Niraj Chavan

Trendelenburg Position in Gynecologic Robotic-Assisted Surgery

OBJECTIVE To estimate the necessity of routine patient positioning in steep Trendelenburg in robotic-assisted gynecologic surgery performed for benign indications. DESIGN Descriptive study (Canadian Task Force classification II-2). SETTING University-affiliated community hospital. PATIENTS Twenty women undergoing robotic-assisted gynecologic surgery for benign indications. INTERVENTION Robotic-assisted total hysterectomy, supracervical hysterectomy, myomectomy, and sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS Demographic data and perioperative variables were recorded including age, body mass index, procedure type, console time, perioperative complications, estimated blood loss, hospital length of stay, and degree of Trendelenburg position. The degree of Trendelenburg position was measured at the end of each procedure using an electronic level. The surgeons were blinded to the degree of Trendelenburg used. All procedures were performed successfully without conversion to laparotomy. All patients were discharged to home within 24 hours. No perioperative complications were noted. The mean (SD; 95% CI) Trendelenburg position used in this cohort was 16.4 (4.1; 14.4-18.3) degrees. Patient body mass index was 28.5 (5.3; 26.1-31.1). Median console time was 87.5 (27-112) minutes. CONCLUSION Robotic-assisted benign gynecologic surgery can be effectively performed without use of the steep Trendelenburg position. The practice of routine adherence to steep Trendelenburg positioning in benign gynecologic robotic surgery should be questioned.

Minimally Invasive Hysterectomies—A Survey on Attitudes and Barriers among Practicing Gynecologists

STUDY OBJECTIVE To explore attitudes and hysterectomy practices among gynecologists in the United States and to identify potential barriers to offering minimally invasive hysterectomies. DESIGN Mixed-mode (online and on-paper) survey of a random sample of 1500 practicing obstetrician-gynecologists. SETTING Nationwide survey in the United States. PARTICIPANTS Nonretired obstetrician-gynecologists identified through a physician list from the American Medical Association. INTERVENTIONS Postal and online survey. MEASUREMENTS & MAIN RESULTS: We received a response from 376 physicians (25.8% response rate). The average age of respondents was 47.9 years, and 87% were generalists. Participants performed on average 4 surgical cases per week and 32 hysterectomies per year, most of which were abdominal hysterectomies. When asked for preferred mode of access for themselves or their spouse, 55.5% chose vaginal hysterectomy (VH), 40.6% chose laparoscopic hysterectomy (LH), and 8% chose abdominal hysterectomy (AH). Younger physicians (<40) and high surgical volume physicians were significantly more likely to chose a laparoscopic approach and identified significantly fewer barriers for performing LH. The main barriers to performing VH were technical difficulty, potential for complications, and caseload of VH. The main barriers for performing LH were training during residency, technical difficulty, personal surgical experience and operating time. The majority of gynecologists wanted to decrease their AH rates and increase their LH rates. The most significant identified contraindications to VH were prior laparotomy, a uterus larger than 12 weeks, narrow introitus, adnexal mass, and minimal uterine descent. CONCLUSIONS While a large majority of gynecologists would prefer a VH or LH for themselves or their spouse, AH remains the most common hysterectomy method in the United States. A generation gap appears to be brewing with younger gynecologist more in favor of the laparoscopic approach. More emphasis should be placed on training gynecologists in performing minimally invasive hysterectomies, given their desire to change their surgical mode of access.

Use of Bidirectional Barbed Suture in Laparoscopic Myomectomy: Evaluation of Perioperative Outcomes, Safety, and Efficacy

STUDY OBJECTIVE To compare perioperative outcomes during laparoscopic myomectomy using a bidirectional barbed suture vs conventional smooth suture. DESIGN Retrospective analysis of 138 consecutive laparoscopic myomectomies performed by a single surgeon over 3 years (Canadian Task Force classification II-2). SETTING Major university teaching hospital. PATIENTS One hundred thirty-eight women with symptomatic uterine myomas. INTERVENTIONS In women undergoing laparoscopic myomectomy from February 2007 through April 2010, conventional smooth sutures were used in 31 patients, and bidirectional barbed suture in 107 patients. MEASUREMENTS AND MAIN RESULTS The primary indications for laparoscopic myomectomy in either group were pelvic pain or pressure and abnormal uterine bleeding. Use of bidirectional barbed suture was found to significantly shorten the mean (SD) duration of surgery (118 [53] minutes vs 162 [69] minutes; p <.05) and reduce the duration of hospital stay (0.58 [0.46] days vs 0.97 [0.45] days; p <.05). No significant differences were observed between the 2 groups insofar as incidence of perioperative complications, estimated blood loss, and number or weight of myomas removed during surgery. CONCLUSION Use of bidirectional barbed suture seems to facilitate closure of the hysterotomy site in laparoscopic myomectomy.

Bidirectional barbed suture: an evaluation of safety and clinical outcomes.

The use of bidirectional barbed suture appears to be safe for closing the vaginal cuff in a total laparoscopic hysterectomy and for closing the hysterotomy site during laparoscopic myomectomy.

The impact of surgeon volume on perioperative outcomes in hysterectomy.

Background and Objectives: To estimate the effect of surgeon volume on key perioperative outcomes after all modes of hysterectomy. Methods: We performed a review of 1914 hysterectomies performed at a large, academic tertiary-care hospital. Women who underwent abdominal, laparoscopic, vaginal, or robotic hysterectomy for benign non-obstetric indications in 2006, 2009, and 2010 were included. Results: Gynecologic surgeons were categorized according their average annual hysterectomy case volume: low volume (<11 cases per year), intermediate volume (11–50 cases per year), and high-volume (>51 cases per year). Taking all modes of hysterectomy together, surgeries performed by high-volume surgeons required a shorter operative time (155.11 minutes vs 199.19–203.35 minutes, P < .001) and resulted in less estimated blood loss compared with low- and intermediate-volume surgeons (161.09 mL vs 205.58–237.96 mL, P < .001). The 3 surgical volume groups did not differ from each other significantly in the conversion to laparotomy, readmission rate, or incidence of intraoperative or postoperative complications. These findings were maintained when subgroup analyses were performed by type of hysterectomy, with few exceptions. In the subgroup of vaginal hysterectomies by intermediate-volume surgeons, there were slightly more postoperative complications. There were fewer intraoperative complications in laparoscopic/robotic hysterectomies performed by high-volume surgeons, though not statistically significant. Conclusions: Hysterectomies performed by high-volume surgeons at our institution during the 3-year study period were associated with shorter operative times and less estimated blood loss.

Type of High-School Credentials and Older Age ADL and IADL Limitations: Is the GED Credential Equivalent to a Diploma?

PURPOSE Educational attainment is a robust predictor of disability in elderly Americans: older adults with high-school (HS) diplomas have substantially lower disability than individuals who did not complete HS. General Educational Development (GED) diplomas now comprise almost 20% of new HS credentials issued annually in the United States but it is unknown whether the apparent health advantages of HS diplomas extend to GED credentials. This study examines whether adults older than 50 years with GEDs have higher odds of incident instrumental or basic activities of daily living (IADLs) limitations compared with HS degree holders. METHODS We compared odds of incident IADL limitations by HS credential type using discrete-time survival models among 9,426 Health and Retirement Study participants followed from 1998 through 2008. RESULTS HS degree holders had lower odds of incident IADLs than GED holders (OR = 0.72, 95% CI = 0.58, 0.90 and OR = 0.69, 95% CI = 0.56, 0.86 for ADLs and IADLs, respectively). There was no significant difference in odds of incident IADL limitations between GED holders and respondents without HS credentials (OR = 0.89, 95% CI = 0.71, 1.11 for ADLs; OR = 0.88, 95% CI = 0.70, 1.12 for IADLs). IMPLICATIONS Although GEDs are widely accepted as equivalent to high school diplomas, they are not associated with comparable health advantages for physical limitations in older age.

Laparoscopic-Assisted Vaginal Hysterectomy vs Laparoscopic Supracervical Hysterectomy for Treatment of Nonprolapsed Uterus

STUDY OBJECTIVE To compare perioperative outcomes between laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopic supracervical hysterectomy (LSH) for the nonprolapsed uterus. DESIGN Retrospective chart analysis (Canadian Task Force classification II-2). SETTING Three university-affiliated community hospitals. PATIENTS Women undergoing LAVH or LSH because of benign indications without concomitant pelvic organ prolapse. INTERVENTION Laparoscopic hysterectomy with or without adnexectomy. MEASUREMENTS AND MAIN RESULTS Data from 265 LAVH procedures and 181 LSH procedures performed at 3 university-affiliated community hospitals were included in the analysis from January 2001 to December 2007. The cases were successive. Exclusion criteria included surgery performed to treat malignancy or pelvic organ prolapse, and procedures that were converted to laparotomy. Two hundred forty-eight LAVH procedures and 173 LSH procedures were completed successfully. There was no significant difference in mean (SD) operating time between the 2 groups (145.1 [45.6] minutes for LAVH vs 143 [51.7] minutes for LSH; p = .66). Hospital stay was significantly shorter in the LSH group (1.6 [0.6] days vs 1.2 [0.5] days; p = .001). Patients in the LAVH group had significantly larger uterine weight (147.7 [84.8] g vs 121.5 [105.5] g; p = .005). Postoperative hemoglobin change and febrile morbidity were similar between the groups, as were overall perioperative complications (19% vs 15%, respectively; p = .36) and conversion rate to laparotomy (6.9% vs 4.6%; p = .27). CONCLUSION Compared with LAVH, LSH offers the benefits of a shorter hospital stay when performed in patients without uterine prolapse. Other perioperative outcomes studied were not significantly different between groups.

Detection rate of prostate cancer using prostate specific antigen in patients presenting with lower urinary tract symptoms: a retrospective study.

BACKGROUND Need for undertaking prostate biopsies for detection of prostate cancer is often decided on the basis of serum levels of prostate specific antigen (PSA). AIM To evaluate the case detection rate of prostate cancer among patients presenting with lower urinary tract symptoms (LUTS) on the basis of PSA levels and to assess the scope of prostate biopsy in these patients. SETTING AND DESIGN A retrospective study from a tertiary care center. MATERIALS AND METHODS The clinical and histopathological data of 922 patients presenting with LUTS in the last five years was obtained from the medical record section. They had been screened for prostate cancer using PSA and /or digital rectal examination examination followed by confirmation with prostate biopsy. STATISTICAL ANALYSIS USED Detection rate and receiver operating characteristic curve were performed using SPSS 16 and Medcalc softwares. RESULTS The detection rate of prostate cancer according to the PSA levels was 0.6%, 2.3%, 2.5%, 34.1% and 54.9% in the PSA range of 0-4, 4-10, 10-20, 20-50 and> 50 ng/ml, respectively. Maximum prostate cancer cases were detected beyond a PSA value of 20 ng/ml whereas no significant difference in the detection rate was observed in the PSA range of 0-4, 4-10 and 10-20 ng/ml. CONCLUSION A low detection rate of prostate cancer observed in the PSA range of 4-20 ng/ml in LUTS patients indicates the need for use of higher cutoff values of PSA in such cases. Therefore we recommend a cutoff of 20 ng/ml of PSA for evaluation of detection rate of prostate cancer among patients presenting with LUTS.

Maternal smoking during pregnancy is associated with mitochondrial DNA methylation

Abstract Maternal smoking during pregnancy (MSDP) has detrimental effects on fetal development and on the health of the offspring into adulthood. Energy homeostasis through ATP production via the mitochondria (mt) plays a key role during pregnancy. This study aimed to determine if MSDP resulted in differences in DNA methylation to the placental mitochondrial chromosome at the transcription and replication control region, the D-Loop, and if these differences were also present in an alternate neonatal tissue (foreskin) in an independent birth cohort. We investigated mtDNA methylation by bisulfite-pyrosequencing in two sections of the D-Loop control region and in long interspersed nuclear element-1 (LINE-1) genomic sequences in placenta from 96 mother–newborn pairs that were enrolled in a Rhode Island birth cohort along with foreskin samples from 62 infants from a Kentucky birth cohort. In both placenta and foreskin, mtDNA methylation in the light chain D-Loop region 1 was positively associated with MSDP in placenta (difference +2.73%) ( P  = 0.001) and foreskin (difference + 1.22%) ( P  = 0.08). Additionally, in foreskin, a second segment of the D-Loop-heavy chain region 1 showed a small but significant change in methylation with MSDP (+ 0.4%, P  = 0.04). No methylation changes were noted in either tissue at the LINE-1 repetitive element. We identified a similar pattern of epigenetic effect to mitochondria arising in cells from different primordial lineages and in different populations, associated with MSDP. These robust and consistent results build evidence that MSDP may impact mt D-Loop methylation, as one mechanism through which this exposure affects newborn health.

Impact of Pre-Pregnancy Body Mass Index and Gestational Weight Gain on Preterm Birth [6A]

INTRODUCTION:This study was undertaken to evaluate the differential impact of pre-pregnancy body mass index (PPBMI) and gestational weight gain (GWG) on preterm birth (PTB).METHODS:Vital statistics (birth) data collected by the National Center for Health Statistics (NCHS) was utilized. Using the 201