Minimally invasive outpatient hysterectomy for a benign indication: A systematic review.

BACKGROUND: Outpatient surgery in gynaecology may offer advantages including cost reduction, patient convenience and hospital bed optimisation without compromising patient safety and satisfaction. With the continual rise in health costs since 2000, outpatient surgery could be a line of action to improve financial resource utilisation and a solution for continuing to treat patients during crises such as the coronavirus disease 2019 pandemic. OBJECTIVE: This systematic review provides an overview of the literature on minimally invasive outpatient hysterectomy for benign indications. METHOD: A focused systematic review of the medical literature between 2018 and 2022 on outpatient gynaecological surgery for a benign indication was conducted using the PubMed and Google Scholar search engines. We then narrowed our selection to articles that referred to hysterectomy. Successful same-day discharge (SDD) was defined as the patient's return home on the day of the procedure without an overnight stay. RESULTS: Fifteen articles that focused on minimally invasive surgery were included in this review. Most of the studies (n = 11) were conducted in the United States. Outpatient surgery had a mean success rate of 60 % and a mean readmission rate of 3 %. The main reasons for SDD failure were patient choice, failed voiding, the need for pain management, nausea or vomiting, or both and the late timing of surgery. SDD was not associated with more complications and readmissions compared with inpatient care. The three main attribute predictors of SDD were young age, early timing of surgery and short total operative time. Patient satisfaction with SDD was high in absolute terms and relative to satisfaction with hospitalisation. CONCLUSION: Minimally invasive outpatient hysterectomy for a benign indication is feasible and safe but is associated with a notable risk of failure. To increase the success rate of outpatient management, patients must be well selected and surgery pathways must be planned in advance. The implementation of enhanced recovery protocols may help promote outpatient hysterectomy for a benign indication.

Assessment of women's sexual quality of life after benign adnexal surgery using vNOTES approach in comparison to conventional laparoscopy: protocol for a randomised controlled trial.

INTRODUCTION: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has already proven its non-inferiority to conventional abdominal laparoscopy (CAL) for hysterectomy without conversion. The results in terms of efficacy and safety are promising. However, we note a lack of medical literature and no specific randomised controlled trial assessing women's sexual function after vNOTES for benign adnexal surgery. The aim of this RCT is to confirm the non-inferiority of the vNOTES approach for benign adnexal pathology compared with CAL on women's sexual function. Secondary outcomes will evaluate vNOTES's efficiency, morbidity and postoperative complications compared with CAL for benign adnexal surgery. The relationship between adnexal mass morcellation and the quality of the histological analysis will also be evaluated as secondary outcome. METHODS AND ANALYSIS: Women aged 18-70 years undergoing a benign adnexal surgery at the Geneva University Hospitals will be eligible and randomised with a 1:1 ratio to the CAL arm or the vNOTES arm, if inclusion criteria are met. Participants will complete the Female Sexual Function Index, the Couple Satisfaction Index-16 and a self-reported questionnaire on dyspareunia within 4 weeks prior to randomisation and at 3+6 months after surgery. General and clinical data will be collected when the patient is enrolled in the study, during hospitalisation and at 1 month postoperative to assess secondary outcomes.An absence of impairment on sexual function will be confirmed with a stability or an improvement of the evaluated scores in each group at 3 and 6 months postoperative compared with the preoperative scores. We expect to have no statistically significant difference in sexuality questionnaires scores between the two groups. ETHICS AND DISSEMINATION: Protocol of this study was validated by the Cantonal Research Ethics Commission of Geneva, Switzerland, on 9 August 2022. We aim to publish the study's results in peer-reviewed journals within 3 years. TRIAL REGISTRATION NUMBER: NCT05761275.

A hybrid technique for the removal of a large prolapsed pedunculated submucous leiomyoma.

Uterine leiomyomas are the most common benign pelvic tumor in females. Pedunculated submucous FIGO type 0 leiomyomas may eventually protrude through the cervical canal and prolapse into the vagina taking the name of "nascent" leiomyomas. Vaginal myomectomy is the main treatment for isolated prolapsed myoma and is successful in more than 95% of cases. We propose a hybrid technique that consists of a transvaginal myomectomy followed by an operative hysteroscopy with cervical torsion to complete the removal of the leiomyoma's pedicle. Our case demonstrates an uneventful removal of a large nascent leiomyoma using a hybrid technique for complete resection of the leiomyoma limiting the risk of recurrence.

Fast-Track in Minimally Invasive Gynecology: A Randomized Trial Comparing Costs and Clinical Outcomes.

Study Objective: Evaluate the effects of a fast-track (FT) protocol on costs and post-operative recovery. Methods: One hundred and seventy women undergoing total laparoscopic hysterectomy for a benign indication were randomized in a FT protocol or a usual care protocol. A FT protocol included the combination of minimally invasive surgery, analgesia optimization, early oral refeeding and rapid mobilization of patients was compared to a usual care protocol. Primary outcome was costs. Secondary outcomes were length of stay, post-operative morbidity and patient satisfaction. Main Results: The mean total cost in the FT group was 13,070 ± 4,321 Euros (EUR) per patient, and that in the usual care group was 3.5% higher at 13,527 ± 3,925 EUR (p = 0.49). The FT group had lower inpatient surgical costs but higher total ambulatory costs during the first post-operative month. The mean hospital stay in the FT group was 52.7 ± 26.8 h, and that in the usual care group was 20% higher at 65.8 ± 33.7 h (p = 0.006). Morbidity during the first post-operative month was not significantly different between the two groups. On their day of discharge, the proportion of patients satisfied with pain management was similar in both groups [83% in FT and 78% in the usual care group (p = 0.57)]. Satisfaction with medical follow-up 1 month after surgery was also similar [91% in FT and 88% in the usual care group (p = 0.69)]. Conclusion: Implementation of a FT protocol in laparoscopic hysterectomy for benign indications has minimal non-significant effects on costs but significantly reduces hospital stay without increasing post-operative morbidity nor decreasing patient satisfaction. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04839263.

Operative Complications and Outcomes Comparing Small and Large Uterine Weight in Case of Laparoscopic Hysterectomy for a Benign Indication.

Study Objective: This study was performed to evaluate the association between uterine weight and operative outcomes in women undergoing laparoscopic hysterectomy for a benign indication. Methods: This is a secondary analysis of a randomized trial with data collected prospectively and retrospectively. The data of 159 women undergoing laparoscopic hysterectomy for a benign indication were analyzed. Women were divided in two groups according to the postoperative uterine weight: small uterus group (<250 grams) and large uterus group (≥250 grams). Operative complications were compared between the two groups. Operative outcomes (need for uterine morcellation, operative duration, estimated blood loss), postoperative pain, and hospital length of stay were also analyzed. Main Results: Operative complications were not significantly different between the two groups (37% in the large uterus group versus 41% in the small uterus group). Operative outcomes showed a significantly increased use of uterine morcellation in the large uterus group (61% in the large uterus group versus 10% in the small uterus group). The operative duration was 150 min in the small uterus group and 176 min in the large uterus group, which corresponds to an increase of 17% in the large uterus group. The mean pain score on the day of surgery was identical in both groups (VAS pain score 5), but significantly in favor of the large uterus group on day 1 postoperatively (VAS pain score 4 in the small uterus group and 3 in the large uterus group). There was no statistical difference between groups in the mean hospital stay (62 ± 37 hours in the small uterus group versus 54 ± 21 hours in the large uterus group). In terms of surgical indication, the small uterus group comprised more patients with endometriosis/adenomyosis (36%) and the large uterus group more patients with leiomyoma (93%). Conclusion: The results from this study show that, even if a large uterine weight is associated with increased uterine morcellation requirement and operative duration, a laparoscopic approach is safe and does not increase operative complications nor pain and/or length of hospital stay in women undergoing hysterectomy for a benign indication.

Cell Spillage after Contained Electromechanical Morcellation Using a Specially Designed In-Bag System for Laparoscopic Myomectomy: Prospective Cohort Pilot Study.

STUDY OBJECTIVE: Few reports have investigated the use of endoscopic retrieval bags in the context of laparoscopic myomectomy with electromechanical morcellation. We performed a leak test of a specially designed endoscopic bag system in women undergoing laparoscopic myomectomy with contained electromechanical morcellation. DESIGN CLASSIFICATION: Prospective study. SETTING: University hospital. PATIENTS: Thirty-one women undergoing laparoscopic myomectomy with contained electromechanical morcellation. INTERVENTIONS: Electromechanical morcellation was introduced for large specimen extraction during laparoscopic procedures. Complications such as retained/disseminated parasitic tissue were documented. MEASUREMENTS AND MAIN RESULTS: Systematic peritoneal washings were performed at 3 specific times: at baseline, T1, once the peritoneal cavity was accessed laparoscopically; T2, when the myometrial incision was closed after myomectomy; and T3, after contained electromechanical morcellation. After retrieval of the endoscopic bag from the abdominal cavity, visual inspection and water test on the bag with NaCl infiltration were performed to detect leaks attributed to intraoperative perforations. A pathologist performed cytologic analyses on the 3 washings. The mean endoscopic bag procedure duration was 9 minutes. The use of a specially designed endoscopic bag system was found to be easy in 45% of cases, and no complications were reported. Cytologic washings were positive for smooth muscle cell detection in 8 cases (25.8%) at T2 and 3 cases (9.7%) at T3. All positive cases at T3 already had detectable smooth muscle cells at T2. After retrieval from the abdominal cavity, perforations on the optic access of the endoscopic bag were observed in 3 cases. CONCLUSION: The results from this pilot study are encouraging. The use of a specially designed endoscopic bag system could be an adjuvant to reduce the risk of disseminating cells during myomectomy.