Laparoscopic administration of bupivacaine at the uterosacral ligaments during benign laparoscopic and robotic hysterectomy: a randomized controlled trial.

BACKGROUND: Postoperative pain continues to be an undermanaged part of the surgical experience. Multimodal analgesia has been adopted in response to the opioid epidemic, but opioid prescribing practices remain high after minimally invasive hysterectomy. Novel adjuvant opioid-sparing analgesia to optimize acute postoperative pain control is crucial in preventing chronic pain and minimizing opioid usage. OBJECTIVE: This study aimed to determine the effect of direct laparoscopic uterosacral bupivacaine administration on opioid usage and postoperative pain in patients undergoing benign minimally invasive (laparoscopic and robotic) hysterectomy. STUDY DESIGN: This was a single-blinded, triple-arm, randomized controlled trial at an academic medical center between March 15, 2021, and April 8, 2022. The inclusion criteria were patients aged >18 years undergoing benign laparoscopic or robotic hysterectomy. The exclusion criteria were non-English-speaking patients, patients with an allergy to bupivacaine or actively using opioid medications, patients undergoing transversus abdominis plane block, and patients undergoing supracervical hysterectomy or combination cases with other surgical services. Patients were randomized in a 1:1:1 fashion to the following uterosacral administration before colpotomy: no administration, 20 mL of normal saline, or 20 mL of 0.25% bupivacaine. All patients received incisional infiltration with 10 mL of 0.25% bupivacaine. The primary outcome was 24-hour oral morphine equivalent usage (postoperative day 0 and postoperative day 1). The secondary outcomes were total oral morphine equivalent usage in 7 days, last day of oral morphine equivalent usage, numeric pain scores from the universal pain assessment tool, and return of bowel function. Patients reported postoperative pain scores, total opioid consumption, and return of bowel function via Qualtrics surveys. Patient and surgical characteristics and primary and secondary outcomes were compared using chi-square analysis and 1-way analysis of variance. Multiple linear regression was used to identify predictors of opioid use in the first 24 hours after surgery and total opioid use in the 7 days after surgery. RESULTS: Of 518 hysterectomies screened, 410 (79%) were eligible, 215 (52%) agreed to participate, and 180 were ultimately included in the final analysis after accounting for dropout. Most hysterectomies (70%) were performed laparoscopically, and the remainder were performed robotically. Most hysterectomies (94%) were outpatient. Patients randomized to bupivacaine had higher rates of former and current tobacco use, and patients randomized to the no-administration group had higher rates of previous surgery. There was no difference in first 24-hour oral morphine equivalent use among the groups (P=.10). Moreover, there was no difference in numeric pain scores (although a trend toward significance in discharge pain scores in the bupivacaine group), total 7-day oral morphine equivalent use, day of last opioid use, or return of bowel function among the groups (P>.05 for all). The predictors of increased 24-hour opioid usage among all patients included only increased postanesthesia care unit oral morphine equivalent usage. The predictors of 7-day opioid usage among all patients included concurrent tobacco use and mood disorder, history of previous laparoscopy, estimated blood loss of >200 mL, and increased oral morphine equivalent usage in the postanesthesia care unit. CONCLUSION: Laparoscopic uterosacral administration of bupivacaine at the time of minimally invasive hysterectomy did not result in decreased opioid usage or change in numeric pain scores.

Association of Surgical Start Time with Outcomes of Benign Hysterectomy.

STUDY OBJECTIVE: To evaluate whether surgical start time is associated with clinical and financial outcomes of hysterectomies performed for benign indications. DESIGN: Retrospective cohort study. SETTING: University 5-hospital healthcare system. PATIENTS: Women who underwent benign hysterectomy between 2014 and 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed demographic, operative, and financial data to evaluate the relationships between surgical start time and perioperative outcomes including operating room time, estimated blood loss, length of stay, same-day discharge, and adverse perioperative events. Additionally, we evaluated the impact of surgical start time on total hysterectomy charges. Descriptive statistics and multivariate logistic and linear regressions were performed adjusting for confounders. Our study identified 2894 women who underwent benign hysterectomy, with 1910 hysterectomies starting prior to 12 pm (am group) and 984 hysterectomies starting after 12 pm (pm group). A pm start time was associated with higher estimated blood loss (Median 100, interquartile range 50, 200 in the am group vs Median 125, interquartile range 75, 250), increased length of stay, and decreased likelihood of same-day discharge. No significant differences were noted in the rates of adverse perioperative events between the 2 groups. Surprisingly, an afternoon start time was associated with decreased total hospital charges (median am $14 055.30 versus median pm $11 724.80). These cost differences persisted after multivariate linear regression, and when stratified by hysterectomy surgical approach, remained significant in the open and laparoscopic cohorts. CONCLUSION: Afternoon hysterectomy start time is associated with increased blood loss and length of stay with decreased rates of same-day discharge; however, there was no associated increase in perioperative adverse events or mortality. Awareness regarding surgical start time and outcomes can guide surgical scheduling and optimize same-day discharge.

The small leucine-rich repeat secreted protein Asporin induces eyes in Xenopus embryos through the IGF signalling pathway.

Small leucine-rich repeat proteoglycan (SLRP) family proteins play important roles in a number of biological events. Here, we demonstrate that the SLRP family member Asporin (ASPN) plays a crucial role in the early stages of eye development in Xenopus embryos. During embryogenesis, ASPN is broadly expressed in the neuroectoderm of the embryo. Overexpression of ASPN causes the induction of ectopic eyes. By contrast, blocking ASPN function with a morpholino oligonucleotide (ASPN-MO) inhibits eye formation, indicating that ASPN is an essential factor for eye development. Detailed molecular analyses revealed that ASPN interacts with insulin growth factor receptor (IGFR) and is essential for activating the IGF receptor-mediated intracellular signalling pathway. Moreover, ASPN perturbed the Wnt, BMP and Activin signalling pathways, suggesting that ASPN thereby creates a favourable environment in which the IGF signal can dominate. ASPN is thus a novel secreted molecule essential for eye induction through the coordination of multiple signalling pathways.

Craniosynostosis: Clinical Presentation, Genetics, and Prenatal Diagnosis.

IMPORTANCE: Craniosynostosis is a fetal condition caused by premature closure of the cranial sutures. Through provider awareness, we can raise suspicion in high-risk individuals, increase prenatal detection, optimize genetic testing, perform appropriate antenatal surveillance and delivery planning, and allow for a comprehensive, multidisciplinary approach to treatment. OBJECTIVE: The aim of this study was to review what is currently known regarding the genetics, pathophysiology, diagnosis, and treatment of craniosynostosis for the obstetric care provider. EVIDENCE ACQUISITION: A comprehensive literature review was performed using the PubMed database with the search term "craniosynostosis." The search was limited to the English language. RESULTS: A total of 220 articles were identified, and a total of 53 were used in completion of this article. The results highlight the multiple factors involved with abnormal suture formation, including various genetic factors. Although rare at this time, prenatal detection can allow families to prepare and practitioners to provide appropriate clinical treatment. Both 3-dimensional sonography and magnetic resonance imaging have been identified as modalities to aid in detection for high-risk individuals. Early referral allows for less-invasive surgical outcomes with lower complication rates. RESULTS: Familiarity with craniosynostosis among obstetric providers can improve patient counseling, prenatal detection rates, and appropriate antepartum, intrapartum, and postpartum counseling.

Diagnosis and Management of Pearly Penile Papules.

Pearly penile papules (PPP) are common, benign lesions that appear on the corona of the glans penis during adolescence or early adulthood. Despite their benign nature, PPP are known to cause significant distress because of their resemblance to sexually transmitted infections such as condyloma acuminata. PPP can be clinically distinguished based on their uniform, dome-shaped papules that orient in one to two rows around the glans penis. There is no association between PPP and sexually transmitted infections, and treatment is generally reserved for patients with excessive concern. Physicians should be aware of this distinction in order to adequately reassure anxious patients. For patients who still desire treatment after counseling, cryotherapy and laser therapy represent two reliable treatment options with low rates of recurrence.