Antonio R. Gargiulo

Pregnancy outcomes following robot-assisted myomectomy

STUDY QUESTION What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri? SUMMARY ANSWER Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy in our cohort, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy. WHAT IS KNOWN ALREADY Reproductive outcomes after traditional laparoscopic myomectomy are well documented. However, reproductive outcomes following robotic myomectomy are not well studied. This paper describes the pregnancy outcomes for a large cohort of women after robotic myomectomy. STUDY DESIGN, SIZE, DURATION This is a retrospective cohort of women who became pregnant after robot-assisted myomectomy at three centers. Of the 872 women who underwent robotic myomectomy during the period October 2005-November 2010, 107 subsequently conceived resulting in 127 pregnancies and 92 deliveries through 2011. PARTICIPANTS/MATERIAL, SETTING, METHODS Women of reproductive age with fibroids who wanted a minimally invasive treatment option and desired uterine preservation were recruited. We conducted a multicentre study with three centers, two in a private practice and one in an academic setting. Pregnancy outcomes and their relationship to myoma characteristics were analyzed. MAIN RESULTS AND ROLE OF CHANCE Mean ± SD age at myomectomy was 34.8 ± 4.5 years and 57.4% [95% confidence interval (CI) 48.0, 66.3] of women were overweight or obese. The mean number of myomas removed was 3.9 ± 3.2 with a mean size of 7.5 ± 3.0 cm and mean weight of 191.7 ± 144.8 g. Entry of the myoma into the endometrial cavity occurred in 20.6% (95% CI 15.0, 27.7) of patients. The mean time to conception was 12.9 ± 11.5 months. Assisted reproduction techniques were employed in 39.4% (95% CI 32.6, 46.7) of these women. Seven twin pregnancies and two triplet pregnancies occurred, for a multiple pregnancy birth rate of 9.8% (95% CI 5.0, 17.8). Spontaneous abortions occurred in 18.9% (95% CI 13.0, 26.6). Preterm delivery prior to 35 weeks of gestational age occurred in 17.4% (95% CI 10.9, 26.5). One uterine rupture (1.1%; 95% CI 0.3, 4.7) was documented. Pelvic adhesions were discovered in 11.4% (95% CI 7.0, 18.0) of patients delivered by Cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision (compared with all other sites) in logistic regression analyses (P = 0.01). None of the myoma characteristics were related to spontaneous abortion. BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION Given the retrospective nature of the data collection, some pregnancies may not have been captured. In addition, owing to the high prevalence of infertility patients in this cohort, the data cannot be used to counsel women who are undergoing RALM about fertility rates after surgery. GENERALIZABILITY TO OTHER POPULATIONS Prospective studies are needed to determine if the results shown in our cohort are generalizable to all women seeking a minimally invasive option for the conservative treatment of symptomatic fibroids with pregnancy as a desired outcome. STUDY FUNDING/COMPETING INTEREST(S) There was no funding source for this study.

Robot-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy.

OBJECTIVE: To compare surgical outcomes of laparoscopic myomectomy and robot-assisted laparoscopic myomectomy. METHODS: Retrospective cohort study of 115 consecutive laparoscopic myomectomy and 174 consecutive robot-assisted laparoscopic myomectomy performed at Brigham and Womens Hospital over a period of 31 months. Uterine incisions were closed in multiple layers (running barbed suture was used for most cases in the laparoscopic myomectomy group). Surgical outcomes measured included operative time, estimated intraoperative blood loss, length of hospital stay, and perioperative complications. Odds ratios and 95% confidence intervals were calculated from multivariable logistic regression models; adjusted geometric means were estimated from linear regression models on logged outcomes because of skewed distributions. RESULTS: Surgical groups were similar in age, body mass index, and leiomyoma characteristics. Robot-assisted laparoscopic myomectomy had significantly longer operative time than laparoscopic myomectomy (adjusted geometric mean of 195.1 compared with 118.3 minutes, P<.001) and higher estimated blood loss (adjusted geometric mean of 110.0 compared with 85.9 mL, P=.04), but postoperative complications were similar. CONCLUSION: Robot-assisted laparoscopic myomectomy and laparoscopic myomectomy have similar operative outcomes in a high-volume surgical practice. Operative time and intraoperative estimated blood loss were significantly greater in the robot-assisted laparoscopic myomectomy group, but the level of statistical significance for intraoperative estimated blood loss was marginal and the clinical significance was undetermined. Use of barbed suture in the laparoscopic myomectomy group may account for these differences. LEVEL OF EVIDENCE: II

Risk of Leakage and Tissue Dissemination With Various Contained Tissue Extraction (CTE) Techniques: An in Vitro Pilot Study

STUDY OBJECTIVE To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. DESIGN In vitro study (Canadian Task Force classification: II-1). SETTING Academic hospital simulation laboratory. INTERVENTION Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indigo carmine dye and morcellated under laparoscopic guidance within a plastic box trainer. CTE was performed via 3 different techniques: a stitch-sealed rip-stop nylon bag and multi-port approach; a one-piece clear plastic 50 × 50-cm isolation bag and multi-port approach; or a 1-piece clear plastic 50 × 50-cm isolation bag and single-site approach. Four trials of each CTE method were performed and compared with an open morcellation control. All bags were insufflated to within 10 to 25 mmHg pressure with a standard CO2 insufflator. Visual evidence of spilled tissue or dye was recorded, and fluid washings of the box trainer were sent for cytologic analysis. MEASUREMENTS AND MAIN RESULTS Blue dye spill was noted in only 1 of 12 CTE trials. Spillage was visualized from a seam in 1 of the 4 stitch-sealed rip-stop nylon bags before morcellation of the specimen. The only trial in which gross tissue chips were visualized in the box trainer after morcellation was the open morcellation control. However, cytologic examination revealed muscle cells in the open morcellation washings and in the washings from the trial with dye spill. Muscle cells were not observed at cytologly in any of the other samples. CONCLUSION CTE did not result in any leakage or tissue dissemination with use of the single-site or multi-port approach when using a 1-piece clear plastic 50 × 50-cm isolation bag. Further studies are needed to corroborate these findings in an in vivo context and to evaluate use of alternate bag options for specimen containment.

Techniques for contained morcellation in gynecologic surgery

OBJECTIVE To demonstrate 2 step-by-step techniques for contained morcellation of uterine tissue. DESIGN Instructional video showing laparoscopic electromechanical morcellation within an endoscopic pouch, and alternatively, tissue extraction via ultra-minilaparotomy. SETTING Academic medical center. PATIENT(S) Women undergoing laparoscopic myomectomy or hysterectomy. INTERVENTION(S) For contained electromechanical morcellation, the specimen is placed within an endoscopic pouch, the edges of which are exteriorized through a 15-mm cannula. The cannula is repositioned inside the pouch for insufflation. A bladed fixation trocar enters the pouch through an assistant port and is secured by its retention disk and balloon tip. Gas inflow is changed to this assistant port, through which the laparoscope is inserted. A power morcellator is introduced via the 15-mm port site, and morcellation thus proceeds within the containment system. Residual fragments of tissue are collectively retrieved by withdrawing the endoscopic pouch. For tissue extraction via ultra-minilaparotomy, the specimen is placed within a pouch that is drawn up through a flexible, self-retaining retractor seated in a 2 to 3-cm incision. The specimen is cored out sharply with a scalpel. MAIN OUTCOME MEASURE(S) None. RESULT(S) Contained morcellation is technically feasible, efficient (mean additional operative time is approximately 30 minutes), and prevents intraperitoneal dispersion of tissue fragments. Our group has safely performed >100 such procedures and removed specimens weighing nearly 1,500 grams. Potential complications include viscous injury upon insertion of the bladed trocar, and pouch failure. CONCLUSION(S) These techniques allow surgeons to adopt the new standard of contained morcellation and permit removal of extensive pathology with a minimally invasive approach.

Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters

BACKGROUND Safe tissue removal is a challenge for minimally invasive procedures such as myomectomy, supracervical hysterectomy, or total hysterectomy of a large uterine specimen. There is concern regarding disruption or dissemination of tissue during this process, which may be of particular significance in cases of undetected malignancy. Contained tissue extraction techniques have been developed in an effort to mitigate morcellation-related risks. OBJECTIVE The objective of the study was to quantify perioperative outcomes of contained tissue extraction using power morcellation, specifically evaluating parameters of tissue or fluid leakage from within the containment system. STUDY DESIGN This was a study including a multicenter prospective cohort of adult women who underwent minimally invasive hysterectomy or myomectomy using a contained power morcellation technique. Blue dye was applied to the tissue specimen prior to removal to help identify cases of fluid or tissue leakage from within the containment system. RESULTS A total of 76 patients successfully underwent the contained power morcellation protocol. Mean time for the contained morcellation procedure was 30.2 minutes (±22.4). The mean hysterectomy specimen weight was 480.1 g (±359.1), and mean myomectomy specimen weight was 239.1 g (±229.7). The vast majority of patients (73.7%) were discharged home the same day of surgery. Final pathological diagnosis was benign in all cases. Spillage of dye or tissue was noted in 7 cases (9.2%), although containment bags were intact in each of these instances. CONCLUSION Findings are consistent with prior work demonstrating the feasibility of contained tissue extraction; however, further refinement of this technique is warranted.

Autoimmune progesterone dermatitis: clinical presentation and management with progesterone desensitization for successful in vitro fertilization

OBJECTIVE To report clinical cases of autoimmune progesterone (P) dermatitis, its relationship to IVF, and the potential for P desensitization to treat these cases to achieve viable pregnancies. DESIGN Clinical description. SETTING Institutional hospitalary practice. Allergy Division. PATIENT(S) Six patients from the Allergy Clinic consulting for cyclic rashes or anaphylaxis related to the luteal phase of the menstrual cycle. Three of the conditions were related to IVF. INTERVENTION(S) Skin tests were performed with P. For IVF, rapid 8- and 10-step P desensitization protocols were performed, with increasing doses administered every 20 minutes via intravaginal suppositories. A rapid oral desensitization protocol was performed in one patient who required an oral contraceptive for uterine bleeding. MAIN OUTCOME MEASURE(S) Progesterone skin test results. Tolerance to P desensitization. Achievement of viable pregnancies. RESULT(S) Skin tests were positive in all patients and negative in 10 controls. Desensitization was successful in four patients: three patients for IVF, resulting in viable pregnancies. Another patient achieved tolerance to oral contraceptives. CONCLUSION(S) Women with autoimmune P dermatitis can be desensitized successfully to P. We provide the first evidence of successful P desensitization in patients requiring IVF culminating in successful pregnancies.

Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium.

ObjectivesBasic fibroblast growth factor (bFGF) is an angiogenic growth factor present in human endometrium and myometrium. Women with leiomyoma-related abnormal uterine bleeding have local dysregulation of bFGF and its type 1 receptor (FGF-R). This study was designed to evaluate if adenomyosis expresses bFGF and FGF-R, and if present, to compare bFGF and FGF-R expression in adenomyosis and autologous endometrium. DesignMenopausal uteri containing endometrium and adenomyosis were analyzed using immunohistochemistry with monoclonal antibodies specific for bFGF, FGF-R, and proliferating cell nuclear antigen (PCNA), a marker of cellular proliferation. The expression and intensity of staining for bFGF, FGF-R, and PCNA were evaluated in the glandular epithelium and stroma of adenomyosis and endometrium. ResultsGlandular epithelial staining was significantly greater in adenomyosis compared with autologous endometrium for bFGF and FGF-R. Stromal staining for bFGF and PCNA was significantly increased in adenomyosis compared with autologous endometrium. ConclusionsUpregulation of the bFGF receptor/ligand system and increased cellular proliferation in adenomyosis may contribute to the pathogenesis of abnormal uterine bleeding associated with adenomyosis.

Transabdominal follicular aspiration for oocyte retrieval in patients with ovaries inaccessible by transvaginal ultrasound

OBJECTIVE To investigate the efficacy of ultrasound-guided transabdominal follicular aspiration when the ovaries are not accessible transvaginally. DESIGN Retrospective case-control study. SETTING University-hospital based in vitro fertilization (IVF) clinic. PATIENT(S) 69 women undergoing transabdominal follicular aspiration for oocyte retrieval, including 12 cases of mixed abdominal/vaginal aspiration, compared with controls matched by age, follicle number, and year of procedure undergoing standard transvaginal aspiration. INTERVENTION(S) Transabdominal follicular aspiration when one or more ovaries could not be retrieved via standard transvaginal aspiration. MAIN OUTCOME MEASURE(S) Total and mature oocytes retrieved, damaged oocytes, fertilization rate, embryo number and quality, and clinical and ongoing pregnancy rates. RESULT(S) Cases of transabdominal aspiration had slightly fewer oocytes retrieved, but no statistically significant differences were found for damaged oocytes, fertilization rates, embryo number and quality, or pregnancy rates. In 12 years, one complication requiring hospitalization was noted. CONCLUSION(S) This study demonstrates that transabdominal ultrasound-guided follicular aspiration is safe and efficacious, yielding clinical results in women with significant ovarian displacement, comparable with results achieved by transvaginal aspiration in women with normally positioned ovaries. Transabdominal ultrasound-guided aspiration should be the modality of choice when the ovaries are not accessible transvaginally.

Robot-assisted laparoscopy, natural orifice transluminal endoscopy, and single-site laparoscopy in reproductive surgery.

Minimally invasive gynecologic surgery is continuously pushing its limits by embracing ever more sophisticated technology. This is also true for reproductive surgery, arguably the birthplace of gynecologic endoscopy, where minimally invasive treatment of uterine, tubal, ovarian, and peritoneal pathology has long become the gold standard. This article describes in some detail three novel minimally invasive surgery approaches that have seen the light during the past decade: robot-assisted laparoscopic surgery, natural orifice transluminal endoscopic surgery, and single-incision laparoscopic surgery. These fascinating technologies, far from being widely adopted, are sure to generate scientific controversy for years to come. Nonetheless, they follow in the footsteps of the tradition of innovation that is a defining aspect of our specialty and hold the promise to potentially revolutionize the field of reproductive surgery.

Fertility preservation and the role of robotics.

Reproductive surgery employs microsurgical techniques to achieve preservation of natural fertility and enhancement of assisted reproductive technologies. The minimalist approach of this branch of gynecology has made it the natural trailblazer of laparoscopic surgery. Minimally invasive conservative treatment of uterine, tubal, ovarian, and peritoneal pathology has long been the gold standard for women of reproductive age. Advanced laparoscopic surgery provides clear advantages over classic microsurgery, at the cost of significant technical challenges. Robot-assisted laparoscopic surgery is now posed to bridge this technical gap and promises to be the next revolution in the field of reproductive surgery.