Cutting-edge care: unleashing artificial intelligence's potential in gynecologic surgery.

PURPOSE OF REVIEW: Artificial intelligence (AI) is now integrated in our daily life. It has also been incorporated in medicine with algorithms to diagnose, recommend treatment options, and estimate prognosis. RECENT FINDINGS: AI in surgery differs from virtual AI used for clinical application. Physical AI in the form of computer vision and augmented reality is used to improve surgeon's skills, performance, and patient outcomes. SUMMARY: Several applications of AI and augmented reality are utilized in gynecologic surgery. AI's potential use can be found in all phases of surgery: preoperatively, intra-operatively, and postoperatively. Its current benefits are for improving accuracy, surgeon's precision, and reducing complications.

Feasibility and Perioperative Outcomes of Minimally Invasive Higher Order Myomectomy.

STUDY OBJECTIVE: To investigate perioperative outcomes of minimally invasive higher order myomectomy as defined by removal of 10 or more fibroids. DESIGN: A retrospective cohort study between January 2018 and December 2022. SETTING: A tertiary academic medical center. PATIENTS: Women who underwent minimally invasive myomectomy via laparoscopic or robotic approach. INTERVENTIONS: Surgical intervention in the form of minimally invasive myomectomy. MEASUREMENTS AND MAIN RESULTS: A total of 735 women met inclusion criteria of whom 578 had fewer than 10 fibroids removed, and 157 patients had 10 or more removed (average number of fibroids removed 3.8 vs 14.7, p <.001; specimen's weight 317.4 g vs 371.0 g, p = .07). Body mass index was similar in both groups (p = .66) and patients with higher order myomectomy were more likely to have a history of myomectomy (12.0% vs 26.8%, p <.001). The average estimated blood loss (EBL) was 246 mL vs 470 mL in each group (p <.001). There were no significant differences in packed red blood cell transfusion (1.0% vs 0.6%, p = .65), conversion to laparotomy (0.5% vs 0.6%, p = .86), or complications including visceral injury, wound complication, venous thromboembolism, ileus, or readmission (5.9% vs 4.5%, p = .49). The hospital length of stay was similar in both groups (0.5 days vs 0.5 days, p = .63). On linear regression analysis, after adjusting for specimen's weight, operative time, and history of myomectomy, EBL remained significantly higher in patients with 10 or more fibroids removed (p = .02). CONCLUSION: EBL is increased in higher order myomectomy; however, blood transfusions, conversion to laparotomy, complication rates, and length of hospital stay did not differ compared with patients with fewer than 10 fibroids removed, highlighting the feasibility of minimally invasive higher order myomectomy.

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.

Persistence of Symptoms After Total vs Supracervical Hysterectomy in Women with Histopathological Diagnosis of Adenomyosis.

STUDY OBJECTIVE: To compare symptom persistence in women with adenomyosis based on retention or removal of the cervix at the time of hysterectomy. DESIGN: Retrospective cohort study and follow-up survey (Canadian Task Force classification xx). SETTING: Tertiary care academic hospital in Boston, Massachusetts. PATIENTS: Women (n = 1580) who underwent laparoscopic hysterectomy for benign indications between 2008 and 2012 at Brigham and Women's Faulkner Hospital and Brigham and Women's Hospital. INTERVENTION: Retrospective chart review and follow-up survey. MEASUREMENTS AND MAIN RESULTS: Among the 1580 women contacted, 762 (48%) responded to the postoperative symptom resolution survey. Of these 762 women, 623 agreed to participate in the study. Menopausal women or those who had undergone bilateral salpingo-oophorectomy were excluded. Adenomyosis was identified on histopathologic evaluation of the uterus in 171 of the remaining 443 women (39%). Compared with women without adenomyosis, those with adenomyosis were older on average (mean age, 46.6 ± 6.8 years vs 45.0 ± 5.5 years; p = .009) and more likely to report that abnormal bleeding and pain led to their hysterectomy (87.7% vs 79.8%; p = .03 and 64.9% vs 51.4%; p = .009, respectively). The rates of total and supracervical hysterectomies were similar in the 2 groups. Following surgery, women with adenomyosis were less likely than those without adenomyosis to report persistent pain (adjusted odds ratio [aOR], 0.43; 95% confidence interval [CI], 0.20-0.93; p = .03). Persistent bleeding was similar in the 2 groups (aOR, 0.97; 95% CI, 0.49-1.93; p = .94). Among women with adenomyosis, multivariable logistic regression showed no difference in persistence of symptoms with cervical removal or retention at the time of hysterectomy. CONCLUSION: Compared with women without adenomyosis, those with histopathologically proven adenomyosis were less likely to report persistent pain following hysterectomy. Retention of the cervix does not appear to increase the risk of symptom persistence or postprocedure patient satisfaction.

The sticky business of adhesion prevention in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: The negative impact of postoperative adhesions has long been recognized, but available options for prevention remain limited. Minimally invasive surgery is associated with decreased adhesion formation due to meticulous dissection with gentile tissue handling, improved hemostasis, and limiting exposure to reactive foreign material; however, there is conflicting evidence on the clinical significance of adhesion-related disease when compared to open surgery. Laparoscopic surgery does not guarantee the prevention of adhesions because longer operative times and high insufflation pressure can promote adhesion formation. Adhesion barriers have been available since the 1980s, but uptake among surgeons remains low and there is no clear evidence that they reduce clinically significant outcomes such as chronic pain or infertility. In this article, we review the ongoing magnitude of adhesion-related complications in gynecologic surgery, currently available interventions and new research toward more effective adhesion prevention. RECENT FINDINGS: Recent literature provides updated epidemiologic data and estimates of healthcare costs associated with adhesion-related complications. There have been important advances in our understanding of normal peritoneal healing and the pathophysiology of adhesions. Adhesion barriers continue to be tested for safety and effectiveness and new agents have shown promise in clinical studies. Finally, there are many experimental studies of new materials and pharmacologic and biologic prevention agents. SUMMARY: There is great interest in new adhesion prevention technologies, but new agents are unlikely to be available for clinical use for many years. High-quality effectiveness and outcomes-related research is still needed.

The menstrual cycle and blood loss during laparoscopic myomectomy.

INTRODUCTION: Operative morbidity of laparoscopic myomectomy largely relates to the potential for intraoperative blood loss. We sought to determine whether blood loss varies according to the menstrual cycle. MATERIAL AND METHODS: A retrospective study of 268 women who underwent a laparoscopic myomectomy from 2007 to 2012. Patients were categorized into five menstrual groups: follicular phase, luteal phase, oligomenorrheic or amenorrheic on hormonal therapy, postmenopausal or other. Patient and procedure characteristics were compared for the follicular phase group, luteal phase group, and hormonal therapy group. The estimated blood loss was compared across the five groups using a regression model. RESULTS: A total of 268 women underwent a laparoscopic myomectomy: 108 (40.3%) were in the follicular phase, 92 (34.3%) were in the luteal phase, 44 (16.4%) were on hormonal therapy, nine (3.4%) were postmenopausal, and 15 (5.6%) could not be classified. Baseline patient characteristics were similar between the groups with the exception of endometriosis. Geometric mean estimated blood loss was 91.9 mL in the follicular phase group, 108.7 mL in the luteal phase group, 114.1 mL in the hormonal therapy group, and 39.8 mL in the postmenopausal group. There was no significant difference in the geometric mean estimated blood loss when comparing the follilcuar phase, luteal phase, and hormonal phase groups (p = 0.41). Upon adjusted multivariable analysis of all five menstrual groups, there was also no difference in estimated blood loss. CONCLUSIONS: Intraoperative blood loss during laparoscopic myomectomy does not vary significantly with the phase of the menstrual cycle.

Essure Surgical Removal and Subsequent Symptom Resolution: Case Series and Follow-Up Survey.

Transcervical sterilization is a minimally invasive option for permanent contraception with high reported rates of patient satisfaction. A small percentage of women subsequently choose to have the tubal inserts removed due to regret or perceived side effects. There is limited information with regard to the improvement in the symptom profile following surgical removal of the tubal inserts. We present a retrospective case series of 11 women who underwent surgical removal of Essure by hysteroscopy, salpingectomy, and/or hysterectomy. The predominant symptom at presentation was pain (n = 10; 90.91%), as well as bleeding (n = 6; 54.54%) and/or dyspareunia (n = 5; 45.45%). After surgical removal, the majority of patients (n = 8; 72.72%) reported an improvement of their symptoms. However, 3 (27.27%) patients continued to have persistent symptoms after surgery. Before surgical removal of Essure, it is important to thoroughly discuss the risk of continuing symptoms with patients.

Open power morcellation versus contained power morcellation within an insufflated isolation bag: comparison of perioperative outcomes.

STUDY OBJECTIVE: To compare perioperative outcomes, particularly operative time, between uncontained and in-bag power morcellation of uterine tissue at the time of laparoscopic surgery. DESIGN: Canadian Task Force classification II-3. SETTING: Academic tertiary care hospitals. PATIENTS: Women undergoing laparoscopic hysterectomy or myomectomy who required morcellation of uterine tissue for specimen extraction. INTERVENTIONS: Outcomes among patients who had in-bag power morcellation were compared with outcomes among patients who had traditional power morcellation. The technique for in-bag morcellation entails placing the specimen into a large containment bag within the abdomen, insufflating the bag within the peritoneal cavity, and then using a power morcellator to remove the specimen from inside the bag. MEASUREMENTS AND MAIN RESULTS: The cohort consisted of 85 consecutive patients who underwent surgery with morcellation of uterine tissue. Prospective data collected from 36 patients who underwent in-bag morcellation were compared with retrospective data collected from the immediately preceding 49 patients who had uncontained power morcellation. Baseline demographics were comparable between the 2 groups although women who underwent in-bag morcellation were on average older than the open morcellation group (mean age in years [standard deviation], 49.19 [1.12] vs 44.06 [8.93]; p = .01). The mean operating room time was longer in the in-bag morcellation group (mean time in minutes [standard deviation], 119.0 [55.91] vs 93.13 [44.90]; p = .02). The estimated blood loss, specimen weight, hospital length of stay, and perioperative complication rate did not vary between the 2 groups. Operative times did not vary significantly by surgeon. There were no cases of malignancy or isolation bag disruption. CONCLUSIONS: In-bag power morcellation, a tissue extraction technique developed to reduce the risk of tissue dissemination, results in perioperative outcomes comparable with the traditional laparoscopic approach. In this cohort, the mean operative time was prolonged by 26 minutes with in-bag morcellation but may potentially be reduced with further refinement of the technique.

In-bag morcellation.

In-bag morcellation seems to be a viable alternative to open power morcellation and offers the advantage of minimal to no spillage of tissue or fluids during morcellation. We report our initial experience and technique using this approach.

MAUDE: analysis of robotic-assisted gynecologic surgery.

STUDY OBJECTIVE: To evaluate the adverse events encountered during robotic gynecologic surgery, as reported to the FDA MAUDE database from January 2006 to December 2012. DESIGN: Database search (Canadian Task Force classification III). INTERVENTION: A search of the FDA MAUDE database was performed by brand name "da Vinci" and manufacturer "Intuitive Surgical." Reports reflecting gynecologic procedures either by description or procedure name were included. A record of reports was kept to ensure that no duplicates were added. The date and type of event (operator-related error, technical system failure, or surgical injuries attributed to use of the robot) and the clinical outcome were recorded. MEASUREMENTS AND MAIN RESULTS: Twenty-six percent of reported events (n = 73) resulted in injury, and 8.5% (n = 24) resulted in death. Of note, although adnexal procedures were performed in <3% of the cohort, they accounted for 20% of the fatalities. Twenty-one percent of injuries were attributed to operator-related error, and 14% to technical system failure; 65% were not directly related to use of the robot. Fifteen deaths were reported during planned hysterectomy. Four of those were due to injury to a major blood vessel (iliac artery in 3, and aorta in 1), although a detailed description of how the injury occurred was absent from the event description. CONCLUSION: It is important to continue to evaluate the occurrence of injuries during robot-assisted surgery in an effort to identify unique challenges associated with this advanced technology.

Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study.

STUDY OBJECTIVE: To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. DESIGN: In vitro study (Canadian Task Force classification: II-1). SETTING: Academic hospital simulation laboratory. INTERVENTION: Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indigo carmine dye and morcellated under laparoscopic guidance within a plastic box trainer. CTE was performed via 3 different techniques: a stitch-sealed rip-stop nylon bag and multi-port approach; a one-piece clear plastic 50 × 50-cm isolation bag and multi-port approach; or a 1-piece clear plastic 50 × 50-cm isolation bag and single-site approach. Four trials of each CTE method were performed and compared with an open morcellation control. All bags were insufflated to within 10 to 25 mmHg pressure with a standard CO2 insufflator. Visual evidence of spilled tissue or dye was recorded, and fluid washings of the box trainer were sent for cytologic analysis. MEASUREMENTS AND MAIN RESULTS: Blue dye spill was noted in only 1 of 12 CTE trials. Spillage was visualized from a seam in 1 of the 4 stitch-sealed rip-stop nylon bags before morcellation of the specimen. The only trial in which gross tissue chips were visualized in the box trainer after morcellation was the open morcellation control. However, cytologic examination revealed muscle cells in the open morcellation washings and in the washings from the trial with dye spill. Muscle cells were not observed at cytologly in any of the other samples. CONCLUSION: CTE did not result in any leakage or tissue dissemination with use of the single-site or multi-port approach when using a 1-piece clear plastic 50 × 50-cm isolation bag. Further studies are needed to corroborate these findings in an in vivo context and to evaluate use of alternate bag options for specimen containment.

Comparison of Nintendo Wii and PlayStation2 for enhancing laparoscopic skills.

BACKGROUND AND OBJECTIVE: The increase in laparoscopic surgery has led to a growing need to train residents in this skill. Virtual reality simulators and box trainers have been used as educational tools outside of the operating room, but both approaches have advantages and disadvantages. Video games have been an area of interest in the search for other modalities to train residents. Experience with the traditional single controller unit video games have been correlated with better surgical skill acquisition. In 2006, Nintendo introduced the Wii, a novel gaming modality that mimics movements in laparoscopy better than traditional games do. Our objective was to compare the Nintendo Wii and PlayStation2 for enhancing laparoscopy skills. METHODS: The study included stratified randomization of 23 less experienced ( 12 laparoscopy cases per year) and 19 more experienced ( 12 per year) physicians, residents, and medical students to 30 min of Wii versus PlayStation2 in a university-affiliated hospital Department of Obstetrics and Gynecology. Pre- and posttest bead transfer and suturing scores were obtained. RESULTS: Baseline characteristics were similar for both video game groups. Participants assigned to Wii and PlayStation2 both demonstrated significant improvement in bead transfer. Neither Wii nor PlayStation2 participants improved in suturing scores. The Wii group improved more in bead transfer scores when compared to the PlayStation2 group (60 points vs. 40 points, respectively), but this difference was not statistically significant. CONCLUSIONS: Both Wii and PlayStation2 significantly improved laparoscopic skills in bead transfer. These video games may be inexpensive alternatives to laparoscopy training simulators.

Photoacoustic-Guided Laparoscopic and Open Hysterectomy Procedures Demonstrated With Human Cadavers.

Hysterectomy (i.e., surgical removal of the uterus) requires severing the main blood supply to the uterus (i.e., the uterine arteries) while preserving the nearby, often overlapping, ureters. In this paper, we investigate dual-wavelength and audiovisual photoacoustic imaging-based approaches to visualize and differentiate the ureter from the uterine artery and to provide the real-time information needed to avoid accidental ureteral injuries during hysterectomies. Dual-wavelength 690/750 nm photoacoustic imaging was implemented during laparoscopic and open hysterectomies performed on human cadavers, with a custom display approach designed to visualize the ureter and uterine artery. The proximity of the surgical tool to the ureter was calculated and conveyed by tracking the surgical tool in photoacoustic images and mapping distance to auditory signals. The dual-wavelength display showed up to 10 dB contrast differences between the ureter and uterine artery at three separation distances (i.e., 4 mm, 5 mm, and 6 mm) during the open hysterectomy. During the laparoscopic hysterectomy, the ureter and uterine artery were visualized in the dual-wavelength image with up to 24 dB contrast differences. Distances between the ureter and the surgical tool ranged from 2.47 to 7.31 mm. These results are promising for the introduction of dual-wavelength photoacoustic imaging to differentiate the ureter from the uterine artery, estimate the position of the ureter relative to a surgical tool tip, map photoacoustic-based distance measurements to auditory signals, and ultimately guide hysterectomy procedures to reduce the risk of accidental ureteral injuries.

Pilot study of fractional CO2 laser therapy for genitourinary syndrome of menopause in gynecologic cancer survivors.

PURPOSE: The objectives of this study were to evaluate the feasibility and efficacy of fractional CO2 laser therapy in gynecologic cancer survivors. METHODS: This was a pilot, multi-institutional randomized sham-controlled trial of women with gynecologic cancers with dyspareunia and/or vaginal dryness. Participants were randomized to fractional CO2 laser treatment or sham laser treatment. The primary aim was to estimate the proportion of patients who had improvement in symptoms based on the Vaginal Assessment Scale (VAS). Secondary aims included changes in sexual function assessed using the Female Sexual Functioning Index (FSFI) and urinary symptoms assessed using the the Urinary Distress Inventory (UDI-6). RESULTS: Eighteen women participated in the study, ten in the treatment arm and eight in the sham arm. The majority of participants had stage I (n = 11, 61.1 %) or II (n = 3, 16.7 %) endometrial cancer with adenocarcinoma histology (n = 9, 50 %). In total, 15 (83.3 %) of the participants completed all treatments and follow-up visit. There was no difference in the change in the median VAS score from baseline to follow-up. However, there was an improvement in change in the median total FSFI score with treatment compared with sham (Δ 6.5 vs -0.3, p = 0.02). The change in the median UDI-6 score was lower in the treatment arm (Δ -14.6 vs -2.1, p = 0.17), but this was not statistically significant. There were no reported serious adverse events. CONCLUSIONS: Fractional CO2 laser therapy is feasible in gynecologic cancer survivors, with preliminary evidence of safety. In addition, there was preliminary evidence of improvement in sexual function compared with sham treatment. Clinicaltrial.gov Identifier: NCT03372720 (OSU-17261; NCI-2017-02051).

A Phase I Clinical Trial to Assess Safety and Tolerability of Injectable Collagenase in Women with Symptomatic Uterine Fibroids.

Uterine fibroids feature excessive deposition of types I and III collagen. Previous ex vivo studies showed an FDA-approved collagenase (EN3835)-digested types I and III collagen fibers in fibroid tissues; however, collagenase had not been evaluated in vivo for effects on uterine fibroids. The objective was to assess the safety and tolerability of collagenase injection directly into uterine fibroids. This was a prospective, open label, dose escalation study. The study participants were fifteen women aged 35-50 years with symptomatic uterine fibroids planning to undergo hysterectomy. Three subjects received saline and methylene blue, three subjects received a fixed dose of EN3835, and 9 subjects received stepped, increasing dosages of EN3835, all by transvaginal, ultrasound-guided injections. Primary outcome measures were safety and tolerability of the injection and change in collagen content between treated and control tissues. There were no significant adverse events following injection of EN3835 into uterine fibroids. Masson's trichrome stains revealed a 39% reduction in collagen content in treated samples compared to controls (p <0.05). Second harmonic generation (SHG) analysis showed treated samples to have a 21% reduction in density of collagen compared to controls. Picrosirius-stained collagenase-treated fibroids showed collagen fibers to be shorter and less dense compared to controls. Subjects reported a decrease in fibroid-related pain on the McGill Pain Questionnaire after study drug injection in Group 2 at both 4-8 days and 60-90 days post-injection. The findings indicated that injection of collagenase was safe and well tolerated. These results support further clinical investigation of collagenase as a minimally invasive treatment of uterine fibroids. NCT0289848.

Novel Management of Ectopic Pregnancy in a Noncommunicating Rudimentary Horn of a Unicornuate Uterus.

Pregnancy in a rudimentary horn is a rarely encountered form of ectopic pregnancy and is often an emergent situation because of the risk of rupture of the horn. A 31-year-old gravida 3 para 1 woman with 7 to 8 weeks' gestational age was found to have a viable pregnancy in a rudimentary noncommunicating horn of a unicornuate uterus. She elected termination of the pregnancy via local intracardiac lidocaine and intra-amniotic methotrexate injections. Subsequent removal of the rudimentary horn was necessary to prevent recurrence. Because of the risk of rupture, the diagnosis and management of an ectopic pregnancy in a rudimentary horn can be emergent.