Transvaginal versus transabdominal specimen extraction in minimally invasive surgery: a systematic review and meta-analysis.

AIM: Natural orifice specimen extraction (NOSE) is an alternative to conventional transabdominal retrieval. We aimed to compare outcomes following transvaginal specimen extraction (TVSE) and transabdominal specimen extraction (TASE) in minimally invasive abdominal surgery. METHODS: An electronic database search of PubMed, Embase and CENTRAL was performed from inception until March 2023. Comparative studies evaluating TVSE versus TASE in adult female patients were included. Studies involving transanal NOSE, endoluminal surgery, or TVSE with concomitant hysterectomy were excluded. Weighted mean differences (WMD) and odds ratio were estimated for continuous and dichotomous outcomes respectively. Primary outcomes were postoperative day 1 (POD1) pain and length of stay (LOS). Secondary outcomes were operative time, rescue analgesia, morbidity, and cosmesis. A review of sexual, oncological, and technical outcomes was performed. RESULTS: Thirteen studies (2 randomised trials, 11 retrospective cohort studies), involving 1094 patients (TASE 583, TVSE 511), were included in the analysis. Seven studies involved colorectal disease and six assessed gynaecological conditions. TVSE resulted in significantly decreased POD1 pain (WMD 1.08, 95% CI: 0.49, 1.68) and shorter LOS (WMD 1.18 days, 95% CI: 0.14, 2.22), compared to TASE. Operative time was similar between both groups, with fewer patients requiring postoperative rescue analgesia with TVSE. Overall morbidity rates, as well as both wound-related and non-wound related complication rates were better with TVSE, while anastomotic morbidity rates were comparable. Cosmetic scores were higher with TVSE. TVSE did not result in worse sexual or oncological outcomes. CONCLUSION: TVSE may be feasible and beneficial compared to TASE when performed by proficient laparoscopic operators, using appropriate selection criteria. Continued evaluation with prospective studies is warranted.

Surgical and oncological safety of nipple-sparing mastectomy in an Asian population.

BACKGROUND: Nipple-sparing mastectomy (NSM) allows for excellent postmastectomy reconstruction aesthetics and is used for both therapeutic and risk-reducing purposes. Reservations regarding the potential for locoregional recurrence and concerns about nipple-areolar complex (NAC) necrosis remain amongst many surgeons. We review the surgical and oncological outcomes after NSM in our institution. METHODS: All NSM cases at the National Cancer Centre Singapore and Singapore General Hospital between 2005 and 2015 were reviewed. Tumour characteristics, reconstruction methods, surgical and oncological outcomes are described. RESULTS: A total of 139 NSMs were performed for 130 patients. The median age was 46 years (range 21-66). The use of NSM increased from 2% of all breast reconstructions in 2005 to 37% in 2015. The majority (n = 119; 86%) were for cancer treatment and 20 (14%) for risk-reducing purposes. Among those performed for cancer, patients mainly had early stage breast cancer (n = 106, 89%). Autologous reconstruction (n = 111, 80%) was most common. Early complications requiring surgical intervention occurred in 24 (17%) NSMs, including 9 partial/complete flap loss and 2 complete NAC loss. Smoking, previous breast radiation and periareolar incision were all not associated with a higher re-intervention rate (p = 0.93, 0.41 and 0.91, respectively). Median follow-up was 43 months (range 5-145). Five patients (4%) developed local recurrence, including 2 NAC recurrences. The 2- and 5-year overall survival rate is 97 and 90%, respectively. CONCLUSION: NSM is an oncologically safe procedure in selected patients with acceptable low complication rates.