Beyond the cuff: a consideration of factors that affect sexual function after benign hysterectomy.

PURPOSE OF REVIEW: Hysterectomy is the most common gynecologic surgical procedure performed on women in the United States. While there are data supporting that hysterectomy for benign indication often does not reduce sexual function and may in fact improve sexual function as fibroids and endometriosis are resected, it remains unclear if there are factors within the perioperative period that affect sexual function in the years following surgery. To date, there is no consensus on what factors can optimize patients' sexual function after hysterectomy. RECENT FINDINGS: We present the current literature that assesses factors which may contribute to sexual function after hysterectomy. Preoperative demographic factors, including increasing age, pelvic pain, and preoperative sexual dysfunction, play a large role in postoperative sexual function. Perioperatively, there is a growing amount of data suggesting that premenopausal salpingo-oophorectomy at the time of hysterectomy may increase the risk of sexual dysfunction after hysterectomy, and no conclusive evidence that subtotal hysterectomy improves sexual function. The route of hysterectomy and technique of cuff closure can impact sexual function after hysterectomy due to the risk of shortening the vaginal length. SUMMARY: There is a lack of high-quality evidence that can provide a consensus on factors to optimize sexual function after hysterectomy. A growing area of research in the excision of endometriosis procedures is the consideration of nerve-sparing surgery. Considering the many variables that exist when counseling a patient on benign hysterectomy and its effects on sexual function, it is critical to understand the current research that exists with regards to these factors.

Laparoscopic Excision of Retroperitoneal Adnexal Cyst.

STUDY OBJECTIVE: To demonstrate the laparoscopic excision of a retroperitoneal adnexal cyst and describe the advanced surgical techniques and anatomic considerations in a patient with previous abdominopelvic surgery. DESIGN: Stepwise demonstration of advanced laparoscopic techniques with narrated video footage. SETTING: Adnexal masses after hysterectomy are a common reason for repeat abdominal surgery.1 Up to 9% of patients may require future adnexal surgery if ovarian preservation was chosen at the time of hysterectomy.2 Indications for surgery can include persistent adnexal masses, masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery.2 This patient is a 53-year-old postmenopausal female with a history of a total abdominal hysterectomy and left salpingectomy who underwent excision of an 8 cm retroperitoneal left adnexal cyst (Still 1). INTERVENTIONS: Excision of a retroperitoneal adnexal cyst can be performed through a laparoscopic approach with several key strategies: CONCLUSION: Knowledge of retroperitoneal anatomy is crucial in the surgical management of retroperitoneal adnexal masses because dissection can be technically challenging and anatomy may be distorted due to pelvic adhesive disease. Use of advanced laparoscopic techniques and understanding surgical planes are important for safe dissection. High and early ligation of the infundibulopelvic ligament at the pelvic brim and a complete ureterolysis with parametrial excision are often necessary to remove all ovarian tissue to prevent an ovarian remnant.

Growing pains: strategies for improving ergonomics in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: To evaluate factors contributing to the development of work-related musculoskeletal disorders (WMSDs) and review strategies for mitigating ergonomic strain in minimally invasive gynecologic surgery. RECENT FINDINGS: Factors associated with increased ergonomic strain and the development of WMSDs include increasing patient body mass index (BMI), smaller surgeon hand size, noninclusive design of instruments and energy devices and improper positioning of surgical equipment. Each type of minimally invasive surgery (laparoscopic, robotic, vaginal) confers its own ergonomic risk to the surgeon. Recommendations have been published regarding optimal ergonomic surgeon and equipment positioning. Intraoperative breaks and stretching are effective in reducing surgeon discomfort. Formal training in ergonomics has not yet been widely implemented, but educational interventions have been effective in reducing surgeon discomfort and can improve surgeon recognition of suboptimal ergonomics. SUMMARY: Considering the serious downstream effects of WMSDs on surgeons, it is imperative to implement strategies for WMSD prevention. Optimal positioning of the surgeons and operative equipment should be routine. Intraoperative breaks and stretching should be incorporated during procedures and between every case. Formal education in ergonomics should be provided to surgeons and trainees. Additionally, more inclusive instrument design by industry partners should be prioritized.

Ice-POP: Ice Packs for Postoperative Pain: A Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate the benefit of ice packs as a supplement to standard pain management following laparoscopic hysterectomy (LH). DESIGN: This Institutional Review Board-approved randomized controlled trial involved patients undergoing LH for benign conditions. Subjects were randomized to receive standard enhanced recovery after surgery pain management or standard enhanced recovery after surgery plus ice packs. SETTING: Two academic tertiary care centers PATIENTS: Patients undergoing planned outpatient LH with the minimally invasive gynecologic surgery team between February 2019 and November 2020 were considered. Patients with chronic pain, current opioid use ≥1 week, or planned overnight hospitalizations were excluded. Primary outcome data were available for 51 subjects (24 control, 27 intervention). INTERVENTIONS: Ice packs were placed on the abdomen in the operating room. MEASUREMENTS AND MAIN RESULTS: Pain was assessed at multiple time points throughout the study using a visual analogue scale (VAS). Opioid requirement was assessed using morphine milligram equivalent. There was no difference between the groups on any demographic variables. Morphine milligram equivalent requirements were also not different between the groups (p = .63). Postoperative day 1 (POD#1) VAS scores were not different (p = .89). Eighty-five percent of subjects reported feeling that their pain was controlled. Subjects who reported that they did not feel their pain was controlled did not use more opioids on POD#1 (p = .37), nor did they have higher POD#1 VAS scores (p = .55). Eighty-seven percent of the intervention subjects said they would use ice again, and 82.6% of them said they would recommend ice to others. There were no adverse events related to ice. All subjects were prescribed 20 tablets oxycodone and averaged 2.9 (SD 3.4) tablets used after discharge. CONCLUSION: Ice packs are an acceptable supplement for postoperative pain control, but they do not reduce postoperative pain or opioid usage compared to standard pain management without ice packs.

Neural activity in trigeminal neuralgia patients with sensory and motor stimulations: A pilot functional MRI study.

OBJECTIVE: Trigeminal neuralgia (TN) is a neuropathic pain syndrome that typically exhibits paroxysmal pain. However, the true mechanism of pain processing is unclear. We aim to evaluate the neural activity changes, before and after radiofrequency rhizotomy, in TN patients using functional MRI (fMRI) with sensory and motor stimulations. METHODS: Six patients with classical TN participated in the study. Each patient underwent two boxcar paradigms of fMRI tasks: air-sensation and jaw-clenching around 1-3 weeks before and after the surgical intervention. McGill Pain Questionnaire (MPQ) was used to evaluate the pain intensity prior to fMRI study. RESULTS: Before rhizotomy, the jaw-clenching stimulation yielded reduced brain activation in primary motor (M1) and primary (SI) and secondary somatosensory (SII) cortices. Following intervention, activation in those regions returned to near normal levels observed in healthy subjects. For air-sensation stimulation, several pain and pain modulation regions such as right thalamus, right putamen, insula, and brainstem, were activated before the intervention, but subsided after the intervention. This correlated well with the change of MPQ scores (p < 0.01). CONCLUSIONS: In our study, we observed significant pain reduction accompanied by increased motor activities after rhizotomy in patients with TN. We hypothesize that the reduced motor activities identified in fMRI may be reversed after the treatment with radiofrequency rhizotomy. More research is warranted.

Enhanced Recovery After Surgery in Minimally Invasive Gynecologic Surgery.

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach to optimize patient outcomes by minimizing surgical stress with the goal of returning to normal physiologic function. Using minimally invasive surgery as the preferred route for gynecologic surgery is an integral component of ERAS and is strongly correlated with improved postoperative outcomes. Implementation of ERAS programs in minimally invasive gynecologic surgery results in substantial improvements in clinical outcomes with higher rates of same-day discharge, reduction in postoperative nausea and vomiting, improved patient satisfaction, and decreased opioid consumption without increase in complications, readmissions, or health care costs.

Omental evisceration in a gravid woman following second-trimester laparoscopy: A case report.

Surgeons performing laparoscopy in pregnancy are developing specific practices to improve care of gravid women. In this case, a pregnant 26-year-old patient underwent laparoscopic ovarian cystectomy in the second trimester, with cyst wall removal through an 8 mm umbilical port site incision. She returned four days later with pain and drainage from the umbilicus, and examination under anesthesia revealed omental evisceration through the umbilical incision. The patient healed well following excision of affected omentum, reapproximation of fascia in a simple, interrupted fashion, and closure of skin in a subcuticular fashion. Due to increased intra-abdominal pressure associated with a gravid uterus and other factors, port site closure for incisions smaller than 10 mm may improve healing and prevent complications of laparoscopic surgery in pregnancy.

Postoperative Bladder Filling After Outpatient Laparoscopic Hysterectomy and Time to Discharge: A Randomized Controlled Trial.

OBJECTIVE: To determine whether backfilling the bladder postoperatively will reduce time to discharge in patients undergoing outpatient laparoscopic hysterectomy. METHODS: In a single-blind, randomized, controlled trial among women undergoing outpatient laparoscopic hysterectomy, patients were randomly assigned to a backfill-assisted void trial or a trial of spontaneous voiding. The primary outcome was time to discharge assessed by length of time spent in the postanesthesia care unit. Secondary outcomes included time to first spontaneous void, urinary retention rates, and postoperative complications within 8 weeks. We estimated that 152 patients (76/group) would provide greater than 80% power to identify a 30-minute difference in the primary outcome with a SD of 56 minutes and a two-sided α of 0.05. RESULTS: Between June 2017 to May 2018, 202 women were screened, 162 women were randomized, and results were analyzed for 153 women. Seventy-five patients (group A) who had a backfill-assisted voiding trial and 78 patients (group B) who had a spontaneous voiding trial were included in the analysis. The mean time to discharge was 273.4 minutes for group A vs 283.2 minutes for group B, which was not found to be significant (P=.45). The mean time to first spontaneous void was 181.1 minutes in group A vs 206.0 minutes in group B. There was a statistically significant reduction of 24.9 minutes in time to first spontaneous void with patients randomized to the backfill group (P=.04). Five of 75 patients (6.7%) in group A and 10 of 78 patients (12.8%) in group B developed urinary retention postoperatively and required recatheterization before discharge, which was also not significant (P=.20). CONCLUSION: Bladder filling before removing the Foley catheter is a simple procedure shown to reduce time to first spontaneous void, but not time to discharge in patients undergoing outpatient laparoscopic hysterectomy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03126162.

Antenatal corticosteroids for preterm premature rupture of membranes: single or repeat course?

OBJECTIVE: The aim of this article is to determine the risk of maternal chorioamnionitis and neonatal morbidity in women with preterm premature rupture of membranes (PPROM) exposed to one corticosteroid course versus a single repeat corticosteroid steroid course. STUDY DESIGN: Secondary analysis of a cohort of women with singleton pregnancies and PPROM. The primary outcome was a clinical diagnosis of maternal chorioamnionitis. Using multivariate logistic regression, we controlled for maternal age, race, body mass index, diabetes, gestational age at membrane rupture, preterm labor, and antibiotic administration. Neonatal morbidities were compared between groups controlling for gestational age at delivery. RESULTS: Of 1,652 women with PPROM, 1,507 women received one corticosteroid course and 145 women received a repeat corticosteroid course. The incidence of chorioamnionitis was similar between groups (single course = 12.3% vs. repeat course = 11.0%; p = 0.8). Women receiving a repeat corticosteroid course were not at increased risk of chorioamnionitis (adjusted odds ratio, 1.28; 95% confidence interval, 0.69-2.14). A repeat course of steroids was not associated with an increased risk of any neonatal morbidity. CONCLUSION: Compared with a single steroid course, our findings suggest that the risk of maternal chorioamnionitis or neonatal morbidity may not be increased for women with PPROM receiving a repeat corticosteroid course.

Discovery of novel and potent leukotriene B4 receptor antagonists. Part 1.

The inhibition of LTB(4) binding to and activation of G-protein-coupled receptors BLT1 and BLT2 is the premise of a treatment for several inflammatory diseases. In a lead optimization effort starting with the leukotriene B(4) (LTB(4)) receptor antagonist (2), members of a series of 3,5-diarylphenyl ethers were found to be highly potent inhibitors of LTB(4) binding to BLT1 and BLT2 receptors, with varying levels of selectivity depending on the substitution. In addition, compounds 33 and 38 from this series have good in vitro ADME properties, good oral bioavailability, and efficacy after oral delivery in guinea pig LTB(4) and nonhuman primate allergen challenge models. Further profiling in a rat non-GLP toxicity experiment provided the rationale for differentiation and selection of one compound (33) for clinical development.

Effects of LTB4 receptor antagonism on pulmonary inflammation in rodents and non-human primates.

Asthma, chronic obstructive pulmonary disease (COPD) and acute lung injury/acute respiratory distress syndrome (ALI/ARDS) are characterized by neutrophilic inflammation and elevated levels of leukotriene B4 (LTB4). However, the exact role of LTB4 pathways in mediating pulmonary neutrophilia and the potential therapeutic application of LTB4 receptor antagonists in these diseases remains controversial. Here we show that a novel dual BLT1 and BLT2 receptor antagonist, RO5101576, potently inhibited LTB4-evoked calcium mobilization in HL-60 cells and chemotaxis of human neutrophils. RO5101576 significantly attenuated LTB4-evoked pulmonary eosinophilia in guinea pigs. In non-human primates, RO5101576 inhibited allergen and ozone-evoked pulmonary neutrophilia, with comparable efficacy to budesonide (allergic responses). RO5101576 had no effects on LPS-evoked neutrophilia in guinea pigs and cigarette smoke-evoked neutrophilia in mice and rats. In toxicology studies RO5101576 was well-tolerated. Theses studies show differential effects of LTB4 receptor antagonism on neutrophil responses in vivo and suggest RO5101576 may represent a potential new treatment for pulmonary neutrophilia in asthma.

Outpatient total hip arthroplasty.

Patients younger than 65 years were studied to determine what percentage of patients would enroll in a study of outpatient total hip arthroplasty, its safety, and benefits of the program. Of 192 eligible patients, 69 (36%) enrolled, and 53 (77%) of these went home the same day of surgery. Of 53, 44 maintained a diary for the first 3, weeks and 52 completed a satisfaction questionnaire at 6 weeks. Patients were followed for 6 months for occurrence of complications. There were no medical readmissions. Of 52 patients who completed a 6 week questionnaire, 50 (96%) were satisfied with the decision to have outpatient total hip arthroplasty. There were no objective physical benefits identified. This study reports the distribution of acceptance and completion of same day discharge for patients with total hip arthroplasty in a metropolitan population. It confirms safety in selected patients.

Imaging and navigation measurement of acetabular component position in THA.

There are six different definitions of acetabular position based on observed inclination and anteversion made in either the (1) anterior pelvic plane or (2) coronal planes and based on whether each of the observations made in one of these two planes is (1) anatomic, (2) operative, or (3) radiographic. Anteroposterior pelvic tilt is the angle between the anterior pelvic plane and the coronal plane of the body. The coronal plane is a functional plane and the anterior pelvic plane is an anatomic pelvic plane. A cup may be in the "safe zone" by one definition but may be out of the "safe zone" by another definition. We reviewed published studies, analyzed the difference in varying definitions, evaluated the influence of the anterior pelvic tilt, and provided methods to convert from one definition to another. We recommend all inclination and anteversion measurements be converted to the radiographic inclination and anteversion based on the coronal plane, which is equivalent to the inclination and anteversion on the anteroposterior pelvic radiograph.

Metal-on-metal hip arthroplasty does equally well in osteonecrosis and osteoarthritis.

Many previous reports suggest total hip arthroplasty performs suboptimally in young patients with osteonecrosis. We retrospectively compared the performance of metal-on-metal articulation in a select group of 107 patients with 112 hips (98 uncemented and 14 cemented stems) 60 years of age or younger with either osteonecrosis (27 patients, 30 hips) or primary osteoarthritis (80 patients, 82 hips). We evaluated all patients with patient-generated Harris hip score forms and serial radiographs. Five mechanical complications were caused by impingement, two with pain, two dislocations, and one liner dissociation. At a minimum followup of 2.2 years (mean, 5.5 years; range, 2.2-11.7 years), we observed no osteolysis or aseptic loosening in the osteonecrosis group, whereas one osteoarthritic hip had cup revision for loosening (none showed evidence of osteolysis). None of the stems were loose. Patients with osteonecrosis or primary osteoarthritis were similar in clinical and radiographic performance. The patients with metal-on-metal hip arthroplasty for osteonecrosis had no revisions for aseptic loosening, but did have one liner change in a cup for painful impingement.

The emotional state of the patient after total hip and knee arthroplasty.

The new processes of total hip and knee arthroplasty partly engendered by mini-incision surgery have helped patients achieve all three goals of their operation: pain relief, improvement in function, and satisfaction. Satisfaction means the patient is no longer self-conscious about their disability and has regained the ability to live in their world in their usual way. The emotional state of the patient preoperatively, in the hospital, and during recovery will affect their feeling of satisfaction. Proper preoperative education makes patients more optimistic, and they anticipate fewer problems. In the hospital, a multimodal pain management program limits the use of parenteral narcotics and avoids the side effects of nausea and vomiting, which is the most important factor for in-hospital satisfaction. Recovery with an active physical therapy program individualized for the abilities and goals of the patient improves function and satisfaction. Surgeons must understand the expectations of the patient, direct them to realistic goals, and use the new processes of patient care to allow patients to exceed their expectations.