Oz Harmanli

Massive subcutaneous emphysema in robotic sacrocolpopexy

Robotic sacrocolpopexy may increase insufflation complications including massive subcutaneous emphysema.

Risk of recurrence of anal sphincter lacerations.

OBJECTIVE: To estimate the rate of recurrence of anal sphincter lacerations in subsequent pregnancies and analyze the risk factors associated with recurrent lacerations METHODS: Data were obtained from the Pennsylvania Health Care Cost Containment Council, Division of In-Patient Statistics, regarding all cases of third- and fourth-degree perineal lacerations that occurred during a 2-year period (from January 1990 through December 1991). All subsequent pregnancies in this group of women over the next 10 years were identified, and the rate of recurrence of sphincter tears and risk factors for recurrence were analyzed. RESULTS: The rate of anal sphincter lacerations was 7.31% (n = 18,888) during the first 2 years of study (1990–1991). In the next 10 years, these patients with prior lacerations were delivered of 16,152 pregnancies. Of these, 1,162 were by cesarean. Among the 14,990 subsequent vaginal deliveries, 864 (5.76%) had a recurrence of a third- or fourth-degree laceration. Women with prior fourth-degree lacerations had a much higher rate of recurrence than those with prior third-degree laceration (7.73% versus 4.69%). The rate for recurrent lacerations was significantly lower than the rate for initial lacerations (odds ratio 1.29, 95% confidence interval [CI] 1.2–1.4). Forceps delivery with episiotomy had the highest risk for recurrent laceration (17.7%, odds ratio 3.6, 95% CI 2.6–5.1), whereas vacuum use without episiotomy had the lowest risk (5.88%, odds ratio 1.0, 95% CI 0.6–1.7). CONCLUSION: Prior anal sphincter laceration does not appear to be a significant risk factor for recurrence of laceration. Operative vaginal delivery, particularly with episiotomy, increases the risk of recurrent laceration as it does for initial laceration. LEVEL OF EVIDENCE: III

BMI and Uterine Size: Is There Any Relationship?

To evaluate the influence of BMI on the prevalence of fibroids and uterine weight. Uterine pathology specimens of all the women who underwent hysterectomy for benign indications from 1995 to 2002 were studied. Patient characteristics such as age, race, body mass index (BMI), and parity were collected by chart review. The data were statistically analyzed using a 1-way analysis of variance and regression analysis. Uterine weight and fibroids were the dependent variables and BMI, age, and parity were the independent variables. The correlation between BMI and the presence/number of fibroids and their size was also studied. Among the 873 patients who underwent hysterectomy for benign indications, 47.1% were obese and these women had the highest mean uterine weight of 349.53 g. Overall, BMI had a significant correlation with the uterine size (P<0.0001). For every 1-point increase in BMI, uterine weight increased by 7.56 g. BMI positively correlated with uterine size both in the women with fibroids (P=0.038) and in those without fibroids (P=0.016). After controlling for fibroids, every 1-point increase in BMI resulted in an increase of 4.56 g in uterine weight (P<0.0001). In addition, there was a significant correlation between BMI and the presence of fibroids (P<0.0001), but not with the size of fibroids (P=0.11). A significant correlation was found between BMI and uterine weight in all the women, independent of age and parity. For every 1-point increase in BMI, there was a 7.56 g increase in uterine weight. This association needs to be further assessed in healthy women without uterine pathology.

Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology.

Vaginal hysterectomy fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Despite proven safety and effectiveness, the vaginal approach for hysterectomy has been and remains underused in surgical practice. Factors associated with underuse of vaginal hysterectomy include challenges during residency training, decreasing case numbers among practicing gynecologists, and lack of awareness of evidence supporting vaginal hysterectomy. Strategies to improve resident training and promote collaboration and referral among practicing physicians and increasing awareness of evidence supporting vaginal hysterectomy can improve the primary use of this hysterectomy approach.

Using lubricant for speculum insertion.

Speculum insertion can be associated with considerable discomfort during routine pelvic examination. Physiologically, vaginal entry requires lubrication. However, traditional teaching recommends, if anything, warm water only for lubrication, because lubricants are believed to interfere with Pap and infection tests. There is level I evidence that modest lubrication of the external surface of the speculum does not impair cytologic and infectious evaluation of the cervix. This should be reflected in contemporary teaching and guidelines.

POP-Q 2.0: its time has come!

The Pelvic Organ Prolapse Quantification (POP-Q) system has been critical in the growth of the urogynecology field. It is time to revise the POPQ to make it simpler, more intuitive, more precise, less arbitrary, and more practical.

Asymptomatic microscopic hematuria in women requires separate guidelines

The guidelines recently updated by the American Urological Association for the evaluation of asymptomatic microscopic hematuria (AMH) are based on data derived predominantly from men. They cannot be reliably applied to females as the epidemiology of AMH is gender dependent. The research on women in this area has been limited. It is incumbent on the experts in the field of female pelvic medicine to advance the science and develop management algorithms for AMH in women.

Obstetrician-gynecologists' opinions on elective bilateral oophorectomy at the time of hysterectomy in the United States: a nationwide survey.

ObjectiveThis study aims to assess obstetrician-gynecologists’ opinions on elective bilateral oophorectomy (BO) at the time of hysterectomy in the United States and to describe factors that influence their views. MethodsIn April 2012, an anonymous survey was mailed twice to practicing obstetrician-gynecologists, randomly selected from a list produced by the American Medical Association, in an effort to assess their opinions regarding elective BO at the time of hysterectomy. The effects of gynecologists’ various characteristics on their opinions were also evaluated. ResultsOf 1,002 mailed surveys, 443 (44%) were returned completed. Of the respondents, 59% were male and 79% were white. The largest age group was 51 to 55 years (20%), and the mean time since completion of residency was 23 years. In women with an average risk of ovarian cancer, the proportions of physicians who favored elective BO were as follows: women younger than 51 years, 32%; women aged 51 to 65 years, 62%; women older than 65 years, 6%. These recommendations were not influenced by the physicians’ age, sex, training, or geographic region. If a hysterectomy candidate was younger than 51 years and had a personal history of breast or ovarian cancer and a family history of ovarian cancer, these proportions were increased to 77% and 64%, respectively. Other factors that influenced the respondents’ recommendations were the women’s personal history of cardiovascular disease (21%), osteoporosis (23%), and sexual dysfunction (23%). ConclusionsOne third of obstetrician-gynecologists continue to recommend elective BO for hysterectomy candidates younger than 51 years. The majority recommend elective BO for women aged 51 to 65 years. Their demographic characteristics do not influence their opinions.

Vaginal Hysterectomy for Treatment of Cervical Ectopic Pregnancy.

BACKGROUND Cervical ectopic pregnancy can lead to catastrophic hemorrhage, and may be managed conservatively with intra-amniotic methotrexate (MTX), systemic MTX, or both; surgical evacuation with or without balloon tamponade; and uterine artery embolization. However, some patients require hysterectomy, which has traditionally been performed abdominally. CASE A 39-year-old parous woman was diagnosed with cervical ectopic pregnancy at an estimated 7 1/7 weeks of gestation. Her β-hCG level remained at 29,433 milli-international units/mL, and the gestational sac persisted on ultrasonography after first intra-amniotic then multidose systemic MTX treatment. After a review of other fertility-sparing procedures, she chose definitive treatment with hysterectomy because she did not desire future childbearing. She underwent a successful vaginal hysterectomy, a novel approach for this condition. CONCLUSION Vaginal hysterectomy can be performed successfully for treatment of cervical ectopic pregnancy in patients who have completed childbearing and for whom conservative treatment has failed.

Minimally Invasive Diagnosis and Treatment of Endometrial Cancer After LeFort Colpocleisis

Background Endometrial carcinoma is rare after LeFort colpocleisis. Standards for its diagnosis and treatment have not been established. Case A 74-year-old woman presented with postmenopausal bleeding 14 months after LeFort colpocleisis. Here, we describe the use of the colpocleisis channels in our novel 2-stage approach. In the first stage, endometrial carcinoma was diagnosed with vaginohysteroscopy and dilatation and curettage via the channels. In the second stage, the cancer was optimally treated with total robotic hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection. Assistance and specimen retrieval were achieved through the vaginal channels. The patient recovered without compromise to the pelvic floor. Conclusions Endometrial cancer after LeFort colpocleisis can be diagnosed and treated with minimally invasive approaches without disrupting the colpocleisis or the pelvic floor support.