Association between pathological positivity rate of endometriosis, demographics, and concomitant gynecological conditions.

Background: To date, there remains a paucity of present-day literature on the topic of demographics and the biopsy-proven pathological positivity rate of endometriosis. Objective: The goal of this study was to explore the association between patients' demographics and other concomitant gynecological conditions or procedures and the pathological positivity rate of excision of endometriosis. Design: Retrospective cohort study. Methods: All women >18 years old who underwent laparoscopic surgery for endometriosis at a tertiary care hospital from October 2011 to October 2020. Women were classified into two groups: (1) Study group: women with >80% pathological positivity rate of endometriosis and (2) Control group: women with <80% pathological positivity rate. Results: A total of 401 women were included in the analysis. No difference was noted in the 80% pathological positivity rate based on body mass index [BMI; 68.7% in normal BMI versus 80% in underweight, versus 74.5% in overweight, and 74.1% in obese patients (p = 0.72)]. The percentage of patients reaching 80% pathological positivity of endometriosis was lower in women who had undergone previous laparoscopy for endometriosis compared to surgery naïve women (66.5% versus 76.5%, p = 0.03). In addition, a higher percentage of women who underwent concomitant hysterectomy (83.5% versus 68.8% for non-hysterectomy, p = 0.005) or bilateral oophorectomy (92.7% versus 70.0% for non-oophorectomy, p = 0.002) reached 80% pathological positivity. Women with an associated diagnosis of fibroids (79.7% versus 70.5%) or adenomyosis (76.4% versus 71.7%) were more likely to reach 80% pathological positivity compared to women without any other coexisting pathology; however, the observed differences were not statistically significant. After applying a log-binomial regression model, compared to White non-Hispanics, Hispanic patients were 30% less likely to reach 80% positivity (RR: 0.70, 95% CI: 0.49-1.02), although not statistically significant. Conclusion: No significant racial difference was found when comparing the rates of 80% pathological positivity of suspected endometriosis lesions among groups. Endometriosis pathological positivity rate was unaffected by patients' BMI and the presence of concomitant pathologies. In addition, prior laparoscopic surgery for endometriosis might cause tissue changes that result in a decrease in the observed pathological positivity rate of endometriosis lesions during subsequent surgeries.

Fertility sparing double discoid excision of rectosigmoid deep endometriosis under robotic-integrated ultrasound guidance.

OBJECTIVE: To present the use of robotic-integrated ultrasound for performing a double discoid excision of multifocal rectosigmoid endometriosis. DESIGN: Video article. STATEMENT OF CONSENT: The patient included in this video gave consent for publication of the video and posting of the video online, including social media, journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus), and other applicable sites. PATIENT: A 26-year-old G0 woman with chronic pelvic pain, dyschezia, and dysmenorrhea refractory to medical management desired future fertility. Imaging was suggestive of deep infiltrating endometriosis involving the rectosigmoid colon. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Double discoid excision of multifocal rectosigmoid endometriosis using robotic-integrated ultrasound. RESULTS: Not applicable. CONCLUSIONS: Performing a complete preoperative evaluation in patients with suspected endometriosis is important for determining the extent of disease and necessity of a multidisciplinary approach. Robotic-integrated ultrasound can provide additional information, including the size and depth of bowel endometriosis lesions, which can play a role in surgical decision making. Performing a double discoid excision of multifocal rectosigmoid endometriosis using robotic-integrated ultrasound is a technique that can avoid the need for a segmental bowel resection.

Deep Endometriosis of the Terminal Ileum Presenting With Cyclic Recurrent Small Bowel Obstruction.

Here, we discuss a case of a 42-year-old premenopausal female who presented with chronic pelvic pain and recurrent small bowel obstruction during menstruation. The patient reported a nine-year history of pelvic pain and a four-year history of episodic small bowel obstruction requiring multiple prior inpatient admissions. During these admissions, the obstruction was managed conservatively with bowel rest and nasogastric tube placement; however, symptoms would recur with subsequent menstrual cycles. Computed tomography showed diffusely dilated loops of small bowel with a transition point in the central anterior pelvis, and magnetic resonance enterography revealed a mass-like area involving small bowel loops in the mid pelvis. The patient underwent laparoscopic surgical intervention including bowel resection with re-anastomosis, hysterectomy, bilateral salpingectomy, and left oophorectomy. Intraoperative findings included severe distention of the proximal bowel with a discrete deep endometriosis lesion of the terminal ileum which was confirmed on final pathologic examination. This case emphasizes the importance of considering endometriosis as the etiology of recurrent catamenial small bowel obstruction, particularly in premenopausal women.

Laparoscopic shaving of rectosigmoid deep infiltrating endometriosis under laparoscopic ultrasound guidance.

OBJECTIVE: To present laparoscopic shaving of rectosigmoid endometriosis using the novel approach of laparoscopic ultrasound guidance to enhance complete excision. DESIGN: Video article. SETTING: Academic Tertiary Hospital. PATIENT(S): A 41-year-old G3P2012 female with longstanding history of pelvic pain refractory to medical management. Imaging was suggestive of deep infiltrating endometriosis involving the rectosigmoid colon. INTERVENTION(S): Laparoscopy for rectosigmoid endometriosis with the use of intraoperative ultrasound. MAIN OUTCOME MEASURE(S): Laparoscopic excision of rectosigmoid endometriosis under ultrasound guidance. RESULT(S): N/A. CONCLUSION(S): It is important to perform a complete pre-operative evaluation to determine the extent of disease and the necessity of a multidisciplinary approach. Intraoperative laparoscopic ultrasound can provide additional information including size and depth of lesions, which could play a role in surgical decision making. Laparoscopic ultrasound may enhance complete excision of deep endometriosis lesions and decrease the incidence of recurrence.

Rare Case of Osseus Metaplasia in a Detached Remnant Leiomyoma Following Hysteroscopic Myomectomy.

Uterine leiomyoma is the most common benign tumor of the uterus, affecting reproductive-age women. Although women with uterine fibroids are commonly asymptomatic, in symptomatic patients, hysteroscopic myomectomy is considered the first-line surgical treatment for intracavitary fibroids in women who wish to maintain fertility.  Osseous metaplasia in uterine fibroids is the transformation of fibroids cells into pure mature or immature bone. It is rare, and few case reports present with osseous metaplasia in uterine fibroids. This is the first report in the literature of osseous metaplasia in a remnant fibroid after hysteroscopic myomectomy. Every effort should be attempted to ensure complete retrieval of the detached fibroid remnant after hysteroscopic resection, as this might decrease the risk for subsequent surgeries.

Robot-Assisted Surgery for Endometriosis Current and Future Perspectives.

Successful resection of all visible lesions may effectively treat endometriosis-related infertility and pelvic pain. Minimally invasive surgery provides significant advantages, with lower rates of surgical complications such as surgical trauma, infection, postoperative pain, and hospital stay. Robotic surgery is shown to have similar perioperative outcomes to conventional laparoscopy; however, complex stage III and IV endometriosis, especially cases requiring significant resection such as deep infiltrating endometriosis, widespread peritoneal implants, and urologic and intestinal involvement, may benefit most from a robotic approach. There are certain aspects of endometriosis surgery where utilization of robotic technology might provide an additional benefit. These include (1) heterogeneity of lesions, and thus difficulty in identification; (2) difficulty in accurately predicting surgical complexity; and (3) prolonged operative time for complex cases. The objective of this review is to describe the current and future perspectives of robotic surgery as it pertains to endometriosis.

Use of low dose vaginal misoprostol in office hysteroscopy: a pre-post interventional study.

A pre-post interventional study of patients undergoing office hysteroscopy alone and in combination with endometrial biopsy was performed during October 2015-March 2018 to evaluate the effect of low dose vaginal misoprostol on patient's pain. Pain scores were assessed using the visual analog scale at the completion of the procedure. There were 646 patients included in the study. Of these, 462 had office hysteroscopy alone; 206 (44.6%) received 50 mcg of vaginal misoprostol the night prior to the procedure and the remaining 256 (55.4%) patients had no cervical ripening. The reported pain score following hysteroscopy was significantly lower among patients who received misoprostol [4(0-10) vs. 5(0-10); p=.001]. Most patients (78.2%) did not report any misoprostol related side effects. Of the 184 patients who underwent a combination of office hysteroscopy and endometrial biopsy, 97 (52.7%) received pre-procedure vaginal misoprostol while 87 (47.3%) did not. Post procedure pain was independent of pre-treatment with vaginal misoprostol (6.3 ± 2.7 vs. 6.6 ± 2.7; p = .54).Impact statementWhat is already known on this subject? Office hysteroscopy and endometrial biopsy is increasingly performed for evaluation of various gynaecologic conditions, however, patients' perceived pain at the time of procedure may lead to incomplete procedures. Various doses of misoprostol have been tested to reduce patients' pain, however none lower than 200 mcg vaginally, and at these doses, side effects are reported.What the results of this study add? To date, there is a scarcity of published data on the use of low dose misoprostol (50 mcg) in gynaecologic procedures. Our study found that the use of low dose vaginal misoprostol prior to office hysteroscopy is associated with lower reported pain and tenaculum utilisation during the procedure. However, vaginal misoprostol prior to successive office hysteroscopy and endometrial biopsy failed to decrease the reported pain, and the overall pain score was higher than hysteroscopy alone.What the implications are of these findings for clinical practice and/or further research? The use of low dose vaginal misoprostol (50 mcg) the evening prior to office hysteroscopy is associated with lower reported pain and tenaculum utilisation and is not associated with significant side effects. Therefore, 50 mcg of misoprostol could be used in clinical practice as a method to reduce patients' reported pain during office hysteroscopy.

Infertility in patients with bowel endometriosis.

The impact of bowel endometriosis on fertility is unclear, and the optimal management of patients who wish to conceive is not well-defined. Infertile patients with bowel endometriosis may either undergo surgery to enhance fertility or assisted reproductive technology (ART). It is necessary to consider that some complications may occur in patients undergoing ART because of the ovarian stimulation needed during these procedures. Interpretation of the available data on fertility outcomes after colorectal surgery for deep endometriosis is difficult as several studies do not distinguish patients with real infertility from those wishing to conceive without proven infertility and outcomes of complex surgery are operator-dependent. The effect of bowel surgery to increase the likelihood of spontaneous conception is yet to be established. Limited data are available on fertility outcomes after the removal of endometriotic nodules without the excision of bowel endometriotic implants.

Robotic Surgery for Urologic Deep Infiltrating Endometriosis: A Review and Case Presentations.

Urologic involvement is seen in 1.2-3.9% of women with endometriosis. The bladder (84%) is the most common location of urinary tract endometriosis and the retro-trigone and dome of the bladder are the most frequently affected sites. Ureteral involvement is commonly extrinsic and leads to compression and fibrosis of peri-ureteral tissue, leading to obstruction. Robotic-assisted laparoscopy provides additional advantages of 3D visualization, shorter learning curve compared to conventional laparoscopy, improved dissection in tight pelvic spaces, and facilitation of suturing techniques. In this review, we present the multidisciplinary management of four cases of deep infiltrating endometriosis of the urinary tract in a tertiary referral center of expertise and a review of the literature.

Cost-effectiveness of a preoperative pelvic MRI in pelvic organ prolapse surgery.

OBJECTIVE: To investigate the cost-effectiveness of preoperative pelvic magnetic resonance imaging (MRI) in identifying women at high risk of surgical failure following apical repair for pelvic organ prolapse (POP). METHODS: A decision tree (TreeAgePro Healthcare software) was designed to compare outcomes and costs of screening with a pelvic MRI versus no screening. For the strategy with MRI, expected surgical outcomes were based on a calculated value of the estimated levator ani subtended volume (eLASV) from previously published work. For the alternative strategy of no MRI, estimates for surgical outcomes were obtained from the published literature. Costs for surgical procedures were estimated using the 2008-2014 National Inpatient Sample (NIS). A cost-effectiveness analysis from a third-party payer perspective was performed with the primary measure of effectiveness defined as avoidance of surgical failure. Deterministic and probabilistic sensitivity analyses were performed to assess how robust the calculated incremental cost-effectiveness ratio was to uncertainty in decision tree estimates and across a range of willingness-to-pay values. RESULTS: A preoperative MRI resulted in a 17% increased chance of successful initial surgery (87% vs. 70%) and a decreased risk of repeat surgery with an ICER of $2298 per avoided cost of surgical failure. When applied to annual expected women undergoing POP surgery, routine screening with preoperative pelvic MRI costs $90 million more, but could avoid 39,150 surgical failures. CONCLUSION: The use of routine preoperative pelvic MRI appears to be cost-effective when employed to identify women at high risk of surgical failure following apical repair for pelvic organ prolapse.

Association between Preoperative Adenomyosis Detection Rate during Pelvic Ultrasonography and the Specialty of the Reading Physician.

STUDY OBJECTIVE: To compare the detection rate of adenomyosis when ultrasound is performed by a radiologist compared with a gynecologic expert sonologist. DESIGN: A retrospective, single-center study. SETTING: A university teaching hospital. PATIENTS: All women above 18 years of age with a positive histopathology diagnosis of adenomyosis obtained in a hysterectomy specimen from October 1, 2011, to October 1, 2017, were screened for inclusion. Cases without a preoperative pelvic ultrasound report, those with coexisting premalignant/malignant conditions, and patients presenting to the clinic with symptoms other than abnormal uterine bleeding, dysmenorrhea, or abdominal pain were excluded. A total of 412 cases were included in the final analysis. MEASUREMENTS AND MAIN RESULTS: The preoperative ultrasound was performed by a radiologist in 241 patients (59%) and by an expert gynecologic sonologist in 171 patients (42%). Patients' age, body mass index, race, ethnicity, parity, and history of prior cesarean section were comparable between the 2 groups. The adenomyosis detection rate was significantly higher in the expert gynecologic sonologist group compared with radiologists (95 [56%] vs 29 [12%], p <.01). After controlling for patients' race, body mass index, prior cesarean sections, and presence of myomas using multivariable logistic regression, gynecologic expert sonologists were 7.8 times more likely to detect adenomyosis than radiologists (odds ratio = 7.84; 95% confidence interval, 4.58-13.44). Regardless of medical specialty, the presence of myomas significantly decreased the detection of adenomyosis compared with the absence of myomas (odds ratio = 0.23; 95% confidence interval, 0.13-0.39). CONCLUSION: The detection rate of adenomyosis was significantly higher when ultrasound was performed by expert gynecologic sonologists compared with radiologists. The presence of myomas significantly decreased detection rates regardless of specialty. Ultrasound evaluation for detecting adenomyosis should be preferentially performed by gynecologic expert sonologists.

Minimally Invasive Surgery for the Obese Patient Among the Spectrum of Gynaecologic Surgery-A Surgical Viewpoint.

The prevalence of obesity has increased, achieving an epidemic status. Obesity has surgical and medical implications on the health of a woman. A minimally invasive surgical approach has several advantages and is considered the preferred approach for various procedures in obese women. The spectrum of gynaecologic surgical care spans over three main domains: benign gynaecologic surgery, reconstructive pelvic surgery, and gynaecologic cancer surgery. In this viewpoint, we chose a signature procedure for each main domain to compare minimally invasive surgery (MIS) trends for obese patients across all domains. Discrepancy was found in minimally invasive surgical trends for obese patients across different gynaecologic surgical domains. Fellowship training or maintaining high surgical volume might help to bridge this gap in the domain of benign gynaecologic surgery and improve quality care offered to obese patients.

Laparoscopic approach to cornual ectopic: a step-by-step demonstration.

OBJECTIVE: To concisely review what is known about cornual ectopic pregnancies and to provide a step-by-step demonstration of the resection of a large cornual ectopic pregnancy, highlighting various laparoscopic techniques. DESIGN: A video review of cornual ectopic pregnancy and a laparoscopic approach for treatment featuring a patient case at 9 weeks gestation. SETTING: Tertiary care facility. PATIENTS: A 31-year-old G2P1001 at 9 weeks 0 days by transvaginal ultrasound and with a beta human chorionic gonadotropin of 13,099 presented to the emergency department for vaginal bleeding and cramping left lower quadrant pain. She was hemodynamically stable. Her ultrasound was suspicious for a cornual ectopic pregnancy, which was confirmed by magnetic resonance imaging. INTERVENTIONS: The patient was taken to the operating room for resection, given the size of the pregnancy, concern for intraoperative blood loss, concern for persistent pregnancy, and concern that patient would not be able to reliably follow up for multiple appointments. Patient underwent laparoscopic resection of a large cornual ectopic pregnancy. Included is a short review of laparoscopic suturing techniques. MAIN OUTCOME MEASURES: Pathology, decline in beta hCG, and post-operative course. RESULTS: The patient's pathology was confirmatory for cornual ectopic pregnancy. Her beta human chorionic gonadotropin decreased as expected, and she had a normal post-operative course. CONCLUSIONS: Laparoscopic cornual resection is a safe and effective method for management of large cornual ectopic pregnancy, and fertility outcomes are similar to patients after salpingectomy for non-interstitial ectopic pregnancy.

Contemporary management of adnexa at the time of benign hysterectomy: a review of the literature.

Ovarian cancer is the leading cause of Gynecological cancer related mortality in the USA. Due to the absence of an effective screening method, concomitant adnexal management during hysterectomy or other pelvic surgeries is a prime consideration. Bilateral salpingo-oophorectomy (BSO) offers the benefit of eliminating the risk of ovarian cancer however it leads to surgical menopause with unfavourable overall health outcomes. With the latest verification that serous tubal intraepithelial carcinoma detected in the distal fimbriated end of the fallopian tube being the precursor of Type 2 ovarian cancers, there is an increased trend of performing bilateral salpingectomy (BS) as a risk reduction strategy for ovarian cancer. Women with a high risk for ovarian cancer due to familial or genetic mutations and those diagnosed with endometriosis need particular attention while planning adnexal management during hysterectomy. Physician and patient's shared decision-making regarding adnexal management during benign hysterectomy taking into consideration the route of hysterectomy is an important portion of pre-operative planning. The objective of this article is to understand the current trends of BSO and BS during benign hysterectomy and appreciate the pros and cons to aid in pre-operative counselling of patients.

Laparoscopic Surgeons' Perspectives on Risk Factors for and Prophylaxis of Trocar Site Hernias: A Multispecialty National Survey.

BACKGROUND AND OBJECTIVES: Although trocar site hernias (TSHs) occur in only 1.5% to 1.8% of all laparoscopic procedures, TSHs can present serious postoperative complications. The purpose of this study was to survey surgeons who are active members of the Society of Laparoendoscopic Surgeons (SLS) to elicit their experiences with TSHs, including fascial closure preferences. METHODS: After reviewing the clinical and epidemiological literature to compile relevant questions, an anonymous survey was designed using Qualtrics web-based software. The survey link was emailed to all SLS members. Descriptive analyses included frequencies, percentages, and χ2 or Fisher's exact tests to assess statistical associations. RESULTS: There were 659 SLS members who completed the survey: 323 general surgeons, 242 gynecologists, 45 colorectal surgeons, 25 bariatric surgeons, and 24 urologists. Nearly 7 in 10 respondents (68.4%) reported at least 1 patient developing a TSH within the previous decade. Compared with other specialties, bariatric surgeons had the smallest proportion of respondents reporting fascial closure for 10- to 12-mm trocars (68%) and the largest proportion indicating no fascial closure for trocars of any size (28%) (P < .01). Among all respondents, 86.6%, 15.3%, and 2.4% close 10- to 12-mm, 8-mm, and 5-mm ports, respectively, without differences according to surgical volume or practice setting. Approximately 6% reported no fascial closure for any size. CONCLUSION: Port size remains one of the main risk factors for TSH development, with most respondents closing only 10- to 12-mm ports regardless of surgical volume or practice setting. The general trend for port closure for bariatric surgeons is significantly different from that of other surgeons.

Laparoscopic Entry Technique Using a Veress Needle Insertion with and without Concomitant CO2 Insufflation: A Randomized Controlled Trial.

STUDY OBJECTIVE: To compare the time and number of attempts needed for successful Veress needle entry during laparoscopic surgery using concomitant versus subsequent CO2 insufflation approaches. DESIGN: Randomized controlled trial. SETTING: University teaching hospital. PATIENTS: One hundred consecutive patients scheduled for laparoscopic surgery by 2 high-volume laparoscopic surgeons were screened and randomized, and 95 of these were included in the final analysis. Ninety (45 in each group) was the precalculated priori number of patients needed to detect a 50% difference in the time (seconds) to obtain adequate insufflation with 90% power and alpha of 5%. INTERVENTIONS: Patients were randomized to either Veress needle entry with concomitant (Con) or subsequent (Sub) CO2 insufflation. MEASUREMENTS AND MAIN RESULTS: Forty-six patients were randomized to the Con group and 49 to the Sub group. Patient age, body mass index, prior surgical history, presence of adhesions, and type of procedure performed were similar between both groups. The median time required for adequate insufflation in the Con group was 103.5 seconds (Q1-Q3, 80.0-130.0) compared with 113.0 seconds (Q1-Q3, 102.0-144.0) in Sub group (p = .16). Approximately 89% (95% confidence interval, 80.1%-98.1%) of patients in Con group achieved successful entry in the first attempt compared with only 67% (95% confidence interval, 54.2%-80.0%) in Sub group (p = .01). The incidence of preperitoneal insufflation and failed entry was comparable between the 2 groups. No patient developed solid organ, visceral, or vascular injuries; gas embolism; or case conversion to laparotomy in relation to the Veress needle entry technique. CONCLUSION: Veress needle entry with concomitant CO2 insufflation was associated with a higher rate of successful entry during the first attempt of Veress needle insertion. The total time required for insufflation and rates of complications between the 2 techniques were similar.

Association between Obesity, Surgical Route, and Perioperative Outcomes in Patients with Uterine Cancer.

OBJECTIVE: To study temporal trends of hysterectomy routes performed for uterine cancer and their associations with body mass index (BMI) and perioperative morbidity. METHODS: A retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2013 databases was conducted. All patients who were 18 years old and older with a diagnosis of uterine cancer and underwent hysterectomy were identified using ICD-9-CM and CPT codes. Surgical route was classified into four groups: total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopic assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH) including both conventional and robotically assisted. Patients were then stratified according to BMI. RESULTS: 7199 records were included in the study. TLH was the most commonly performed route of hysterectomy regardless of BMI, with proportions of 50.9%, 48.9%, 50.4%, and 51.2% in ideal, overweight, obese, and morbidly obese patients, respectively. The median operative time for TAH was 2.2 hours compared to 2.7 hours for TLH (p < 0.01). The median length of stay for TAH was 3 days compared to 1 day for TLH (p < 0.01). The percentage of patients with an adverse outcome (composite indicator including transfusion, deep venous thrombosis, and infection) was 17.1 versus 3.7 for TAH and TLH, respectively (p < 0.01). CONCLUSION: During the last decade, TLH has been increasingly performed in women with uterine cancer. The increased adoption of TLH was seen in all BMI subgroups.