Mobolaji O. Ajao

Nonresectoscopic Endometrial Ablation in High-Risk Surgical Patients: A Cohort Study

STUDY OBJECTIVE To evaluate the use of nonresectoscopic endometrial ablation in women with high anesthetic and surgical risk compared with low-risk women based on the American Society of Anesthesia (ASA) physical status stratification. DESIGN This is a cohort study of women who were classified as high-risk (HR) or low-risk (LR) cohorts based on ASA physical status stratification. The ASA classification includes 6 grades: ASAP1, a normal healthy person; ASAP2, mild systemic disease; ASAP3, severe systemic disease; ASAP4, severe systemic disease that is a constant threat to life; ASAP5, a critically ill patient who is not expected to survive without the operation; and ASAP6, declared brain-dead patient whose organs are being removed for donor purposes. Baseline characteristics including comorbidities were obtained. Outcome measures included amenorrhea, treatment failure, and operative complications. The time to treatment failure was compared using Kaplan-Meier analysis. Risk adjustments were performed using regression models. SETTING Academic medical center in the Upper Midwest. PATIENTS Seven-hundred eleven women underwent nonresectoscopic endometrial ablation at our institution between January 1998 and December 2005. INTERVENTIONS Bipolar radiofrequency was used in 448 women and thermal balloon ablation in 263 women. MEASUREMENTS AND MAIN RESULTS The HR cohort had a higher proportion of women with cardiac disease (27.1% vs. 6.7%, p < .001) and more women with nongynecologic cancer (12.3% vs. 2.9%, Fisher exact test, p < .001). Nonetheless, endometrial ablation had comparable efficacy in both the HR and LR cohorts with 5-year failure rates of 11.7% and 14.8% (p = .659), respectively. Amenorrhea rates were also similar in both cohorts (29.7% vs. 27.2%, p = .645). After adjusting for known confounders including age, parity, dysmenorrhea, previous tubal ligation, uterine length, and the type of the procedure, the calculated hazard ratio for failure in the HR cohort was 0.80 (95% confidence interval; 0.31-1.74, p = .607), and the adjusted odds ratio for amenorrhea was 1.27 (95% confidence interval, 0.71-2.20; p = .411). Complications were rare in both groups. The mortality rate in the HR cohort was significantly higher compared with the LR cohort (7.9% vs. <1%, p < .001), but this was not related to the ablation procedures. CONCLUSION For women who are high anesthetic and surgical risks because of serious underlying comorbidities, nonresectoscopic endometrial ablation can provide minimally invasive, safe, and effective therapy for menorrhagia.

Case Report: Three-Dimensional Printed Model for Deep Infiltrating Endometriosis

The combination of a thorough physical examination and imaging with either magnetic resonance imaging (MRI) or pelvic ultrasound are important in the preoperative planning for deep infiltrating endometriosis (DIE). A 2-dimensional (2D) rendering of the pathology by imaging does not always accurately represent intraoperative findings. The detailed topographical relationship and extent of surrounding tissue invasion can be better appreciated by 3-dimensional (3D) modeling. A 49-year-old patient with history of endometriosis and persistent pain underwent preoperative MRI that showed features consistent with DIE endometriosis. Surgery was performed, and the findings were documented. A 3D printed model of the DIE was generated from the MRI and retrospectively compared with intraoperative findings. The 3D model demonstrated both the laterality and spatial relationship of the endometriotic nodule to the posterior uterine wall and rectum. Three-dimensional printing of DIE may be a beneficial adjunct to 2D imaging and can identify further structural relationships to support surgical planning.

Prospective Evaluation of Manual Morcellation Techniques: Minilaparotomy versus Vaginal Approach

STUDY OBJECTIVE To compare the number of days required to return to daily activities after laparoscopic hysterectomy with 2 tissue extraction methods: manual morcellation via colpotomy or minilaparotomy. Secondary outcomes were additional measures of patient recovery, perioperative outcomes, containment bag integrity, and tissue spillage. DESIGN Multicenter prospective cohort study and follow-up survey (Canadian Task Force classification II-2). SETTING Two tertiary care academic centers in northeastern United States. PATIENTS Seventy women undergoing laparoscopic hysterectomy with anticipated need for manual morcellation. INTERVENTIONS Tissue extraction by either contained minilaparotomy or contained vaginal extraction method, along with patient-completed recovery diary. MEASUREMENTS AND MAIN RESULTS Recovery diaries were returned by 85.3% of participants. There were no significant differences found in terms of average pain at 1, 2, or 3 weeks after surgery or in time to return to normal activities. Patients in both groups used narcotic pain medication for an average of 3 days. After adjusting for patient body mass index, history of prior surgery, uterine weight, and surgeon, there were no differences found for blood loss, operative time, length of stay, or incidence of any intra- or postoperative complication between groups. All patients had benign findings on final pathology. More cases in the vaginal contained extraction group were noted to have bag leakage on postprocedure testing (13 [40.6%] vs 3 [8.3%] tears in vaginal and minilaparotomy groups, respectively; p = .003). CONCLUSION Regarding route of tissue extraction, contained minilaparotomy and contained vaginal extraction methods are associated with similar patient outcomes and recovery characteristics.

Incisional Outcomes of Umbilical Versus Suprapubic Minilaparotomy for Tissue Extraction: a Retrospective Cohort Study

STUDY OBJECTIVE To compare outcomes following umbilical minilaparotomy and suprapubic minilaparotomy for tissue extraction. DESIGN CLASSIFICATION Retrospective cohort study (Canadian Task Force classification II-2). SETTING Two large academic medical centers. PATIENTS Women who underwent a minilaparotomy for tissue extraction following a laparoscopic hysterectomy or myomectomy between 2014 and 2016. INTERVENTIONS Umbilical or suprapubic minilaparotomy for tissue extraction. MEASUREMENTS AND MAIN RESULTS A total of 374 women underwent laparoscopic hysterectomy or myomectomy with minilaparotomy, including 289 (77.3%) with an umbilical minilaparotomy and 85 (22.7%) with a suprapubic minilaparotomy. The 2 groups were similar in terms of age, body mass index, parity, surgical history, procedure type, surgical approach, and surgical indication. The size of the minilaparotomy incision and the specimen weight were significantly smaller in the umbilical minilaparotomy group (mean, 3.3 ± 0.8 cm vs 4.2 ± 0.6 cm [p < .001] and 472.6 ± 357.1 g vs 683.0 ± 475.7 g [p < .001], respectively). Two women in the suprapubic minilaparotomy group sustained a bladder injury during creation of the incision. There were no other complications related to the minilaparotomy in either group. Postoperative outcomes related to the minilaparotomy incision were compiled using the medical record and a follow-up survey. Of the 374 women in this cohort, 163 responded to a detailed survey about their minilaparotomy incision (response rate, 43.5%). With regard to the minilaparotomy, 52.7% of women reported incisional symptoms; 25.9% had increased pain at the incision, 8.3% had an incisional infection, and 2.7% reported an incisional hernia. There was no significant between-group difference in incisional outcomes; however nearly 3 times as many women in the umbilical minilaparotomy group reported concerns about incisional hernia (3.1% vs 1.2%; p = .833). These findings were maintained in a multivariable logistic regression analysis. No patient or procedure characteristics were significantly associated with the development of hernia. CONCLUSION There were no significant difference in incisional symptoms, pain, or infection following umbilical minilaparotomy vs a suprapubic minilaparotomy for tissue extraction. Although not statistically significant, the rate of incisional hernia was higher at the umbilical site compared with the suprapubic site.

Management of Endometriosis Involving the Urinary Tract.

Endometriosis is a common cause of infertility and disabling pelvic pain in reproductive age women. The most widely accepted theory of its pathogenesis is the retrograde flow of menstrual products, although extra-abdominal and extrapelvic diagnoses have been made. After the pelvic peritoneum and gynecologic structures, the most commonly affected sites are the lower gastrointestinal and urinary tracts. When the urinary tract is involved, the bladder is the predominant site, followed by the ureters. The focus of this seminar will thus be these two anatomic sites. Delayed diagnosis is unfortunately common for endometriosis as a whole, but more so when extrapelvic sites are involved. While the first-line therapy for endometriosis is medical management, urinary tract involvement often represents advanced stage of the disease, thereby requiring surgical intervention. With timely diagnosis and intervention by skilled gynecologic or urologic surgeons, favorable outcomes can be attained.

Morcellation Techniques for Laparoscopic Hysterectomy and Myomectomy: A Retrospective Study

Measurements and Main Results: Anamnesis was studied; US of small pelvic organs, laparoscopy with chromosalpingoscopy, hysteroscopy, uterine cavity curettage with histological investigation of endometrium were performed. Duration of sterility ranged from 3 to 5 years. In both forms of sterility, on the basis of anamnesis, salpingoperitoneal variant was presumed in 45-50% of patients, with laparoscopy – in 100% of cases. Uterine factor was presumed in 19-26% on the basis of anamnesis and US. While using hysteroscopy, chronic endometritis was revealed in case of primary sterility in 26,3% of patients, histologically – in 31,5%, in case of hysteroscopy, endometrial polyps were detected in 15,8%, in case of histological study – in 78,9% of patients; histologically, combination of endometritis with polyps was found in 31,5%. Endometrium turned out to be unchanged in 10,5% of cases of primary sterility. In case of secondary sterility, chronic endometritis by means of hysteroscopy was established in 12,5%, histological study – in 33,3%; endometrial polyps – in 25% hysteroscopically and in 83,3% morphologically. Combination of endometritis with endometrial polyps was revealed in 25% of patients in this group. When using histological study, endometrial pathology was detected in 100% of secondary sterility. Conclusion: Endoscopic methods are the main in sterility diagnostics. Nevertheless, histological study of endometrium is necessary even with unchanged hysteroscopic picture.