Eve Zaritsky

Laparoscopic 5-mm trocar site herniation and literature review.

This report concludes that there is no evidence to recommend routine closure of 5-mm trocar incisions; the choice should be left to the discretion of the individual surgeon.

Same-Day Discharge After Laparoscopic Hysterectomy

OBJECTIVE: To estimate readmission rates and emergency care use by patients discharged home the same day after laparoscopic hysterectomy. METHODS: This was a retrospective case series of patients discharged home the same-day after total or supracervical laparoscopic hysterectomy in a managed care setting. Chart reviews were performed for outcomes of interest which included readmission rates, emergency visits, and surgical and demographic characteristics. The two hysterectomy groups were compared using &khgr;2 tests for categorical variables and t tests or Wilcoxon rank-sum tests for continuously measured variables. RESULTS: One-thousand fifteen laparoscopic hysterectomies were performed during the 3-year study period. Fifty-two percent (n=527) of the patients were discharged home the same-day; of those, 46% (n=240) had total laparoscopic hysterectomies and 54% (n=287) had supracervical. Cumulative readmission rates were 0.6%, 3.6%, and 4.0% at 48 hours, 3 months, and 12 months, respectively. The most common readmission diagnoses included abdominal incision infection, cuff dehiscence, and vaginal bleeding. Less than 4% of patients presented for emergency care within 48 or 72 hours, most commonly for nausea or vomiting, pain, and urinary retention. Median uterine weight was 155 g, median blood loss was 70 mL, and median surgical time was 150 minutes. There was no difference in readmission rates or emergency visits for the total compared with the supracervical laparoscopic hysterectomy group. CONCLUSION: Same-day discharge after laparoscopic hysterectomy is associated with low readmission rates and minimal emergency visits in the immediate postoperative period. Same-day discharge may be a safe option for healthy patients undergoing uncomplicated laparoscopic hysterectomy. LEVEL OF EVIDENCE: III

Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With Morcellation.

OBJECTIVE: To estimate the incidence of occult uterine sarcoma and leiomyosarcoma in hysterectomies for leiomyomas and the risk associated with their morcellation. METHODS: We conducted a population-based cohort study. All uterine sarcomas from 2006–2013 in an integrated health care system were identified. Age- and race-specific incidences of occult uterine sarcoma were calculated. Kaplan-Meier survival analysis was performed. Crude and adjusted risk ratios of recurrence and death associated with morcellation at 1, 2, and 3 years were estimated using Poisson regression with inverse probability weighting. RESULTS: There were 125 hysterectomies with occult uterine sarcomas identified among 34,728 hysterectomies performed for leiomyomas. The incidence of occult uterine sarcoma and leiomyosarcoma was 1 of 278 or 3.60 (95% confidence interval [CI] 2.97–4.23) and 1 of 429 or 2.33 (95% CI 1.83–2.84) per 1,000 hysterectomies. For stage I leiomyosarcoma (n=111), eight (7.2%) were power and 27 (24.3%) nonpower-morcellated. The unadjusted 3-year probability of disease-free survival for no morcellation, power and nonpower morcellation was 0.54, 0.19, and 0.51, respectively (P=.15); overall survival was 0.64, 0.75, and 0.68, respectively (P=.97). None of the adjusted risk ratios for recurrence or death were significant except for death at 1 year for power and nonpower morcellation groups combined (6/33) compared with no morcellation (4/76) (5.12, 95% CI 1.33–19.76, P=.02). We had inadequate power to infer differences for all other comparisons including 3-year survival and power morcellation. CONCLUSION: Morcellation is associated with decreased early survival of women with occult leiomyosarcomas. We could not accurately assess associations between power morcellation and 3-year survival as a result of small numbers.

Diagnosis of Stage I Endometriosis: Comparing Visual Inspection to Histologic Biopsy Specimen

STUDY OBJECTIVE To evaluate positive predictive value (PPV) of visual diagnosis at laparoscopy compared with biopsy findings according to severity of endometriosis. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING Academic referral center. PATIENTS Women who underwent laparoscopic biopsies for suspected endometriosis. INTERVENTIONS A total of 238 biopsy specimens (73 endometriomas and 165 peritoneal implants) were taken from 104 patients undergoing laparoscopy for evaluation of chronic pelvic pain thought to be caused by endometriosis. MEASUREMENTS AND MAIN RESULTS Accuracy of laparoscopic findings compared with histology-proved endometriosis by severity of disease and location of endometriotic lesions. Overall PPV per patient was 86.5%, which was 75.8% for stage I disease compared with 89.7%, 100%, and 90.6%, respectively, for disease stages II to IV (p = .037). The PPV per biopsy specimen of stages I to IV endometriosis was 66.1%, 78.0%, 92.0%, and 81.1%, respectively (.049). When endometriomas and peritoneal biopsy specimens were analyzed separately, no difference in PPV existed (79% vs 77%; p = .67). CONCLUSION High overall PPV existed in our study, especially in patients with advanced disease. The PPV per patient was higher than the PPV per biopsy specimen indicating that ability to diagnose endometriosis may be improved by performing multiple biopsies. This is particularly true in stage I where failure to confirm may be greatest.

Minilaparotomy vs Laparoscopic Hysterectomy: Comparison of Length of Hospital Stay

STUDY OBJECTIVE To compare length of hospital stay for minilaparotomy vs laparoscopic hysterectomy. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Kaiser Permanente Northern California, a large integrated health care delivery system. PATIENTS Women >18 years of age undergoing laparoscopic or minilaparotomy hysterectomy because of benign indications from June 2009 through January 2010. INTERVENTION Hysterectomy via minilaparotomy or laparoscopy. MEASUREMENTS AND MAIN RESULTS Medical records were reviewed for outcomes of interest including length of stay and surgical and demographic data. Parametric and non-parametric analyses were used to compare the 2 groups. The study was powered to detect a difference of 8 hours in length of stay. Two hundred sixty-three cases were identified as hysterectomy via minilaparotomy (n = 100) or laparoscopy (n = 163). The laparoscopy group demonstrated a significantly shorter mean (SD) length of stay (19 [14] hours vs. 42 [20] hours; p < .001) and less blood loss (126 [140] mL vs. 241 [238] mL; p < .001). The minilaparotomy group experienced a shorter procedure time (113 [47] minutes vs. 197 [124] minutes; p < .001). There was no difference between the groups insofar as patient morbidity including intraoperative and postoperative complications, emergency visits, readmissions, or repeat operations. CONCLUSION Compared with minilaparotomy, laparoscopic hysterectomy is associated with shorter length of hospital stay, longer operating time, and no increased patient morbidity.

Postcoital Vaginal Rupture in a Young Woman with No Prior Pelvic Surgery

INTRODUCTION Reports of postcoital vaginal rupture in the literature are limited to cases involving women who are postmenopausal, have recently undergone pelvic surgery, or have suffered genitourinary trauma. AIM We report a case of postcoital vaginal rupture in a 23-year-old woman with no prior surgical history who complained of acute onset, severe vaginal pain after consensual intercourse. RESULTS Examination under anesthesia revealed a 6-cm laceration of the posterior fornix, which extended into the abdominal cavity. The laceration was repaired using a combined vaginal and laparoscopic approach. CONCLUSIONS Coitus-induced vaginal rupture in a reproductive aged woman with no prior pelvic surgery or other risk factors is a rare clinical presentation. Prior reports of rupture in premenopausal women have recommended repair via laparotomy. This case documents successful transvaginal and laparoscopic repair, and reviews the etiological mechanisms for coitus-induced injury.

Uretero-Fallopian Fistula After Gynecological Surgery for Endometriosis: A Case Report

Urinary tract injuries are unfortunate complications of pelvic surgery. These frequently involve the bladder. The incidence of iatrogenic ureteral lesions ranges from 0.05% to 30%. Even though some lesions are observed intraoperatively, most remain undiscovered and reveal themselves later. Fistulas of ureteral origin usually involve the vagina or more rarely the uterus. Uretero-fallopian fistulas are even more rare. We report a case of uretero-fallopian fistula that developed after surgery for endometriosis.

Same-Day Discharge After Minimally Invasive Myomectomy.

OBJECTIVE: To estimate readmission rates of patients discharged home the same day after a minimally invasive myomectomy. METHODS: This is a retrospective case series of patients who underwent minimally invasive myomectomy and were discharged the same day, which examines the feasibility and safety by rates of readmission within Kaiser Permanente Northern California. Chart review was performed for outcomes of interest including readmission rates, emergency department, and urgent clinic visits within 48 hours, 7 days, and up to 3 months along with surgical and demographic characteristics. RESULTS: Of the 403 minimally invasive myomectomies performed during the study period, 88% (N=356) of patients were discharged home the same day. No readmissions required reoperation or were life-threatening. Two patients (0.6%) were readmitted within 48 hours for postoperative fever. A cumulative total of five patients (1.4%) were readmitted within 3 months. Urgent care and emergency department visits occurred in zero and seven patients (2.0%) within 48 hours of discharge, most commonly for pain and urinary retention. Median leiomyoma weight was 204 g, median body mass index was 26, median blood loss was 75 mL, and median surgical time was 157 minutes. CONCLUSION: Same-day discharge after minimally invasive myomectomy was found to have a low readmission rate and low health care utilization in the immediate postoperative period. Same-day discharge appears to be a safe option for healthy patients after undergoing an uncomplicated minimally invasive myomectomy.

Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System

OBJECTIVE To examine trends in minimally invasive hysterectomy and power morcellation use over time and associated clinical characteristics. METHODS We conducted a trend analysis and retrospective cohort study of all women 18 years of age and older undergoing hysterectomy for benign conditions at Kaiser Permanente Northern California collected from electronic health records. Generalized estimating equations and Cochran-Armitage testing were used to assess the primary outcomes, hysterectomy incidence, and proportion of hysterectomies by surgical route and power morcellation. Logistic regression analysis was used to assess secondary outcomes, clinical characteristics, and complications associated with surgical route. RESULTS There were 31,971 hysterectomies from 2008 to 2015; the incidence decreased slightly from 2.86 (95% confidence interval [CI] 2.85-2.87) to 2.60 (95% CI 2.59-2.61) per 1,000 women (P<.001). Minimally invasive hysterectomies increased from 39.8% to 93.1%, almost replacing abdominal hysterectomies entirely (P<.001). Vaginal hysterectomies decreased slightly from 26.6% to 23.4% (P<.001). The proportion of nonrobotic laparoscopic hysterectomies with power morcellation increased steadily from 3.7% in 2008 to a peak of 11.4% in 2013 and decreased to 0.02% in 2015 (P<.001). Robot-assisted laparoscopic hysterectomies remained a small proportion of all hysterectomies comprising 7.8% of hysterectomies in 2015. Women with large uteri (greater than 1,000 g) were more likely to receive abdominal hysterectomies than minimally invasive hysterectomy (adjusted relative risk 11.62, 95% CI 9.89-13.66) and laparoscopic hysterectomy with power morcellation than without power morcellation (adjusted relative risk 5.74, 95% CI 4.12-8.00). Laparoscopic supracervical hysterectomy was strongly associated with power morcellation use (adjusted relative risk 43.89, 95% CI 37.55-51.31). CONCLUSION A high minimally invasive hysterectomy rate is primarily associated with uterine size and can be maintained without power morcellation.

Adjuvant gemcitabine-docetaxel chemotherapy for stage I uterine leiomyosarcoma: Trends and survival outcomes

OBJECTIVE To assess recent trends of administering adjuvant gemcitabine-docetaxel (GD) chemotherapy for Stage I uterine leiomyosarcoma, and to compare disease-free and overall survival between women who received and did not receive adjuvant GD chemotherapy. METHODS All patients diagnosed with Stage I uterine leiomyosarcoma in a California-Colorado population-based health plan inclusive of 2006-2013 were included in a retrospective cohort. Adjuvant GD chemotherapy rates, clinico-pathologic characteristics and survival estimates were assessed. RESULTS Of 111 women with Stage I uterine leiomyosarcoma, 33 received adjuvant GD (median 4cycles), 77 received no chemotherapy, and 1 patient excluded for non-GD chemotherapy. GD-chemotherapy and no-chemotherapy groups were similar with respect to age, stage (IA/IB), uterine weight, mitotic index, body mass index, and Charlson comorbidity score. Non-Hispanic white women were twice as likely to receive adjuvant chemotherapy as non-white or Hispanic women (37.7 vs. 17.1%, P=0.02). The proportion of women receiving adjuvant GD chemotherapy increased from 6.5% in 2006-2008 to 46.9% in 2009-2013 (P<0.001). There was no significance difference in unadjusted Kaplan-Meyer estimated disease-free (P=0.95) or overall survival (P=0.43) between GD-chemotherapy and no-chemotherapy cohorts. Corresponding adjusted Cox proportional hazard ratios for adjuvant GD chemotherapy compared to no chemotherapy were 1.01 (95% confidence interval [CI] 0.57-1.80, P=0.97) for recurrence and 1.28 (95% CI 0.69-2.36, P-0.48) for mortality. CONCLUSIONS Use of adjuvant GD chemotherapy for Stage I uterine leiomyosarcoma has increased significantly in the last decade, despite unclear benefit. Compared to no chemotherapy, 4-6cycles of adjuvant GD chemotherapy does not appear to alter survival outcomes.