted hysterectomy increased rapidly over the 3-year study period from 0.5% to 9.5% of all hysterectomies. Laparoscopic hysterectomy rates during this same time period increased from 24.3% to 30.5%. At hospitals where the robotic procedure was used starting in 2007, it accounted for 22.4% of all hysterectomies by 2010. Increased uptake of robotic-assisted hysterectomy was paralleled by a decrease in the rate of abdominal hysterectomy both in hospitals where robotic-assisted hysterectomy was performed and in those where it was not performed. Propensity score–matched analysis showed similar complication rates for robotic-assisted and laparoscopic hysterectomy (5.5% vs 5.3%); relative risk [RR] was 1.03, with a 95% confidence interval (CI) of 0.86 to 1.24. Hospitalization for longer than 2 days was significantly less common in patients who underwent robotic-assisted hysterectomy compared with the laparoscopic hysterectomy cohort (19.6 vs 24.9%, P < 0.001), whereas there was no difference in the rate of transfusion (1.4% vs 1.8%; RR, 0.80; 95% CI, 0.55–1.16) or the rate of discharge to a nursing facility (0.2% vs 0.3%; RR, 0.79; 95% CI, 0.35–1.76; P > 0.05 for both comparisons). The total costs of robotically assisted hysterectomy per case was more than for laparoscopic hysterectomy; the difference was $2189 (95% CI, $2030–$2349). These data show that the uptake of robotically assisted hysterectomy for benign gynecologic disorders increased substantially between 2007 and 2010. The morbidity profiles for robotically assisted and laparoscopic hysterectomy were similar, but the cost of the robotic procedure was substantially higher.

Assessment of the estrogen and progesterone endometrial receptors Bcl-2 and Ki-67 after menopause

Objectives The aim of the study was to assess the expression of estrogen receptor (ER), progesterone receptor (PR), Ki-67, and Bcl-2 and their correlation in the endometrium of postmenopausal women in a hypoestrogenic state in order to identify which women, including those with an atrophic endometrium, would be at risk for proliferative changes. Study design This is an observational cross-sectional study. Patients and methods The study included 85 postmenopausal women, with atrophic endometrial specimens collected from asymptomatic women, who underwent surgery for benign gynecologic disease. An endometrial sample was obtained and ER, PR, Bcl-2, and Ki-67 levels were evaluated in the stromal and glandular compartments. Results The average age of the women in the study was 56.8 years, with an average menopausal period of 81.5 months (SEM=6.39). A high expression of ER (94.1%), PR (80%), Ki-67 (75.3%), and Bcl-2 (65.9%) was seen in the endometrial glands. Correlation of ER and PR with Ki-67 (P=0.0017 and 0.0003) and Bcl-2 (P=0.0354 and 0.0105) was observed. Conclusion The women in this study showed considerable endometrial expression of ER, PR, Ki-67, and Bcl-2, probably because of the continuous stimuli generated by the estrogens, which may cause endometrial stimulation even at low levels.

Techniques to reduce shoulder pain after laparoscopic surgery for benign gynaecological disease: a systematic review

Due to the well-known advantages of minimal invasive surgery, the majority of procedures for benign gynaecological diseases are performed by laparoscopy. Although laparoscopic surgery results in improved patient satisfaction, a considerable portion of patients have complaints of post-operative shoulder pain. This review presents an overview of the currently evaluated techniques to reduce shoulder pain after laparoscopic surgery for benign gynaecological disease. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted using Medline, Embase and Cochrane databases. Randomised clinical trials reporting techniques to reduce shoulder pain after laparoscopic gynaecologic procedures for benign diseases were included. Eighty-eight articles were screened for inclusion. A total of 15 articles were included in the final review. The following studies described the techniques used to reduce shoulder pain: six studies evaluated the effect of local anaesthetics, three studies evaluated the effect of pulmonary recruitment manoeuvre and three studies evaluated the effect of intraperitoneal drainage. The remaining three studies evaluated the effect of saline installation, minilaparoscopy and gasless laparoscopy by using the Laprolift®. Overall, the pulmonary recruitment manoeuvre and intraperitoneal drainage were found to reduce the incidence and severity of shoulder pain (SP). Based on the current evidence, safety and possibility to implement the technique in daily practice, pulmonary recruitment manoeuvre can be recommended to reduce both the incidence and severity of SP.

Bladder Dysfunction after Gynecologic Laparoscopic Surgery for Benign Disease

Study Objective To estimate the incidence of and factors leading to bladder dysfunction after laparoscopic gynecological surgery for benign disorders. Design Prospective observational study (Canadian Task Force Classification II-3). Setting Tertiary referral hospital in Sydney, Australia. Patients One hundred eight women undergoing elective laparoscopic surgery for benign gynecological disease. Intervention Prospective assessment bladder function. Data were collected with respect to preoperative baseline bladder function, demographic, intraoperative and postoperative data and bladder function and time to discharge. Measurements and Main Results Postoperative bladder dysfunction was defined as a residual of >100 mL after a void of >150 mL on more than 1 occasion or a bladder volume >600 mL with no urge to void, with 20/102 (19.6%) women having postoperative bladder dysfunction. There was no statistically significant difference in baseline bladder function, mean operative time, anatomic site of surgery, number of operative sites, type of disease, duration of catheterization, or units of morphine required during hospitalization for women with or without bladder dysfunction. Women with dysfunction had a statistically significant greater length of stay from removal of catheter to discharge (28 vs 44 hours; p =.04). Conclusion Postoperative bladder dysfunction appears idiosyncratic, with no single factor predictive of this problem. Possibilities for the demonstrated rate of dysfunction include normal bladder behavior, unmasking future bladder dysfunction, response to drugs, or neurologic issues. The implications of postoperative bladder dysfunction may have consequences for health care resource use and allocation, acute patient management, and possible long-term urinary function consequences and are worthy of further study.