Journal of minimally invasive gynecology最新文献

Objective: To investigate the positioning of deep epigastric vessels in obese patients to determine the need to redefine laparoscopic port placement 'safe zones' based on body habitus.

Design: Retrospective case series.

Setting: University-affiliated 500-bed hospital.

Participants: One hundred ninety-four male and female subjects who underwent abdominal and pelvic computed tomography (CT) scans with contrast, stratified by body mass index (BMI) per World Health Organization (WHO) criteria. Patients < 18 years of age and those with conditions potentially altering epigastric vessel locations were excluded.

Interventions: N/A RESULTS: The location of the right and left deep epigastric vessels from the midline at the umbilicus were mapped at 5 levels using CT images with contrast: the xiphoid, midway (M1) between the xiphoid and anterior superior iliac spine (ASIS), the ASIS, midway (M2) between the ASIS and pubic symphysis (PS), and at the PS. Key demographics showed a mean age of 50.2 ± 18.8 with a mean BMI of 30.4 ± 8.6. The mean distance of the deep epigastric vessels from the midline increased significantly at every level when categorized by BMI group. Distances exceeded 8cm at the M1 and ASIS levels for BMI>35 and >40 categories, with values up to 11.3cm in the BMI>40 category. Regression analyses showed a significant positive correlation between BMI and the distance to the midline at all levels except the PS.

Conclusion: The mean distance from the midline to the deep epigastric vessels increases with increasing BMI, indicating lateral displacement of the vessels in obese patients. Our findings suggest positioning ports more than 10cm from the midline in patients with BMI>35 to minimize injury risks. Previously established safe zone mappings of deep epigastric vessels are more applicable to patients with a BMI<35 and can increase the risk of vessel injury in patients with a BMI>35.

Objective: This study aims to perform a systematic review and meta-analysis to compare the incidence of specific postoperative urologic complications, such as vesicovaginal fistula and ureterovaginal fistula, in patients undergoing minimally invasive radical hysterectomy (MIRH) vs abdominal radical hysterectomy (ARH) for early-stage cervical cancer.

Data sources: A comprehensive literature search was conducted in PubMed, the Cochrane Library, Web of Science, ScienceDirect, and Google Scholar up to April 2024.

Method: Comparative studies evaluating postoperative urologic complications following MIRH and ARH were included. Meta-analyses were conducted using fixed- and random-effects models, with subgroup analyses based on publication year, study quality, BMI, and geographical region.

Tabulation, integration, and results: The meta-analysis included 35 studies. Overall, MIRH (N = 17,957) was associated with a significantly higher odds ratio (OR) of 3.189 (95% CI: 2.637-3.856, p <.001) for postoperative urologic complications compared to ARH (N = 31,878). Ureterovaginal fistula was the most frequently reported complication, with an OR of 4.440 (95% CI: 3.398-5.804, p <.001). Subgroup analysis showed a higher OR for studies published between 2016 and 2024 (OR: 3.637, 95% CI: 2.965-4.462, p <.001) and in low-quality studies (OR: 3.981, 95% CI: 3.237-4.897, p <.001).

Conclusion: MIRH is associated with a higher incidence of postoperative urologic complications compared to ARH, particularly ureterovaginal fistula. These findings underscore the importance of careful patient selection and the potential need for improved surgical techniques or training to reduce these risks. (CRD42024553756).

Study objective: To evaluate the surgical outcomes of hybrid hysterectomy for enlarged uteri, compared to laparoscopic and open approaches.

Design: Matched case-control study SETTING: Tertiary-care academic medical center.

Patients: Patients who underwent hybrid hysterectomy between January 1, 2010, and December 31, 2021, were included. For comparison, a matched case-control approach was used with two propensity score-matched groups: patients who underwent laparoscopic hysterectomy and those who underwent open hysterectomy.

Interventions: Hybrid hysterectomy, laparoscopic hysterectomy, and open hysterectomy.

Measurements and main results: A total of 76 patients underwent hybrid hysterectomy for enlarged uteri that could not be removed intact through a colpotomy. Two comparison groups were identified by propensity-score matching the hybrid cohort to laparoscopic (n=3020) and open cohorts (n=340) based on the following criteria: age, BMI, uterine weight, year of surgery, surgeon type, hysterectomy subtype, and indication for the procedure. Operative time for the hybrid group (152 min) was comparable to the open group (148 min), but longer than the laparoscopic group (112 min, P<0.001). Compared to the hybrid group (with EBL of 50 ml), the open group had a significantly higher median EBL (200 ml, P<0.001), and the laparoscopy group had a significantly lower median EBL (27.5 ml, P=0.015). Median length of hospital stay for the hybrid group (1 day) was shorter than the open group (3 days, P<0.001), and longer than the laparoscopic group (0 days, P<0.001). Postoperative opioid administered to the hybrid group (55.0 MME) was significantly lower than the open group (91.9 MME, P=0.012), and significantly higher than the laparoscopic group (23.6 MME, P<0.001).

Conclusion: Our results indicate an advantage of the hybrid technique over an exclusively open approach when morcellation of the specimen is not appropriate. The hybrid approach is associated with less blood loss, shorter length of hospital stay, and decreased postoperative pain, with comparable operative time, and complication rates compared to the open approach.

Objective: To compare the long-term efficacy of conventional laparoscopic sacrocolpopexy with those of robot-assisted laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse.

Design: Retrospective cohort study.

Setting: Tertiary referral center in China.

Patients: A total of 139 patients -74 having laparoscopic and 65 robotic-assisted sacrocolpopexy between January 2015 and December 2021 were included.

Interventions: Either laparoscopic or robotic-assisted sacrocolpopexy.

Measurements and main results: The median follow-up times of the laparoscopic group and robotic-assisted group were 60 (interquartile range 39-91) and 46 (interquartile range 38-73) months, respectively. Compared with laparoscopy, the robotic-assisted group had a shorter operative time (164 ± 37 minutes vs 186 ± 36 minutes; p = .001) with no clinically meaningful blood loss between the groups (76 ± 32.1 mL vs 87.6 ± 33 mL). Mesh exposure occurred in 3 patients (4.1%) in the laparoscopic and 2 patients (3.1%) in the robotic-assisted group. The composite success rate did not significantly differ between laparoscopic and robotic-assisted groups (89.2% vs 90.8%, p = .757). Kaplan-Meier survival analysis also revealed no significant differences in the overall rates of recurrent pelvic organ prolapse between the two groups (p = .915).

Conclusion: There is no difference in the rates of prolapse recurrence or mesh exposure at nearly 4 years between laparoscopic or robotic-assisted sacrocolpopexy. There was an average 20-minute time saving for robotic-assisted procedures, with no clinically important difference in blood loss between the surgical approaches.

Study objective: To compare outcomes of vaginal surgery in women with moderate or severe symptomatic cesarean scar defect (with or without residual myometrium).

Design: Retrospective cohort study.

Setting: Gynecology department of a teaching hospital.

Patients: Fifty-three women, between January 2014 and December 2019, underwent vaginal surgery for symptomatic cesarean scar defect: 20 women with moderate defect (with residual myometrium) and 33 with severe defect (without residual myometrium).

Interventions: Vaginal surgical approach to repair cesarean scar defect.

Measurements and main results: surgery by comparing the myometrial residual thickness before and after surgery. The secondary objectives were evaluation of vaginal surgery efficacy on symptoms resolution, per and postoperative courses, and subsequent fertility. Failure rate was evaluated as the need for a second surgery. After vaginal surgery, the residual myometrium significantly increased from 2.4 mm ± 0.9 mm to 6.6 mm ± 2.4 mm (p <.01) in the moderate group and from 0 mm to 4.4 mm ± 2.2 mm (p <.01) in the severe group. The prevalence of abnormal uterine bleeding was significantly reduced after surgery in both groups (p <.01). Pelvic pain was significantly reduced only in the moderate group (p <.01). The rate of complications (5% vs 9.1%) and second surgery (15% vs 24.2%) were not significantly different between moderate and severe groups, respectively. The median time to conceive (7 months vs 12 months); pregnancy rates (84.6% vs 68.2%); and live birth rates (76.9% vs 50%) were not statistically significant in the moderate and severe groups respectively, with 90% of pregnancies occurring naturally. Women delivered by cesarean section at 38 weeks of gestation in both groups, and no uterine rupture was reported.

Conclusion: Despite the absence of residual myometrium, vaginal repair of severe cesarean scar defect was effective in increasing myometrial thickness, in relieving bleeding symptoms, and in allowing to achieve pregnancy.

Study objective: The primary objective of this study was to describe vaginal hysterectomy practice patterns as well as facilitators and inhibitors to performing vaginal hysterectomy among gynecologic surgeons. Secondary objectives were to describe facilitators and inhibitors to the teaching and training of vaginal hysterectomy.

Design: Quantitative analysis of an online survey and qualitative analyses of the one-on-one interviews on gynecologic surgeons was conducted. This study was approved by the IRB.

Setting: Online survey and one-on -one virtual interviews.

Participants: Members of the AAGL and the Society of Gynecologic Surgeons INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: A total of 505 gynecologic surgeons completed the survey. Most surgeons were white (66.9%) and had a clinic in North America (67.5%). About 48% of respondents reported "no barrier" to performing vaginal hysterectomies including pathology, visualization and exposure, and performance of concomitant procedures. Higher surgical volume was the only factor most commonly rated by surgeons as enabling teaching of vaginal hysterectomy "quite a bit" (31.3%). Most surgeons agreed that vaginal hysterectomies are important to women's health (82.8%) and that all gynecologic surgeons should be able to perform vaginal hysterectomies (66.3%). In terms of medical education and training, most surgeons thought that residents should be required to achieve competency for vaginal hysterectomy prior to graduation (71.7%) and disagreed (56.0%) that we should eliminate residency graduation requirements for vaginal hysterectomy numbers. From the one-on-one interviews, major themes identified included: Advocacy, Centralizing Efforts, Compensation and Incentives, Cycle of Low Experience, Decreasing Regional Trends, Lack of Industry Support, Transvaginal versus Laparoscopy Culture, Varied Training Targets and Resources, Innovations in Training, and Self-Motivation.

Conclusions: Vaginal hysterectomy remains important to our field. Identified barriers and major themes from this study can direct future efforts to increase its adoption.