Comparative study between robotic laparoscopic myomectomy and abdominal myomectomy

Study objectiveTo compare short-term surgical outcomes of robotic and abdominal myomectomy and to analyze the factors affecting the short-term outcomes.DesignRetrospective study of a consecutive case series at Emory Saint Joseph’s Hospital, Atlanta, USA.Subjects and methodFrom February 2007 to June 2009, 122 patients with symptomatic leiomyomata underwent either robotic assisted laparoscopic myomectomy (RALM, n = 77) or abdominal myomectomy (AM, n = 45). The variables investigated included the type of surgery, age, BMI, gravity, parity, number of leiomyomata, diameter of largest tumor size, total operative time, estimated blood loss, and length of hospital stay.ResultsNo significant differences were found between the two groups regarding age, gravity and parity. However, BMI, number of leiomyomata and tumor sizes were significantly higher in AM compared to RALM. The total operative time was significantly longer in RALM compared to AM. The total estimated blood loss and length of hospital stay were significantly lower in RALM compared to the AM group. The predicted odds of staying one day or less in the hospital for patients receiving RALM was 193.5 times the odds for patients receiving AM when adjusted for the number of leiomyomata and the tumor size. The probability of one day admission or less in the hospital was significantly increased for patients receiving RALM.ConclusionRALM has shorter hospital stay, less blood loss and increased operative time compared to AM, regardless of tumor size and number of tumors. Although operative time was increased with the RALM procedure, blood loss and hospital stay were integral outcomes in the study result.     

Position-related injury is uncommon in robotic gynecologic surgery

ObjectiveTo assess the rate and risk factors for position-related injury in robotic gynecologic surgery.MethodsA prospective database from 12/2006 to 1/2014 of all planned robotic gynecologic procedures was retrospectively reviewed for patients who experienced neurologic injury, musculoskeletal injury, or vascular compromise related to patient positioning in the operating room. Analysis was performed to determine risk-factors and incidence for position-related injury.ResultsOf the 831 patients who underwent robotic surgery during the study time period, only 7 (0.8%) experienced positioning-related injury. The injuries included minor head contusions (n = 3), two lower extremity neuropathies (n = 2), brachial plexus injury (n = 1) and one large subcutaneous ecchymosis on the left flank and thigh (n = 1). There were no long term sequelae from the positioning-related injuries. The only statistically significant risk factor for positioning-related injury was prior abdominal surgery (P = 0.05). There were no significant associations between position-related injuries and operative time (P = 0.232), body mass index (P = 0.847), age (P = 0.152), smoking history (P = 0.161), or medical comorbidities (P = 0.229–0.999).ConclusionsThe incidence of position-related injury among women undergoing robotic surgery was extremely low (0.8%). Due to the low incidence we were unable to identify modifiable risk factors for position-related injury following robotic surgery. A standardized, team-oriented approach may significantly decrease position-related injuries following robotic gynecologic surgery.     

Effect of body mass index on clinical outcomes of patients undergoing total laparoscopic hysterectomy

ObjectiveTo evaluate the effect of normal body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) and obesity on clinical results among patients who underwent total laparoscopic hysterectomy (TLH).MethodsIn a prospective study at the Civil Hospital of Culiacan in Sinaloa State, Mexico, data were compared from 209 patients who underwent TLH between July 6, 2009, and December 30, 2011. The following primary variables were analyzed for 77 normal BMI patients, 82 overweight patients, and 50 obese patients: procedure duration, operative bleeding, major and minor trans-operative complications, length of hospital stay, and postoperative pain.ResultsThe mean duration of surgical procedure (P < 0.001) and operative bleeding (P = 0.002) were lower for patients with normal BMI compared with the other 2 groups. The rate of conversion to laparotomy was similar among the 3 groups. Overall, the frequency of complications was 6.2% (n = 13/209); the frequency of complications by study group was 2.6%, 4.8%, and 14% for the normal BMI, overweight and obesity groups, respectively (P < 0.05). Major complications were more frequent among patients with obesity (P = 0.010).ConclusionThe duration of surgical procedure and operative morbidity were found to increase, mainly owing to major complications, among patients with obesity (BMI ≥ 30).     

Health-Related Quality of Life Following Robotic Surgery: A Pilot Study

ObjectivesTo determine the relationship between BMI, age, and the physical, functional, and psychosocial areas of health-related quality of life (HRQoL) and patient satisfaction in women with endometrial cancer undergoing robotic-assisted surgery.MethodsDuring the first two years of the robotic surgery program, we prospectively collected data concerning patient demographics and surgical outcomes. At the first postoperative visit (21 to 28 days after surgery), all participants completed a HRQoL questionnaire. We examined the association between BMI and age, as well as the different areas of HRQoL, using chi-square and ANOVA.ResultsOf 109 participants, 41 were 70 years of age or older, and 51 had a BMI of 30 kg/m² or more. Following surgery, the mean (± SD) duration of hospital stay was 1.9 ± 1.5 days, and reported pain level was highest on the second postoperative day, with a mean score of 3.4 ± 2.1 on a seven-point scale. Moreover, two thirds of women reported no pain by the first postoperative visit, and only 18.2% of women aged 70 years or older used any narcotic for pain control. These results indicated that there was little influence of the surgery on HRQoL, and women resumed typical activities within an average of 11 days after surgery. Lastly, participants’ average rating of satisfaction was 6.7 on a seven-point scale.ConclusionThis pilot study has demonstrated the advantages for HRQoL of robotic-assisted surgery in the management of endometrial cancer. Women with endometrial cancer benefited from use of robotic surgery regardless of age or BMI.     

Laparoscopic Versus Abdominal Myomectomy: Practice Patterns and Health Care Use in British Columbia

ObjectiveTo examine the relative frequency and surgical outcomes of laparoscopic myomectomy compared with abdominal myomectomy in British Columbia.MethodsA linked database containing hospital admission, operating room, and emergency room data from 2007 to 2011 from eight Vancouver Coastal Health and Providence Health Region hospitals in British Columbia was used to conduct a retrospective cohort study of women who had myomectomy for uterine fibroids. All consecutive women who had abdominal or laparoscopic myomectomy at five hospitals were included in the study. Patients who had submucosal fibroids or hysteroscopic procedures were excluded. Abdominal and laparoscopic myomectomies were contrasted in terms of patient characteristics and surgical outcomes. Statistical significance was assessed using t tests, Wilcoxon, chi-square, and Fisher exact test; a two-sided P value < 0.05 was considered significant.ResultsOf eight hospitals offering gynaecologic surgery, myomectomies were performed at five hospitals located in metropolitan areas. Of 436 women undergoing myomectomy, 88 cases (20.2%) were laparoscopic, 342 (78.4%) were abdominal, and 6 (1.38%) were laparoscopic with conversion to laparotomy. Women who had laparoscopic rather than abdominal myomectomies were slightly older (mean 38.7 vs. 37.4 years, respectively, P < 0.05). No significant difference was observed in median operative time (106 vs. 95 min), but length of stay was decreased for laparoscopic myomectomies (median 1 vs. 2 days, P < 0.01). No significant differences were observed between laparoscopic and abdominal routes in the rates of admission to intensive care, prolonged hospitalization (> 3 days), or rehospitalization.ConclusionMyomectomies are performed in urban, metropolitan areas in British Columbia, and a significant fraction of myomectomies are performed by laparoscopy. Compared with abdominal myomectomies, laparoscopic myomectomies in pre-selected patients are associated with decreased length of stay and comparable perioperative surgical outcomes.     

Robotically assisted laparoscopic hysterectomy versus total abdominal hysterectomy and lymphadenectomy for endometrial cancer

ObjectiveTo compare surgical morbidity and clinical–pathologic factors for patients with endometrial cancer (EC) undergoing robotic-assisted laparoscopic hysterectomy (RALH) versus total abdominal hysterectomy (TAH) with aortic and/or pelvic lymphadenectomy (LA).MethodsDuring the first 14 months of a robotics surgical program, 56 patients with EC were scheduled to undergo RALH with LA. Cases were analyzed for operative (op) time, estimated blood loss (EBL), transfusion, intra- and post-op complications, surgical–pathologic data, patient demographics and length of stay (LOS). Data was compared to 106 serially treated patients with EC who underwent TAH with LA immediately prior to initiation of our robotics program.ResultsThree robotic cases (5.4%) were converted to TAH secondary to intra-op factors. FIGO stages for RALH vs. TAH were: stage I (82 vs. 69%), stage II (7 vs. 7.5%) and stage III (11 vs. 21.5%). Patients' mean age was 59 ± 10 vs. 63 ± 11 years (p = 0.05) and body mass index (BMI) was 29 ± 6.5 vs. 34 ± 9 kg/m² (p = 0.0001) for the robotic and open groups, respectively. Severe medical co-morbidities affected 5.4% of robotic patients compared to 8.5% of open cases (p > 0.05). Comparing RALH and TAH, mean op time was 177 ± 55 vs.79 ± 17 min (p = 0.0001), EBL was 105 ± 77 vs. 241 ± 115 ml (p < 0.0001), transfusion was 0 vs. 8.5% (p = 0.005), and LOS was 1.0 ± 0.5 vs. 3.2 ± 1.0 days (p < 0.0001). Robotic patients incurred a 3.6% major peri-operative complication rate while women undergoing open procedures had an incidence of 20.8% (p = 0.007). Total lymph node count was 19 ± 13 nodes for robotic cases vs. 18 ± 10 nodes obtained from open hysterectomy patients.ConclusionsPatients with EC who underwent RALH with LA during the first year of our robotics program were younger, thinner and had less cardio-pulmonary illness than patients previously treated with TAH and LA. LOS, EBL and peri-op complication rates were significantly lower for the robotic cohort.     

Influence de l’indice de masse corporelle sur la prise en charge et le pronostic des patientes avec carcinome endométrial

ObjectiveThe aim of this study was to evaluate the outcome of surgery, postoperative morbidity and prognosis of patients with endometrial cancer in function of the body mass index (BMI).Patients and methodsThe study cohort consisted of consecutive women undergoing surgery for endometrial cancer in our institution between January 2000, and September 2012. Individual records of all patients were reviewed and analyzed. Patient BMI was categorized as underweight, normal, overweight and obese.ResultsA total of 192 patients were evaluated. Patients were followed for one to 153 months with a mean of 52.56 months. The mean BMI and the range of each of the BMI categories were 16.97 kg/m² (14–18), 22.97 kg/m² (20–24.9), 27.61 kg/m² (25.7–29.4), 37.34 kg/m² (30–71). Women with higher BMI were more frequently affected by hypertension (8.3%, 31.43%, 58.13% and 59.7% respectively, P < 0.0001) and diabetes (16.67%, 4.3%, 13.9% and 29.85% respectively, P = 0.02). Women with normal BMI had more frequently postmenopausal replacement therapy than the other categories (P = 0.0004). Surgical operative time, mean length of hospitalization in days were not significantly different among the 4 groups. In the obese group there were significantly higher peroperative blood loss (P = 0.01), more wound abces (P = 0.05), more eventration (P = 0.02) and more reinterventions for complications (P = 0.03). Patients had the same protocols of treatment (surgery and adjuvant treatment) and histological characteristics were the same between groups but obese patients had much less positive lymph nodes (P = 0.03). There were no statistically significant difference in overall 5-years survival between groups (P = 0.54)Discussion and conclusionsOur study demonstrate a survival equivalency for obese and non-obese women even though obese women showed less positive lymph nodes.     

A comparison of two different regimens of total intravenous anesthesia for transvaginal ultrasound-guided oocyte retrieval

ObjectiveTo evaluate the effects of Bispectral index (BIS)-guided total intravenous anesthesia (TIVA) with fentanyl-propofol vs. remifentanil-propofol on recovery time, total propofol consumption, length of postanesthesia care unit (PACU) stay, total hospital stay, postoperative pain and side effects in patients undergoing TUGOR.Study designProspective randomized observer-blinded study. The study included 60 patients that were scheduled to undergo TUGOR under BIS-guided TIVA. They were invited to enroll in the study during the period from November 2009 to August 2011 at TAIBA Hospital in Kuwait. Patients were randomly allocated into two groups of 30 patients each: general anesthesia with fentanyl and propofol (group I) or general anesthesia with remifentanil and propofol (group II). The primary outcomes of this study were recovery time and the length of PACU stay.ResultsPatients in group II had significantly rapid recovery, shorter PACU stay (23.5 ± 1.73 vs. 27.1 ± 1.43 min; P < 0.01), less amount of total propofol consumption, less total hospital stay and higher patient satisfaction with analgesia and sedation compared to patients in group I with no difference in intraoperative hemodynamic parameters, postoperative VAS scores of pain, postoperative nausea and vomiting; and without affecting IVF outcomes.ConclusionBIS-guided total intravenous anesthesia with remifentanil and propofol appears to be a safe and an effective regimen for patients undergoing TUGOR.     

Effect of 25-hydroxyvitamin D on metabolic parameters and insulin resistance in patients with polycystic ovarian syndrome

ObjectivesTo investigate the correlation between the levels of 25-hydroxyvitamin D and insulin resistance in patients with polycystic ovarian syndrome (PCOS).Patients and methodsIn 30 untreated PCOS patients and 15 control subjects, levels of 25-hydroxyvitamin D were measured. In addition, endocrine and metabolic variables were evaluated and a glucose tolerance test was performed to assess indices of insulin resistance.ResultsObese PCOS women (n = 15) had lower 25-hydroxyvitamin D levels than lean PCOS women (n = 15) and control subjects (8.9 ± 3.1 vs 26.5 ± 6.4 vs 79.2 ± 19.1 nmol/l respectively; P < 0.001). In the entire cohort, 25-hydroxyvitamin D levels were negatively correlated with body mass index (r = ?0.390), fasting insulin (r = ?0.707), HOMA-β (r = ?0.705), and HOMA-IR (r = ?0.635), and positively correlated with QUICKI (r = 0.723) (all P < 0.001).ConclusionIn PCOS women, low 25-hydroxyvitamin D levels are associated with obesity and insulin resistance.     

What is the optimal minimally invasive surgical procedure for endometrial cancer staging in the obese and morbidly obese woman?

ObjectiveThirty-three percent of U.S. women are either obese or morbidly obese. This is associated with an increased risk of death from all causes and is also associated with an increased risk of endometrial carcinoma. We sought to compare minimally invasive surgical techniques for staging the obese and morbidly obese woman with endometrial cancer.Materials and methodsConsecutive robotic endometrial cancer staging procedures were collected from 2005–2007 and were compared to consecutive laparoscopic cases (2000–2004). Demographics including age, weight, body mass index (BMI), operative time, estimated blood loss, lymph node retrieval, hospital stay and complications were collected and compared.ResultsDuring the study period, there were 36 obese and 13 morbidly obese women who underwent surgery with the DaVinci® robotic system and 25 obese and 7 morbidly obese women who underwent traditional laparoscopy. For both the obese and morbidly obese patient, robotic surgery was associated with shorter operative time (p = 0.0004), less blood loss (p < 0.0001), increased lymph node retrieval (p = 0.004) and shorter hospital stay (p = 0.0119).ConclusionsRobotic surgery is a useful minimally invasive tool for the comprehensive surgical staging of the obese and morbidly obese woman with endometrial cancer. As this patient population is at increased risk of death from all causes, including post-operative complications, all efforts should be made to improve their outcomes and minimally invasive surgery provides a useful platform by which this can occur.     

Single-Port Access Laparoscopic-Assisted Vaginal Hysterectomy: A Novel Method with a Wound Retractor and a Glove

Study ObjectiveTo present our initial experience with single port–access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH) by use of a wound retractor and a glove.DesignContinuing, prospective study (Canadian Task Force classification II-3).SettingUniversity teaching, research hospital, and a tertiary care center.PatientsWe performed the SPA-LAVH in 24 patients from May 6, 2008, through October 8, 2008.InterventionsAll cases of SPA-LAVH were performed by a single surgeon (T. J. K.).Measurements and Main ResultsWe analyzed the data to determine the outcome of SPA-LAVH and compared the initial 10 cases (group A) and the latter 14 cases (group B) to consider the learning curve. Median and range are used to describe non-normal data. A total of 24 consecutive patients have undergone SPA-LAVH, for benign gynecologic conditions, including 16 uterine myomas and 8 cases of adenomyosis, regardless of body mass index or previous abdominal or pelvic surgery. All cases but 3 were performed exclusively through a single port. The median operative time, weight of the uterus, and estimated blood loss were 119 minutes (range 90 to 255 minutes), 347 g (range 225 to 732 g), and 400 mL (range 100 to 1000 mL), respectively. The decline in hemoglobin from before surgery to postoperative day 1 was from 0.7 to 4.3 g/dL, with a median of 2.05 g/dL. The median hospital stay (postoperative day) was 3 days (range 3 to 7). When we compared the operative outcomes between the 2 groups, there was a tendency toward a decreased operative time in group B, although the difference was not significant. However, there was a significant decrease in the estimated blood loss and hospital stay in group B (p = .00, = .04, respectively).ConclusionThe SPA-LAVH was safe and effective, and the procedure could be learned over a short period of time. Additional experience and continued investigation are warranted. Journal of Minimally Invasive Gynecology     

The Effect on Perioperative Bleeding of Placental Extraction From an Exteriorized Uterus During Caesarean Section

ObjectiveTo evaluate the effect on perioperative bleeding of an alternative technique for Caesarean section, in which placental extraction is performed while the uterus is exteriorized.MethodsWe performed a retrospective matched cohort study using data obtained through chart review. Group 1 included women who had CS performed using the technique of placental removal while the uterus was exteriorized, and group 2 included women who had CS performed using the conventional method of placental removal from a non-exteriorized uterus. Women in each group were matched for number of previous Caesarean sections, indications for CS, and gestational age. The primary outcome was the difference between preoperative and postoperative hemoglobin concentrations. Secondary outcomes included the incidence of blood transfusion, estimated blood loss (EBL), operative time, the incidence of postoperative endometritis, and length of hospital stay.ResultsA total of 90 charts were reviewed (45 per group). Baseline clinical characteristics were similar in both groups. The mean decrease in hemoglobin concentration was 22% less in women who had placental extraction from an exteriorized uterus than in those who had the conventional placental extraction (13.2 g/L vs. 16.9 g/L, P = 0.016). Among secondary outcomes, women in group 1 had a lower mean EBL (531.1 mL vs. 691.1 mL, P < 0.05) and a shorter mean duration of surgery (28.0 minutes vs. 40.5 minutes, P < 0.05).ConclusionExteriorizing the uterus prior to removal of the placenta during CS may decrease intraoperative and immediate postoperative bleeding compared with the conventional technique. Further studies on this technique are indicated.     

The Impact of Erectile Dysfunction on the Quality of Life of Men Undergoing Hemodialysis and Its Association with Depression

IntroductionErectile dysfunction (ED) is highly prevalent among men undergoing hemodialysis.AimThis study was performed to identify the influence of ED on the patient's quality of life (QoL) and to evaluate the influence of depression on erectile function of these patients.Main Outcome MeasuresFor this multicenter cross-sectional study, 275 patients were interviewed through questionnaires: the five-item version of the International Index of Erectile Function was used for diagnosing and classifying ED; the Medical Outcomes Study Questionnaire 36-Item Short Form Health Survey (SF-36) for scoring QoL; and the Hospital Anxiety and Depression Scale (HADS) to evaluate depressive symptoms. Linear regression was used to examine the associations between some of the variables and ED. Predialytic biochemical and hematological parameters were determined during the longer interdialytic period.ResultsPatients had a mean age of 48.6 ± 12.8 years, and the ED prevalence was 72.3%. Advanced age, diabetes and depression score were independent risk factors for the development of ED as confirmed by linear regression (P < 0.001, P = 0.002, and P < 0.001, respectively). QoL was worse among patients with any degree of ED, and the scores were statistically significant for overall health rating (P = 0.016), physical composite score (P = 0.003), bodily pain (P = 0.042), physical functioning (P < 0.001), and vitality (P = 0.005). Furthermore, more severe forms of ED were associated with a lower QoL. After adjustment for some variables, such as age, time under dialysis, hemoglobin, albumin, parathyroid hormone, Kt/V, and depression, linear regression showed that domains related to poorer physical functioning (P = 0.047) and decreased vitality (P = 0.009) were significantly related to ED.ConclusionDepression is an important trigger for the development of ED in hemodialysis patients, and this sexual condition is an independent risk factor for their poor QoL. Fernandes GV, dos Santos RR, de Lima LG, de Macêdo BS, da Fonte JE, de Carvalho BSP, Coelho SN, and Calado AA. The impact of erectile dysfunction on the quality of life of men undergoing hemodialysis and its association with depression.     

Maternal serum CA-125 level is elevated in severe preeclampsia

AimThe aim of this study was to determine the relationship between serum concentrations of cancer antigen-125 (CA-125) and pre-eclampsia severity.MethodsWe evaluated 91 females with a singleton pregnancy. Serum CA-125 levels were measured in subjects with severe pre-eclampsia (n = 34) and those with mild pre-eclampsia (n = 24). Females with healthy pregnancies (n = 31) served as the control group. The three study groups were statistically similar in terms of maternal age, gestational age, and body mass index.ResultsThe CA-125 level was significantly higher in the severe pre-eclampsia group than that in the mild pre-eclampsia and control groups (p < 0.05). No significant difference in CA-125 levels between the mild pre-eclampsia and control groups was observed. CA-125 level was positively correlated with proteinuria (r = 0.489, p = 0.000), systolic blood pressure (r = 0.503, p = 0.018), and diastolic blood pressure (r = 0.532, p = 0.000). In contrast, CA-125 was negatively correlated with birth weight (r = 0.266, p = 0.012) and gestational age at birth (r = 0.250, p = 0.018).ConclusionsCA-125 level increased in severe pre-eclampsia, which reflected abnormal trophoblastic invasion and chronic inflammation. Elevated levels of CA-125 in pre-eclamptic patients may be a marker of the disease severity.     

Macular thickness measured by optical coherence tomography correlates with proteinuria in pre-eclampsia

ObjectivesPre-eclampsia is associated with ocular changes. The aim of this study was to examine the macular changes of patients with early-onset severe pre-eclampsia using optical coherence tomography (OCT).MethodsThis prospective study was performed at Tygerberg Academic Hospital, a secondary and tertiary referral centre in Cape Town, South Africa. Twenty women with early onset pre-eclampsia and 20 women without hypertensive or vascular complications, matched for gestational age, were examined before and after delivery.ResultsThere was a trend showing a positive correlation between increased central retinal thickness and increasing proteinuria in patients with pre-eclampsia antepartum (left eye r = 0.52, p = 0.04) and postpartum (left eye r = 0.60, p = 0.01). A positive correlation between average central 1 mm and proteinuria was noted antepartum (left eye r = 0.63, p = 0.01) and postpartum (right eye r = 0.52, p = 0.03). There were no significant correlations between blood pressure and any of the retinal parameters. Two of the 23 patients with pre-eclampsia developed serous retinal detachments, both of which resolved completely postpartum.ConclusionsMacular thickness parameters measured using OCT correlated with the degree of proteinuria in pre-eclampsia. These changes reversed soon after delivery.     

Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques

ObjectivesThe study purpose was to compare hysterectomy and lymphadenectomy completed via robotic assistance, laparotomy, and laparoscopy for endometrial cancer staging with respect to operative and peri-operative outcomes, complications, adequacy of staging, and cost.MethodsOne hundred and ten patients underwent hysterectomy with bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy for endometrial cancer staging. All cases were performed by a single surgeon, at a single institution (40 robotic, 40 laparotomy, and 30 laparoscopic) and were retrospectively reviewed to compare demographics and peri-operative variables including, operative time, estimated blood loss, lymph node count, hospital stay, complications, and return to normal activity. Additionally, a cost comparison between all three modalities was performed.ResultsPatients undergoing robotic assisted hysterectomy and staging experienced longer operative time than the laparotomy cohort with no difference in comparison to the laparoscopic cohort (184 min, 108.6 min, 171 min, p < 0.0001, p = 0.14). Estimated blood loss was significantly reduced for the robotic cohort in comparison to the laparotomy cohort and comparable to laparoscopic cohort (166 cc, 316 cc, 253 cc, p = 0.01, p = 0.25). The complication rate was lowest in the robotic cohort (7.5%) relative to the laparotomy (27.5%) and laparoscopic cohorts (20%) (p = 0.015, p = 0.03). Average return to normal activity for the robotic patients was significantly shorter than those undergoing laparotomy (24.1 days versus 52 days, p < 0.0001) and those undergoing laparoscopy (31.6 days, p = 0.005). Lymph node retrieval did not differ between the 3 groups (robotic 17 nodes, laparotomy 14 nodes, laparoscopic 17 nodes). The total average cost for hysterectomy with staging completed via laparotomy was $12,943.60, for standard laparoscopy $7569.80, and for robotic assistance $8212.00. The difference in cost between laparotomy and robotic cohorts was significant p = 0.0001 while there was no statistically significant difference in cost between laparoscopy and robotic cohorts p = 0.06.ConclusionsRobotic hysterectomy provides comparable node retrieval to laparotomy and laparoscopic procedures in the case of the experienced laparoscopic surgeon. While robotic hysterectomy takes longer to perform than hysterectomy completed via laparotomy, it is equivalent to laparoscopic hysterectomy and provides the patient with a more expeditious return to normal activity with reduced post-operative morbidity. Additionally, the average cost for hysterectomy and staging was highest for laparotomy, followed by robotic, and least for standard laparoscopy.     

Positive correlations between circulating adiponectin and MMP2 in preeclampsia pregnant

ObjectiveThe aims of the present study were to compare plasma concentrations of the adiponectin, leptin, metalloproteinases (MMP9 and MMP2) and its tissue inhibitors (TIMP1 and TIMP2) in preeclamptic (PE) and healthy pregnant (HP) groups and correlate them.MethodsA total of 105 pregnant women with pre-pregnancy body mass index (BMI) values ⩽30 kg/m² were enrolled for this study (59 PE and 46 HP). Biomarkers were measured using ELISAs.ResultsAdiponectin (32%), leptin (45%), MMP2 (20%), TIMP1 (31%) and TIMP2 (23%) levels were higher in PE compared to HP (all P < 0.05). In addition there were positive correlations between adiponectin and MMP2 (r = 0.33; P = 0.03) and adiponectin and TIMP2 (r = 0.33; P = 0.03) in PE group, but not in HP.ConclusionOur findings show that adiponectin, leptin, MMP2, TIMP1 and TIMP2 levels are increased in PE and adiponectin may contribute to higher levels of MMP2 and TIMP2 in this disease.     

A Randomized Trial of Oral Misoprostol in Premenopausal Women Before Hysteroscopy

ObjectiveTo determine if the use of oral misoprostol in premenopausal women undergoing diagnostic hysteroscopy produces a clinically important difference in pre-procedural cervical dilatation.MethodsAt a tertiary care hospital, premenopausal women undergoing diagnostic hysteroscopy were randomized to receive either 400 μg of misoprostol or a vitamin B6 placebo orally 12 hours before the procedure. Patients were stratified on the basis of parity. The primary outcome was the pre-procedural dilatation of the cervix. Secondary outcomes included the need to further dilate the cervix, the time required to further dilate the cervix, and side effects.ResultsSixty-four women (11 nulliparous and 53 parous) undergoing diagnostic hysteroscopy consented to participate in the study. Thirty-three women received misoprostol and 31 received placebo. Baseline demographics showed no difference in age and parity between the two groups. There were no significant differences in pre-procedural dilatation (5.0 mm vs. 4.7 mm, P = 0.52), need to further dilate the cervix (56.7% vs. 63.0%, P = 0.63), and time required to further dilate the cervix (12.7 seconds vs. 25.7 seconds, P = 0.27). Significantly more women in the misoprostol group experienced menstrual-like cramping (24.2% vs. 3.3%, P = 0.03) and vaginal spotting (21.2% vs. 3.3%, P = 0.05).ConclusionIn premenopausal women, there is no improvement in pre-procedural cervical dilatation with administration of oral misoprostol 12 hours before diagnostic hysteroscopy. Further research is required in both nulliparous and parous premenopausal women to determine whether oral misoprostol improves cervical dilatation and, if so, the ideal dose, route and timing.     

Analysis of disease recurrence and survival for women with uterine malignancies undergoing robotic surgery

ObjectivesTo evaluate recurrence-free survival (RFS) and overall survival (OS) for patients who underwent robotic-assisted laparoscopic hysterectomy (RALH) for uterine malignancies.MethodsMedical records from 372 patients with uterine malignancies who underwent RALH from 3/06 to 3/09 at two institutions were reviewed for clinico-pathologic data, adjuvant therapies, disease recurrence, and survival. Median follow-up for survival analysis was 31 ± 14 months. Thirty (8.1%) patients were lost to follow-up before 12 months and censored from the recurrence analysis.ResultsMean age and BMI of 372 patients was 61.8 ± 9.8 years and 32.2 ± 8.4 kg/m² (range 19–70). Robotic procedures included RALH 16 (4.3%), RALH with pelvic lymphadenectomy (PL) 96 (25.8%), and RALH with pelvic-and-aortic lymphadenectomy (PAL) 252 (67.7%) cases. Histology included 319 (85.8%) endometrioid and 53 (12.6%) high-risk histologies. Mean pelvic and aortic lymph node counts were 16.8 ± 8.7 and 8.4 ± 4.5, respectively. Lymph node metastases were identified in 26 (7.3%) cases. Adjuvant therapies were prescribed for 108 (29.1%) of patients: 7.8% brachytherapy, 1.9% pelvic radiation + brachytherapy, 7.8% chemotherapy, 11.6% chemotherapy + radiation. Risk of recurrence for all patients was 8.3% and 17 (4.6%) patients died of disease. The estimated 3-year recurrence-free survival (RFS) for the entire study group was 89.3% and the estimated 5-year overall survival (OS) was 89.1%, compared to 92.5% and 93.4% for the endometrioid sub-set.ConclusionsPatients with endometrial cancer undergoing robotic hysterectomy with staging lymphadenectomies during our 3-years of robotic experience had low-risk for recurrence and excellent disease-specific survival at a median follow-up time of 31 months.     

Plasma antithrombin levels correlate with albumin and total protein in gestational hypertension and preeclampsia

ObjectiveTo analyze the antithrombin-III (AT-III) activity in the plasma in relation to the serum albumin and total protein in preeclampsia and gestational hypertension.Study designThe medical records of 139 patients who were diagnosed with gestational hypertension (n = 33) and preeclampsia (n = 106) were reviewed, and the relationships between the activity of AT-III and serum albumin or total protein were evaluated.Main outcome measuresThe plasma AT-III activity in gestational hypertension and preeclampsia was correlated with the serum albumin and TP levels.ResultsThere were significant correlations between AT-III activity and albumin in gestational hypertension (r = 0.504, p = 0.003) and preeclampsia (r = 0.343, p = 0.003). There were also significant correlations between AT-III activity and TP in gestational hypertension (r = 0.619, p = 0.001) and preeclampsia (r = 0.366, p = 0.001). Regression coefficients between AT-III and albumin and between AT-III and TP in gestational hypertension (23.7 and 14.0, respectively) were significantly steeper than those in preeclampsia (14.6 and 9.6, respectively).ConclusionsThe plasma AT-III activity in gestational hypertension and preeclampsia was correlated with the serum albumin and TP levels. This suggests that AT-III activity is more likely to decrease in gestational hypertension than in preeclampsia.