E.T. Carey

Short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve: a pilot randomized controlled trial

OBJECTIVE To examine the short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve when ovarian preservation is planned in view of determining the feasibility of conducting the study on a larger scale. DESIGN Pilot randomized controlled trial. SETTING Tertiary care, academic medical center. PATIENT(S) Thirty premenopausal women aged 18 to 45 years undergoing laparoscopic hysterectomy with ovarian preservation for benign indications from April 2012 to September 2012. INTERVENTION(S) Bilateral salpingectomy (n = 15) versus no salpingectomy (n = 15) at the time of laparoscopic hysterectomy with ovarian preservation. MAIN OUTCOME MEASURE(S) Antimüllerian hormone (AMH) measured preoperatively, at 4 to 6 weeks postoperatively, and at 3 months postoperatively, with operative time and estimated blood loss abstracted from the medical records. RESULT(S) The mean AMH levels were not statistically significantly different at baseline (2.26 vs. 2.25 ng/ml), 4 to 6 weeks postoperatively (1.03 vs. 1.25 ng/ml), or 3 months postoperatively (1.86 vs. 1.82 ng/ml) among women with salpingectomy versus no salpingectomy, respectively. There was also no statistically significant temporal change in the mean AMH level from baseline to 3 months postoperatively (-0.07 vs. -0.08 ng/ml) between the two groups. No difference in operative time (116 vs. 115 minutes) or estimated blood loss (70 vs. 91 mL) was observed. CONCLUSION(S) Salpingectomy at the time of laparoscopic hysterectomy with ovarian preservation is a safe procedure that does not appear to have any short-term deleterious effects on ovarian reserve, as measured by AMH level. Conducting a trial of this nature that is adequately powered with long-term follow-up evaluation would be feasible and is required to definitively confirm these results.

Effect of extreme obesity on outcomes in laparoscopic hysterectomy.

STUDY OBJECTIVE To estimate the effect of body mass index (BMI) on several outcomes in laparoscopic hysterectomy, in particular in the extremes of obesity. DESIGN Retrospective cohort study (Canadian Task Force classification II-3). SETTING Tertiary-care university-based teaching hospital. PATIENTS Eight hundred thirty-four patients who underwent laparoscopic hysterectomy from January 2007 to October 2011. INTERVENTION Laparoscopic hysterectomy for benign indications. MEASUREMENTS AND MAIN RESULTS Demographic, operative, and postoperative data were abstracted from medical records. The primary outcome was a composite index score that took into account operative time, nonsurgical operating room time, estimated blood loss, length of hospital stay, number of complications, and severity of complications according to the Dindo-Clavien classification. We individually examined elements of the composite index as a secondary outcome. Models were developed to assess the association of BMI with the composite index score and the components of the index, controlling for age, presence of diabetes, tobacco use, surgeon, type of hysterectomy (total vs supracervical), use of robotics, uterine weight, number of additional procedures performed, presence of adhesions requiring lysis, and deeply infiltrating endometriosis as potential confounders. Mean (SD) BMI was 31.4 (8.1). Mean (SD) uterine weight was 345 (388) g. Mean operative time was 150 (61) minutes. Increasing BMI was associated with a worse composite score (p < .01); longer operative time (p = .03), nonsurgical operating room time (p = .02), and total operating room time (p < .01); greater estimated blood loss (p < .01); and complication severity (p = .01). CONCLUSION These data suggest that there is a significant association of BMI with surgical outcomes in laparoscopic hysterectomy, and the effect is most pronounced in the morbidly obese. These patients may stand to gain the greatest differential benefit from a laparoscopic approach to surgery. However, they should be properly counseled about the challenge that obesity poses to the operation.

Pathologic Characteristics of Hysterectomy Specimens in Women Undergoing Hysterectomy after Global Endometrial Ablation

STUDY OBJECTIVE To describe uterine pathologic features in women who underwent hysterectomy because of failed global endometrial ablation (GEA). DESIGN Retrospective cohort study from 1998 through 2005 (Canadian Task Force classification III). SETTING Tertiary referral center. PATIENTS Sixty-nine women who underwent hysterectomy because of GEA failure. INTERVENTIONS Pathology reports were available for 67 patients. Descriptions of hysterectomy specimens after GEA were reviewed. MEASUREMENTS AND MAIN RESULTS Rates of pathologic findings in hysterectomy specimens after failed GEA were determined. Reasons for hysterectomy in the 67 patients with available pathology reports were bleeding in 34 (51%), pain in 19 (28%), and bleeding and pain in 14 (21%). The pathology reports of these specimens showed leiomyomas in 33 specimens (49%); intramural myomas were present in 15 women (44%) who underwent hysterectomy because of bleeding and 8 women (42%) who underwent hysterectomy because of pain. Hematometra was identified in 7 pathologic specimens (10%). Specifically, hematometra was identified in specimens from 5 of 19 women who underwent hysterectomy because of pain (26%). CONCLUSION Hematometra was a significant finding in women who underwent hysterectomy because of persistent pain after GEA. A possible pathologic predictor of GEA failure may be intramural leiomyomas.

Biopsychosocial Correlates of Persistent Postsurgical Pain in Women with Endometriosis

To examine pain and biopsychosocial correlates over time for women with persistent postsurgical pain after surgery for endometriosis.

Pharmacological Management of Chronic Pelvic Pain in Women.

Chronic pelvic pain (CPP) is a multifaceted condition that often has both peripheral and central generators of pain. An understanding of neurobiology and neuropsychology of CPP should guide management. Successful treatment of CPP is typically multimodal, and pharmacologic treatment strategies include analgesics, hormonal suppression, anesthetics, antidepressants, membrane stabilizers, and anxiolytics. Evidence for these and other emerging pharmacologic therapies is presented in this article.

Bilateral accessory breast tissue of the vulva: A case report introducing a novel labiaplasty technique

INTRODUCTION We present the case of a 23-year-old female with bilateral ectopic breast tissue of the vulva, the repair of which necessitated a novel labiaplasty technique. Labiaplasty is becoming an increasingly frequent cosmetic procedure, and the popularity of brief didactic labiaplasty courses has risen in response to consumer demand. There is a paucity of detailed anatomic description of female sensory innervation patterns to the clitoris and surrounding structures. This places patients at risk for denervation of clitoral structures during labiaplasty procedures. Our novel technique proposes a method of individualized patient neurosensory mapping preoperatively, which allows for surgical planning to avoid injury to the sensory branches of the dorsal clitoral nerve. METHODS A 23-year-old female presented with bilateral vulvar masses that involved the clitoral complex, which had first become apparent during the second trimester of pregnancy, and failed to resolve in the postpartum period. We describe the preoperative planning and intraoperative approach and dissection to labiaplasty in this patient, which was complex given the size of the masses, and specifically designed to avoid injury to sensory branches of the dorsal clitoral nerve. DISCUSSION As labiaplasty becomes more common, it is important to approach labiaplasty patients with a detailed understanding of the sensory innervation of the clitoris and surrounding structures, to avoid nerve injury and resultant sexual dysfunction. Traditional labiaplasty approaches may violate the sensory innervation patterns of the clitoral region, thus causing a sensory loss that affects patient sexual function. Our novel approach to preoperative clitoral nerve sensory mapping provides an alternative method of labiaplasty that may avoid denervation injury.

New developments in the pharmacotherapy of neuropathic chronic pelvic pain

Advancements in further understanding the pathophysiology of chronic pelvic pain syndromes continue to direct therapy. The mechanisms of chronic pelvic pain are often multifactorial and therefore require a multidisciplinary approach. The final treatment plan is often an accumulation of organ-specific treatment and chronic pain medications directed to the CNS and PNS. This article is a review of commonly used medications for chronic pelvic neuropathic pain disorders as well as an introduction to recent innovative developments in pain medicine.

Uterine weight and complications after abdominal, laparoscopic, and vaginal hysterectomy

BACKGROUND: Although uterine size has been a previously cited barrier to minimally invasive hysterectomy, experienced gynecologic surgeons have been able to demonstrate that laparoscopic and vaginal hysterectomy is feasible with increasingly large uteri. By demonstrating that minimally invasive hysterectomy continues to have superior outcomes even with increased uterine weights, opportunity exists to meaningfully decrease morbidity, mortality, and cost associated with abdominal hysterectomy. OBJECTIVE: We sought to determine if there is an association between uterine weight and posthysterectomy complications and if differences in that association exist across vaginal, laparoscopic, and abdominal approaches. STUDY DESIGN: We conducted a cohort study of prospectively collected quality improvement data from the American College of Surgeons National Surgical Quality Improvement Program database, composed of patient information and 30‐day postoperative outcomes from >500 hospitals across the United States and targeted data files, which includes additional data on procedure‐specific risk factors and outcomes in >100 of those participating hospitals. We analyzed patients undergoing hysterectomy for benign conditions from 2014 through 2015, identified by Current Procedural Terminology code. We excluded patients who had cancer, surgery by a nongynecology specialty, or missing uterine weight. Patients were compared with respect to 30‐day postoperative complications and uterine weight, stratified by surgical approach. Bivariable tests and multivariable logistic regression were used for analysis. RESULTS: In all, 27,167 patients were analyzed. After adjusting for potential confounders, including medical and surgical variables, women with 500‐g uteri were >30% more likely to have complications compared to women with uteri ≤100 g (adjusted odds ratio, 1.34; 95% confidence interval, 1.17–1.54; P < .0001), women with 750‐g uteri were nearly 60% as likely (adjusted odds ratio, 1.58; 95% confidence interval, 1.37–1.82; P < .0001), and women with uteri ≥1000 g were >80% more likely (adjusted odds ratio, 1.85; 95% confidence interval, 1.55–2.21; P < .0001). The incidence of 30‐day postsurgical complications was nearly double in the abdominal hysterectomy group (15%) compared to the laparoscopic group (8%). Additionally, for each stratum of uterine weight, abdominal hysterectomy had significantly higher odds of any complication compared to laparoscopic hysterectomy, even after adjusting for potential demographic, medical, and surgical confounders. For uteri <250 g, abdominal hysterectomy had twice the odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.80–2.33), and among women with uteri between 250–500 g, abdominal hysterectomy was associated with an almost 80% increase in odds of any complication (adjusted odds ratio, 1.76; 95% confidence interval, 1.41–2.19). Even among women with uteri >500 g, abdominal hysterectomy was still associated with a >30% increased odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 1.35; 95% confidence interval, 1.07–1.71). CONCLUSION: We found that while uterine weight was an independent risk factor for posthysterectomy complications, abdominal hysterectomy had higher odds of any complication, compared to laparoscopic hysterectomy, even for markedly enlarged uteri. Our study suggests that uterine weight alone is not an appropriate indication for abdominal hysterectomy. We also identified that it is safe to perform larger hysterectomies laparoscopically. Patients may benefit from referral to experienced surgeons who are able to offer laparoscopic hysterectomy even for markedly enlarged uteri.