Peter C. Jeppson

Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared With Laparoscopy and Laparotomy

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.

Mesh Sacrocolpopexy Compared With Native Tissue Vaginal Repair: A Systematic Review and Meta-analysis

OBJECTIVE: To systematically review outcomes after mesh sacrocolpopexy compared with native tissue vaginal repairs in women with apical prolapse. DATA SOURCES: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through June 4, 2012. METHODS OF STUDY SELECTION: For anatomic and functional analyses, we included studies comparing mesh sacrocolpopexy to native tissue vaginal repairs with at least 6 months follow-up. The primary outcome was anatomic “success” after surgery. Secondary outcomes were reoperation and symptom outcomes. We included large case series and comparative studies with shorter follow-up to increase power for adverse event analyses. TABULATION, INTEGRATION, AND RESULTS: Evidence quality was assessed with the Grades for Recommendation, Assessment, Development and Evaluation system. Meta-analyses were performed when at least three studies reported the same outcome. We included 13 comparative studies for anatomic success, reoperation, and symptom outcomes. Moderate-quality evidence supports improved anatomic outcomes after mesh sacrocolpopexy; very low-quality evidence shows no differences in reoperation between sacrocolpopexy and native tissue vaginal repairs. Evidence was insufficient regarding which procedures result in improved bladder or bowel symptoms. Low-quality evidence showed no differences in postoperative sexual function. Adverse event data were compiled and meta-analyzed from 79 studies. When including larger noncomparative studies, ileus or small bowel obstruction (2.7% compared with 0.2%, P<.01), mesh or suture complications (4.2% compared with 0.4%, P<.01), and thromboembolic phenomena (0.6% compared with 0.1%, P=.03) were more common after mesh sacrocolpopexy compared with native tissue vaginal repairs. CONCLUSION: When anatomic durability is a priority, we suggest that mesh sacrocolpopexy may be the preferred surgical option. When minimizing adverse events or reoperation is the priority, there is no strong evidence supporting one approach over the other.

Salpingo-oophorectomy at the Time of Benign Hysterectomy: A Systematic Review.

OBJECTIVE: To compare the long-term risks associated with salpingo-oophorectomy with ovarian conservation at the time of benign hysterectomy. DATA SOURCES: MEDLINE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials were searched from inception to January 30, 2015. We included prospective and retrospective comparative studies of women with benign hysterectomy who had either bilateral salpingo-oophorectomy (BSO) or conservation of one or both ovaries. METHODS OF STUDY SELECTION: Reviewers double-screened 5,568 citations and extracted eligible studies into customized forms. Twenty-six comparative studies met inclusion criteria. Studies were assessed for results, quality, and strength of evidence. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant, intervention, comparator, and outcomes data. When compared with hysterectomy with BSO, prevalence of reoperation and ovarian cancer was higher in women with ovarian conservation (ovarian cancer risk of 0.14–0.7% compared with 0.02–0.04% among those with BSO). Hysterectomy with BSO was associated with a lower incidence of breast and total cancer, but no difference in the incidence of cancer mortality was found when compared with ovarian conservation. All-cause mortality was higher in women younger than age 45 years at the time of BSO who were not treated with estrogen replacement therapy (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.04–1.92). Coronary heart disease (HR 1.26, 95% CI 1.04–1.54) and cardiovascular death were higher among women with BSO (HR 1.84, 95% CI 1.27–2.68), especially women younger than 45 years who were not treated with estrogen. Finally, there was an increase in the prevalence of dementia and Parkinson disease among women with BSO compared with conservation, especially in women younger than age 50 years. Clinical practice guidelines were devised based on these results. CONCLUSION: Bilateral salpingo-oophorectomy offers the advantage of effectively eliminating the risk of ovarian cancer and reoperation but can be detrimental to other aspects of health, especially among women younger than age 45 years.

Multivalvular bacterial endocarditis after suction curettage abortion

BACKGROUND: Bacterial endocarditis is a potentially life-threatening disease associated with significant morbidity and mortality. It is estimated that one patient per 1 million will develop endocarditis after elective abortion. CASE: A young woman with no history of cardiac defects developed acute bacterial endocarditis after elective abortion performed without appropriately timed antibiotic prophylaxis. She subsequently required surgical debridement of the tricuspid valve and replacement of the aortic valve. She experienced numerous postoperative sequelae eventually culminating in death. CONCLUSION: Although rare, it is possible to develop multivalvular, right-sided and left-sided endocarditis after elective pregnancy termination in a patient without preexisting cardiac disease. This patient should have received antibiotic prophylaxis before initiation of the suction curettage.

Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines

Objective The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy. Data Sources Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. Study Eligibility We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication. Study Appraisal and Synthesis Methods Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type. Results Eighty‐four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage. Conclusion Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.

Hysterectomy for pelvic organ prolapse: indications and techniques.

Pelvic organ prolapse (POP) is the third most common indication for hysterectomy. Although the techniques for hysterectomy do not differ for prolapsed versus nonprolapsed uteri, there are special considerations when performing a hysterectomy for POP. It is important to remember that a hysterectomy is not sufficient treatment for POP; subsequently after the uterus is removed attention should be paid to correcting the vaginal prolapse. A midurethral sling should be considered for all patients undergoing vaginal prolapse surgery to prevent or treat urinary incontinence.

Current Diagnosis and Management of Pelvic Fistulae in Women

Pelvic fistulae are an abnormal communication among the genitourinary tract, the gastrointestinal tract, and the vagina or perineum. Genital tract fistulae have been described in the medical literature for the past several thousand years. Advancements in both the diagnosis and treatment of vaginal fistulae have been obtained over the past century as surgical interventions have become safer and surgical techniques have improved. The most common cause of fistulae worldwide is obstructed labor. In developed countries, fistulae most commonly occur after benign gynecologic surgery, but obstructed labor, malignancy, radiation exposure, and inflammatory bowel disease can also cause fistulae. Fistulae significantly affect quality of life. Diagnostic studies and radiologic imaging can help aid the diagnosis, but a thorough physical examination is the most important component in the evaluation and diagnosis of a fistula. Temporizing treatments are available to help ease patient suffering until surgical management can be performed. Surgical repairs can be performed using an abdominal, vaginal, or transanal approach. Although technically challenging, surgical repair is usually successful, but closure of the fistula tract does not guarantee continence of urine or feces, because there is often underlying damage to the bowel and bladder.

Comparison of Perioperative Complications by Route of Hysterectomy Performed for Benign Conditions.

Objective The aim of this study was to compare perioperative complications by route of hysterectomy before and after the introduction of robotic surgery. Methods This is an ancillary analysis of a multicenter, retrospective cohort study with historical controls through the Fellows’ Pelvic Research Network. Hysterectomies performed for benign conditions were collected prior to introduction of the robot (prerobot) and the year after introduction of the robot (postrobot) at each institution. To obtain a representative annual case distribution for each institution, a maximum of 20 cases per month were selected using stratified random sampling. Patient demographics and intraoperative and postoperative complication data were collected. Results One thousand four hundred forty cases were included in this study, 732 in the prerobot and 708 in the postrobot period. Intraoperative complications in the prerobot group were highest in the abdominal group (7.4%) followed by vaginal (3.9%) and laparoscopic (3.7%) groups. Postoperative complications were higher in the vaginal (8.3%) and abdominal (7.4%) groups compared with laparoscopic (1.8%) groups (P = 0.03), because of a higher proportion of infections. In the postrobot period, intraoperative complications were lower in the vaginal (2.8%), robotic (3%), and laparoscopic (4.6%) groups compared with abdominal (10.8%) (P = 0.04). Postoperative complications were lowest in the vaginal (5.1%), laparoscopic (3.6%), and robotic (3%) approaches compared with the abdominal (13.9%) approach (P = 0.003). Conclusions Vaginal hysterectomy has comparable rates of perioperative complications when compared with robotic and laparoscopic approaches and should be considered as a primary surgical approach in the growing armamentarium of minimally invasive approaches for hysterectomy for benign conditions.

Accuracy of the digital anal examination in women with fecal incontinence

Introduction and hypothesisThis study aims to determine the accuracy of digital rectal examination (DRE) to detect anal sphincter defects when compared to endoanal ultrasound (US) in women with fecal incontinence (FI).MethodsSeventy-four patients identified by retrospective chart review who presented with complaints of bothersome FI who underwent endoanal US are the subjects of this analysis. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for the ability of the DRE to detect anal sphincter defects.ResultsAnal sphincter defect was suspected on DRE in 75%. At endoanal US, external sphincter defects were noted in all three segments in 41% (complete defect) while partial defects were noted in 30%. DRE demonstrated a sensitivity of 82%, specificity of 32%, +likelihood ratio 1.2 (95% confidence interval (CI), 0.95–1.16) and −likelihood ratio of 0.6 (95% CI, 0.2–1.24) for detecting a complete EAS defect on endoanal US.ConclusionDRE has poor specificity for detecting anal sphincter defects seen on endoanal US.

Autologous graft for treatment of midurethral sling exposure without mesh excision.

BACKGROUND: The midurethral sling is an effective treatment for stress urinary incontinence. Mesh exposure is a known complication of this procedure, with an associated rate of approximately 4%. Other than sling excision, there is minimal information on other options that may help to preserve an effective sling when an exposure has occurred. CASE: A patient presented with a mesh exposure 9 weeks after a retropubic midurethral sling. Conservative treatment with vaginal estrogen failed, as did primary reclosure in the operating room. She was then successfully treated with a full-thickness autologous vaginal epithelium graft. CONCLUSION: We report an alternative surgical option to mesh excision, which may help preserve an otherwise effective midurethral sling complicated by mesh exposure.