Abdominal Gynecologic Procedures in Pancreas Transplant Recipients.

INTRODUCTION: With the growing population of pancreas transplant recipients followed long-term, some female recipients are going to require surgical intervention for gynecologic symptoms and pathologies. Currently, there is a lack of literature describing how to approach this population and whether pelvic gynecologic procedures (GYN) can be performed safely given the proximity of the pancreatic (and possibly renal) allograft. In this single-center retrospective analysis, all pancreas transplant recipients that subsequently underwent GYN were reviewed. METHODS: Subjects were identified by cross-referencing all pancreas transplants performed between January 2003 and December 2022 for any subsequent GYN. Demographics at transplant and GYN, indications and procedure performed, operative time, presence and involvement of a transplant surgeon, complications length of stay, and readmissions were reviewed. RESULTS: Seventeen patients who underwent a total of 19 GYN after pancreas transplantation were identified. Operations performed included tubal ligation (n = 2), total abdominal hysterectomy with (n = 6) or without bilateral salpingectomy (n = 2), oophorectomy versus cyst drainage (n = 2), bilateral oophorectomy (n = 1), and unilateral (n = 4) versus bilateral (n = 2) salpingectomy. Four were performed through an open laparotomy and 15 were performed laparoscopically. In 11 cases, a transplant surgeon was involved intra-operatively. Eight of the 17 patients developed post-operative complications including post-operative fevers, fluid overload, neutropenia, elevated creatinine (n = 2), nephrolithiasis, urinary tract infection, and incisional hernia. Five required readmission. CONCLUSION: GYN can be performed safely following pancreas transplantation, but careful planning and the involvement of the transplant surgery team are advised.

Fear, anxiety, and knowledge levels of women who underwent gynecologic surgery during the COVID-19 pandemic.

OBJECTIVE: The objective of this study was to evaluate the fear, anxiety, and knowledge level in women who underwent gynecological surgical procedures during the COVID-19 pandemic. METHODS: This cross-sectional study was conducted on 188 women who underwent a gynecologic surgical operation in Mugla, Turkey. Data were collected by using demographics and obstetric detail form, questionnaire on knowledge, attitudes, and practice toward COVID-19, and State-Trait Anxiety Inventory-I (STAI-I). RESULTS: Most of the women perceived their surgical process as very urgent. Women felt fear mostly for being infected with the virus, and they were afraid of transmitting COVID-19 to another one. The COVID-19 knowledge scores of women who had undergone cancer surgery were statistically significantly higher than others (p=0.017). The STAI-I scores of women increased as their COVID-19 knowledge scores increased (p<0.05). CONCLUSION: This study demonstrated that women were afraid of COVID-19 infection during gynecological operation and due to hospitalization, sociodemographic characteristics affected the knowledge levels about COVID-19 infection, and the anxiety levels of the women. Planning appropriate interventions to decrease the fear and anxiety of women who undergo gynecological surgery during the pandemic is important to ensure that women adhere to their treatment and follow-up in the postoperative period.

The influence of simultaneous posterior colporrhaphy and perineoplasty on the efficiency and safety of mesh-augmented sacrospinal fixation (apical sling) in advanced POP repair.

BACKGROUND: Pelvic organ prolapse (POP) is one of the most common pathologies of the pelvic floor, and it can be found among 40-60% of women who have given birth. Correction of the defect of the DeLancey level II without reconstruction of the apical defect is doomed to failure. Also, in the structure of pelvic floor defects, there is often an incompetency of the perineal body, as a consequence of traumatic delivery. Perineoplasty is considered to be the main method of correction for perineal body incompetency. However, it is worth mentioning that there are no randomized trials, which estimate the influence of simultaneous correction of the perineal body on the effectiveness of transvaginal apical fixation. METHODS: It is planned to include 310 patients in this trial. Patients who met the inclusion/exclusion criteria will be randomized into 2 groups: 1st group-patients who will undergo mesh-augmented sacrospinal fixation with anterior and posterior colporrhaphy without perineoplasty, 2nd group-patients who will undergo mesh-augmented sacrospinal fixation with anterior and posterior colporrhaphy and perineoplasty. Patients will be called to an appointment 6, 12, and 24 months after discharge. DISCUSSION: The aim of this trial is to evaluate the efficiency and safety of simultaneous perineoplasty on the clinical and anatomical efficacy of mesh-augmented sacrospinal fixation in advanced pelvic organ prolapse repair. Based on previous studies, it was difficult to estimate and comprehend whether colpoperinoplasty actually reduces the risk of prolapse recurrence. TRIAL REGISTRATION: NCT05422209. Registered on 18 May 2022.

Patient positioning in minimally invasive gynecologic surgery: strategies to prevent injuries and improve outcomes.

Effective patient positioning is a critical factor influencing surgical outcomes, mainly in minimally invasive gynecologic surgery (MIGS) where precise positioning facilitates optimal access to the surgical field. This paper provides a comprehensive exploration of the significance of strategic patient placement in MIGS, emphasizing its role in preventing intraoperative injuries and enhancing overall surgical success. The manuscript addresses potential complications arising from suboptimal positioning and highlights the essential key points for appropriate patient positioning during MIGS, encompassing what the surgical team should or shouldn't do. In this perspective, the risk factors associated with nerve injuries, sliding, compartment syndrome, and pressure ulcers are outlined to guide clinical practice. Overall, this paper underscores the critical role of precise patient positioning in achieving successful MIGS procedures and highlights key principles for the gynecological team to ensure optimal patient outcomes.

Comparing Remimazolam and Propofol for Postoperative Anesthesia Satisfaction in Outpatient Gynecological Surgery: A Randomized Clinical Trial.

Purpose: This study aimed to compare the efficacy of remimazolam and propofol regarding postoperative anesthesia satisfaction in patients undergoing outpatient gynecological surgery. Patients and Methods: This was a single-center, open-label, non-inferiority, randomized clinical trial. Patients aged ≥ 18 years who underwent outpatient gynecological surgery with sedation were enrolled. Participants were randomly assigned to be sedated with remimazolam or propofol. The primary endpoint was the immediate postoperative anesthesia satisfaction score, evaluated through the Iowa Satisfaction with Anesthesia Scale (ISAS). Results: 168 patients were randomly allocated to either the remimazolam group (n = 84) or the propofol group (n = 84). The mean (standard deviation) ISAS scores immediately after surgery were 1.7 (0.6) for the remimazolam group and 2.0 (0.7) for the propofol group (difference, -0.2; 97.5% confidence interval [CI]: -0.5 to -0.0; p = 0.02), indicating non-inferiority. The length of post-anesthesia care unit (PACU) stay was longer in the remimazolam group than in the propofol group (27.6 [9.1] min vs 22.4 [7.0] min; difference, 5.2 [95% CI: 2.7 to 7.6] min; p < 0.001). High-intensity injection pain was less frequently observed in the remimazolam group than in the propofol group (3.6% vs 45.2%; difference, -41.7% [95% CI: -54.2% to -29.1%]; p < 0.001). The nausea score was higher in the remimazolam group immediately after surgery than in the propofol group. Pain, nausea, sleep quality, anxiety, and depression scores were higher in the remimazolam group than in the propofol group on postoperative day 1. The incidence of adverse events and other secondary endpoints was comparable between the two groups. Conclusion: Remimazolam was non-inferior to propofol regarding postoperative anesthesia satisfaction in patients undergoing outpatient gynecological surgery. Therefore, it should be considered as a new sedation alternative in such procedures.

How I Do It: EnPlace sacrospinous ligament fixation.

Pelvic organ prolapse (POP) is a common condition that significantly impairs a woman's quality of life.  Currently a range of interventions from non-surgical to surgical options exist, all with their unique advantages and disadvantages.  Among these, the EnPlace system stands out as a truly minimally invasive transvaginal percutaneous device designed to repair apical POP by bilaterally anchoring sutures to the sacrospinous ligaments.  Readers will familiarize themselves with the EnPlace, relevant historical studies, and the technique for EnPlace transvaginal percutaneous sacrospinous ligament fixation for hysteropexy or colposuspension.

New Insights into the Assessment of Peri-Operative Risk in Women Undergoing Surgery for Gynecological Neoplasms: A Call for a New Tool.

Existing tools for predicting postoperative complications in women undergoing surgery for gynecological neoplasms are evaluated in this narrative review. Although surgery is a very efficient therapy for gynecological tumors, it is not devoid of the possibility of negative postoperative outcomes. Widely used tools at present, such as the Surgical Apgar Score and the Modified Frailty Index, fail to consider the complex characteristics of gynecological malignancies and their related risk factors. A thorough search of the PubMed database was conducted for our review, specifically targeting studies that investigate several aspects impacting postoperative outcomes, including nutritional status, obesity, albumin levels, sodium levels, fluid management, and psychological well-being. Research has shown that both malnutrition and obesity have a substantial impact on postoperative mortality and morbidity. Diminished sodium and albumin levels together with compromised psychological well-being can serve as reliable indicators of negative consequences. The role of appropriate fluid management in enhancing patient recovery was also investigated. The evidence indicates that although current mechanisms are useful, they have limitations in terms of their range and do not thoroughly address these recently identified risk factors. Therefore, there is a need for a new, more comprehensive tool that combines these developing elements to more accurately forecast postoperative problems and enhance patient results in gynecological oncology. This paper highlights the need to create such a tool to improve clinical practice and the treatment of patients.

Early prediction of intraoperative hypothermia in patients undergoing gynecological laparoscopic surgery: A retrospective cohort study.

Intraoperative hypothermia is one of the most common adverse events related to surgery, and clinical practice has been severely underestimated. In view of this, this study aims to build a practical intraoperative hypothermia prediction model for clinical decision-making assistance. We retrospectively collected clinical data of patients who underwent gynecological laparoscopic surgery from June 2018 to May 2023, and constructed a multimodal algorithm prediction model based on this data. For the construction of the prediction model, all data are randomly divided into a training queue (70%) and a testing queue (30%), and then 3 types of machine learning algorithms are used, namely: random forest, artificial neural network, and generalized linear regression. The effectiveness evaluation of all predictive models relies on the comprehensive evaluation of the net benefit method using the area under the receiver operating characteristic curve, calibration curve, and decision curve analysis. Finally, 1517 screened patients were filtered and 1429 participants were included for the construction of the predictive model. Among these, anesthesia time, pneumoperitoneum time, pneumoperitoneum flow rate, surgical time, intraoperative infusion, and room temperature were independent risk factors for intraoperative hypothermia and were listed as predictive variables. The random forest model algorithm combines 7 candidate variables to achieve optimal predictive performance in 2 queues, with an area under the curve of 0.893 and 0.887 and a 95% confidence interval of 0.835 to 0.951 and 0.829 to 0.945, respectively. The prediction efficiency of other prediction models is 0.783 and 0.821, with a 95% confidence interval of 0.725 to 0.841 and 0.763 to 0.879, respectively. The intraoperative hypothermia prediction model based on machine learning has satisfactory predictive performance, especially in random forests. This interpretable prediction model helps doctors evaluate the risk of intraoperative hypothermia, optimize clinical decision-making, and improve patient prognosis.

An open comparative randomized prospective study: Direct trocar insertion vs Veress needle technique in laparoscopic surgeries.

Laparoscopy is a minimally invasive technique utilized for both diagnostic and surgical approaches. Minimally invasive procedures compared to laparotomy offer the advantages of reduced hospital stay, lower morbidity, decreased pain, and faster recovery. Common methods for laparoscopic entry include Veress needle insertion (VNI), direct optical trocar entry, direct trocar insertion (DTI), and the Hasson technique. This study aims to compare the efficacy and safety of VNI and DTI in laparoscopic gynecological surgeries. An open comparative randomized prospective study was conducted involving 200 women aged 18 to 70 years, scheduled for laparoscopic surgery at 2 tertiary centers. Participants were randomized into 2 groups: 1 using VNI and other using DTI. The groups were homogeneous regarding age, parity, and body mass index. The mean age of the VNI group is 45.22 ±â€…11.65 and the DTI group is 44.89 ±â€…10.5 (P = .833). There were no statistical significance in terms of the presence of chronic diseases and history of previous abdominal surgery between the groups (P = .802 and P = .510, respectively). Entry time to the abdomen, the decrease in hemoglobin values, and hospitalization length were found to be statistically significant between the entry methods (P < .001, P = .002, and P < .001, respectively). Entry time, the decrease in hemoglobin value, and hospitalization length were higher in the VNI group. In conclusion, although there is no definitive consensus on the optimal laparoscopic entry technique, direct trocar entry is an effective alternative to the Veress needle insertion technique. Direct trocar entry is associated with shorter entry times, fewer perioperative complications, less reduction in hemoglobin levels, and shorter hospitalization duration compared to VNI.

Risk analysis of postoperative nausea and vomiting in patients after gynecologic laparoscopic surgery.

AIMS: This study is designed to identify risk factors of postoperative nausea and vomiting (PONV) in patients after gynecologic laparoscopic surgery and establish a nomogram model. METHODS: In this retrospective and multicenter study, we collected and analyzed data from 1233 patients who underwent gynecologic laparoscopic surgery. The Lasso algorithm was used to optimize the selection of independent variables in the development group. Multivariate logistic regression analysis was used to explore the risk factors of PONV to develop the predictive nomogram model. Finally, we used an internal and external verification group and machine learning (ML) to evaluate the accuracy and clinical applicability of the model. RESULTS: The dosage of sufentanil in patient-controlled intravenous analgesia (PCIA), the dosage of remifentanil, the use of neostigmine, duration of surgery and the maximum value of the PETCO2 were risk factors of PONV in patients after gynecologic laparoscopic surgery. In contrast, the dosage of propofol during the surgery and the use of steroids were protective factors. The nomogram was then established to predict the incidence of PONV in these patients based on the above eight indicators. The C-index of the development group, internal, and external verification groups are 0.802, 0.857, and 0.966, respectively. CONCLUSION: A nomogram model was developed to predict the incidence of PONV in patients after gynecologic laparoscopic surgery. This model was found to be reliable and of high clinical value.

Implementation and outcomes in benign gynecological surgery with HUGO™ RAS system 12 months initial experience.

We share our experience with the Hugo™ Robotic-Assisted Surgery system in benign gynecological surgeries. We retrospectively analyzed patients who underwent elective robotic surgeries for benign gynecological conditions at our surgical center from February 2023 to February 2024. Data collected included patient demographics, surgery indications, and outcomes. Perioperative data on port-placement time, arm configurations, docking, and console time were documented. Procedural outcome data including troubleshooting and overall satisfaction were also recorded. The primary outcome was perioperative data on port placement, docking time, arm configuration, and console time. The secondary outcome was defined as team satisfaction, system troubleshooting, arm repositioning, and complications graded 3-4 on the Clavien-Dindo Scale. A total of 60 patients underwent procedures for benign gynecological conditions using the Hugo™ RAS over the 12-month study period, primarily for pelvic endometriosis (53%), hysterectomies (27%), and adnexal surgery (10%). The mean port-placement time was 13 min and 41 s. In 31% of cases, low-port placement was used, with arm positioning being asymmetrical in 63% and symmetrical in 37%, demonstrating the system's flexibility in customizing port configurations while optimizing cosmetic outcomes. Docking time averaged 5 min and 51 s, and console time was 1 h and 5 min. Operational challenges included arm tremors and limited workspace for the assistant. This study details our knowledge using the Hugo™ RAS. Learning curves of port placement, arm positioning, docking, and procedure time can be rapidly adapted in a well-trained team. Our experience suggests the technology is still in its learning curve period.

Ultra-low-impact laparoscopy: a new concept for a minimally invasive surgery.

INTRODUCTION: Minimally invasive surgery is considered the gold standard for the treatment of gynecological diseases. Our study aims to assess the effectiveness of the new concept of ultra-low-impact laparoscopy as a combination of low-impact laparoscopy, consisting in the use of miniaturized instruments through 3-5mm ports and low-pressure pneumoperitoneum, with regional anesthesia to evaluate the perioperative outcomes. METHODS: A cross-sectional study was performed from May 2023 to December 2023, to enroll 26 women affected by benign gynecological disease and threated by mini-invasive surgical approach. The surgical procedures were performed following the low-impact laparoscopy protocol and the regional anesthesia protocol. The postoperative pain, nausea, and vomiting and the antiemetic/analgesic intake were evaluated. Postoperative surgical and anesthesiological variables were analyzed. RESULTS: Operative time was within 90 min (41.1 ± 17.1 mean ± standard deviation (SD)) and no conversion to laparotomy or general anesthesia was required. According to VAS score, the postoperative pain during the whole observation time was less than 3 (mean). Faster resumption of bowel motility (6.5 ± 2.1 mean ± SD) and women's mobilization (3.1 ± 0.7 mean ± SD) were observed as well as low incidence of post-operative nausea and vomit. Early discharge and patient's approval were recorded. Intraoperatively pain score was assessed on Likert scale during all stages. CONCLUSION: Ultra-low-impact laparoscopy showed to provide a satisfying recovery experience for patients in terms of short hospital stays, cosmetic result, and pain relief, without compromising surgical outcomes. The encouraging results lead us to recruit a greater number of patients to validate our technique as a future well-established produce.

Post-operative outcomes associated with anterior mesh location after laparoscopic sacrocolpopexy.

OBJECTIVE: To investigate the relationship between the anatomical position of the anterior arm of the mesh, measured by ultrasound through the bladder neck-mesh distance technique and the surgical outcomes after laparoscopic sacrocolpopexy (SCP) for apical prolapse. STUDY DESIGN: It was a retrospective analysis of prospectively collected data in a tertiary care hospital. Between January 2019 and September 2019, 63 women who underwent laparoscopic SCP due to apical prolapse were included. Bladder neck-mesh distance was measured immediately after surgery. The pelvic floor was evaluated using the Pelvic Organ Prolapse Quantification (POP-Q) System before, 1 month, and 2.7 years (mid-term) after the surgery. Post-operative stress urinary incontinence (SUI) and Patient Global Impression of Improvement (PGI-I) scores were also assessed. The correlation between bladder neck-mesh distance and the post-operative outcomes was investigated using the Spearman rank correlation coefficient. RESULTS: At mid-term follow-up visit, bladder neck-mesh distance was inversely correlated with the correction of apical prolapse and post-operative SUI. No correlation was detected with the anterior compartment prolapse correction. PGI-I scores were high in all patients at mid-term follow-up, irrespective of bladder neck-mesh distance values. CONCLUSION: The shorter the bladder neck-mesh distance, the better the outcome for apical compartment repair. Bladder neck-mesh distance had no correlation with the anterior anatomical correction. Shorter bladder neck-mesh distance values were positively correlated to better PGI-I scores and a higher risk of SUI.

Interaction mechanism of discharge readiness between discharge teaching and post-discharge outcomes in gynecological inpatients: a mediation analysis.

BACKGROUND: With the rapid implementation of enhanced recovery after surgery, most gynecological patients are discharged without full recovery. Discharge planning is necessary for patients and their families to transition from hospital to home. Discharge teaching and discharge readiness are two core indicators used to evaluate the quality of discharge planning, which impacts the post-discharge outcomes. To improve post-discharge outcomes, the interaction mechanism of the three variables needs to be determined, but few studies have focused on it. OBJECTIVES: Explore the mediating effect of discharge readiness between discharge teaching and post-discharge outcomes of gynecological inpatients. METHODS: Discharge teaching and discharge readiness were measured by the Quality of Discharge Teaching Scale (QDTS) and Readiness for Hospital Discharge Scale (RHDS). Post-discharge outcomes on postoperative Day 7 (POF-D7) and postoperative Day 28 (POF-D28) were measured by a self-designed tool. Spearman correlations, Kruskal‒Wallis tests and Mann‒Whitney U tests were conducted to explore the correlation between post-discharge outcomes and other variables. Mediation analysis was used to explore the mediating effect of discharge readiness between discharge teaching and post-discharge outcomes. RESULTS: QDTS and RHDS showed strong positive correlations with post-discharge outcomes. The mediation analyses verified that RHDS was a full mediator between QDTS and POF-D7, and the indirect effect accounted for 95.6% of the total direct effect. RHDS was a partial mediator between QDTS and POF-D28, and the indirect effect accounted for 50.0% of the total direct effect. RHDS was a full mediator between QDTS and total scores of post-discharge outcomes, and the indirect effect accounted for 88.9% of the total direct effect. CONCLUSIONS: Discharge teaching can improve the post-discharge outcomes of gynecological inpatients through the intermediary role of discharge readiness. Doctors and nurses should value the quality of discharge teaching and the discharge readiness improving of gynecological inpatients. Future studies should note the interaction mechanism of the three variables to explore more efficient ways of improving post-discharge outcomes of gynecological inpatients.

Incidence of stress urinary incontinence after laparoscopic sacrocolpopexy.

OBJECTIVE: The aim of the study was to evaluate the occurrence of stress urinary incontinence after pelvic organ prolapse surgery using the laparoscopic sacrocolpopexy method. This is a retrospective multicenter study. METHODS: The study included 131 patients who underwent laparoscopic sacrocolpopexy and underwent at least a one-year follow-up in the form of a clinical examination. RESULTS: The group included patients with an average age of 63.4 years (38-80 years), BMI 26.6 kg/m2 (19.4-36 kg/m2), and parity 2 (0-4). Before surgery, 30 (22.9%) patients showed stress incontinence, and after surgery there were 50 (38.2%); the difference was statistically significant (P = 0.0007). Thirty (22.9%) patients underwent subsequent anti-incontinence surgery, while 10 (7.6%) patients experienced significant improvement of stress incontinence. CONCLUSION: Pelvic organ prolapse reconstruction surgery by laparoscopic sacrocolpopexy is associated with the risk of postoperative stress incontinence in 38.2%, of which de novo in 22.9% of cases.

Surgical treatment of recurrent gynecological malignancies.

OBJECTIVE: A comprehensive overview of surgical treatment of recurrent gynecological malignancies. Recurrent breast malignancies are not included in this review. METHODOLOGY: A review providing overview of surgical treatment options for recurrent malignancies of adnexa of the uterus (ovary, fallopian tube), uterine corpus, uterine cervix, and carcinoma of the vagina and vulva. CONCLUSION: Optimal surgical treatment for patients with recurrent cancer is based on multidisciplinary approach with stratification according to individual prognostic markers. These include patient's performance status, outcome of primary surgery, current extent of recurrence, and histopathological, molecular, and biochemical characteristics. Decision about choice of treatment should be individually discussed and evaluated by the multidisciplinary oncogynecological commission board.

Laparoscopic modified simple ureteroneocystomy in iatrogenic lower third ureter injury during gynecology surgery.

OBJECTIVE: Our objective was to propose a laparoscopic modified simple ureteroneocystostomy for repairing iatrogenic ureteral injuries. In laparoscopic modified simple ureteroneocystostomy, the highest point of the bladder was found by cystoscopy, then we implanted a "fish mouth" ureter end into the bladder, leaving at least 1 cm of ureter end in the bladder as an anti-reflux procedure. CASE REPORT: We retrospectively reviewed a case series of lower third iatrogenic ureter injury during gynecology surgery of 11 patients who received laparoscopic modified simple ureteroneocystostomy at Da Lin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, from January 2011 to December 2020. One patient needs percutaneous nephrotomy due to infection and had the ureteroneocystostomy two months later. No obstruction, ureter stenosis/stricture, bladder leakage or other renal complications were noted after repair. CONCLUSION: Laparoscopic modified simple ureteroneocystostomy is technically feasible for repairing lower third ureter injuries, with no major complications.