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

Objective

To describe the surgical outcomes of single port access laparoscopic subtotal hysterectomy (LSH) using in-bag manual morcellation and evaluate the feasibility of this procedure.

Laparoscopic subtotal hysterectomy using the plasma kinetic and lap loop systems: an alternative approach in the surgical management of women with uterine fibroids

OBJECTIVE: To evaluate the safety and applicability of laparoscopic subtotal hysterectomy (LSH) using the plasma kinetic (PK) and lap loop systems as an alternative surgical approach in the management of uterine fibroids in women who have completed their families. STUDY DESIGN: Sixty-two consecutive LSH were performed during this prospective study from March 2003 to March 2005 at Princess Royal University Hospital, Kent, UK. RESULTS: All study patients had menorrhagia resistant to at least one form of therapy, with a mean duration of symptoms of 3.5 years. In addition, four patients had previous myomectomy. The mean number of fibroids removed was 2.7. The mean weight of the uterus was 141.9 g. The mean operative time was 46.8 min, and the mean blood loss was 126.6 mL. The overall perioperative complication rate was 4.8% with no visceral injury, or return to theatre. At follow-up, all patients were satisfied with surgery. CONCLUSION: The study describes the first application of the PK and Lap Loop systems in LSH for the surgical management of uterine fibroids in women in whom fertility is not an issue, and its findings suggest that this minimally invasive technique is a safe, and valid alternative. Larger adequately-powered studies are however still required.     

Comparison study of single-port (Octoport™) and four-port total laparoscopic hysterectomy

Objective

To compare the perioperative surgical outcomes and complication rates between single-port total laparoscopic hysterectomy and conventional four-port total laparoscopic hysterectomy.

Study design

Between June 2009 and April 2011, 56 patients underwent total laparoscopic hysterectomy. Of these 56 patients, 28 underwent single-port (Octoport™) total laparoscopic hysterectomy and 28 underwent conventional four-port total laparoscopic hysterectomy. We analyzed the following parameters for all the patients: age, body mass index, operative time, blood loss, change in hemoglobin level, vaginal stump suture time and length of hospital stay.

Results

The general characteristics of the patients were similar in both groups. There were no statistically significant differences in blood loss, hemoglobin change, length of postoperative hospital stay and complication rate. However, the mean operative time of the single-port group was significantly longer than that of the four-port group (93.5 ± 24.0 min vs. 78.7 ± 17.4 min; P = 0.011). The operative time for vaginal stump suture was profoundly decreased with experience in the single-port group.

Conclusion

With the exception of operative time, the surgical outcomes and incidence of complications of the single-port group were comparable to those of the four-port group. However, the operative time decreased in the single-port group with increasing experience.     

Vaginal Versus Robotic Hysterectomy and Concomitant Pelvic Support Surgery: A Comparison of Postoperative Vaginal Length and Sexual Function

Study ObjectiveTo compare the change from pre- to postoperative total vaginal length (TVL) in women who underwent either a total vaginal hysterectomy (TVH) with uterosacral ligament suspension (USLS) or a robotic hysterectomy (RH) with colpopexy (SCP). Secondary objectives included comparing sexual function, pelvic floor function, and prolapse recurrence between routes of surgery.DesignThis was a retrospective cohort study (Canadian Task Force classification II-2).SettingThis was conducted at 1 tertiary academic medical center over a 2-year period.PatientsWomen who underwent either TVH/USLS or RH/SCP.InterventionsBaseline and postoperative POP-Q Pelvic Organ Prolapse Quantification exams were recorded as well as postoperative validated questionnaires. Twenty-nine subjects were needed in each group to detect a 1.5-cm difference in TVL.Measurements and Main ResultsThere were 38 TVH/USLS and 46 RH/SCP participants. RHs were either total (28/46 [61%]) or supracervical (18/46 [39%]). The mean postoperative follow-up was 9.5 ± 3.1 months. For the primary outcome, women in the TVH/USLS group had a decrease in TVL, whereas women in the RH/SCP group had an increase in TVL (−0.6 ± 1.0 cm vs 0.5 ± 0.8 cm, p < .001). Among sexually active women (55/84, 65.5%), there was no difference in postoperative sexual function between groups based on Pelvic Organ Prolapse/Urinary incontinence Sexual Function Questionnaire short form scores, with good sexual function in both groups (32.6 ± 6.2 TVH/USLS vs 35.1 ± 7.3 RH/SCP, p = .22). Although both groups showed good postoperative apical support, the TVH/USLS group had a slightly lower mean C point compared with the RH/SCP group (−6.8 ± 1.2 vs −7.7 ± 1.8, p = .02). Both groups showed good postoperative pelvic floor function, with no difference in mean postoperative Pelvic Organ Prolapse Distress Inventory scores (42.2 ± 45.4 vs 52.7 ± 46.6, p = .44). Recurrent prolapse (defined as any prolapse at or beyond the hymen) was not different between groups (13.2% for TVH/USLS vs 6.5% for RH/SCP, p = .46).ConclusionVaginal length decreased after vaginal hysterectomy with pelvic support surgery compared with RH with pelvic support surgery, with no differences in postoperative sexual function or pelvic floor function between groups.     

Pelvic Pain and Patient Satisfaction After Laparoscopic Supracervical Hysterectomy: Prospective Trial

Study ObjectiveTo evaluate the occurrence and intensity of cyclic pelvic pain and patient satisfaction after laparoscopic supracervical hysterectomy and to explore the effect of the procedure on pelvic pain relief in women with perioperative detection of endometriosis and in women with histologic confirmation of adenomyosis.DesignProspective observational study with 12-month follow-up after laparoscopic supracervical hysterectomy (Canadian Task Force classification II-2).SettingUniversity teaching hospital in Norway.PatientsOne hundred thirteen premenopausal women with preoperative cyclic pelvic pain treated via laparoscopic supracervical hysterectomy.InterventionsStudy participants underwent laparoscopic supracervical hysterectomy and were followed up at the outpatient clinic at 12 months after the procedure.Measurements and Main ResultsThe main outcomes were occurrence, intensity, and reduction of cyclic pelvic pain and patient satisfaction measured using an ordinal and a visual analog scale at 12 months after the procedure. Of the 113 women included in the study, 8 were lost to follow-up. Consequently, 105 women (92.9%) were followed up at 12 months after surgery. All women had cyclic pelvic pain preoperatively, but only 34 (32.4%) experienced this pain at 12 months after the procedure. The intensity of pelvic pain was reduced from a mean (SD) of 5.5 (2.4) preoperatively to 0.7 (1.5) at 12 months after the procedure on a visual analog scale of 0 to 10 (p < .01). Endometriosis was diagnosed perioperatively in 14 women (12.4 %), and adenomyosis was confirmed at histologic analysis in 19 (18.1%). In women with perioperative detection of endometriosis or histologic confirmation of adenomyosis, there were no significant differences in main outcomes at 12 months after laparoscopic supracervical hysterectomy when compared with women without these diagnoses.ConclusionLaparoscopic supracervical hysterectomy is associated with high patient satisfaction and reduces cyclic pelvic pain to a minimum by 12 months after the procedure.     

Abdominal vs vaginal hysterectomy: a comparative study of the postoperative quality of life and satisfaction

Objective: To compare the short-term results of the quality of life and satisfaction of patients submitted to total abdominal hysterectomy (TAH) and vaginal hysterectomy (VH) for benign uterine disease. Methods: Women referred for hysterectomy for uterine myoma were randomized to TAH (n=30) or VH (n=30). The exclusion criteria were uterine prolapse, indication associated surgical procedures and uterine size ≥300 cm³. After a month, follow-up questionnaires had a response rate of 100%, and consisted of an interview with application of SF-36 questionnaire (functional capacity, physical aspect and pain) and evaluation of satisfaction rate. Results: There were no differences in the patients’ mean age, parity, body mass index, preoperative hemoglobin levels and uterine size between groups. Lower postoperative quality-of-life scores were found in the TAH group when compared to the VH group in functional capacity (P=0.002), physical aspect (P=0.008) and pain (P=0.002). The general satisfaction rate with the surgery was similar in the two groups of patients (P=0.147). However, a higher rate of patients submitted to VH would choose the same therapeutic modality (65.5 vs 90%; P=0.021). Conclusions: A better postoperative quality of life (functional capacity, physical aspect and pain) and higher satisfaction rate was found in the VH when compared to TAH.     

Hysterectomy improves quality of life and decreases psychiatric symptoms: a prospective and randomised comparison of total versus subtotal hysterectomy

OBJECTIVE: To conduct a prospective and concurrent evaluation of changes in health status and quality of life and psychological outcome measures over one year in women randomised to total or subtotal abdominal hysterectomy. The concurrent evaluation was the impact of total versus subtotal hysterectomy on bladder, bowel and sexual function. DESIGN: Prospective, randomised, double-blind study. SETTING: A large UK Teaching Hospital (St George's Hospital, London) and a large District General Hospital (Mayday University Hospital, Croydon). METHODS. SAMPLE: Two hundred and seventy-nine women undergoing hysterectomy for benign disease were randomly allocated to total hysterectomy (n= 146) or subtotal hysterectomy (n= 133). MAIN OUTCOME MEASURES: Quality of life assessment using the Short-Form-36 health survey (SF-36) and psychological outcome measures using the General Health Questionnaire-28 (GHQ-28) before the operation and 6 and 12 months after. RESULTS: Quality of life and psychological symptoms were similar in the two groups at baseline. Following surgery, quality of life improved in six of the eight domains, with no significant difference between the groups, with the exception of emotions which showed a greater improvement in subtotal hysterectomy women between baseline and 12 months. When this difference was examined further by looking at change in the GHQ subscales, there were no significant differences between total and subtotal hysterectomy women in the amount of change in anxiety, depression, somatic symptoms or social dysfunction, between baseline and post-operative measurements. All women showed an improvement in psychological symptoms following both operations. CONCLUSION: Hysterectomy, whether total or subtotal, may improve quality of life and psychological outcome.     

Changes in body image satisfaction during pregnancy: a comparison of high exercising and low exercising women

OBJECTIVE: This study aimed to compare ratings of body image satisfaction (BIS) from 6 months prepregnancy to 23-30 weeks' gestation for high exercising and low exercising pregnant women. The authors also aimed to assess and compare expectations of BIS for the post-partum period in high and low exercising women. DESIGN: A partial prospective approach was implemented. SAMPLE: A total of 71 healthy pregnant women (40 high exercisers and 31 low exercisers) participated. METHODS: Participants completed a series of questionnaires at 15-22 weeks' gestation and 23-30 weeks' gestation. MAIN OUTCOME MEASURES: There were two main outcome measures. At 15-22 weeks' gestation there was an exercise inventory and two versions of the Body Cathexis Scale (BCS) (retrospective prepregnancy BIS and current BIS). At 23-30 weeks' gestation there was an exercise inventory and two versions of the BCS (current BIS and projected post-partum BIS). RESULTS: At 15-22 weeks' gestation, high exercisers demonstrated significantly higher levels of BIS compared to low exercisers. There were no other significant differences between groups. Within groups, high exercisers were significantly more satisfied with their bodies at 15-22 weeks' gestation compared to 6 months prepregnancy, and expected to be less satisfied with their bodies at 6 weeks' post-partum than they were during pregnancy. Low exercisers demonstrated no significant changes over time. CONCLUSIONS: The findings suggest that women are able to assimilate the bodily changes of pregnancy without a negative shift in BIS. However, women who exercise during pregnancy may respond more favourably to changes in their bodies at early pregnancy compared to women who remain sedentary.     

Barbed Suture versus Conventional Suture for Vaginal Cuff Closure in Total Laparoscopic Hysterectomy: Randomized Controlled Clinical Trial

Study ObjectiveTo determine the surgical time, suture time, presence of postoperative dyspareunia, and complications that occur after closing the vaginal cuff with a barbed suture compared with conventional suture.DesignA randomized, controlled clinical trial (Canadian Task Force classification I).SettingPrivate gynecologic clinic in Medellin, Colombia.PatientsOne hundred fifty women who underwent total laparoscopic hysterectomy for benign pathology.InterventionsThe patients underwent total laparoscopic hysterectomy with intracorporeal closure of the vaginal cuff and were randomized to 2 groups, 1 using a barbed suture (V-Loc 90; Medtronic/Covidien, New Haven, CT) and 1 using polyglactin 910 (coated Vicryl suture; Ethicon/Johnson & Johnson, New Brunswick, NJ).Measurements and Main ResultsThe total operative time, closing time of the vaginal vault, presence of complications in the cuff, and incidence of postoperative dyspareunia were recorded. The patients were evaluated at a postoperative office visit 2 weeks after the procedure and by telephone interview at 24 weeks. Seventy-five patients were included in the barbed suture group and 75 patients in the polyglactin 910 group. The average time to complete the suture of the vaginal cuff was 12.01 minutes (± 5.37 standard deviation) for the barbed suture group versus 13.49 minutes (± 6.48) in the polyglactin 910 group (95% confidence interval, –.44 to 3.4; p = .130). Blood loss was 31.56 ± 22.93 mL in the barbed suture group versus 30.82 ± 21.75 mL in the polyglactin 910 group (95% confidence interval, –7.95 to 6.47; p = .840). The frequency of postoperative events such as hematoma, cellulitis, cuff dehiscence, fever, emergency consultation, and hospitalization was not statistically significant between groups. No statistically significant difference was found regarding deep dyspareunia at 24 postoperative weeks.ConclusionNo differences were found in surgical time or frequency of adverse events when comparing patients after vaginal cuff closure with barbed suture versus polyglactin 910.     

Robotic Single-Incision Transumbilical Total Hysterectomy Using a Single-Site Robotic Platform: Initial Report and Technique

The benefits of laparoscopic surgery over open abdominal surgery have been well documented. Efforts continue for development of strategies that further reduce the size of abdominal incisions and the number of trocars used. Laparoendoscopic single-site surgery (LESS) is a promising approach that can further enhance cosmetic satisfaction and reduce the risks of laparoscopic surgery. Loss of triangulation, instrument crowding and clashing, poor visualization, and ergonomic problems are the most challenging issues associated with the use of LESS. The combination of LESS and the robotic system seems to be a promising choice to overcome the technical difficulties of LESS. The da Vinci Single-Site Surgical Platform is a novel semi-rigid robotic operating system. We present our initial clinical experience with robotic-assisted single-incision transumbilical total hysterectomy using the novel da Vinci Single-Site Surgical Platform.     

Advanced Training of Gynecologic Surgeons and Incidence of Intraoperative Complications after Total Laparoscopic Hysterectomy: A Retrospective Study of More Than 2000 Cases at a Single Institution

Study Objective

To investigate whether surgeon factors including level of training undertaken in laparoscopic surgery, time in specialist practice, and case volume were associated with surgical morbidity for total laparoscopic hysterectomy (TLH).

Women's Sexual Behavior,Body Image and Satisfaction with Surgical Outcomes after Hysterectomy: A Comparison of Vaginal and Abdominal Surgery

The aim of this study was to investigate the impact of vaginal and abdominal hysterectomy on women's sexual behavior, sexual dysfunction, body image and satisfaction with surgery. A prospective study was conducted on 90 women to evaluate the outcomes of hysterectomy. Data were collected prior to surgery, three months and two years after surgery, using self-report questionnaires. The results showed significant differences in women's sexual behavior and sexual dysfunction before and after hysterectomy, independent of the surgical procedure performed. Women in both groups reported improvements in sexual desire, sexual activity and sexual intercourse three months and two years after surgery. Sexual dysfunction such as dyspareunia, vaginismus, lack of orgasm and loss of sexual interest diminished significantly after surgery. Regression analyses revealed that postmenopausal status, severity of gynecological complaints and frequency of sexual intercourse were the most important factors for improved sexual outcomes. Women in the abdominal group were dissatisfied with their body image because of the abdominal scar, experienced more pain and had a longer period of recovery from surgery compared to women in the vaginal group. According to the results, sexual behavior alone is not an important factor in choosing vaginal or abdominal hysterectomy. However, sexual behavior was important in both groups when evaluating outcomes after hysterectomy.     

Interrelation Between Appearance Anxiety and Sexual Functions in Women: The Role of Surgical Scars,Morphologic Features,and Accompanying Depression

IntroductionThe findings regarding the association between body mass index (BMI) and sexuality outcomes are mixed. Subjective body image has been found to be more salient in predicting sexual function than actual body size. Previous studies have demonstrated appearance anxiety to be particularly significant.AimTo evaluate the association between appearance anxiety and female sexual functions. Specific aims included the evaluation of body morphologic measurements with indicators other than BMI and determining the predictive role of surgical scars for appearance anxiety and female sexual function.MethodsSexually active women who had been in a stable heterosexual relationship for ≥6 months participated in this study. Demographic features, anthropometric measurements including BMI, skin-fold thickness (SFT) measurements from 3 regions of the body (triceps, scapula, and abdomen) and waist circumference (WC) were assessed. Finally, participants were asked to complete the Appearance Anxiety Inventory, Female Sexual Function Index, and Beck Depression Inventory. Multivariate path analyses and hierarchical multiple regression analyses were performed.Main Outcome MeasuresThe correlations of age, BMI, presence of surgical scars, and measurements of BMI, WC, and SFT as independent variables with Beck Depression Inventory, Appearance Anxiety Inventory, and Female Sexual Function Index scores were the main outcomes of the study.ResultsThe data of 329 women were analyzed. The median age of the participants was 33 (19–52) years. The mean BMI was 24.5 (SD 3.5) kg/m². The prevalence of female sexual dysfunction was 22.8%. Multivariate analyses revealed that increased appearance anxiety (?0.45), presence of surgical scars (?0.28), accompanying depression (?0.15), SFT abdomen measurement (?0.16), and age (?0.13) were significantly associated with sexual function. Appearance anxiety was found to be associated with accompanying depression (0.56), presence of surgical scar (0.38), and measurements of the WC (0.22), BMI (0.14), SFT-abdomen (0.12), and SFT-triceps (?0.31).Clinical ImplicationsClinicians should take the strong relationship between appearance anxiety and female sexual function into consideration. Body morphologic evaluation should not be limited to BMI; surgical scars and WC and SFT measurements may play a considerable role.Strengths & LimitationsA major limitation of this study was the lack of personal distress evaluation in the participants.ConclusionSexual complaints in middle-aged women revealed the strongest correlation with appearance anxiety. Further longitudinal studies are needed to reveal its underlying factors and implications for sexuality.Cihan A, Cihan E. Interrelation Between Appearance Anxiety and Sexual Functions in Women: The Role of Surgical Scars, Morphologic Features, and Accompanying Depression. J Sex Med 2019;16:1769–1778.     

Success rate and patient satisfaction with the Essure sterilisation in an outpatient setting: a prospective study of 857 women

After 857 women with Essure system inserted for tubal obstruction as a method of sterilization in an outpatient setting, insertion is achieved in close to 99% of the women. Physician described the procedure as very difficult in 15% of the cases, mainly due to anatomical tubal anomalis or tubal spasm, and women felt highly satisfied in all cases.     

Primary invasive carcinoma of vagina with third degree uterovaginal prolapse: a case report and review of literature

Background  Primary vaginal carcinoma associated with third degree uterovaginal prolapse is very rare. Case  We present a case report of a postmenopausal woman who presented with an invasive carcinoma of vagina associated with third degree uterovaginal prolapse treated by Mitra’s operation. She was asymptomatic and had no recurrence during last 1 year of follow-up. Conclusion  Vaginal ulcer associated with long standing genital prolapse need careful evaluation (including punch biopsy) for underlying carcinoma. Treatment due to the rarity of this entity was controversial previously and current review of literature suggests surgical treatment with or without radiotherapy as the optimum treatment for early stage and radiotherapy for advanced stage vaginal carcinoma associated with genital prolapse. Early diagnosis with adequate treatment can minimize the morbidity and mortality associated with vaginal carcinoma.     

Devic’s neuromyelitis optica and pregnancy: distinction from multiple sclerosis is essential

Background  Devic’s neuromyelitis optica (NMO) is a severe neurological disease characterized by optic neuritis and transverse myelitis, which is commonly misdiagnosed as multiple sclerosis (MS). This rare syndrome has a poor prognosis, and there are very few cases described during pregnancy. Case  We report the occurrence of NMO in a primigravida at 20 weeks, in which gestation had an adverse effect on the disease course, and emphasize the main parameters to distinguish NMO from MS. Conclusion  It is essential that a proper diagnosis is established before pregnancy is planned, since the prognosis for NMO and MS might differ. Although the association of gestation and NMO is extremely rare, the few available data demonstrate a significant risk of disease exacerbation. NMO patients require long term immunossupression and need to carefully evaluate the risk of getting pregnant.     

Perioperative Interventions to Minimize Blood Loss at the Time of Hysterectomy for Uterine Leiomyomas: A Systematic Review and Meta-analysis

Study ObjectiveHysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify nonhormonal interventions, perioperative surgical interventions, and devices to minimize blood loss at the time of hysterectomy for leiomyoma.Data SourcesLibrarian-led search of Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases from 1946 to 2018 with hand-guided updates.Methods of Study SelectionIncluded studies reported on keywords of hysterectomy, leiomyoma, and operative blood loss/postoperative hemorrhage/uterine bleeding/metrorrhagia/hematoma. The review excluded a comparison of route of hysterectomy, morcellation, vaginal cuff closure, hormonal medications, vessel sealing devices for vaginal hysterectomy, and case series with <10 patients.Tabulation, Integration, and ResultsSurgical blood loss, postoperative hemoglobin (Hb) drop, hemorrhage, transfusion, and major and minor complications were analyzed and aggregated in meta-analyses for comparable studies in each category. A total of 2016 unique studies were identified, 33 of which met the inclusion criteria, and 22 were used for quantitative synthesis. The perioperative use of misoprostol in abdominal hysterectomy (AH) was associated with a lower postoperative Hb drop (0.59 g/dL; 95% confidence interval [CI], 0.39–0.79; p < .01) and blood loss (?96.43 mL; 95% CI, ?153.52 to ?39.34; p < .01) compared with placebo. Securing the uterine vessels at their origin in laparoscopic hysterectomy (LH) was associated with decreased intraoperative blood loss (?69.07 mL; 95% CI, ?135.20 to ?2.95; p = .04) but no significant change in postoperative Hb (0.24 g/dL; 95% CI, ?0.31 to 0.78; p = .39) compared with securing them by the uterine isthmus. Uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with standard ligation (?27.72 mL; 95% CI, ?35.07 to ?20.38; p < .01). The postoperative Hb drop was not significantly different with a bipolar electrosurgical device versus suturing in AH (0.26 g/dL; 95% CI, ?0.19 to 0.71; p = .26). There was no significant difference between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the Hb drop (0.02 g/dL; 95% CI, ?0.15 to 0.20; p = .79) or blood loss (?50.88 mL; 95% CI, ?106.44 to 4.68; p = .07) in LH. Blood loss in LH was not decreased with the LigaSure (Medtronic, Minneapolis, MN) impedance monitoring EBVS compared with competing EBVS systems monitoring impedance or temperature (2.00 mL; 95% CI, ?8.09 to 12.09; p = .70). No significant differences in hemorrhage, transfusion, or major complications were noted for all interventions.ConclusionPerioperative misoprostol in AH led to a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines) although the clinical benefit is likely limited. Remaining interventions, although promising, had at best low-quality evidence to support their use at this time. Larger and rigorously designed randomized trials are needed to establish the optimal set of perioperative interventions for use in hysterectomy for leiomyomas.     

Intrauterine adhesions (IUA): has there been progress in understanding and treatment over the last 20 years?

We review the current evidence about the treatment modalities of intrauterine adhesions (IUA) or Asherman’s Syndrome (AS). Systematic approach, audit and well-structured research is mandatory in order to establish the best treatment for the individual needs of patients. The clinical practice changed significantly over the last 20 years with technological advances in hysteroscopy and imaging techniques. Hysteroscopic treatment seems effective and safe. IUA or AS is a rather uncommon finding in general gynaecological practice. The referral to a tertiary centre will help to centralise the most difficult cases and create the opportunity to study more in detail the efficacy of each treatment modality and to compare the different treatment techniques.