C. Ascher-Walsh

Robot-assisted Laparoscopic Myomectomy Is an Improvement Over Laparotomy in Women with a Limited Number of Myomas

STUDY OBJECTIVE To compare surgical and immediate postoperative results of robot-assisted laparoscopic myomectomy vs myomectomy via laparotomy in patients with 3 myomas or fewer. DESIGN Case-control (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Seventy-five women who had undergone robotic-assisted laparoscopic myomectomy were compared with patients who had undergone myomectomy via laparotomy. INTERVENTIONS Medical records were reviewed for surgical and postoperative variables. Both groups had 3 myomas or fewer confirmed at preoperative magnetic resonance imaging or final pathology report. MEASUREMENTS AND MAIN RESULTS No significant differences were observed between patients insofar as preoperative demographic data. There was a significant increase in mean duration of surgery for robotic-assisted myomectomy. There was a significant decrease in blood loss, change in hematocrit concentration on postoperative day 1, length of stay, number of days to regular diet, and febrile morbidity in robotic-assisted myomectomies. There were no significant differences in operative or postoperative complications. CONCLUSION Although robotic-assisted myomectomy took substantially longer, most of the other variables improved in comparison with similar procedures performed via laparotomy.

A Comprehensive Approach to the Treatment of Uterine Leiomyomata

Leiomyomas (fibroids) are the most common tumors in women, with a prevalence between 30% and 50%. They affect women primarily during their reproductive years, spontaneously regressing after menopause in most women. They may cause significant symptoms of pain, dysmenorrhea, abnormal uterine bleeding, and infertility. Because leiomyomas are so common, treatment should be reserved for those patients with symptoms. Treatment options have recently expanded beyond hysterectomy. Medical therapies, including gonadotropin-releasing hormone agonists and progesterone modulators, have become more widely used. Less invasive options such as uterine fibroid embolization, magnetic resonance imaging-guided focused ultrasound, and radiofrequency ablation are being used to avoid more invasive surgery. Because of limited and negative information regarding these alternatives to surgery, they are not recommended for women desiring future fertility. If surgery is desired or required, often less invasive approaches via hysteroscopy for intracavitary lesions or robot-assisted laparoscopy for patients with a small number of myomas have become preferred options. Treatment should be tailored to the patient.

Age-Stratified Risk of Unexpected Uterine Sarcoma Following Surgery for Presumed Benign Leiomyoma

BACKGROUND Estimates of unexpected uterine sarcoma following surgery for presumed benign leiomyoma that use age-stratification are lacking. PATIENTS AND METHODS A retrospective cohort of 2,075 patients that had undergone myomectomy was evaluated to determine the case incidence of unexpected uterine sarcoma. An aggregate risk estimate was generated using a meta-analysis of similar studies plus our data. Database-derived age distributions of the incidence rates of uterine sarcoma and uterine leiomyoma surgery were used to stratify risk by age. RESULTS Of 2,075 patients in our retrospective cohort, 6 were diagnosed with uterine sarcoma. Our meta-analysis revealed 8 studies from 1980 to 2014. Combined with our study, 18 cases of leiomyosarcoma are reported in 10,120 patients, for an aggregate risk of 1.78 per 1,000 (95% confidence interval [CI]: 1.1-2.8) or 1 in 562. Eight cases of other uterine sarcomas were reported in 6,889 patients, for an aggregate risk of 1.16 per 1,000 (95% CI: 0.5-4.9) or 1 in 861. The summation of these risks gives an overall risk of uterine sarcoma of 2.94 per 1,000 (95% CI: 1.8-4.1) or 1 in 340. After stratification by age, we predict the risk of uterine sarcoma to range from a peak of 10.1 cases per 1,000, or 1 in 98, for patients aged 75-79 years to <1 case per 500 for patients aged <30 years. CONCLUSION The risk of unexpected uterine sarcoma varies significantly across age groups. Our age-stratified predictive model should be incorporated to more accurately counsel patients and to assist in providing guidelines for the surgical technique for leiomyoma.

Long-term quality of life and pelvic floor dysfunction after bariatric surgery

OBJECTIVE To evaluate effects of bariatric surgery on pelvic floor mediated quality of life in morbidly obese women. STUDY DESIGN Prospective cohort study of 44 women undergoing bariatric surgery. RESULTS Thirty-six women gave data at baseline and at mean follow-up of 3.15 years following bariatric surgery. Although urinary impact questionnaire scores improved (-34.92, P = .0020), colorectal-anal impact questionnaire and pelvic organ prolapse impact questionnaire scores did not improve despite significant weight loss. Baseline female sexual function index scores were low (17.70 ± 8.38) and did not improve with weight loss (16.91 ± 9.75, P = .5832). Pelvic organ prolapse/urinary incontinence sexual questionnaire scores did improve (35.78 ± 6.06 preoperatively vs 38.22 ± 6.03 postoperatively, P = .0193). CONCLUSION Bariatric surgery is associated with significant improvement in the impact of urinary incontinence on quality of life. Sexual function was poor, and improved only on the pelvic organ prolapse/urinary incontinence sexual questionnaire that evaluated urinary incontinence.

Sling Procedures after repair of obstetric vesicovaginal fistula in Niamey, Niger.

Introduction and hypothesisThe purpose of this paper is to evaluate the results of sling procedures for stress incontinence after repair of vesicovaginal fistulae at the National Hospital in Niamey, Niger.MethodsThis study is a retrospective chart review of 701 women surgically treated for vesicovaginal fistulae. One hundred forty women subsequently underwent a sling procedure for stress incontinence after fistula repair.ResultsThe demographics among the groups were similar. No significant difference was seen in results between the sling types except the risk of erosion was significantly greater in the synthetic sling group. There was a trend towards greater sling success in the fascia lata group.ConclusionsCorrection of incontinence is a common and difficult challenge following repair of obstetric vesicovaginal fistula. Compared to published studies on sling procedures, these patients have higher rates of continued incontinence. This is likely due to the frequent loss of a urethral sphincter as well as high prevalence of detrusor overactivity and decreased bladder capacity.

Effect of hormone replacement and selective estrogen receptor modulators (SERMs) on the biomechanics and biochemistry of pelvic support ligaments in the cynomolgus monkey (Macaca fascicularis)

OBJECTIVE To evaluate the effect of selective estrogen receptor modulators and ethinyl estradiol on the biomechanical and biochemical properties of the uterosacral and round ligaments in the monkey model of menopause. STUDY DESIGN A randomized, double-blind, placebo-controlled study on 11 female macaque monkeys. Ovariectomized monkeys received 12 weeks of placebo, raloxifene, tamoxifen, or ethinyl estradiol. Biomechanical step-strain testing and real-time polymerase chain reaction was performed on the uterosacral and round ligaments. RESULTS Tamoxifen and raloxifene uterosacrals expressed differing collagen I/III receptor density ratios, but both selective estrogen receptor modulators showed decreased tensile stiffness compared to ethinyl estradiol and controls. CONCLUSION These findings support a possible effect of selective estrogen receptor modulators on biomechanical and biochemical properties of uterosacrals. This may play a role in pelvic organ prolapse.

Patient Preferences for Abdominal Incisions Used for Pelvic Organ Prolapse Surgery.

Objectives Approaches for performing sacrocolpopexy (laparotomy, laparoscopy, and robotically assisted) differ with regard to length of surgery, postoperative pain, and cosmetic appearance of skin incisions. The aim of our study is to better understand what factors influence patient preferences for surgical approach. Methods A cross-sectional study was performed using a survey. Females 18 years or older presenting to gynecologic offices were asked to complete a survey that included photographs of patient incisions 6 weeks postoperatively along with a schematic representation of each incision type (laparotomy with low transverse incision, traditional laparoscopy, and robotically assisted). Patients were first asked to rank each incision based on cosmetic appearance only. They were next given varying clinical scenarios associated with each surgical approach and asked if their preference of incision changed. A sample size of 90 subjects was needed in order to detect a 30% difference in incision preference based on appearance with an &agr; of 0.05 and 80% power. Results One hundred fifty patients completed the survey. Based on cosmetic appearance alone, 70% chose laparoscopic surgery, 23% chose open, and 7% chose the robotic approach (P < 0.0001). The majority of the subjects would not change their incision preference of laparoscopy based on differing scenarios of postoperative pain (62.6%), length of surgery (65.3%), and length of hospital stay (73.6%). When asked to rank factors important in decision making, complication rate (53.9%) and surgeon experience with the procedure (32.8%) were ranked as most important. Conclusions Based on cosmetic appearance, patients prefer the laparoscopic approach for abdominal sacrocolpopexy for pelvic organ prolapse surgery. However, complication rates and surgeon experience with the procedure are important factors in the patient’s decision making.

Predictors of laparoscopic simulation performance among practicing obstetrician gynecologists

BACKGROUND: While simulation training has been established as an effective method for improving laparoscopic surgical performance in surgical residents, few studies have focused on its use for attending surgeons, particularly in obstetrics and gynecology. Surgical simulation may have a role in improving and maintaining proficiency in the operating room for practicing obstetrician gynecologists. OBJECTIVE: We sought to determine if parameters of performance for validated laparoscopic virtual simulation tasks correlate with surgical volume and characteristics of practicing obstetricians and gynecologists. STUDY DESIGN: All gynecologists with laparoscopic privileges (n = 347) from 5 academic medical centers in New York City were required to complete a laparoscopic surgery simulation assessment. The physicians took a presimulation survey gathering physician self‐reported characteristics and then performed 3 basic skills tasks (enforced peg transfer, lifting/grasping, and cutting) on the LapSim virtual reality laparoscopic simulator (Surgical Science Ltd, Gothenburg, Sweden). The association between simulation outcome scores (time, efficiency, and errors) and self‐rated clinical skills measures (self‐rated laparoscopic skill score or surgical volume category) were examined with regression models. RESULTS: The average number of laparoscopic procedures per month was a significant predictor of total time on all 3 tasks (P = .001 for peg transfer; P = .041 for lifting and grasping; P < .001 for cutting). Average monthly laparoscopic surgical volume was a significant predictor of 2 efficiency scores in peg transfer, and all 4 efficiency scores in cutting (P = .001 to P = .015). Surgical volume was a significant predictor of errors in lifting/grasping and cutting (P < .001 for both). Self‐rated laparoscopic skill level was a significant predictor of total time in all 3 tasks (P < .0001 for peg transfer; P = .009 for lifting and grasping; P < .001 for cutting) and a significant predictor of nearly all efficiency scores and errors scores in all 3 tasks. CONCLUSION: In addition to total time, there was at least 1 other objective performance measure that significantly correlated with surgical volume for each of the 3 tasks. Higher‐volume physicians and those with fellowship training were more confident in their laparoscopic skills. By determining simulation performance as it correlates to active physician practice, further studies may help assess skill and individualize training to maintain skill levels as case volumes fluctuate.

Low Cost 3D Printing for the Creation of Cervical Cerclage Pessary Used to Prevent Preterm Birth: A Preliminary Study [26R]

INTRODUCTION: Cervical cerclage pessaries have become increasingly utilized for cervical incompetence and in patients at risk for preterm birth. Commercially available pessaries come in various sizes using a “one size fits most” approach which does consider each womans unique anatomy. The effectiveness of these pessaries is limited by poor fit, and a lack of easily achieved customization. This preliminary study was designed to test the feasibility of 3-dimensional printing techniques to create personalized/patient specific 3D printed cervical cerclage pessaries. METHODS: Patient specific imaging data was collected at a routine prenatal ultrasound, including cervical length/radius and distance from external cervical OS to the anterior vaginal fornix. Using SolidWorks (Dassault Systemes) software, these measurements were converted into geometry files and a 3D pessary was electronically rendered in stereolithography (STL) format. An inversion mold of this spatial model was created using the same software. A hospital based prototyping center was used to print the 3D mold on a ProJet 3500 HDMax (3D Systems) printer, which was then filled with silicone (Sylgard 184, Dow Corning) to create a medical grade pessary. RESULTS: Multiple patient specific medical grade 3D pessaries were printed at a cost of less than

Beta-3 adrenoceptor expression in the uterosacral ligament in the postmenopausal women with pelvic organ prolapse

50 per mold. CONCLUSION: Current 3D printing techniques can be used to create low cost personalized/patient specific cerclage pessaries from measurements during routine prenatal ultrasounds. This method overcomes the commercial limitations requiring special ordering of a device which may not fit a patients specific need. This technique provides an alternative means for rapidly obtaining a cervical pessary for medical application.