Nicole Donnellan

Plasma MicroRNAs as Novel Biomarkers for Endometriosis and Endometriosis-Associated Ovarian Cancer

Purpose: Endometriosis, a largely benign, chronic inflammatory disease, is an independent risk factor for endometrioid and clear cell epithelial ovarian tumors. We aimed to identify plasma miRNAs that can be used to differentiate patients with endometriosis and ovarian cancer from healthy individuals. Experimental Design: We conducted a two-stage exploratory study to investigate the use of plasma miRNA profiling to differentiate between patients with endometriosis, patients with endometriosis-associated ovarian cancer (EAOC), and healthy individuals. In the first stage, using global profiling of more than 1,000 miRNAs via reverse transcriptase quantitative PCR (RT-qPCR) in a 20-patient initial screening cohort, we identified 23 candidate miRNAs, which are differentially expressed between healthy controls (n = 6), patients with endometriosis (n = 7), and patients with EAOC (n = 7) based on the fold changes. In the second stage, the 23 miRNAs were further tested in an expanded cohort (n = 88) of healthy individuals (n = 20), endometriosis (n = 33), EAOC (n = 14), and serous ovarian cancer cases (SOC; n = 21, included as controls). Results: We identified three distinct miRNA signatures with reliable differential expression between healthy individuals, patients with endometriosis, and patients with EAOC. When profiled against the control SOC category, our results revealed different miRNAs, suggesting that the identified signatures are reflective of disease-specific pathogenic mechanisms. This was further supported by the fact that the majority of miRNAs differentially expressed in human EAOCs were mirrored in a double transgenic mouse EAOC model. Conclusion: Our study reports for the first time that distinct plasma miRNA expression patterns may serve as highly specific and sensitive diagnostic biomarkers to discriminate between healthy, endometriosis, and EAOC cases. Clin Cancer Res; 19(5); 1213–24. ©2013 AACR.

Vaginal cuff dehiscence after different modes of hysterectomy.

OBJECTIVE: To update the incidence of vaginal cuff dehiscence after different modes of hysterectomy and to describe surgical and patient characteristics of dehiscence complications. METHODS: This was an observational cohort study at a large academic hospital. All women who underwent hysterectomy and dehiscence repair between January 2006 and December 2009 were identified. Data from this study period were analyzed separately and in combination with our preliminary study (January 2000 to December 2005) for a 10-year analysis (January 2000 to December 2009). The primary outcome was incidence of vaginal cuff dehiscence after total laparoscopic hysterectomy compared with abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy (LAVH). RESULTS: Between 2006 and 2009, the overall incidence of dehiscence was 0.39% (95% confidence interval [CI] 0.21–0.56). The incidence after total laparoscopic hysterectomy was 0.75% (95% CI 0.09–1.4), which was the highest among all modes of hysterectomy (LAVH was 0.46% [95% CI 0.0–1.10]; total abdominal hysterectomy was 0.38% [95% CI 0.16–0.61]; and total vaginal hysterectomy was 0.11%, [95% CI 0.0–0.32]). This incidence was appreciably lower than previously reported (4.93% in 2007 publication, 2.76% readjusted calculation). The 10-year cumulative incidence of dehiscence after all modes of hysterectomy was 0.24% (95% CI 0.15–0.33) and 1.35% (95% CI 0.72–2.3) among total laparoscopic hysterectomies. During the 10-year study period, total laparoscopic hysterectomy-related dehiscence was significantly increased compared with other modes of hysterectomy, with a risk ratio of dehiscence after total laparoscopic hysterectomy of 9.1 (95% CI 4.1–20.3) compared with total abdominal hysterectomy, risk ratio of 17.2 (95% CI 3.9–75.9) compared with total vaginal hysterectomy, and risk ratio of 4.9 (95% CI 1.1–21.5) compared with LAVH. CONCLUSION: Our updated 1.35% incidence of dehiscence after total laparoscopic hysterectomy is much lower than previously reported. LEVEL OF EVIDENCE: II

Small Bowel Obstruction Resulting from Laparoscopic Vaginal Cuff Closure with a Barbed Suture

Surgical trends favor the minimally invasive approach for gynecologic procedures. Technology, equipment, and surgical materials have evolved to simplify technically challenging skills and decrease operative times to permit successful completion of procedures via the laparoscopic approach. However, with the introduction of new advances, surgeons must also be aware of potential complications that may arise. A barbed suture is an attractive suture option that allows for easier and faster laparoscopic suturing by eliminating repeated knots and the need to maintain tension on the suture line. Here we present the case of a small bowel obstruction caused by barbed suture used for vaginal cuff closure at the time of total laparoscopic hysterectomy. Implementation of a new technology or surgical material in laparoscopy to improve care must be optimized to prevent untoward events in our patients.

Abdominal wall endometriosis: 12 years of experience at a large academic institution

OBJECTIVE The objective of the study was to review patient characteristics and intraoperative findings for excised cases of abdominal wall endometriosis (AWE). STUDY DESIGN A 12 year medical record search was performed for cases of excised AWE, and the diagnosis was confirmed on pathological specimen. Descriptive data were collected and analyzed. RESULTS Of 65 patients included, the primary clinical presentation was abdominal pain and/or a mass/lump (73.8% and 63.1%, respectively). Most patients had a history of cesarean section (81.5%) but 6 patients (9.2%) had no prior surgery. Time from the initial surgery to presentation ranged from 1 to 32 years (median, 7.0 years), and time from the most recent relevant surgery ranged from 1 to 32 years (median, 4.0 years). Five patients (7.7%) required mesh for fascial closure following the resection of the AWE. We were unable to demonstrate a correlation between the increasing numbers of open abdominal surgeries and the time to presentation or depth of involvement. Age, body mass index, and parity also were not predictive of depth of involvement. There were increased rates of umbilical lesions (75% vs 5.6%, P < .001) in nulliparous compared with multiparous women as well as in women without a history of cesarean section (66.7% vs 1.9%, P < .001). CONCLUSION In women with a mass or pain at a prior incision, the differential diagnosis should include AWE. Although we were unable to demonstrate specific characteristics predictive for AWE, a large portion of our population had a prior cesarean section, suggesting a correlation.

Complement Pathway Is Frequently Altered in Endometriosis and Endometriosis-Associated Ovarian Cancer

Purpose: Mechanisms of immune dysregulation associated with advanced tumors are relatively well understood. Much less is known about the role of immune effectors against cancer precursor lesions. Endometrioid and clear-cell ovarian tumors partly derive from endometriosis, a commonly diagnosed chronic inflammatory disease. We performed here a comprehensive immune gene expression analysis of pelvic inflammation in endometriosis and endometriosis-associated ovarian cancer (EAOC). Experimental Design: RNA was extracted from 120 paraffin tissue blocks comprising of normal endometrium (n = 32), benign endometriosis (n = 30), atypical endometriosis (n = 15), and EAOC (n = 43). Serous tumors (n = 15) were included as nonendometriosis-associated controls. The immune microenvironment was profiled using Nanostring and the nCounter GX Human Immunology Kit, comprising probes for a total of 511 immune genes. Results: One third of the patients with endometriosis revealed a tumor-like inflammation profile, suggesting that cancer-like immune signatures may develop earlier, in patients classified as clinically benign. Gene expression analyses revealed the complement pathway as most prominently involved in both endometriosis and EAOC. Complement proteins are abundantly present in epithelial cells in both benign and malignant lesions. Mechanistic studies in ovarian surface epithelial cells from mice with conditional (Cre-loxP) mutations show intrinsic production of complement in epithelia and demonstrate an early link between Kras- and Pten-driven pathways and complement upregulation. Downregulation of complement in these cells interferes with cell proliferation. Conclusions: These findings reveal new characteristics of inflammation in precursor lesions and point to previously unknown roles of complement in endometriosis and EAOC. Clin Cancer Res; 20(23); 6163–74. ©2014 AACR.

Intraperitoneal instillation of bupivacaine for reduction of postoperative pain after laparoscopic hysterectomy: a double-blind randomized controlled trial.

STUDY OBJECTIVE To evaluate the effect on postoperative pain of intraperitoneal instillation of dilute bupivacaine at the conclusion of laparoscopic hysterectomy. DESIGN Prospective, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I). SETTING Tertiary care, urban, academic teaching hospital. PATIENTS Women aged 18 to 65 years undergoing total or supracervical laparoscopic hysterectomy with or without salpingo-oophorectomy. INTERVENTION Randomization to intraperitoneal instillation of bupivacaine vs normal saline solution at the conclusion of laparoscopic hysterectomy performed because of benign indications. MEASUREMENTS AND MAIN RESULTS A total of 160 patients consented to participate in the study and were randomized to receive either intraperitoneal instillation of 100 mg bupivacaine in 100 mL normal saline solution or 100 mL normal saline solution alone, at the conclusion of laparoscopic hysterectomy. Sixty seven of 77 patients (87%) in the treatment group and 73 of 80 patients (91%) in the placebo group completed the study. There were no significant differences in demographic profile, indication for hysterectomy, or number of previous surgeries between the two groups. All patients were prescribed a standardized routine postoperative analgesic regimen. Pain was measured by patient self-report using a 10-cm visual analog scale (VAS) at 1, 2, 4, 6, 12, and 24 hours postoperatively. Mean VAS scores at all time points were between 2.0 and 4.3 and were highest in the first postoperative hour. VAS scores were not significantly different between the two groups at any time point. None of the measured secondary outcomes were significantly different between the bupivacaine and placebo groups, including total postoperative opioid analgesic use in morphine equivalents (23.2 mg vs 27.5 mg; p = .09), length of hospital stay in hours (23.3 vs 23.0; p = .49), patient satisfaction on a 10-cm VAS (9.0 vs 8.2; p = .12), and complication rates (9% vs 15%; p = .35). CONCLUSION Intraperitoneal instillation of bupivacaine at the conclusion of laparoscopic hysterectomy does not reduce postoperative pain. Opioid analgesic use, length of hospital stay, overall patient satisfaction, and complication rates are also unchanged. Self-reported postoperative pain was low in both groups after this major gynecologic surgery performed laparoscopically.

Development and Validation of a Laparoscopic Simulation Model for Suturing the Vaginal Cuff.

OBJECTIVE: To create a novel surgical simulation model for training laparoscopic suturing of the vaginal cuff and to present evidence regarding its validity as a training and assessment tool. METHODS: The three phases of this study included model construction, validity and reliability testing, and evaluation of the model as an assessment tool. The model was created using corduroy, quilt batting, and neoprene. Construct validity was determined by comparing the scores on the Global Operative Assessment of Laparoscopic Skills scale (25 points) between “expert” and “novice” groups. Experts included gynecologic surgeons (n=5) experienced in total laparoscopic hysterectomies, and novices (n=20) included gynecology trainees (postgraduate year [PGY]-2 to PGY-7). Three additional novel metrics were added to the Global Operative Laparoscopic Assessment of Laparoscopic Skills scale for a total of 40 points. The contrasting groups method was used to determine the minimum passing score. RESULTS: More than 90% of the participants “agreed” that the model resembled live surgery. Advanced novices (PGY-5 to PGY-7) performed similarly to the experts with similar median times (experts 7.3 minutes compared with advanced novices 6.3 minutes, P=.40) and total score (experts 36.5 compared with advanced novices 35.5, P=.34). In contrast, early novices (PGY-2 to PGY-4) tended to take significantly longer than experts (11.8 compared with 7.3 minutes, P<.01) and had a significantly lower total score (27 compared with 36.5, P<.01). Prior surgical experience was strongly correlated with total scores (&rgr;=0.68). The passing total score was 32 out of 40. CONCLUSION: This novel laparoscopic surgical simulation model allows novice surgeons to practice techniques of laparoscopic suturing to achieve competence before entering the operating room.

Patient and provider factors associated with endometrial Pipelle sampling failure

OBJECTIVE To explore risk factors associated with sampling failure in women who underwent Pipelle biopsy. METHODS A consecutive sample of 201 patient records was selected from women who underwent Pipelle biopsy procedures for suspected uterine pathology in a large healthcare system over a 6-month period (January 2013 through June 2013). Personal and medical data including age, BMI, gravidity and parity, and previous history of Pipelle biopsy were abstracted from medical records for each patient. Logistic regression analyses were used to determine factors associated with biopsy sampling failure. RESULTS Pipelle biopsy sampling failed in 46 out 201 women (22.89%), where 8 (17.39%) were due to inability to access the endometrium, 37 (80.43%) were inadequate samples, and 1 (2.18%) was due to unknown reasons. Personal and medical factors found to be related to sampling failure included: postmenopausal bleeding as biopsy indication (OR 7.41, 95% CI 2.27-24.14); history of prior biopsy failure (OR 23.87, 95% CI 3.76-151.61); and provider type (physician vs. midlevel provider) (OR 9.152, 95% CI 2.49-33.69). CONCLUSION We identified several risk factors for biopsy failure that suggest the need for particular care with Pipelle sampling procedures among women with certain characteristics, including postmenopausal bleeding and a history of prior failed Pipelle biopsy. Our finding of a significantly higher risk of sampling failure based on personal and clinical data suggests that providers must take into account additional considerations to improve sampling success.

Uterine-sparing Laparoscopic Resection of Accessory Cavitated Uterine Masses

STUDY OBJECTIVE To demonstrate surgical techniques utilized during uterine-sparing laparoscopic resections of accessory cavitated uterine masses (ACUMs). ACUMs represent a rare uterine entity observed in premenopausal women suffering from dysmenorrhea and recurrent pelvic pain. The diagnosis is made when an isolated extra-cavitated uterine mass is resected from an otherwise normal appearing uterus with unremarkable endometrial lumen and adnexal structures. Pathologic confirmation requires an accessory cavity lined with endometrial epithelium (and corresponding glands and stroma) filled with chocolate-brown fluid. Adenomyosis must be absent. Although the origin of ACUMs is currently unknown, the most common presentation is a 2-4 cm lateral uterine wall mass at the level of the insertion of the round ligament. Hence it has been hypothesized that gubernaculum dysfunction may be responsible for duplication or persistence of paramesonephric tissue leading to ACUM formation as a new Müllerian anomaly. DESIGN A stepwise surgical tutorial describing 2 laparoscopic ACUM resections using a narrated video (Canadian Task Force classification III). SETTING An academic tertiary care hospital. PATIENTS In this video, we present 2 patients who underwent uterine-sparing laparoscopic resections of their ACUM in order to preserve fertility (Case 1) or avoid the complications and surgical recovery time of a total laparoscopic hysterectomy (Case 2). Case 1 is a 19-year-old, gravida 0, para 0 woman with dysmenorrhea and recurrent pelvic pain who presented for multiple emergency room and outpatient evaluations. Transvaginal ultrasonography was unremarkable except for a 28×30×26mm left lateral uterine mass with peripheral vascular flow that was initially felt to be a leiomyoma or rudimentary uterine horn. MRI imaging, however, demonstrated this mass to be more consistent with an ACUM. This was based on the lack of communication between the lesion and the main uterine cavity exhibited by high T2 signal (compatible with endometrial tissue) surrounding low T2/high T1 signal in the dependent aspects (representing blood products). After counseling regarding treatment options including medical management with hormonal contraception, the patient elected for definitive fertility preserving laparoscopic resection. In contrast, case 2 is a 39-year-old, gravida 3, para 3 woman with a 2 month history or left lower quadrant pain following her last vaginal delivery. Transvaginal ultrasonography showed a 23×18×19mm cystic structure within the left uterine wall, which was confirmed to represent an ACUM on MRI. Although she had no desire for fertility preservation, the patient elected for surgical resection of the mass as opposed to a hysterectomy in order to minimize complications and recovery time. INTERVENTIONS Laparoscopic resection of ACUMs in patients desiring uterine preservation. MEASUREMENTS AND MAIN RESULTS Laparoscopic resection of the ACUMs was performed utilizing 2 different techniques. In both cases, dilute vasopressin was injected with a modified butterfly or spinal needle along the uterine-ACUM serosal interphase to aid with hemostasis. In patients desiring to preserve fertility (case 1) monopolar energy is utilized to make an incision along the ACUM serosa to help facilitate dissection. ACUM enucleation is then commenced in a circumferential manner along the ACUM and uterine myometrial interphase utilizing bipolar energy. In contrast to leiomyomas where dissection advances along the pseudocapsule, ACUM have poorly delineated borders with disorganized muscular fibers making dissection particularly difficult. A variety of instruments can be utilized to help in the sequential circumferential dissection in addition to a bipolar device including a single-tooth tenaculum, myoma hook, suction device or fine-needle grasper. Ultimately, the ACUM is transected off its uterine-myometrial attachment and hemostasis is obtain before closing the uterine defect in at least 2 layers using a 2-0 barbed V-Loc (Medtronic, Minneapolis, MN). If fertility preservation is no longer desired, the dissection can greatly be expedited by performing a salpingectomy and skeletonizing the ACUM from the leaves of the broad ligament (case 2). A monopolar L-hook can then be used to transect the ACUM from the remaining uterine body. While difficult, these cases can be completed laparoscopically in approximately 2 hours with minimal blood loss. CONCLUSIONS ACUMs are hypothesized to represent a previously under recognized Müllerian anomaly linked to gubernaculum dysfunction that occurs in premenopausal women with dysmenorrhea and chronic pelvic pain. Uterine and fertility sparing laparoscopic resection is possible but challenging due to poorly defined planes.

Surgical Skills Feedback and myTIPreport

OBJECTIVE To initiate construct validity testing of myTIPreport for procedural skill assessment in a prospective multicenter evaluation study. METHODS Teachers and learners from a convenience-based site selection of obstetrics and gynecology (OBGYN) and female pelvic medicine and reconstructive surgery (FPMRS) training programs performed procedural assessments in myTIPreport. The specifically defined 5-point Dreyfus rating scale describing ability levels from novice to expert was used. Defined as the degree to which a test or measure assesses what it was designed to measure, construct validity of myTIPreport was tested by comparing the medians of procedure-specific overall assessments, by both teachers and learners themselves, of senior learners with junior learners. To minimize type I error, comparisons were performed only when a threshold of 10 or greater feedback encounters per learner group was met. Correlation of teacher assessments and learner self-assessments was examined for myTIPreport. RESULTS From November 2014 to May 2016, 12 OBGYN and 7 FPMRS training programs participated. There were 440 learners and 443 teachers. Feedback was recorded on 5,093 surgical procedures; 4,567 for OBGYN residents and 526 for FPMRS fellows. Each OBGYN procedure had two categories of teacher and learner assessments comparing postgraduate year (PGY)-4 with PGY-1 learner performance. This yielded 48 possible assessment comparisons for the included 24 OBGYN procedures. In all, 28 of these 48 (58%) met the threshold number of observations per learner group. In 28 of these 28 (100%) comparison categories, PGY-4s rated significantly higher than PGY-1s. Similarly, in 16 of 18 (89%) comparison categories meeting inclusion criteria, FPMRS PGY-7s rated significantly higher than FPMRS PGY-5s. Strong correlation was noted of teacher assessments and learner self-assessments in myTIPreport with a Spearman correlation coefficient of 0.89 (P<.001). CONCLUSION As noted for the majority of compared teacher assessments and learner self-assessments, myTIPreport appeared to detect differences between senior and junior learners. These data support the emerging construct validity of myTIPreport for procedural skills assessment.