K. Simpson

Evaluating ureteral patency in the post-indigo carmine era: a randomized controlled trial

BACKGROUND: Many gynecologic, urologic, and pelvic reconstructive surgeries require accurate intraoperative evaluation of ureteral patency. OBJECTIVE: We performed a randomized controlled trial to compare surgeon satisfaction with 4 methods of evaluating ureteral patency during cystoscopy at the time of benign gynecologic or pelvic reconstructive surgery: oral phenazopyridine, intravenous sodium fluorescein, mannitol bladder distention, and normal saline bladder distention. STUDY DESIGN: We conducted an unblinded randomized controlled trial of the method used to evaluate ureteral patency during cystoscopy at time of benign gynecologic or pelvic reconstructive surgery. Subjects were randomized to receive 200 mg oral phenazopyridine, 25 mg intravenous sodium fluorescein, mannitol bladder distention, or normal saline bladder distention during cystoscopy. The primary outcome was surgeon satisfaction with the method, assessed via a 100‐mm visual analog scale with 0 indicating strong agreement and 100 indicating strong disagreement with the statement. Secondary outcomes included comparing visual analog scale responses about ease of each method and visualization of ureteral jets, bladder mucosa and urethra, and operative information, including time to surgeon confidence in the ureteral jets. Adverse events were evaluated for at least 6 weeks after the surgical procedure, and through the end of the study. All statistical analyses were based on the intent‐to‐treat principle, and comparisons were 2‐tailed. RESULTS: In all, 130 subjects were randomized to phenazopyridine (n = 33), sodium fluorescein (n = 32), mannitol (n = 32), or normal saline (n = 33). At randomization, patient characteristics were similar across groups. With regard to the primary outcome, mannitol was the method that physicians found most satisfactory on a visual analog scale. The median (range) scores for physicians assessing ureteral patency were 48 (0‐83), 20 (0‐82), 0 (0‐44), and 23 (3‐96) mm for phenazopyridine, sodium fluorescein, mannitol, and normal saline, respectively (P < .001). Surgery length, cystoscopy length, and time to surgeon confidence in visualization of ureteral jets were not different across the 4 randomized groups. During the 189‐day follow‐up, no differences in adverse events were seen among the groups, including urinary tract infections. CONCLUSION: The use of mannitol during cystoscopy to assess ureteral patency provided surgeons with the most overall satisfaction, ease of use, and superior visualization without affecting surgery or cystoscopy times. There were no differences in adverse events, including incidence of urinary tract infections.

The Essential Elements of a Robotic-Assisted Laparoscopic Hysterectomy

Robotic-assisted laparoscopic hysterectomies are being performed at higher rates since the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA, USA) received US Food and Drug Administration approval in 2005 for gynecologic procedures. Despite the technological advancements over traditional laparoscopy, a discrepancy exists between what the literature states and what the benefits are as seen through the eyes of the end-user. There remains a significant learning curve in the adoption of safe and efficient robotic skills. The authors present important considerations when choosing to perform a robotic hysterectomy and a step-by-step technique. The literature on perioperative outcomes is also reviewed.

Discordance Between Intraoperative Frozen and Final Pathology of Borderline Ovarian Tumors [13P]

INTRODUCTION: When faced with a concerning adnexal mass intraoperatively, frozen pathology can guide intraoperative management. Borderline tumors are challenging to diagnose with frozen section compared to other ovarian pathology. Little is known about the effects of intraoperative diagnosis of ovarian pathology on surgical decision-making. We aimed to determine the rate of discordance between intraoperative diagnosis of a borderline tumor and final pathology and the effect on surgical management. METHODS: All gynecologic surgical cases wherein frozen ovarian pathology was collected between 2004 and 2014 were reviewed. Cases with frozen pathology consistent with a borderline tumor were further evaluated. For cases of borderline diagnosis by frozen pathology, the false positive and negative rates, sensitivity, specificity, and positive and negative predictive values of the intraoperative diagnosis for ovarian frozen sections were determined. Impact on surgical management was investigated. RESULTS: 1139 cases were sent for frozen ovarian pathology; 50 were concerning for a borderline tumor by frozen pathology. Two cases diagnosed as borderline tumors by frozen pathology returned benign on final pathology with unneeded unilateral salpingo-oophorectomies. The false positive rate between frozen and final pathology for borderline tumors was 4% (2/50). The false negative rate was 12.3% (8/65). The sensitivity, specificity, positive and negative predictive value of frozen ovarian pathology for borderline tumors was 77.1%, 92.2%, 93.0% and 98.9%, respectively. CONCLUSION: The false positive rate of intraoperative frozen and final pathology for borderline tumors is 4% in this study. Further studies are needed to evaluate the impact of intraoperative diagnosis on surgical management and reproductive health.

Discordance Between Benign Frozen and Final Ovarian Pathology [23P]

INTRODUCTION: There is limited data on the impact of frozen pathology on intraoperative management and patient outcomes in gynecologic surgery. We aimed to determine the rate of discordance between intraoperative frozen and final pathology and to calculate sensitivity, specificity, positive and negative predictive value. We also examined the impact on perioperative outcomes. METHODS: All cases of frozen ovarian pathology between 2004–2014 at a single institution were reviewed. The primary outcome was the discordance rate between benign frozen and final pathology. Pathology was categorized as benign, malignant (borderline+malignant pathology) or uncertain. Need for reoperation was determined when final pathology was malignant. RESULTS: 1139 cases were submitted for frozen ovarian pathology. Four of the 797 benign frozen cases had malignant final pathology consistent with a 0.5% discordance rate. The sensitivity, specificity, positive and negative predictive value of frozen ovarian pathology was 82.6% (242/293), 92.2% (781/847), 98.4% (242/246), and 98% (781/797), respectively. Three of the discordant cases required reoperation. Of these, two cases were fibroma-thecomas on frozen and granulosa cell tumors on final. The third specimen was consistent with a benign cyst on frozen pathology, and a serous adenocarcinoma on final pathology. The final case was consistent with mature cystic teratoma on frozen pathology and immature cystic teratoma on final pathology and opted for observation in place of reoperation. CONCLUSION: Discordance between benign frozen and final pathology is low. Rarely, when discordance occurs is subsequent surgery required. Further study is necessary to determine the effect of discordance on treatment outcomes.