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1.

Study Objective

To evaluate the intraoperative effects of gonadotropin-releasing hormone (GnRH) analogue pretreatment in patients undergoing cold loop hysteroscopic myomectomy.

Design

Randomized controlled trial (Canadian Task Force classification I).

Setting

Arbor Vitae Center for Endoscopic Gynecology, Rome, Italy.

Patients

A total of 99 patients were randomized and subsequently allocated to the GnRH analogue group or to the nonpharmacologic treatment control group. Fifteen patients were lost after allocation, and 42 patients per group underwent hysteroscopic myomectomy.

Interventions

Cold loop hysteroscopic myomectomy.

Measurements and Main Results

The control group accomplished the treatment in a 1-step procedure more frequently than the GnRH analogue group (92.85% and 73.8% of cases, respectively; p?=?.040). The completion of the treatment was more unlikely in case of G2 myomas (p?=?.006), whereas no differences were recorded for G1 and G0 myomas. The multivariate analysis showed a significant correlation between the multiple-step treatment and the use of GnRH analogue (odds ratio, 5.365; 95% confidence interval [CI], 1.018–28.284; p?=?.048), grading (odds ratio, 4.503; 95% CI, 1.049–19.329; p?=?.043), and size of myomas (odds ratio, 1.128; 95% CI, 1.026–1.239; p?=?.013).

Conclusions

Preoperative GnRH analogue administration did not facilitate the completion of cold loop hysteroscopic myomectomy in a single surgical procedure in G2 myomas and was correlated with a longer duration of the surgery. No significant benefits were found for G0 and G1 myomas. (ClinicalTrials.gov: NCT01873378.)  相似文献   

2.

Study Objective

To compare the surgical technique of temporary bilateral uterine artery blockage with titanium clips in laparoscopic myomectomy with traditional surgery for uterine myomas to determine efficacy, ability to control bleeding, and recurrence.

Design

Randomized, controlled, prospective study (Canadian Task Force classification I).

Setting

Obstetrics and gynecology department in Jinhua Municipal Central Hospital.

Patients

Women with symptomatic uterine myoma.

Interventions

Sixty-four patients with symptomatic uterine myomas were randomly divided into trial (group A, n?=?33) and control groups (group B, n?=?31). Temporary bilateral uterine artery occlusion and myomectomy were used in group A and laparoscopic myomectomy only in group B. Operative time, perioperative bleeding, follow-up relief of menorrhagia, and recurrence of myomas were evaluated.

Measurements and Main Results

All patients in this study underwent successful laparoscopic operation without intraoperative complications. Operative time between groups was not significantly different (p?=?.255 in single-myoma group and p?=?.811 in multiple-myoma group), blood loss in group A was notably lower than the conventional surgery group (p?<?.001). At final follow-up (2 years), recurrence rate and menorrhagia symptom relief were not statistically significant (p?=?.828 and p?>?.999, respectively). The fertility index of antimüllerian hormone showed no statistical difference between groups preoperatively or at 2 days, 3 months, 6 months, and 1 year postoperatively (p?=?.086, p?=?.247, p?=?.670, p?=?.753, and p?=?.857, respectively).

Conclusion

Temporary bilateral uterine artery occlusion during laparoscopic myomectomy does not increase mean operative time, offers a possible option to reduce blood loss effectively, improves menorrhagia, and does not impact recurrence rate compared with conventional surgery.  相似文献   

3.

Study Objective

To determine the accuracy of pelvic ultrasonography (US) in preoperative evaluation before laparoscopic myomectomy.

Design

A prospective cohort study (Canadian Task Force classification II-2).

Setting

A tertiary level referral center of minimally invasive gynecologic surgery, Sant'Orsola University Hospital, Bologna, Italy.

Patients

One hundred one of the 125 women undergoing laparoscopic myomectomy from September 2015 to May 2016 were included.

Interventions

Preoperative pelvic US was performed 2 weeks before surgery.

Measurements and Main Results

Among the 101 women enrolled in this study, preoperative US correctly identified the number of myomas in 73 patients (72.3%). A total of 208 myomas were preoperatively identified by US; 197 (94.7%) were surgically removed, and 11 (5.3%) were not visualized during laparoscopic myomectomy. The 11 undetected myomas were intramural (International Federation of Gynecology and Obstetrics [FIGO] type 3 and 4), with a mean diameter of 19.05?±?5.91?mm. The type, site, and location of the 197 myomas identified by US preoperatively and removed via laparoscopy were confirmed at surgery in 78.7% (155/197), 80.7% (159/197), and 84.3% (166/197) of the cases, respectively. Two-hundred fifty-four total myomas were removed laparoscopically; 197 (77.6%) were preoperatively identified by US, and 57 (22.4%) were missed by US, having had a mean diameter of 13.51?±?7.84?mm and predominantly being the subserosal type (FIGO type 5, 6, and 7) (57.9%, p?<?.05).

Conclusion

Pelvic US is a valuable tool in preoperative evaluation and should be systematically performed when planning laparoscopic myomectomy.  相似文献   

4.

Study Objective

To study the effects of ulipristal acetate (UPA) on adenomyosis-associated clinical symptoms.

Design

A retrospective, single-center observational study (Canadian Task Force classification II-2).

Setting

A university tertiary referral center.

Patients

Premenopausal women (163) with adenomyosis and symptomatic uterine myomas (41 patients, A?+?F group) versus a control group with only myomas (122 patients, F group) treated with the first course of UPA.

Interventions

This was a retrospective study to assess the effects of a 12-week course of UPA (5?mg/d).

Measurements and Main Results

Clinical symptoms including bleeding control, amenorrhea, pain outcomes, and self-perceived severity of the disease and quality of life. Amenorrhea was present in 90.4% of the A?+?F group compared with 77.6% in the F group (p?=?.0017). Optimal bleeding control was significantly higher in the adenomyosis group (pictorial blood loss assessment chart?<?75) than in the F group (90.2% vs 73.8%, p?=?.028). At the end of the first UPA course, the self-reported visual analog scale scores in the A?+?F group were significantly higher than in the F group (p?=?.017), reflecting greater improvement in pain outcomes for women with adenomyosis. UPA treatment improved the quality of life in both study groups. Most of the women rated their global health status as “better” after the first UPA course than before the treatment (A?+?F group: 67.00% and F group: 80.50%, p?=?.223).

Conclusion

Treatment with UPA led to a significant reduction in the clinical symptoms of adenomyosis (bleeding and pain) and achieved a high rate of amenorrhea in a cohort of women with concomitant uterine myomas. Despite the limitations of the study, our results showed that UPA might be a good alternative treatment for adenomyosis.  相似文献   

5.

Study Objective

To compare surgical experience at myomectomy between patients with myomas pretreated with ulipristal acetate versus no pretreatment.

Design

A prospective, observational, multicenter study of myomectomy procedures by any route (hysteroscopic, laparoscopic, or laparotomy) (Canadian Task Force classification II-2).

Setting

Five university-affiliated hospitals including tertiary care and community sites.

Patients

Any patient who underwent hysteroscopic, laparotomic, or laparoscopic myomectomy regardless of medical pretreatment.

Interventions

Surgeons completed a Web-based questionnaire after each myomectomy procedure. Surgeons evaluated visualization, the myoma-myometrium relationship, extrusion, fluid deficit, blood loss, and overall ease of hysteroscopic myomectomies. For laparotomic/laparoscopic myomectomies, plane delineation, myoma separation, blood loss, and overall ease were assessed. The total surgical experience score was calculated by summing the values for each subscale.

Measurements and Main Results

A total of 309 myomectomies were evaluated by 52 surgeons (response rate?=?83%) at 5 institutions. Of 140 hysteroscopic myomectomies, 84 (60%) were performed without pretreatment, 29 (21%) after ulipristal acetate pretreatment, and 27 (19%) after pretreatment with gonadotropin-releasing hormone agonist/other. Of 169 laparotomic/laparoscopic myomectomies, 104 (62%) were performed without pretreatment, 46 (27%) after ulipristal acetate, and 19 (11%) after gonadotropin-releasing hormone agonist/other. The mean surgical experience score (±standard deviation) was comparable between the no pretreatment and ulipristal acetate groups for hysteroscopic myomectomies (13.8?±?2.2 vs 13.3?±?2.2, p?=?.35) and laparotomic/laparoscopic myomectomies (12.9?±?4.1 vs 12.1?±?4.2, p?=?.30). Compared with no pretreatment, more laparotomic/laparoscopic myomectomies after ulipristal acetate pretreatment were associated with difficult delineation of surgical planes (22 [47.8%] vs 23 [22.1%], p?=?.002) and difficult myoma separation (20 [43.5%] vs 21 [20.2%], p?=?.003). More myomas were described as soft with ulipristal acetate pretreatment (14 [30.4%] vs 17 [16.4%], p?=?.049). The rates of profuse/abundant endometrium during hysteroscopy were similar between the no pretreatment (21 [25.0%]) and ulipristal acetate (7 [24.1%], p?=?.93) groups.

Conclusion

Despite differences in surgical nuances, the overall myomectomy experience was not negatively affected by ulipristal acetate pretreatment.  相似文献   

6.

Study Objective

To evaluate whether the presence of a visualizable “flow” effect in the fallopian tube ostia in hysteroscopic routine evaluation is predictive of tube patency.

Design

A retrospective cohort study (Canadian Task Force Classification II-2).

Setting

Data from all patients who underwent surgery because of infertility at the study center between 2008 and 2016 were analyzed retrospectively. The main outcome parameter was fallopian tube patency as assessed by laparoscopic chromopertubation. The predictive parameters tested were the presence of hysteroscopic tube “flow,” general patient characteristics, and intraoperative findings.

Patients

Five hundred eleven infertile women who underwent combined hysteroscopy and laparoscopy were included.

Interventions

All women underwent combined hysteroscopy and laparoscopy. Some had other interventions when necessary, but no additional interventions were taken because of this study.

Results

In an analysis of 998 fallopian tubes, the hysteroscopic assessment of fallopian tube “flow” was highly accurate in predicting fallopian tube patency (p?<?.001), with a sensitivity of 86.4% (95% confidence interval [CI], 83.7–88.8) and a specificity of 77.6% (95% CI, 72.1–82.5). Risk factors for a false-negative hysteroscopy result were the presence of uterine myomas (odds ratio [OR]?=?2.11; 95% CI, 1.10–4.05; p?=?.025), the presence of a hydrosalpinx on the analyzed side (OR?=?2.50, 95% CI, 1.17–5.34; p?=?.019), and the presence of peritubal adhesions surrounding the analyzed tube (OR?=?2.87; 95% CI, 1.21–6.76; p?=?.016).

Conclusion

A visualizable tube “flow” in hysteroscopy was accurate in the prediction of tubal patency, with a positive predictive value of about 91%. Knowledge about hysteroscopic fallopian tube “flow” can help to plan the future approach in an individual patient.  相似文献   

7.

Study Objective

To assess the impact of ovarian endometriomas on endometrial receptivity in frozen embryo transfer (FET) of segmented in vitro fertilization (IVF) cycles.

Design

Retrospective, matched-control study (Canadian Task Force classification II-2).

Setting

A single, private assisted-reproduction technology center.

Patients

Thirty patients diagnosed with unilateral or bilateral endometriomas were compared with 60 patients without endometriomas in a population of 1894 patients who underwent segmented IVF treatment between September 2014 and September 2016.

Intervention

Intracytoplasmic sperm injection with blastocyst freeze-all and FET.

Measurements and Main Results

The primary endpoint of the study was a viable pregnancy (>14 weeks). The mean diameter of diagnosed endometriomas was 25.7?±?10.6?mm. The median antral follicle count was significantly lower in the endometrioma group compared with the entire study population (11.5; interquartile range [IQR], 6.0–17.0 vs 14.0; IQR, 9.0–22.0; p?=?.042). The median number of mature ovarian follicles (≥14?mm) per antral follicle that developed during controlled ovarian stimulation was not significantly different between the groups (11.0 [IQR, 5.8–14.3] vs 10.0 [IQR, 6.0–15.8]; p?=?.908); however, the median number of oocytes retrieved was lower in the endometrioma group (11.5 [IQR, 6.0–21.5] vs 13.5 [IQR, 9.0–20.8]; p?=?.373). The biochemical pregnancy, implantation, and ongoing pregnancy rates were not significantly different between the endometrioma and control groups.

Conclusion

Although ovarian endometriomas result in reduced ovarian reserve and oocyte retrieval, their impact on reproductive outcome is limited with FET.  相似文献   

8.

Study Objective

To determine whether pain, as part of an indication for global endometrial ablation, is an independent risk factor for failure.

Design

Retrospective cohort study (Canadian Task Force classification II-2).

Setting

Academic-affiliated community hospital.

Patients

Women undergoing global endometrial ablation with radiofrequency ablation (RFA), hydrothermablation (HTA), or uterine balloon ablation (UBA) between January 2003 and December 2015.

Interventions

Procedure failure was defined as subsequent hysterectomy after the index ablation.

Measurements and Main Results

A total of 5818 women who underwent an endometrial ablation were identified, including 3706 with RFA (63.7%), 1786 with HTA (30.7%), and 326 with UBA (5.6%). Of the 5818 ablations, 437 (7.5%) involved pain (i.e., pelvic pain, dysmenorrhea, dyspareunia, lower abdominal pain, endometriosis, or adenomyosis) before ablation, along with abnormal uterine bleeding. Pain as part of the preoperative diagnoses before endometrial ablation was a significant risk factor for subsequent hysterectomy compared with all other diagnoses (19.2% vs 13.5%; p?=?.001). Consistent with previous studies, women who underwent ablation at an older age were less likely to fail, which held true even when one of the indications for ablation was related to pain (odds ratio, 0.96/year; 95% confidence interval, 0.95–0.97). When the pathology reports of women who underwent a hysterectomy were examined, women in the pain group had lower rates of adenomyosis than women without pain (38.1% vs 50.1%; p?=?.04). However, there was a trend toward a higher rate of endometriosis on pathology reports (14.3% vs 8.7%; p?=?.09) and even higher rates of visualized endometriosis identified by operative reports in women who had pain before their ablation (42.9% vs 15.8%; p?<?.001). Patients who had pain before their ablation were less likely to have myomas/polyps (p?=?.01).

Conclusion

Pelvic pain before global endometrial ablation is an independent risk factor for failure.  相似文献   

9.

Study Objective

To determine if the number of myomas removed during myomectomy for symptomatic relief affects long-term fertility outcomes in reproductive-aged women.

Design

Retrospective cohort survey study (Canadian Task Force classification II-2).

Setting

University hospital.

Patients

One hundred forty-four patients who underwent myomectomy for symptomatic myomas and attempted to conceive afterward.

Intervention

Questionnaire mailed to reproductive-aged women who received robotic, laparoscopic, or abdominal myomectomy.

Measurements and Main Results

Patients with >6 myomas removed were less likely to achieve pregnancy after myomectomy than patients with ≤6 myomas removed (22.9% vs 70.8%, respectively; p?<?.001). To achieve pregnancy, 45% of those with >6 myomas removed (vs 17.6% of those with ≤6 myomas removed) relied on fertility treatment (clomiphene citrate, letrozole, intrauterine insemination, or in vitro fertilization). Of those with >6 myomas removed who became pregnant, 45.5% had a term birth, 45.5% miscarried, and 9.1% had an ectopic pregnancy. Of those with ≤6 myomas removed who became pregnant, 61.8% had a term birth, 23.5% had a preterm birth, and 13.2% miscarried.

Conclusion

The number of myomas removed during myomectomy significantly affects fertility. Women with >6 myomas removed were less likely to become pregnant, more likely to require fertility treatment, and less likely to have a term birth when compared with women with ≤6 myomas removed.  相似文献   

10.

Study Objective

Endometrial ablation using the NovaSure system (Hologic Inc., Marlborough, MA) is 1 of the treatment options for heavy menstrual bleeding (HMB), which has a reported success rate of 81% to 90%. We aimed to identify predictors for NovaSure endometrial ablation failure. This will contribute to a more effective and individualized preoperative counseling.

Design

A retrospective multicenter cohort study (Canadian Task Force classification II-2).

Setting

One university hospital and 1 large teaching hospital.

Patients

Four hundred eighty-six patients with HMB who had undergone NovaSure endometrial ablation between 2008 and 2014.

Interventions

The NovaSure endometrial ablation system for patients with HMB.

Measurements and Main Results

In total, the required characteristics of 486 patients were collected and analyzed. With a median follow-up of 45 months, 19.3% (n?=?94) required a secondary treatment and thus were considered NovaSure failures. Multivariate logistic regression analysis showed that younger age (p?=?.019), a history of sterilization (p?=?.002), the presence of dysmenorrhea (p?<?.001) and the presence of an intramural leiomyoma on transvaginal sonography (p?=?.005) were independent predictors of NovaSure ablation failure. Preoperative hysteroscopy appeared to be a protective factor (p?=?.001).

Conclusion

Within a median follow-up of 45 months, 19.3% of patients required a secondary treatment. Identification of specific predictive factors for endometrial ablation failure is important in preoperative counseling and patient selection. In the current era of personalized medicine, doctors and patients will ideally choose the therapy that results in the highest chance of success in the individual case.  相似文献   

11.

Study Objective

To determine the risk factors for Pipelle diagnostic failure, which might help healthcare providers choose the appropriate protocol for endometrial evaluation individually.

Design

A single-center prospective study (Canadian Task Force classification II).

Setting

The Obstetrics and Gynecology Hospital of Fudan University.

Patients

Patients (n?=?466) with an indication for endometrial biopsy.

Interventions

All patients received Pipelle and then diagnostic dilation and curettage. The samples were sent for histopathologic diagnosis separately.

Measurements and Main Results

The Pipelle procedure failed in 10 of 466 patients (2.146%). The general sample inadequacy and histopathologic diagnosis inconsistency of Pipelle was 5.921% (27/456) and 14.254% (65/456), respectively. Upon multivariate analysis, history of cervical operation(s) (odds ratio [OR], 26.510; 95% coefficient interval [CI], 2.932–239.784; p?=?.004), prior intrauterine procedure(s) (OR, .096; 95% CI, .017–.554; p?=?.009), and pinpoint cervical os (OR, 5.939; 95% CI, 1.134–31.108; p?=?.035) were significantly associated with Pipelle procedure failure. Meanwhile, uterine volume?<?43?cm3 (OR, 8.229; 95% CI, 1.902–35.601; p?=?.005) and uneven endometrium detected by ultrasound (OR, .176; 95% CI, .042–.734; p?=?.017) had significant correlation with sample inadequacy. Pipelle detected all endometrial cancer cases, whereas only 50.000% (7/14) of endometrial hyperplasia with atypia, 26.471% (9/34) of polyps, and 18.182% (2/11) of polyps with endometrial hyperplasia without atypia cases were detected by Pipelle.

Conclusion

Although Pipelle is the first-line method for endometrial biopsy, it might fail in women with risk factors identified in this study. More considerations should be taken when choosing Pipelle.  相似文献   

12.

Study Objective

To investigate the influence of the use of passive instrument positioners (PIPs) on laparoscopic operative outcomes for endometrial cancer relative to other independent variables.

Design

Retrospective case-controlled study (Canadian Task Force classification II-2).

Setting

Laparoscopies performed by the author in multiple community hospitals.

Patients

A total of 297 consecutive patients between December 2009 and October 2016 with clinically isolated endometrial cancer or retroperitoneal lymphadenopathy on imaging studies.

Interventions

Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and pelvic/aortic lymph node dissection using passive instrument positioners to secure the laparoscope (PIP group) and using instruments providing exposure and historical control by hand control of all instruments (HC group).

Measurements and Main Results

The overall group mean age was 63.2 years (range, 32.4–90.9 years), and patient characteristics were equivalent in the 2 groups. In the PIP group, 1 procedure was converted to a laparotomy (0.5%), and in the HC group, 6 procedures were converted (5.4%; p?=?.008). The mean operative time was 140.1 minutes for the PIP group and 153.8 minutes for the HC group (p?<?.001). The mean length of hospital stay was 44.8 hours for the PIP group and 58.6 hours for the HC group (p?<?.001). Multivariate analysis confirmed that study group (PIP vs HC; p?=?.014) and the presence vs absence of metastatic disease (p?=?.001) influenced conversion; study group (PIP vs HC; p?<?.001), body mass index (p?<?.001), past surgical history (p?=?.010), and assistant training (p?=?.011) influenced operative time; and study group (PIP vs HC; p?<?.001), Eastern Cooperative Oncology Group performance status (p?<?.001), and operative time (p?=?.051) influenced hospital stay.

Conclusion

For clinically localized endometrial cancer managed laparoscopically, the use of PIPs reduces conversions, operative time, and hospital stay.  相似文献   

13.

Study Objective

To evaluate the association between bladder deep infiltrating endometriosis (DIE) and anterior focal adenomyosis of the outer myometrium (aFAOM) diagnosed by preoperative magnetic resonance imaging (MRI).

Design

An observational, cross-sectional study using prospectively collected data (Canadian Task Force classification II-2).

Setting

Single university tertiary referral center.

Patients

All nonpregnant women younger than 42 years who had undergone complete surgical exeresis of endometriotic lesions. For each patient a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon during the month preceding the surgery. Only women with preoperative standardized uterine MRI were retained for this study.

Interventions

Thirty-nine women with histologically proven bladder DIE and an available preoperative MRI were enrolled in the study. Patients were divided into 2 groups: women with aFAOM (aFAOM (+), n?=?19) and women without aFAOM (aFAOM (–), n?=?20). Both groups were compared for general characteristics, medical history, MRI findings, and disease severity.

Measurements and Main Results

Nineteen patients (48.7%) with bladder DIE had aFAOM at preoperative MRI. The rate of associated diffuse adenomyosis was similar in the 2 groups (63.2% [n?=?12] vs 73.7% [n?=?14]; p?=?.48). The rate of an associated ovarian endometrioma (OMA) was significantly lower in the aFAOM (+) group (10.5% [n?=?2] vs 40.0% [n?=?8]; p?=?.03). There were fewer associated intestinal DIE lesions in the aFAOM (+) group compared with the aFAOM (–) group (26.3% vs 75.0%; p?=?.02), with lower involvement of the pouch of Douglas (26.3% vs 70%; p?<?.01). Total American Society for Reproductive Medicine score was significantly lower in the aFAOM (+) group (13.8?±?12.2 vs 62.2?±?46.2; p?<?.01).

Conclusion

aFAOM is present in only half of women with bladder DIE and appears to be associated with lower associated posterior DIE.  相似文献   

14.

Study Objective

To demonstrate the process for establishing or refuting validity for the Limbs and Things hysterectomy model.

Design

Prospective study using Kane's framework for establishing validity (Canadian Task Force classification: II-2).

Setting

Total laparoscopic hysterectomy (TLH) assessments completed in the operating room (OR) and simulation at 3 academic medical centers.

Participants

Obstetrics and gynecology residents (n?=?26 postgraduate years 3–4), a gynecologic oncology fellow (postgraduate year 5), and a gynecology oncology attending.

Interventions

Participants were rated with the myTIPreport feedback application by nonblinded faculty in the OR after TLH. In-person, simulation-based assessments were provided by 2 faculty members blinded to experience level using myTIPreport and Global Operative Assessment of Laparoscopic Skills (GOALS). Videos of simulated TLHs were rated by 2 minimally invasive gynecology fellows.

Measurements and Main Results

OR scores for TLH steps were significantly higher than simulation assessments (p?<?.001) with “competent” marked more frequently in the OR. Number of robotic?+?conventional TLHs performed as primary surgeon was not significantly correlated with OR myTIPreport rating (Spearman r?=?.30, p?=?.14) but was significantly correlated with myTIPreport and GOALS in-person simulation ratings (Spearman r?=?.39–.58, p?=?.001–.04). Agreement between in-person simulation rater 1 and 2 myTIPreport assessments was 71.4% (weighted κ, .68; 95% confidence interval, .45–.90), and intraclass correlation for the GOALS overall assessment was .71 (95% confidence interval, .46–.85), indicating substantial agreement. Blinded video reviews showed similar agreement (73.1%) between raters but less correlation with experience (Spearman r?=?.32–.42, p?=?.11–.03) than in-person reviews. Using area under the receiver operating characteristic curve, mean score for the individual components of GOALS that best differentiated myTIPreport noncompetent and competent levels of performance was 4.3. Feedback acceptability and model realism were rated highly.

Conclusion

The scoring and generalization validity inferences for Limbs and Things and myTIPreport are supported when global assessments of performance are evaluated but not for individual components of the assessment instruments.  相似文献   

15.

Study Objective

To evaluate a new magnetic resonance imaging (MRI) grading system for preoperative differentiation between benign and variant-type uterine leiomyomas including smooth muscle tumors of uncertain malignant potential (STUMPs).

Design

Retrospective analysis (Canadian Task Force classification III).

Setting

Teaching hospital (Teine Keijinkai Hospital).

Patients

Three-hundred thirteen patient medical records were retrospectively reviewed if treated for uterine myomas and diagnosed with variant type leiomyomas or STUMPs (n?=?27) or benign, typical leiomyomas (n?=?286) and treated between January 2012 and December 2014.

Intervention

Uterine myoma classifications using MRI findings according to a 5-grade system (grades I–V) based on 3 elements.

Measurements and Main Results

Uterine myoma MRI classifications were based on 3 elements: T2-weighted imaging (high or low), diffusion-weighted imaging (high or low), and apparent diffusion coefficient values (high or low; apparent diffusion coefficient?<?1.5?×?10?3 mm2/sec was considered low). Grades I to II were designated as typical or benign leiomyomas, grade III as degenerated leiomyomas, and grades IV to V as variant type leiomyomas or STUMPs. Accuracy levels were 98.9%, 100%, 94.3%, 58.8%, and 41.9% for grades I through V lesions, respectively. The grades were divided into 2 groups to discriminate benign leiomyomas and STUMPs (grades I–III were considered negative and grades IV–V positive). Grades IV to V scored 85.2% for sensitivity, 91.3% for specificity, 47.9% positive predictive value, 98.5% negative predictive value, a 9.745 positive likelihood ratio, and a .162 negative likelihood ratio.

Conclusion

This novel MRI grading system for uterine myomas may be beneficial in differentiating benign leiomyomas from STUMPs or variant type leiomyomas and could be a future effective presurgical assessment tool.  相似文献   

16.

Study Objective

Our primary endpoint was to compare the intra- and postoperative complications, whereas secondary endpoints were the occurrence of voiding dysfunction and evaluation of the quality or life of segmental and discoid resection in patients with colorectal endometriosis.

Design

Retrospective study (Canadian Task Force classification II-2).

Setting

Tenon University Hospital in Paris.

Patients

Thirty-one 31 patients who underwent a conservative surgery and 31 patients who underwent.

Interventions

The 2 groups were compared using propensity score matching (PSM) analysis, with a median follow-up of 247 days (8.2 months).

Measurements and Main Results

Discoid colorectal resection was associated with a shorter operating time (155 vs 180 minutes, p?=?.03) and hospital stay (7 vs 8 days, p?=?.002) than segmental colorectal resection; however, a similar intra- and postoperative complication rate was found. A higher rate of postoperative voiding dysfunction was observed in the segmental resection group (19% vs 45%, p?=?.03) as well as duration of voiding dysfunction requiring bladder self-catheterization longer than 30 days (0 vs 22%, p?=?.005).

Conclusion

Our PSM analysis suggests the advantages of discoid resection because it results in a similar surgical complication rate to segmental resection but with advantages in operating time, hospital stay, and voiding dysfunction.  相似文献   

17.

Study Objective

To present a large single-center series of hysterectomies for uteri ≥1?kg and to compare the laparoscopic and open abdominal approach in terms of perioperative outcomes and complications.

Design

A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2).

Setting

An academic research center.

Patients

Consecutive women who underwent hysterectomy for uteri ≥1?kg between January 2000 and December 2016. Patients with a preoperative diagnosis of uterine malignancy or suspected uterine malignancy were excluded. The subjects were divided according to the intended initial surgical approach (i.e., open or laparoscopic). The 2 groups were compared in terms of intraoperative data and postoperative outcomes. Multivariable analysis was performed to identify possible independent predictors of overall complications. A subanalysis including only obese women was accomplished.

Interventions

Total laparoscopic versus abdominal hysterectomy (±bilateral adnexectomy).

Measurements and Main Results

Intra- and postoperative surgical outcomes. A total of 258 patients were included; 55 (21.3%) women were initially approached by open surgery and 203 (78.7%) by laparoscopy. Nine (4.4%) conversions from laparoscopic to open surgery were registered. The median operative time was longer in the laparoscopic group (120 [range, 50–360] vs 85 [range, 35–240] minutes, p?=?.014). The estimated blood loss (150 [range, 0–1700] vs 200 [50–3000] mL, p?=?.04), postoperative hemoglobin drop, and hospital stay (1 [range, 1–8] vs 3 [range, 1–8] days, p?<?.001) were lower among patients operated by laparoscopy. No difference was found between groups in terms of intra- and postoperative complications. However, the overall rate of complications (10.8% vs. 27.2%, p?=?.015) and the incidence of significant complications (defined as intraoperative adverse events or postoperative Clavien-Dindo ≥2 events, 4.4% vs 10.9%, p?=?.04) were significantly higher among patients who initially received open surgery. The laparoscopic approach was found to be the only independent predictor of a lower incidence of overall complications (odds ratio?=?0.42; 95% confidence interval, 0.19–0.9). The overall morbidity of minimally invasive hysterectomy was lower also in the subanalysis concerning only obese patients.

Conclusion

In experienced hands and in dedicated centers, laparoscopic hysterectomy for uteri weighing ≥1?kg is feasible and safe. Minimally invasive surgery retains its well-known advantages over open surgery even in patients with extremely enlarged uteri.  相似文献   

18.

Study Objective

To estimate the risk of venous thromboembolic complications after abdominal, laparoscopic, and vaginal hysterectomy when performed for benign disorders.

Design

A nationwide cohort study (Canadian Task Force classification II-2).

Setting

Data from Danish national registers on all women undergoing hysterectomy for benign conditions from 1996 to 2015.

Patients

Women aged 18 years and older who underwent hysterectomy for benign disease were stratified into 3 groups according to the hysterectomy approach: abdominal, laparoscopic, or vaginal.

Interventions

Hysterectomy.

Measurements and Main Results

Eighty-nine thousand nine hundred thirty-one women met the inclusion criteria. Venous thromboembolism (VTE) as a diagnosis or cause of death was identified. The risk of postoperative VTE was examined with Cox proportional hazard models adjusting for age, surgical approach, and relevant comorbidities. The mean age was 49.9, 47.9, and 54.3 years for women with abdominal, laparoscopic, and vaginal hysterectomy, respectively. The crude incidences of VTE within 30 days after hysterectomy were 0.24% (n?=?142), 0.13% (n?=?12), and 0.10% (n?=?21). The most important predictors of VTE were the approach to hysterectomy and a history of thromboembolic disease. In the multivariable analysis, the risk of VTE was significantly reduced with laparoscopic hysterectomy (hazard ratio [HR]?=?0.51; 95% confidence interval [CI], 0.28–0.92; p?=?.03) and vaginal hysterectomy (HR?=?0.39; 95% CI, 0.24–0.63; p?<?.001) when compared with the abdominal procedure. Data on postoperative heparin thromboprophylaxis were available in 53?566 patients, and the adjusted HR was 0.63 (95% CI, 0.42–0.96; p?=?.03) in patients receiving heparin thromboprophylaxis.

Conclusion

The 30-day cumulative incidence of VTE after hysterectomy for benign conditions was low overall (0.19%). Laparoscopic hysterectomy and vaginal hysterectomy carry a lower risk than the abdominal procedure. Postoperative heparin thromboprophylaxis significantly reduces the risk of VTE and should be considered, especially if risk factors are present.  相似文献   

19.

Study Objective

To determine if there is a difference in readmission rates after same-day discharge compared with postoperative day 1 discharges after laparoscopic hysterectomy.

Design

A retrospective cohort study with 1:2 propensity score matching (Canadian Task Force classification II-2).

Setting

American College of Surgeons National Surgical Quality Improvement Program database.

Patients

Women undergoing benign laparoscopic total or supracervical hysterectomy or laparoscopic-assisted vaginal hysterectomy with or without adnexal surgery between the years 2010 to 2015.

Interventions

Three thousand thirty-two low-risk women discharged on postoperative day 0 and 6064 women discharged on postoperative day 1 were included in the analysis.

Measurements and Main Results

The overall readmission rate was 1.8%; after same-day discharge, the readmission rate was 2.2%, and after postoperative day 1 discharge the readmission rate was 1.7% (p?=?.10). After logistic regression analysis, smoking (adjusted odds ratio [aOR]?=?2.06; 95% confidence interval [CI], 1.49–2.88), nonwhite race (aOR?=?1.53; 95% CI, 1.1007–2.14), and cystoscopy (aOR?=?2.05; 95% CI, 1.49–2.82) were associated with an increased risk of readmission.

Conclusion

There was no statistically significant difference in readmission rates after laparoscopic hysterectomy between women discharged on the day of surgery or postoperative day 1.  相似文献   

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