Psychosocial Stress and MicroRNA Expression Profiles in Myometrial Tissue of Women Undergoing Surgical Treatment for Uterine Fibroids.

Uterine leiomyomas (fibroids) are the most common non-cancerous tumors affecting women. Psychosocial stress is associated with fibroid risk and severity. The relationship between psychosocial stress and fibroid pathogenesis may involve alterations in microRNAs (miRNAs) although this has yet to be examined. We investigated associations between two psychosocial stress measures, a composite measure of recent stressful life events and perceived social status, with expression levels of 401 miRNAs in myometrium (n = 20) and fibroids (n = 44; 20 with paired fibroid and myometrium samples) among pre-menopausal women who underwent surgery for fibroid treatment. We used linear regressions to identify psychosocial stressors associated with miRNAs, adjusting for covariates (age, body mass index, race/ethnicity, and oral contraceptive use). The association between psychosocial stressors and miRNAs was considered statistically significant at an FDR p < 0.10 and showed a monotonic response (nominal p-trend < 0.05). In the myometrium, 21 miRNAs were significantly associated with a composite measure of recent stressful events, and two miRNAs were associated with perceived social status. No fibroid miRNAs were associated with either stress measure. Pathway analyses revealed miRNA-mRNA targets were significantly enriched (FDR p < 0.05) in pathways relevant to cancer/tumor development. Of the 74 differentially expressed miRNAs between myometrium and fibroids, miR-27a-5p and miR-301b were also associated with stress exposure. Our pilot analysis suggests that psychosocial stress is associated with myometrial miRNA expression and, thus, may have a role in the pathogenesis of fibroids from healthy myometrium.

Psychosocial stress and microRNA expression profiles in myometrial tissue of women undergoing surgical treatment for uterine fibroids.

Uterine leiomyomas (fibroids) are the most common non-cancerous tumor affecting women. Psychosocial stress is associated with fibroid risk and severity. The relationship between psychosocial stress and fibroid pathogenesis may involve alterations in microRNAs (miRNAs) although this has yet to be examined. We investigated associations between two psychosocial stress measures, a composite measure of recent stressful life events and perceived social status, with expression levels of 401 miRNAs in myometrium (n = 20) and fibroids (n = 44; 20 matched between tissues) from pre-menopausal women who underwent surgery for fibroid treatment. We used linear regressions to identify psychosocial stressors associated with miRNAs, adjusting for covariates (age, body mass index, and race/ethnicity). Psychosocial stressors were modeled as ordinal variables and results were considered statistically significant if the overall variable significant was below false discovery threshold (FDR < 0.10) and showed a monotonic dose-response (nominal p-trend < 0.05). In the myometrium, 16 miRNAs were significantly associated with total stressful events and two miRNAs were associated with perceived social status. No fibroid miRNAs were associated with either stress measure. Pathway analyses revealed miRNA-mRNA targets were significantly enriched (FDR < 0.05) in pathways relevant to cancer/tumor development. Of the 74 differentially expressed miRNAs between myometrium and fibroids (p < 0.05), miR-27a-5p was also associated with stress exposure. Our pilot analysis suggests that psychosocial stress is associated with changes in myometrium miRNAs, and thus, plays a role in the pathogenesis of fibroids from healthy myometrium.

A Clinically Applicable Prediction Model for the Risk of Transfusion in Women Undergoing Myomectomy.

STUDY OBJECTIVE: We sought to identify the variables independently associated with intra/postoperative blood transfusion at the time of myomectomy. We further hoped to develop an accurate prediction model using preoperative variables to categorize an individual's risk of blood transfusion during myomectomy. DESIGN: Case-control study. SETTING: Not applicable to this study, which used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. PATIENTS: Women who underwent an open/abdominal or laparoscopic (robotic or conventional) myomectomy between 2014 and 2017 at participating ACS-NSQIP sites. INTERVENTION: The primary dependent variable was occurrence of intra/postoperative bleeding requiring blood transfusion. Patient demographics, clinical characteristics, preoperative comorbidities, intraoperative variables, and additional 30-day postoperative outcomes were compared at the bivariable level. For the prediction-model development, only variables that can be reasonably known before surgery were included. Variables associated with intra/postoperative bleeding were entered into 2 separate multivariable logistic regression models. Validation of our prediction model was performed internally using 250 bootstrapped iterations of 50% subsamples drawn from the overall population of myomectomy cases from the ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS: We identified 6387 myomectomies performed during the defined study period. The most common race in our population was black/African American (45.7%), and most of the patients (57.5%) received an open/abdominal route of myomectomy. A total of 623 patients who underwent myomectomy (9.8%) experienced intraoperative/postoperative bleeding with a need for blood transfusion. At the bivariable level, we identified several variables independently associated with the need for blood transfusion at the time of myomectomy. In using only those variables that can be reasonably known before surgery to develop our prediction model, additional multivariable logistic regression elucidated black race, need for preoperative blood transfusion, planned abdominal/open route of surgery, and preoperative hematocrit value as independently associated with blood transfusion. CONCLUSION: We identified a number of perioperative variables associated with intraoperative or postoperative bleeding requiring blood transfusion at the time of myomectomy. We subsequently created a model that accurately predicts individual bleeding risk from myomectomy, using variables that are reasonably apparent preoperatively. Making this prediction model clinically available to gynecologic surgeons will serve to improve the care of women undergoing myomectomy.

Reliability and Validity of 2 Surgical Prioritization Systems for Reinstating Nonemergent Benign Gynecologic Surgery during the COVID-19 Pandemic.

STUDY OBJECTIVE: Scientifically evaluate the validity and reproducibility of 2 novel surgical triaging systems, as well as offer modifications to the Medically-Necessary, Time-Sensitive (MeNTS) criteria for improved application in gynecologic surgeries. DESIGN: Retrospective cohort study. SETTING: Academic university hospital. PATIENTS: Ninety-seven patients with delayed benign gynecologic procedures owing to the coronavirus disease 2019 pandemic. INTERVENTION(S): Surgical prioritization was assessed using 2 novel scoring systems, the Gynecologic Medically-Necessary Time-Sensitive (Gyn-MeNTS) and modified Elective Surgery Acuity Scale (mESAS) systems for all 93 patients included. MEASUREMENTS AND MAIN RESULTS: The interrater reliability and validity of 2 novel surgical prioritization systems (Gyn-MeNTS and mESAS) were assessed. The Gyn-MeNTS scores were calculated by 3 raters and analyzed as continuous variables, with a lower score indicating more urgency/priority. The mESAS score was calculated by 2 raters and analyzed as a 3-level ordinal variable with a higher score indicating more urgency/priority. All 5 raters were blinded to reduce bias. The Gyn-MeNTS interrater reliability was tested using Spearman r and paired t tests were used to detect systematic differences between raters. Weighted κ indicated mESAS reliability. Concurrent validity with mESAS and surgeon self-prioritization (SSP) was examined with Spearman r and logistic regression. Spearman r's for all Gyn-MeNTS rater pairs were above 0.80 (0.84 for 1 vs 2; 0.82 for 1 vs 3; and 0.82 for 2 vs 3, all p <.001) indicating strong agreement. The weighted κ for the 2 mESAS raters was 0.57 (95% confidence interval, 0.40-0.73) indicating moderate agreement. When used together, both scores were significantly independently associated with SSP, with strong discrimination (area under the curve, 0.89). CONCLUSION: Interrater reliability is acceptable for both scoring systems, and concurrent validity of each is moderate for predicting SSP, but discrimination improves to a high level when they are used together.

Ob/Gyn resident self-perceived preparedness for minimally invasive surgery.

BACKGROUND: Very little is known regarding the readiness of senior U.S. Ob/Gyn residents to perform minimally invasive surgery. This study aims to evaluate the self-perceived readiness of senior Ob/Gyn residents to perform complex minimally invasive gynecologic surgery as well as their perceptions of the minimally invasive gynecologic surgery subspecialty. METHODS: We performed a national survey study of 3rd and 4th year Ob/Gyn residents. A novel 58-item survey was developed and sent to residency program directors and coordinators with the request to forward the survey link along to their senior residents. RESULTS: We received 158 survey responses with 84 (53.2%) responses coming from 4th year residents and 74 (46.8%) responses from 3rd year residents. Residents who train with graduates of a fellowship in minimally invasive gynecologic surgery felt significantly more prepared to perform minimally invasive surgery compared to residents without this exposure in their training. The majority of senior residents (71.5%) feel their residency training adequately prepared them to be a competent minimally invasive gynecologic surgeon. However, only 50% feel prepared to perform a laparoscopic hysterectomy on a uterus greater than 12 weeks size, 29% feel prepared to offer a vaginal hysterectomy on a uterus 12-week size or greater, 17% feel comfortable performing a laparoscopic myomectomy, and 12% feel prepared to offer a laparoscopic hysterectomy for a uterus above the umbilicus. CONCLUSIONS: The majority of senior U.S. Ob/Gyn residents feel prepared to provide minimally invasive surgery for complex gynecologic cases. However, surgical confidence in specific procedures decreases when surgical complexity increases.

Intraoperative tranexamic acid to decrease blood loss during myomectomy: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Myomectomy is associated with a significant risk of hemorrhage. Tranexamic acid is a synthetic lysine derivative with antifibrinolytic activity used in other surgical disciplines to reduce blood loss during surgery. However, its utility in gynecologic surgery is not well understood. OBJECTIVE: This study aimed to determine the effect of early administration of intravenous tranexamic acid on perioperative bleeding and blood transfusion requirements in women undergoing myomectomy. STUDY DESIGN: This study was a double-blinded, randomized, placebo-controlled trial conducted in an academic teaching hospital. Women with symptomatic fibroids thought to be at risk for large intraoperative blood loss who met the following criteria were included in the study: (1) at least 1 fibroid ≥10 cm, (2) any intramural or broad ligament fibroid ≥6 cm, and/or (3) at least 5 total fibroids based on preoperative imaging. Patients were randomized to receive a single intravenous bolus injection of tranexamic acid 15 mg/kg (intervention group) versus an intravenous bolus injection of saline of equivalent volume (placebo group) 20 minutes before the initial surgical incision. Perioperative bleeding was defined by measuring intraoperative estimated blood loss, change between pre- and postoperative hemoglobin, and frequency of blood transfusions. Estimated blood loss was calculated by combining the blood volume collected within the suction canister and the weight of used sponges. The 2 groups were compared for age; body mass index; perioperative hemoglobin and hematocrit; perioperative blood loss; duration of surgery; blood transfusion requirements; and the number, total weight, and volume of myomas removed. RESULTS: A total of 60 patients (30 per arm) were enrolled into the study between March 1, 2015, and January 29, 2018. Age, body mass index, baseline hemoglobin and/or hematocrit, number and total weight of myomas removed, and size of myomas did not differ between arms. Of 60 patients, 32 (53%) had laparoscopic myomectomy, 24 (40%) had robotic myomectomy, and 4 (7%) had laparotomy. Median estimated blood loss was 200 mL for the tranexamic acid group and 240 mL for the placebo group (P=.88). There was no difference in median duration of surgery (165 vs 164 minutes; P=.64) or change in perioperative hemoglobin (1.00 vs 1.1 g/dL; P=.64). Patients in the tranexamic acid group did not require blood transfusions; however, 4 patients (13.3%) in the placebo group (P=.11) required blood transfusions. CONCLUSION: Intravenous administration of tranexamic acid in patients undergoing laparoscopic or robotic myomectomies was not associated with decreased blood loss.

Phthalate Exposures and MicroRNA Expression in Uterine Fibroids: The FORGE Study.

Phthalates are associated with multiple, adverse reproductive outcomes including increased risk of uterine leiomyoma (fibroids). Phthalates can interact with epigenetic modifications including microRNAs (miRNAs), which help regulate processes crucial to fibroid pathogenesis. However, no prior study has examined the influence of phthalates on miRNA expression in fibroid tumors. We conducted a preliminary, cross-sectional study to examine the associations between phthalate exposures and miRNA expression levels in fibroid tumors and to explore potential effect modification by race/ethnicity. We quantified expression levels of 754 miRNAs in fibroid tumor samples and analyzed spot urine samples for phthalate metabolites collected from 45 pre-menopausal women undergoing surgery for fibroid treatment at an academic hospital. Associations between miRNA levels in fibroids and phthalate biomarkers were evaluated using linear regression adjusting for age, race/ethnicity, and body mass index (BMI). Statistical tests were adjusted for multiple comparisons. We also performed in silico Ingenuity Pathway Analysis to identify the biological pathways that are regulated by phthalate-associated miRNAs. Mono-hydroxybutyl phthalate and mono(2-ethyl-5-hydroxyhexyl) phthalate were positively associated with miR-10a-5p (ß = 0.76, 95% CI = [0.40, 1.11]) and miR-577 (ß = 1.06, 95% CI = [0.53, 1.59]), respectively. A total of 8 phthalate-miRNA associations varied by race/ethnicity (qinteraction < 0.10). Pathway analysis revealed that mRNA gene targets of phthalate-associated miRNAs were significantly associated with multiple fibroid-related processes including angiogenesis, apoptosis, and proliferation of connective tissues. Collectively, these data suggest that exposures to some phthalates are associated with miRNA in fibroids, and that associations may vary by race/ethnicity. Validation of these findings may provide insight into mechanisms underlying associations between phthalates and fibroids and contribute to novel hypotheses regarding racial/ethnic disparities in fibroids.

Comparing benign laparoscopic and abdominal hysterectomy outcomes by time.

BACKGROUND: While laparoscopic hysterectomy has benefits compared to abdominal hysterectomy, the operative times are longer. Longer operative times have been associated with negative outcomes. This study's purpose was to elucidate if there is an operative time at which 30-day outcomes for laparoscopic hysterectomy become inferior to a more expeditiously completed abdominal hysterectomy. METHODS: This was a retrospective cohort study (Canadian Task Force classification II-2) using the American College of Surgeons National Surgical Quality Improvement Program database to identify women undergoing hysterectomy for benign indications from 2010 to 2016 by current procedural terminology code. Hysterectomy cases were stratified by approach and 60-min intervals. 30-day post-operative outcomes were analyzed by operative time and approach. RESULTS: 109,821 hysterectomies were included in our analysis, of which 66,560 (61%) were laparoscopic, and 43,261 (39%) were abdominal. In a multivariable logistic regression analysis comparing outcomes by surgical approach and operative time, there was no time combination in which patients who had a abdominal hysterectomy had significantly lower odds of the composite complications variable. This was true even in laparoscopic hysterectomies greater than 240 min compared to abdominal hysterectomies completed between 20 and 60 min. When compared to laparoscopic hysterectomies greater than 240 min, abdominal hysterectomies between 20 and 60 min had lower odds of sepsis and abdominal hysterectomies less than 180 min had lower odds of urinary tract infection. CONCLUSION: Given that benefits persist even in prolonged cases, a laparoscopic approach should be offered to most patients undergoing benign hysterectomy. Surgical efficiency should be prioritized for any surgical approach.

Correction to: Comparing benign laparoscopic and abdominal hysterectomy outcomes by time.

The original article was updated to correct the author listing: the last five author names were reversed.

Applications of Tranexamic acid in benign gynecology.

PURPOSE OF REVIEW: Bleeding at the time of benign gynecologic surgery, as well as from benign gynecologic conditions, is a major source of morbidity for many women. Few nonhormonal medical options exist for the treatment of heavy menstrual bleeding, and to reduce surgical bleeding during major gynecologic surgery. Interest in Tranexamic acid (TXA) as a means to reduce surgical blood loss has been growing across many surgical specialties. This review focuses on applications for TXA as a means to reduce heavy menstrual bleeding (HMB) as well as to reduce surgical bleeding during benign gynecologic surgery. RECENT FINDINGS: Tranexamic acid is an effective treatment to reduce the volume of bleeding during menstruation. Tranexamic acid was found to be superior to both placebo and oral progestins, and as good as combined oral contraceptives at reducing menstrual blood volume. Tranexamic acid has also been show to reduce the volume of bleeding during abdominal myomectomy as well as hysterectomy. There is a major need for prospective studies evaluating the utility of TXA for reducing blood loss during benign gynecologic surgery. SUMMARY: Tranexamic acid has been found to be an excellent affordable nonhormonal treatment option for women with HMB and should be considered during major gynecologic surgery.

Association of operative time with outcomes in minimally invasive and abdominal myomectomy.

OBJECTIVE(S): To determine the association of operative time (ORT) with perioperative morbidity and whether there is an ORT at which minimally invasive myomectomy becomes inferior to laparotomy. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): Myomectomy cases identified by CPT code from 2005 to 2016. INTERVENTION(S): Cases were stratified and analyzed by surgical approach and 90-minute intervals. MAIN OUTCOME MEASURE(S): Thirty-day postoperative morbidity. RESULT(S): A total of 11,709 myomectomies were identified; 4,673 (39.9%) were minimally invasive, 6,997 (59.8%) were abdominal, and 39 (0.3%) were conversions. The incidence of complications significantly increased with ORT. After adjusting for confounders, mean ORT in minutes (95% confidence interval) was 113 (111-115) for abdominal, 156 (153-159) for minimally invasive, and 172 (148-200) for conversions. Despite shorter ORT, morbidity was greater in abdominal cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%). The minimally invasive approach in general had lower odds of complications (odds ratio, 0.23; 95% confidence interval, 0.19-0.26). However, when minimally invasive surgery ORT reached ≥ 270 minutes, the odds of a composite complication variable increased compared with abdominal cases <90 minutes (odds ratio, 2.30; 95% confidence interval, 1.69-3.13). Of minimally invasive cases, 88% were completed in <270 minutes. CONCLUSION(S): ORT was predictive of complications for both minimally invasive and abdominal myomectomies. Despite longer ORTs, minimally invasive procedures generally had superior 30-day outcomes up to 270 minutes. Careful patient counseling and preparation to increase surgical efficiency should be prioritized for either approach.

Phthalates exposure and uterine fibroid burden among women undergoing surgical treatment for fibroids: a preliminary study.

OBJECTIVES: To examine the association between phthalate exposure and two measures of uterine fibroid burden: diameter of largest fibroid and uterine volume. DESIGN: Pilot, cross-sectional study. SETTING: Academic medical center. PATIENT(S): Fifty-seven premenopausal women undergoing either hysterectomy or myomectomy for fibroids. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The diameter of the largest fibroid and uterine dimensions were abstracted from medical records. Spot urine samples were analyzed for 14 phthalate biomarkers using mass spectrometry. We estimated associations between fibroid outcomes and individual phthalate metabolites, sum of di(2-ethylhexyl) phthalate metabolites (∑DEHP), and a weighted sum of anti-androgenic phthalate metabolites (∑AA Phthalates) using linear regression, adjusting for age, race/ethnicity, and body mass index. Fibroid outcomes were also examined dichotomously (divided at the median) using logistic regression. RESULTS: Most women were of black ethnicity, overweight or obese, and college educated. In multivariable models, higher levels of mono-hydroxyisobutyl phthalate, monocarboxyoctyl phthalate, monocarboxynonyl phthalate, mono(2-ethylhexyl) phthalate, mono(2-ethyl-5-hydroxyhexyl phthalate) (MEHHP), mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), and mono(2-ethyl-5-carboxypentyl) phthalate (MECPP), ∑DEHP, and ∑AA Phthalates were positively associated with uterine volume. Associations were most pronounced for individual DEHP metabolites (MEHHP, MEOHP, MECPP), ∑DEHP, and ∑AA Phthalates. For example, a doubling in ∑DEHP and ∑AA Phthalates was associated with 33.2% (95% confidence interval 6.6-66.5) and 26.8% (95% confidence interval 2.2-57.4) increase in uterine volume, respectively. There were few associations between phthalate biomarkers and fibroid size. CONCLUSIONS: Exposure to some phthalate biomarkers was positively associated with uterine volume, which further supports the hypothesis that phthalate exposures may be associated with fibroid outcomes. Additional studies are needed to confirm these relationships.

Angular vs. interstitial pregnancy: A case report highlighting diagnostic nuances with stark management differences.

BACKGROUND: In the literature, the terms "angular", "interstitial" and "cornual" have often been inappropriately interchanged. The consequence is under-recognition of their differences as well as inaccurate imaging guidelines which do not reliably distinguish them as distinct entities. Angular pregnancies should be considered viable and may be managed to term. CASE: A woman at 7w5d was transferred for surgical management of a presumed interstitial ectopic pregnancy. Sonography and MRI confirmed an eccentric fundal pregnancy with a thin myometrial mantle of 2-5 mm; the diagnosis of interstitial pregnancy was favored. Upon laparoscopy, the round ligament was displaced lateral to the pregnancy bulge and the diagnosis of angular pregnancy was thus apparent. The pregnancy was continued to term and delivered via repeat cesarean section without incident. CONCLUSION: Angular and interstitial pregnancies are different entities which cannot always be reliably distinguished via imaging alone. Diagnostic laparoscopy may be a final step in determining pregnancy location. Angular pregnancies should be considered potentially viable and may be managed to term.

Hysterectomy for the Transgendered Male: Review of Perioperative Considerations and Surgical Techniques with Description of a Novel 2-Port Laparoscopic Approach.

Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed.

Minimally Invasive Hysterectomy for Uteri Greater Than One Kilogram.

BACKGROUND AND OBJECTIVES: To assess the feasibility and safety of minimally invasive hysterectomy for uteri >1 kg. METHODS: Clinical and surgical characteristics were collected for patients in an academic tertiary care hospital. Included were patients who underwent minimally invasive hysterectomy by 1 of 3 fellowship-trained gynecologists from January 1, 2009, to July 1, 2015 and subsequently had confirmed uterine weights of 1 kg or greater on pathology report. Both robotic and conventional laparoscopic procedures were included. RESULTS: During the study period, 95 patients underwent minimally invasive hysterectomy with confirmed uterine weight over 1 kg. Eighty-eight percent were performed with conventional laparoscopy and 12.6% with robot-assisted laparoscopy. The median weight (range) was 1326 g (range, 1000-4800). The median estimated blood loss was 200 mL (range, 50-2000), and median operating time was 191 minutes (range, 75-478). Five cases were converted to laparotomy (5.2%). Four cases were converted secondary to hemorrhage and one secondary to extensive adhesions. There were no conversions after 2011. Intraoperative transfusion was given in 6.3% of cases and postoperative transfusion in 6.3% of cases. However, after 2013, the rate of intraoperative transfusion decreased to 1.0% and postoperative transfusion to 2.1%. Of the 95 cases, there were no cases with malignancy. CONCLUSIONS: This provides the largest case series of hysterectomy over 1 kg completed by a minimally invasive approach. Our complication rate improved with experience and was comparable to other studies of minimally invasive hysterectomy for large uteri. When performed by experienced surgeons, minimally invasive hysterectomy for uteri >1 kg can be considered feasible and safe.

Comparison of cost and operative outcomes of robotic hysterectomy compared to laparoscopic hysterectomy across different uterine weights.

Operative cost and outcomes between robotic and laparoscopic hysterectomy across different uterine weights. Retrospective cohort study including patients undergoing robotic and laparoscopic hysterectomy for benign disease at an Academic university hospital. One hundred and ninety six hysterectomies were identified (101 robotic versus 95 laparoscopic). Demographic and surgical characteristics were statistically equivalent. Robotic group had a higher body mass index (±SD) (32.9 ± 6.5 versus 30.4 ± 7.1, p 0.012) and more frequent history of adnexal surgery (12.9 versus 4.2%, p 0.031). Laparoscopic group had a higher number of concurrent salpingectomy (81 versus 66.3%, p 0.02). Estimated blood loss did not differ between procedures. Compared to robotic hysterectomies, laparoscopic procedures added 47 min (CI: 31-63 min; p < 0.001) of operative time, costed $1648 more (CI: 500-2797; p = 0. 005) and had triple the odds of having an overnight admission (OR = 2.94 CI: 1.34-6.44; p = 0.007). After stratification of cases by uterine weight, the mean operative time difference between the two groups in uteri between 750 and 1000 g and in uteri >1000 g was 81.3 min (CI: 51.3-111.3, p < 0.0001) and 70 min (CI: 26-114, p < 0.005), respectively, in favor of the robotic group. Mean direct cost difference in uteri between 750 and 1000 g and uteri >1000 g was 1859$ (CI: 629-3090, p < 0.006) and 4509$ (CI: 377-8641, p < 0.004), respectively, also in favor of the robotic group. In expert hands, robotic hysterectomy for uteri weighing more than 750 g may be associated with shorter operative time and improved cost profile.

Feasibility, Safety, and Prediction of Complications for Minimally Invasive Myomectomy in Women With Large and Numerous Myomata.

OBJECTIVE: To assess perioperative outcomes and identify predictors of complications for minimally invasive surgery (MIS) myomectomy in a cohort of women with large and numerous myomata. DESIGN: Case-control study (Canadian Task Force classification II-2). SETTING: Academic tertiary care medical center. PATIENTS: Women undergoing MIS myomectomy performed by 3 high-volume surgeons between April 2011 and December 2014. INTERVENTIONS: Characteristics were compared between women who experienced complications and those who did not. Factors predictive of complications were then identified. MEASUREMENTS AND MAIN RESULTS: A total of 221 women underwent an MIS myomectomy, 47.5% via a laparoscopic approach and 52.5% via robotic surgery. The mean ± SD specimen weight was 408.1 ± 384.9 g, uterine volume was 586.1 ± 534.1 cm3, dominant myoma diameter was 9.6 ± 5.1 cm, and number of myomata removed was 4.5 ± 4.1. The most common complications were hemorrhage >1000 mL (8.6%) and blood transfusion (4.1%). The conversion rate was 1.8%. A dominant myoma diameter of ≥12 cm and a uterine volume of ≥750 cm3 increased the odds of complications (odds ratio [OR], 7.44; 95% confidence interval [CI], 2.03-31.84; p = .004 and OR, 6.15; 95% CI, 1.55-30.02; p = .014 respectively). A receiver operating characteristic curve considering dominant myoma diameter and uterine volume had an area under the curve of 0.81. A combination of dominant myoma diameter of ≥10 cm and uterine volume of 600 cm3 predicted complications with 79% sensitivity and 79% specificity. CONCLUSION: Our cohort had large and numerous myomata with high specimen weights, but complications were comparable to those reported in previous studies of MIS myomectomy with less complex pathology. Hemorrhage and transfusion accounted for the majority of complications, and a combination of dominant myoma diameter and uterine volume was predictive of complications. Both factors can be easily defined before surgery and may be used to guide patient counseling, referrals, and implementation of preventative measures for hemorrhage and transfusion.

Comparison of methods of morcellation: manual versus power.

INTRODUCTION: With the growing controversy surrounding power morcellation (PM), other approaches must be examined so that women may still benefit from minimally invasive gynecologic surgeries. In this study we sought to compare power morcellation to manual morcellation through mini-laparotomy or vaginally. MATERIALS AND METHODS: Retrospective cohort study carried out at an urban teaching hospital including 274 women who underwent a minimally invasive myomectomy or hysterectomy, requiring morcellation for tissue extraction. Surgical outcomes were compared between PM, manual morcellation through mini-laparotomy (MMM) and manual morcellation through the vagina (MMV). Primary outcome measured was operative time. Secondary outcomes were intraoperative and postoperative complications. RESULTS: Compared with PM, MMM was associated with shorter operative time for hysterectomy, (140.5 min vs. 164.2 min, p = 0.05). Intraoperative and postoperative complications were similar among groups. There were four postoperative complications in the MMV group, one related to blood transfusion and three related to postoperative vaginal cuff and pelvic infections. CONCLUSION: Compared with PM, MMM is associated with shorter operative time during hysterectomies. Intraoperative and postoperative complications were similar among groups.