Matthew T. Siedhoff

Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroids: an updated decision analysis following the 2014 Food and Drug Administration safety communications

&NA; Previous decision analyses demonstrate the safety of minimally invasive hysterectomy for presumed benign fibroids, accounting for the risk of occult leiomyosarcoma and the differential mortality risk associated with laparotomy. Studies published since the 2014 Food and Drug Administration safety communications offer updated leiomyosarcoma incidence estimates. Incorporating these studies suggests that mortality rates are low following hysterectomy for presumed benign fibroids overall, and a minimally invasive approach remains a safe option. Risk associated with morcellation, however, increases in women age >50 years due to increased leiomyosarcoma rates, an important finding for patient‐centered discussions of treatment options for fibroids.

Hysterectomy for the Transgendered Male: Review of Perioperative Considerations and Surgical Techniques with Description of a Novel 2-Port Laparoscopic Approach

Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed.

Improving Patient Understanding of Uterine Fibroid Surgery and Morcellation Using Video-Enhanced Intervention: A Pilot Feasibility Study

Background: Uterine fibroids affect 80% of women and are the indication for approximately 200,000 surgeries annually in the United States. It is estimated that 63% of these surgeries are done using minimally invasive techniques. Laparoscopic hysterectomy and myomectomy for uterine fibroids are procedures that have been subject to recent controversy when they are paired with morcellation. These complex and controversial procedures provide a platform for investigation and improvement of preoperative patient education techniques. Objectives: (1) To create a complete research design guiding the conduct of a patient centered feasibility study, to be undertaken at a later time, to measure how and why patients prefer different types of counseling/education (usual verbal counseling vs. video enhanced education/counseling) as they approach minimally invasive gynecologic surgery for uterine fibroids; (2) To prepare the investigation with grounding in the literature on the effectiveness of strategies to improve patient understanding, comfort, and satisfaction when they are used to explain a complicated and controversial surgical technique (e.g. morcellation and uterine fibroid surgery) Methods: This is the research design for a multi-site pilot feasibility study aimed at recruiting 150 women undergoing laparoscopic hysterectomy or myomectomy for uterine fibroids where morcellation is anticipated for tissue extraction. The design grounds hypotheses and methods in the literature, develops or modifies educational tools and patient surveys to assess the tools’ effectiveness, and considers the recruitment and analysis obstacles associated with such a study. The general design includes proposing to recruit potential study participants at their preoperative surgical consultation. They would be offered the opportunity to participate in the ii study after the decision to have surgery has been made, but before they sign surgical consent documentation. Those who are willing to participate will sign informed consent documentation. Participants will then proceed with their preoperative consultation visit and receive patientcentered preoperative counseling via their surgeon, after which they would then be offered the opportunity to view a supplemental educational video about their procedure (i.e. laparoscopic hysterectomy or myomectomy). The potential for the educational video to produce distress or discomfort means that randomization is not an appropriate design: patients should have the ability to “opt in” and, even after they have done so, to stop viewing the video if it becomes distressing. The contribution of this design to future research is its patient-centeredness, since it seeks to understand what kinds of patients seek and can benefit from what kinds of education. For these reasons, all participants’ completion of a baseline survey and the completion of followup surveys is critically important to our ability to analyze differences between patients who seek further education and those who do not, and to understand how those differences may be associated with their operative and postoperative experiences...

Hemostasis Techniques in Myomectomies

Purpose of ReviewMyomectomy can be associated with significant blood loss, particularly when large and numerous fibroids are removed. Surgeons have incorporated a large number of methods to reduce blood loss, including pre-operative optimization, the use of minimally invasive surgery, and intraoperative techniques. The purpose of this review is to summarize these methods and evaluate the literature supporting those with clinical value.Recent FindingsThe use of minimally invasive surgery has clear benefit in reducing blood loss in myomectomy for appropriately selected patients. Preoperative hormonal treatments reduce myoma size and reduce the complexity of myomectomy. Myometrial vasoconstriction, vessel ligation or compression, and the use of barbed suture decrease blood loss in myomectomy.SummarySurgeons should be aware of the large number of pre-operative and intraoperative measures to reduce blood loss in myomectomy and employ those with proven clinical benefit, particularly in operations that are likely to involve excessive bleeding and the need for transfusion.

McCall Culdoplasty during Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial

STUDY OBJECTIVE To assess the feasibility and safety of a McCall culdoplasty at the time of total laparoscopic hysterectomy and to evaluate the differences in the total vaginal length, vaginal apex during Valsalva, and sexual function 12 months after McCall culdoplasty compared with standard cuff closure. DESIGN A pilot randomized controlled, single-masked trial (Canadian Task Force classification I). SETTING An academic tertiary care hospital. PATIENTS Women undergoing total laparoscopic hysterectomy for benign indications from June 2013 to December 2013. INTERVENTIONS Women were randomized (1:1) to McCall culdoplasty followed by standard cuff closure versus standard cuff closure. Patients underwent Pelvic Organ Prolapse Quantification examination and completed the Female Sexual Function Index immediately before surgery and at 6 months and 12 months postoperatively. The primary outcome was the operative time. Secondary outcomes included estimated blood loss, complications, total vaginal length, vaginal apex during Valsalva, and sexual function. MEASUREMENTS AND MAIN RESULTS This study included 50 patients. The groups were similar in terms of preoperative and surgical characteristics. The operative time did not differ between the groups. The estimated blood loss and complications were also similar. The loss to follow-up was similar in both groups. Changes in the total vaginal length, vaginal apex during Valsalva, sexual function, and pain with intercourse did not differ between the groups. CONCLUSION In this pilot study, the addition of McCall culdoplasty to standard cuff closure during total laparoscopic hysterectomy was not associated with an increase in operative time, estimated blood loss, or surgical complications. No differences in the total vaginal length or vaginal apex during Valsalva were observed at the 12-month follow-up. There were no differences in sexual dysfunction or dyspareunia. Given the well-established risk reduction for the development of apical prolapse with McCall culdoplasty during vaginal hysterectomy, this procedure may be a feasible and safe addition to total laparoscopic hysterectomy.

Risk of appendiceal endometriosis among women with deep-infiltrating endometriosis

To determine whether deep‐infiltrating endometriosis (DE) carries an increased risk of appendiceal endometriosis (AppE) as compared with superficial endometriosis or no endometriosis.

Comparison of the levonorgestrel‐releasing intrauterine system, hysterectomy, and endometrial ablation for heavy menstrual bleeding in a decision analysis model

A better understanding of the relative risks and benefits of common treatment options for abnormal uterine bleeding (AUB) can help providers and patients to make balanced, evidence‐based decisions.

Cost-effectiveness of treatments for heavy menstrual bleeding

BACKGROUND: Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown. OBJECTIVE: The objective of the study was to evaluate the relative cost‐effectiveness of 4 treatment options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation, nonresectoscopic endometrial ablation, and the levonorgestrel‐releasing intrauterine system. STUDY DESIGN: We formulated a decision tree evaluating private payer costs and quality‐adjusted life years over a 5 year time horizon for premenopausal women with heavy menstrual bleeding and no suspected malignancy. For each treatment option, we used probabilities derived from literature review to estimate frequencies of minor complications, major complications, and treatment failure resulting in the need for additional treatments. Treatments were compared in terms of total average costs, quality‐adjusted life years, and incremental cost‐effectiveness ratios. Probabilistic sensitivity analysis was conducted to understand the range of possible outcomes if model inputs were varied. RESULTS: The levonorgestrel‐releasing intrauterine system had superior quality‐of‐life outcomes to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel‐releasing intrauterine system was cost‐effective compared with hysterectomy in the majority of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were associated with reduced costs compared with hysterectomy but resulted in a lower average quality of life. According to standard willingness‐to‐pay thresholds, resectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 44% of scenarios, and nonresectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 53% of scenarios. CONCLUSION: Comparing all trade‐offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel‐releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel‐releasing intrauterine system as a first‐course treatment for heavy menstrual bleeding, consideration of cost, procedure‐specific complications, and patient preferences can guide the decision between hysterectomy and ablation.