Gaby N. Moawad

Comparison of methods of morcellation: manual versus power

With the growing controversy surrounding power morcellation (PM), other approaches must be examined so that women may still benefit from minimally invasive gynecologic surgeries. In this study we sought to compare power morcellation to manual morcellation through mini‐laparotomy or vaginally.

Systematic Review of Transabdominal Cerclage Placed via Laparoscopy for the Prevention of Preterm Birth.

Preterm birth is the leading cause of neonatal mortality and morbidity. Multiple interventions are available to minimize this occurrence; however, despite current recommendations including medical management, cervical length screening, and transvaginal cerclage, a substantial number of women still experience preterm birth. For those patients, experts recommend transabdominal cerclage (TAC). In this systematic review, we compared 26 studies (1116 patients) of TAC placed via laparotomy (TAC-lap) and 15 studies (728 patients) of TAC placed via laparoscopy (TAC-lsc). There was no significant difference in overall neonatal survival between the TAC-lsc and TAC-lap groups (89.9% vs 90.8%, respectively; p = .80). When T1 losses were excluded, the neonatal survival rate was significantly higher for the TAC-lsc group (96.5% vs 90.1%; p < .01). In terms of obstetrical outcomes, the TAC-lsc group had a higher rate of deliveries at gestational age (GA) > 34 weeks (82.9% vs 76%; p < .01) and a lower rate of deliveries at GA 23.0 to 33.6 weeks (6.8% vs 14.8%; p < .01). The TAC-lsc group also had fewer T2 losses (3.2% vs 7.8%; p < .01). TAC-lsc offers all the benefits of minimally invasive surgery with better obstetrical outcomes compared with TAC-lap.

Multidisciplinary Resection of Deeply Infiltrative Endometriosis

STUDY OBJECTIVE To describe a multidisciplinary approach for the resection of deeply infiltrative endometriosis using the robotic platform. DESIGN A technical video showing a step-by-step approach for the resection of deeply infiltrative endometriosis (Canadian Task Force classification level III). Institutional review board approval was not required for this study. SETTING There is considerable involvement of the bowel and bladder with deeply infiltrative endometriosis [1-3]. The need for operative procedures involving multiple organs while performing a complete resection is common. The benefits of minimally invasive surgery for a gynecologic pathology have been documented in numerous studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis, and better quality of life [4-6]. We believe that deeply infiltrative endometriosis does not preclude patients from having a minimally invasive resection procedure. In this video, we describe how the robotic platform was used for a seamless transition between surgical specialties including gynecology, colorectal, and urology to ensure complete resection of endometriosis lesions involving multiple organs. PATIENT A 47-year-old woman with a 4-year history of severe pelvic pain, dysuria, dyspareunia, dyschezia, and dysmenorrhea failing multiple medical therapies presented to our clinic to discuss surgical options. After thorough counseling, the decision was made to proceed with definitive surgical management. Postoperatively, the patient was admitted for 2 days of postoperative inpatient care. After meeting all immediate postoperative milestones, she was discharged with an indwelling Foley catheter and instructed to follow up in the clinic with all 3 surgical specialties. At the 1-week interval, she was seen by the urology team; her indwelling catheter was removed after a cystoscopy was performed documenting adequate healing. Two weeks postoperatively, the patient was seen by the gynecology and colorectal teams and was noted to be healing adequately from the procedure. Her six-week visit was also unremarkable. She continued to follow up with the gynecology team for her yearly well-woman examinations and has been symptom free for 2 years after the surgery. She takes norethindrone daily to minimize recurrence. INTERVENTIONS Preoperative pelvic magnetic resonance imaging (MRI) showed bladder endometriosis and extensive rectovaginal endometriosis. We describe the multidisciplinary approach used for surgery and the procedures performed by each specialty. The urology team performed a cystoscopy preoperatively to assess for full-thickness erosions and the location of those lesions in that event. The urology team also reviewed the magnetic resonance images with the radiology team, and the endometriosis lesions were suspected to be close to the bladder trigone, keeping in mind that this finding could be overestimated given that the bladder was deflated at the time the imaging was obtained. Accordingly, at the time of surgery, the decision was made to proceed with cystoscopy and the placement of ureteral stents as a prophylactic measure. An intentional cystotomy and resection of the bladder section involved with endometriosis were performed followed by watertight closure. The trigone area of the bladder was not involved, and ureteral reimplantation was not needed in this case. The gynecology team operated second and performed an extensive dissection of the retroperitoneal space with the development of the pararectal and paravesical spaces. They also ligated the uterine artery at its origin followed by dissection of the uterovesical space, effectively reflecting the bladder off of the lower uterine segment. At this point, they proceeded with a total hysterectomy, and the specimen was removed from the pelvis through the vaginal cuff. Preoperatively, the colorectal surgeon ordered a colonoscopy to determine if full-thickness erosions were present and reviewed the magnetic resonance images with the radiology team. Based on the MRI and colonoscopy, all patients are counseled and consented for the possibility of a low anterior resection and loop ileostomy to protect the anastomosis. Based on the understanding that colorectal and gynecologic surgeries have a different approach when dissecting the pararectal space at our institution, a discussion between the 2 teams is initiated at the multidisciplinary session for surgery planning. In the case we present, the colorectal surgeon opted for the removal of the uterus before his dissection was initiated given that he dissects this space presacrally and not retroperitoneally like the gynecology counterpart. He would also benefit from the extra space for dissection with the uterus out of the pelvis. The colorectal part of the case was initiated by mobilization of the rectum and dissecting the obliterated rectovaginal space. The presacral space was then opened followed by mobilization of the rectosigmoid from its attachment. The case was concluded with full transection and reanastomosis of the rectum section involved with endometriosis. The specimen was also removed from the pelvis through the vaginal cuff. MEASUREMENTS AND MAIN RESULTS Complete resection of deeply infiltrative endometriosis spanning beyond the scope of 1 surgical specialty. No immediate intraoperative, perioperative, or long-term complications from surgery. Complete resolution of endometriosis symptoms. CONCLUSION We encourage collaborative care for planning and performing comprehensive and safe resection of deeply infiltrative endometriosis.

Use of Intravenous Tranexamic Acid During Myomectomy: A Randomized Double-Blind Placebo Controlled Trial

Study Objective: The aim of this research was to evaluate surgical findings, postoperative features, and complications in a series of 64 cases of benign adnexal. mass that was approached in each case with single incision laparoscopic surgery (SILS). Design: In a tertiary medical center in Brazil, 64 patients with presurgery diagnoses of benign adnexal masses underwent laparoscopic surgery using the SILS technique. Each patient’s adnexal mass was presumed to be benign, based on each patient’s echography features, patient’s age, C-125 level, and menopausal status. Setting: Retrospective study. Patients: 64 patients with presurgery diagnoses of benign adnexal masses Intervention: Single incision laparoscopy. Measurements and Main Results: Hystologic results of all the recruited patients showed benign lesions. Benign cysts (28; 43,8%), solid teratomas (10; 15,6%),and endometriosis (8; 12,5%) were the most prevalent results. There was 1 case of an incisional hernia, the only postoperative complication that required new hospital admission. The average length of stay in the hospital was 22 hours (range: 17–28). Conclusion: SILS is a feasible approach for benign adnexal masses, presenting low rates of postoperative complications and short hospital stays.

Minimally Invasive Hysterectomy for Uteri Greater Than One Kilogram.

Background and Objectives: To assess the feasibility and safety of minimally invasive hysterectomy for uteri >1 kg. Methods: Clinical and surgical characteristics were collected for patients in an academic tertiary care hospital. Included were patients who underwent minimally invasive hysterectomy by 1 of 3 fellowship-trained gynecologists from January 1, 2009, to July 1, 2015 and subsequently had confirmed uterine weights of 1 kg or greater on pathology report. Both robotic and conventional laparoscopic procedures were included. Results: During the study period, 95 patients underwent minimally invasive hysterectomy with confirmed uterine weight over 1 kg. Eighty-eight percent were performed with conventional laparoscopy and 12.6% with robot-assisted laparoscopy. The median weight (range) was 1326 g (range, 1000–4800). The median estimated blood loss was 200 mL (range, 50–2000), and median operating time was 191 minutes (range, 75–478). Five cases were converted to laparotomy (5.2%). Four cases were converted secondary to hemorrhage and one secondary to extensive adhesions. There were no conversions after 2011. Intraoperative transfusion was given in 6.3% of cases and postoperative transfusion in 6.3% of cases. However, after 2013, the rate of intraoperative transfusion decreased to 1.0% and postoperative transfusion to 2.1%. Of the 95 cases, there were no cases with malignancy. Conclusions: This provides the largest case series of hysterectomy over 1 kg completed by a minimally invasive approach. Our complication rate improved with experience and was comparable to other studies of minimally invasive hysterectomy for large uteri. When performed by experienced surgeons, minimally invasive hysterectomy for uteri >1 kg can be considered feasible and safe.

Diagnosis of Deeply Infiltrative Endometriosis: Accuracy of a Specific Magnetic Resonance Imaging Protocol

Objective: To evaluate the accuracy of a specific magnetic resonance imaging (MRI) protocol in diagnosing the extent and location of deeply infiltrative endometriosis (DIE). Methods: A retrospective chart review of women age 20 to 51 years of age who had a preoperative evaluation suspicious for DIE base on: 1) preoperative examination showing a rectovaginal mass or nodularity, non-mobile uterus fixed to rectum, and/or an adnexal mass, 2) severe or cyclic dysuria, dyschezia, and/or dyspareunia, or 3) a history of prior surgery for advanced staged endometriosis. These women subsequently underwent an institution specific endometriosis protocol pelvic MRI. Our MRI endometriosis protocol uses a 1.5T machine which takes images in T2, T1 non- fat saturation, and a fat saturation T1 in axial orientation along all three planes pre and postcontrast. Slices are thinner in the T1 and T2 images using the endometriosis protocol compared to the standard protocol. Intra-operative data were collected for women who underwent surgery for endometriosis. MRI findings were compared with intraoperative findings. Twenty-six women who had high suspicion for DIE on our institution specific MRI and subsequently underwent a laparoscopic surgery by a single minimally invasive gynaecologic surgeon were included in our study. Results: Of the twenty-six women, who met criteria for our study, twenty-one were found to have DIE, two were found to have superficial endometriosis, and there was one case of a tubo-ovarian abscess. Two were found to have other pelvic pathology such as fibroids, cysts, adhesions, and/or fibrosis. For patients with a high preoperative suspicion of DIE, our MRI protocol had a sensitivity of 82%, specificity of 80%, PPV of 95%, NPV of 50%. Conclusions: Our standardized endometriosis MRI protocol predicts the extent of DIE. Benefits of MRI include potential to replace multiple imaging exams, improve preoperative planning, and aid in decision for referral to a specialized surgeon.

A Case of Recurrent Rudimentary Horn Ectopic Pregnancies Managed by Methotrexate Therapy and Laparoscopic Excision of the Rudimentary Horn.

This report presents a case of a 31-year-old woman successfully treated medically for a noncommunicating rudimentary horn ectopic pregnancy who presented with a second, successive rudimentary horn pregnancy. Patient underwent laparoscopic excision of right rudimentary horn and right salpingectomy after failed methotrexate therapy. Given the potential for rupture and recurrence, serious efforts should be made to excise a uterine rudimentary horn.

Simulation Based Robotics Training to Test Skill Acquisition and Retention

Study Objective: Laparoscopic management of ectopic pregnancy is a common procedure encountered during Obstetrics and Gynecology (ObGyn) residency training. Although a limited number of commercial products exist to aid simulation in teaching laparoscopic salpingostomy and salpingectomy, these models are either incomplete (ex. partial tube only) or quite expensive, thus limiting application. Our goal was to develop a low fidelity uterine model with simulated ectopic pregnancy that could be used by Ob-Gyn residents when performing simulation for laparoscopic treatment of ectopic pregnancy. Design: Pilot design of a novel low fidelity uterine model with simulated ectopic pregnancy for use in laparoscopic simulation. Setting: The model is manipulated with traditional laparoscopic instruments within a standard laparoscopic task trainer. Patients: Ob-Gyn residents at a single academic center used the created model when performing simulation for laparoscopic salpingostomy and salpingectomy. Intervention: A low fidelity uterine model with simulated ectopic pregnancy was constructed using common items. A plastic maraca functioned as the uterus with attached uterine manipulator. A plastic whoosh ball placed inside a small balloon served as the ectopic pregnancy; this was placed inside a larger balloon and attached to the maraca to simulate fallopian tube with ectopic pregnancy. Additional balloons were added for ovaries and press and seal was used as peritoneum.

Movement to outpatient hysterectomy for benign indications in the United States, 2008–2014

Introduction The past decade has witnessed adoption of conservative gynecologic treatments, including minimally invasive surgery (MIS), alongside steady declines in inpatient hysterectomies. It remains unclear what factors have contributed to trends in outpatient benign hysterectomy (BH), as well as whether these trends exacerbate disparities. Materials and methods Retrospective cohort of 527,964 women ≥18 years old who underwent BH from 2008 to 2014. BH surgical approaches included: open/abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). Quarterly frequencies were calculated by care setting and surgical approach. We used multilevel logistic regression (MLR) using the most recent year of data (2014) to examine the influence of patient-, physician-, and hospital-level preoperative factors and surgical approaches on outpatient migration. Results From 2008–2014, surgical approaches for LH and RH increased, which coincided with decreases in VH and AH. Overall, a 44.2% shift was observed from inpatient to outpatient settings (P<0.0001). Among all outpatient visits MIS increased, particularly for RH (3.6% to 41.07%). We observed increases in the proportion of non-Hispanic Black and Medicaid patients who obtained MIS in 2014 vs. 2008 (P<0.001). Surgical approach (51.8%) and physician outpatient MIS experience (19.9%) had the greatest influence on predicting outpatient BH. Compared with LH, RH was associated with statistically significantly higher likelihood of outpatient BH overall (OR 1.23; 95% CI, 1.16–1.31), as well as in sub-analyses of more complex cases and hospitals that performed ≥1 RH (P<0.05). Conclusion From 2008–2014, rates of LH and RH significantly increased. A significant shift from inpatient to outpatient setting was observed. These findings suggest that RH may facilitate the shift to outpatient BH, particularly for patients with complexities. The adoption of MIS in outpatient settings may improve access to disadvantaged patient groups.

Urethral Solitary Fibrous Tumor: A Rare Pathologic Diagnosis of a Periurethral Mass

Solitary fibrous tumors (SFTs) may occur at any site in the body. SFTs can only be conclusively diagnosed based on histopathologic and immunohistochemical characteristics of the tumor. The presence of SFTs in the abdomen and pelvis is extremely rare. To our knowledge no cases of urethral solitary fibrous tumor in the literature have been reported so far. We present a case of a solitary fibrous tumor arising from the urethra in a twenty-three-year-old female presenting with vaginal mass.