Adam C. Steinberg

Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared With Laparoscopy and Laparotomy

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.

Mesh Sacrocolpopexy Compared With Native Tissue Vaginal Repair: A Systematic Review and Meta-analysis

OBJECTIVE: To systematically review outcomes after mesh sacrocolpopexy compared with native tissue vaginal repairs in women with apical prolapse. DATA SOURCES: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through June 4, 2012. METHODS OF STUDY SELECTION: For anatomic and functional analyses, we included studies comparing mesh sacrocolpopexy to native tissue vaginal repairs with at least 6 months follow-up. The primary outcome was anatomic “success” after surgery. Secondary outcomes were reoperation and symptom outcomes. We included large case series and comparative studies with shorter follow-up to increase power for adverse event analyses. TABULATION, INTEGRATION, AND RESULTS: Evidence quality was assessed with the Grades for Recommendation, Assessment, Development and Evaluation system. Meta-analyses were performed when at least three studies reported the same outcome. We included 13 comparative studies for anatomic success, reoperation, and symptom outcomes. Moderate-quality evidence supports improved anatomic outcomes after mesh sacrocolpopexy; very low-quality evidence shows no differences in reoperation between sacrocolpopexy and native tissue vaginal repairs. Evidence was insufficient regarding which procedures result in improved bladder or bowel symptoms. Low-quality evidence showed no differences in postoperative sexual function. Adverse event data were compiled and meta-analyzed from 79 studies. When including larger noncomparative studies, ileus or small bowel obstruction (2.7% compared with 0.2%, P<.01), mesh or suture complications (4.2% compared with 0.4%, P<.01), and thromboembolic phenomena (0.6% compared with 0.1%, P=.03) were more common after mesh sacrocolpopexy compared with native tissue vaginal repairs. CONCLUSION: When anatomic durability is a priority, we suggest that mesh sacrocolpopexy may be the preferred surgical option. When minimizing adverse events or reoperation is the priority, there is no strong evidence supporting one approach over the other.

Venous thromboembolism prophylaxis in gynecologic surgery: A systematic review

OBJECTIVE: To comprehensively review and critically assess the available gynecologic surgery venous thromboembolism prophylaxis literature and provide clinical practice guidelines. DATA SOURCES: MEDLINE and Cochrane databases from inception to July 2010. We included randomized controlled trials in gynecologic surgery populations. Interventions and comparators included graduated compression stockings, intermittent pneumatic compression, unfractionated heparin, and low molecular weight heparin; placebo and routine postoperative care were allowed as comparators. METHODS OF STUDY SELECTION: One thousand two hundred sixty-six articles were screened, and 14 randomized controlled trials (five benign gynecologic, nine gynecologic oncology) met eligibility criteria. In addition, nine prospective or retrospective studies with at least 150 women were identified and provided data on venous thromboembolism risk stratification, gynecologic laparoscopy, and urogynecologic populations. TABULATION, INTEGRATION, AND RESULTS: Two reviewers independently screened articles with discrepancies adjudicated by a third. Eligible randomized controlled trials were extracted for these characteristics: study, participant, surgery, intervention, comparator, and outcomes data, including venous thromboembolism incidence and bleeding complications. Studies were individually and collectively assessed for methodologic quality and strength of evidence. Overall incidence of clinical venous thromboembolism was 0–2% in the benign gynecologic population. With use of intermittent pneumatic compression for benign major procedures, venous thromboembolism incidence was less than 1%. No venous thromboembolisms were identified in prospective studies of benign laparoscopic procedures. Overall quality of evidence in the benign gynecologic literature was poor. Gynecologic–oncology randomized controlled trials reported venous thromboembolism incidence (including “silent” venous thromboembolisms) of 0–14.8% with prophylaxis and up to 34.6% without prophylaxis. Fair quality of evidence supports that unfractionated heparin and intermittent pneumatic compression are both superior to placebo or no intervention but insufficient to determine whether heparins are superior to intermittent pneumatic compression for venous thromboembolism prevention. Combining two of three risks (aged 60 years or older, cancer, or personal venous thromboembolism history) substantially elevated the risk of venous thromboembolism. CONCLUSION: Intermittent pneumatic compression provides sufficient prophylaxis for the majority of gynecology patients undergoing benign surgery. Additional risk factors warrant the use of combined mechanical and pharmacologic prophylaxis.

Use of a beef tongue model and instructional video for teaching residents fourth-degree laceration repair

Introduction and hypothesisThis study seeks to compare the utility of the beef tongue model versus an instructional video in teaching obstetric and gynecology residents how to repair a fourth-degree laceration.MethodsTwenty-seven residents were randomized to participate in a workshop with a beef tongue model or assigned to watch an instructional video on repair of fourth-degree lacerations and read a chapter on the repair. All subjects were tested with a pre- and postintervention written test. These scores were compared with paired t test at 0.05 significance level.ResultsResidents with no prior experience in fourth-degree laceration repairs showed an improvement in knowledge (49.5% versus 64.1%, p < 0.001) on written exams about the repairs.ConclusionsAn instructional video or beef tongue model and textbook chapter on fourth-degree laceration repair can improve skills in repair of a fourth-degree laceration among residents with no experience in these repairs.

Discrepancies in the female pelvic medicine and reconstructive surgeon workforce.

Introduction It is unclear whether the current distribution of surgeons practicing female pelvic medicine and reconstructive surgery in the United States is adequate to meet the needs of a growing and aging population. We assessed the geographic distribution of female pelvic surgeons as represented by members of the American Urogynecologic Society (AUGS) throughout the United States at the county, state, and American Congress of Obstetricians and Gynecologists district levels. Materials and Methods County-level data from the AUGS, American Congress of Obstetricians and Gynecologists, and the United States Census were analyzed in this observational study. State and national patterns of female pelvic surgeon density were mapped graphically using ArcGIS software and 2010 US Census demographic data. Results In 2013, the 1058 AUGS practicing physicians represented 0.13% of the total physician workforce. There were 6.7 AUGS members available for every 1 million women and 20 AUGS members for every 1 million postreproductive-aged women in the United States. The density of female pelvic surgeons was highest in metropolitan areas. Overall, 88% of the counties in the United States lacked female pelvic surgeons. Nationwide, there was a mean of 1 AUGS member for every 31 practicing general obstetrician-gynecologists. Conclusions These findings have implications for training, recruiting, and retaining female pelvic surgeons. The uneven distribution of female pelvic surgeons throughout the United States is likely to worsen as graduating female pelvic medicine and reconstructive surgery fellows continue to cluster in urban areas.

Primary Amenorrhea with an Abdominal Mass at the Umbilicus

BACKGROUND Transverse vaginal septum is a rare cause of primary amenorrhea. It has a reported incidence of 1:2,100-1:72,000 and a variety of clinical presentations. CASE A 16-year-old patient presented with primary amenorrhea and a large abdominal mass that was palpated on clinical exam and confirmed on MRI imaging. A diagnosis of transverse vaginal septum was ultimately made and the patient underwent a successful surgical excision of the septum and vaginal reconstruction. CONCLUSION The presentation, etiology, diagnosis, and surgical treatment of a transverse vaginal septum are discussed.

Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines

Objective The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy. Data Sources Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. Study Eligibility We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication. Study Appraisal and Synthesis Methods Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type. Results Eighty‐four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage. Conclusion Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.

Pain management strategies for urogynecologic surgery: a review.

Objectives The objectives of this study were to review the recent literature on surgical pain management strategies and to identify those pertinent to urogynecologic surgery. Methods A literature search using Pubmed and MEDLINE was performed for trials on pain management in gynecologic surgery. Evidenced-based recommendations for preoperative, intraoperative, and postoperative pain control strategies for gynecologic procedures by various surgical routes were identified. Articles specifically describing urogynecologic procedures were sought, but quality, randomized trials on pain management modalities in other gynecologic procedures were also included. Results Although few randomized trials on pain management strategies in urogynecologic surgery exist, quality evidence suggests that several preemptive and multimodal analgesia strategies reduce pain and opioid-related adverse events in abdominal, laparoscopic, and vaginal surgery. Evidence supporting these strategies is outlined. Many are likely applicable to urogynecologic procedures. Conclusions Evidence guiding pain management in specific urogynecologic procedures is sparse and should be sought in future studies. When possible, procedure-specific strategies, including preemptive and multimodal techniques, should be implemented.

Pelvic organ prolapse quantification use in the literature.

Objective This study aimed to determine whether the Pelvic Organ Prolapse Quantification (POPQ) system should be simplified based on its use in the peer-reviewed literature. Methods The American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, and International Urogynecology Journal were used for this study. All articles relating to pelvic organ prolapse published in these journals from January 2005 to December 2010 were reviewed for their use of the POPQ system. The POPQ points described in the Materials and/or Results sections of these articles were recorded. Results Two hundred eighty-three articles using the POPQ system were identified. One hundred thirty-two (47%) articles used the POPQ system but only to determine the stage of prolapse. Specific points were not mentioned. One hundred two (36%) articles evaluated specific POPQ points (Aa, Ba, Ap, Bp, C, D). Forty-nine (17%) articles evaluated points Gh, Pb, and Tvl. Conclusions The POPQ system, based on its use in the peer-reviewed literature, may need revisions. An abbreviated version of the system may be considered, allowing for more widespread use.

The impact of flatal incontinence on quality of life

OBJECTIVE The purpose of this study was to determine the impact of flatal incontinence (FI) on quality of life STUDY DESIGN This was a retrospective analysis of 678 consecutive new patients who were evaluated over an 8-month period. The Pelvic Floor Dysfunction Inventory-20 and Pelvic Floor Impact Questionnaire short form-7 were evaluated to compare those women with and without FI. The Student t test and logistic regression were used to determine the impact of FI. RESULTS The 160 women with FI were older (P < .001), had greater parity (P < .001), were more likely to experience chronic constipation (P = .005), and had more vaginal deliveries (P = .002) than those women without FI. Women with FI scored higher for bother on the Pelvic Floor Dysfunction Inventory-20 (94.1 +/- 46.3 vs 64.1 +/- 41.9; P < .001), and on the Pelvic Floor Impact Questionnaire short form-7 (46.2 +/- 50.9 vs 36.2 +/- 43.9; P = .041). CONCLUSION Flatal incontinence negatively impacts women.