Ergonomics: making the OR a comfortable place.

INTRODUCTION: The objective of this video is to highlight strategies to improve operating room (OR) ergonomics, which will result in increased surgeon comfort during minimally invasive gynecologic surgery and decreased risk of musculoskeletal injury. METHODS: Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons, including those who perform minimally invasive gynecologic surgery. WMSDs are repetitive strain injuries that can damage a surgeon's muscles, nerves, and/or joints and commonly affect the neck, back, wrist, and hands. In addition to chronic pain, these injuries can lead to decreased job satisfaction and productivity. RESULTS: This video will discuss general ergonomic principles and demonstrate ergonomic techniques in conventional laparoscopic, vaginal, and robotic surgery. CONCLUSIONS: Minimally invasive gynecologic surgery can be physically taxing on the surgeon. Understanding principles and utilizing techniques of OR ergonomics can minimize these physical demands and result in a long, healthy, and pain-free surgical career.

Simple and effective: transvaginal vesico-vaginal fistula repair with a modified Latzko technique.

INTRODUCTION AND HYPOTHESIS: The incidence of vesico-vaginal fistulas after hysterectomies for benign indications in developed countries is less than one percent. The objective of this video is to demonstrate an easy-to-follow, step-by-step approach to repairing a small, uncomplicated vesico-vaginal fistula transvaginally using a modified Latzko technique. METHODS: In this video, we present a case of a 46-year-old woman who developed a simple, uncomplicated vesico-vaginal fistula after a total abdominal hysterectomy. To correct her fistula, we used a modified Latzko technique, which is a transvaginal approach to vesico-vaginal fistula repair that involves mobilizing the vaginal mucosa around the fistula and then closing the pubo-vesical fascia and vaginal mucosa in layers. RESULTS: The patient had successful surgical correction of her vesico-vaginal fistula without recurrence of the fistula. CONCLUSIONS: For small, uncomplicated vesico-vaginal fistulas, a transvaginal approach has an equivalent success rate to that of other approaches with less invasiveness and faster recovery times. Therefore, it is reasonable to use a modified Latzko technique to help restore the quality of life to women affected by small, uncomplicated vesico-vaginal fistulas.

Pilot Clinical Evaluation of a Confocal Microlaparoscope for Ovarian Cancer Detection.

OBJECTIVE: The aim of this study is to evaluate the performance of a confocal fluorescence microlaparoscope for in vivo detection of ovarian cancer. METHODS/MATERIALS: Seventy-one patients scheduled for open or laparoscopic oophorectomy were consented for the imaging study. High-resolution confocal microlaparoscopic images of the epithelial surface of the ovary were acquired in vivo or ex vivo after tissue staining using acridine orange. Standard histologic evaluation of extracted tissue samples was performed and used as the gold standard of disease diagnosis. Trained human observers from different specialties viewed the microlaparoscopic images, rating each image on a 6-point scale ranging from "definitely not cancer" to "definitely cancer." Receiver operating characteristic curves were generated using these scores and the gold standard histopathologic diagnosis. Area under the receiver operating characteristic curve (AUC) was calculated as a performance metric. RESULTS: Forty-five of the consented patients were used in the final evaluation study. From these 45 patients, 63 tissue locations or samples were identified and imaged with the confocal microlaparoscope. Twenty of the samples were high-grade cancers, and the remaining 43 samples were normal or noncancerous. Twenty-three of the samples were imaged in vivo, and the remaining 40 samples were imaged ex vivo. The average AUC score and standard error (SE) for detection of cancer in all images were 0.88 and 0.02, respectively. An independent-samples t test was conducted to compare AUC scores for in vivo and ex vivo conditions. No statistically significant difference in the AUC score for in vivo (AUC, 0.850; SE, 0.049) and ex vivo (AUC, 0.888; SE, 0.027) conditions was observed, t(6) = 1.318, P = 0.2355. CONCLUSIONS: Area under the receiver operating characteristic curve scores indicate that high-resolution in vivo images obtained by the confocal laparoscope can distinguish between normal and malignant ovarian surface epithelium. In addition, in vivo performance is similar to that which can be obtained from ex vivo tissue.

Assessment of the Role of Intraoperative Frozen Section in Guiding Surgical Staging for Endometrial Cancer.

OBJECTIVE: The aim of this study was to assess the role of intraoperative frozen section (FS) in guiding decision making for surgical staging of endometrioid endometrial cancer (EC). METHODS: Medical records were collected retrospectively on 112 patients with endometrioid EC, who underwent total hysterectomy and bilateral salpingo-oophorectomy at the University of Arizona Medical Center from January 1, 2010, to December 31, 2014. Only patients with endometrioid adenocarcinoma, grade 1, less than 50% myometrial invasion, and tumor size less than 2 cm determined by intraoperative FS omitted lymphadenectomy; otherwise, surgical staging was performed with lymph node dissection. The FS results were compared with the permanent paraffin sections (PSs) to assess the diagnostic accuracy. RESULTS: The concordance rate of different variables between FS and PS in EC was 100%, 89.3% (100/112), 97.3% (109/112), and 95.5% (107/112), respectively, with respecting to histological subtype, grade, myometrial invasion, and tumor size. Diagnostic accurate rate of combined risk factors deciding surgical staging at the time of FS was 95.5% (107/112), and the discordance rate of all risk factors considered between FS and PS was 4.5%, resulting 3 cases (2.7%) undertreated and 2 cases (1.8%) overtreated. CONCLUSIONS: Despite nonideal FS evaluation, intraoperative FS diagnosis for EC is highly reliable by providing guidance for the intraoperative decisions of surgical staging at our institution, and such guidelines may be referenced by the institutions with sufficient gynecologic pathology expertise.

Secretory cell expansion with aging: risk for pelvic serous carcinogenesis.

OBJECTIVE: Recent advances suggest that precancerous lesions of pelvic serous carcinoma (PSC) originate from tubal secretory cells. The purpose of our study was to determine if increased number of secretory cells shows difference in age and location and to examine their association with serous neoplasia. MATERIALS AND METHODS: Three groups (benign control, high-risk, and PSC) of patients with matched ages were studied. The age data was stratified into 10-year intervals ranging from age 20 to older than 80. The number of secretory and ciliated cells from both tubal fimbria and ampulla segments was counted by microscopy and immunohistochemical staining methods. The data was analyzed by standard contingency table and Poisson distribution methods after age justification. RESULTS: We found that the absolute number of tubal secretory cells increased significantly with age within each age group. Age remained a significant risk factor for serous neoplasia after age adjustment. In addition, a dramatic increase of secretory cells was observed in high-risk and PSC patients. Further, secretory cell expansion (SCE) was more prevalent than secretory cell outgrowth in both fimbria and ampulla tubal segments and was significantly associated with serous neoplasia (p<0.001). CONCLUSIONS: These findings suggest that SCE could potentially serve as a sensitive biomarker for early serous carcinogenesis within the fallopian tube. Findings support a relationship between serous neoplasia and increased secretory to ciliated cell ratios. Findings also support a relationship between frequency of SCE and increasing age, presence of high-risk factors and co-existing serous cancers.

Laparoscopic pectopexy for patients with intraabdominal adhesions, lumbar spinal procedures, and other contraindications to sacrocolpopexy: a case series.

Laparoscopic pectopexy is an alternative to sacrocolpopexy utilizing fixation points in the anterior pelvis for vaginal vault suspension; it was originally developed for an obese population. This is a retrospective case series of 7 women who underwent laparoscopic pectopexy at one academic Institution between October 2019 and December 2020. The patients had preoperative vaginal vault prolapse (pelvic organ prolapse quantification system [POP-Q], stage 2 and 3). Pectopexy was performed because of relative contraindications to sacrocolpopexy, including use of antiplatelet therapy, extensive adhesions, and chronic back pain with lumbo-spinal fusion. No intraoperative complications were documented in this cohort. Average blood loss was 32.9 mL. All the patients were discharged home within 24 hours. One patient experienced urinary retention that required release of the retropubic midurethral sling placed at the time of pectopexy. The most recent follow-up examination occurred at an average of 127 days after the procedure. All 7 patients had a resolution of their prolapse (POP-Q ≤1). This case series highlights the application of pectopexy for patients with extensive adhesions, use of antiplatelet therapy and lumbar or sacral spinal surgical history. The complication rates and operative results are comparable with sacrocolpopexy at intermediate-term follow-up in this small case series, indicating that pectopexy may be a promising alternative for patients with relative contraindications to sacrocolpopexy. This is the first report of the application of the technique in North America.

Serous endometrial intraepithelial carcinoma arising in adenomyosis: a report of 5 cases.

Serous endometrial intraepithelial carcinoma (serous EIC) arising in adenomyosis is rare. It may be underrecognized because of its deceiving morphology when embedded in the foci of adenomyosis. Although there is no connection to peritoneal cavity, some cases may be associated with extrauterine disease. It is currently unknown what the etiology for such a disease is. More studies are in need to elucidate the pathogenesis of such a grave malady. We report a series of 5 cases of serous EIC, which may arise in adenomyosis. The 5 cases are in 5 different patients or whom on histopathological examination of their hysterectomy specimens, the finding of adenomyosis involved with serous intraepithelial neoplasia was identified. The finding of interest was the presence of multifoci of adenomyosis; some of those foci were involved in serous EIC. In addition to EIC, lesions of endometrial glandular dysplasia were present in the foci of adenomyosis. To rule out the possibility of endometrial serous carcinoma (ESC) invading into the areas of the adenomyosis, all of the 5 uteri were extensively examined. Among the 5 uteri, the eutopic endometirum showed 1 invasive ESC, 2 serous EIC, and 2 benign resting endometrium without any cancer or precancerous lesions. In 1 uterus with ESC, we did not see any direct spatial connection between the invasive component of ESC and the areas of EIC in the foci of adenomyosis. In 2 uteri with serous EIC within the endometrial cavity, there was a distance of at least 0.5 cm between the lesions within the endometrial cavity and the serous EIC in adenomyosis. The remaining 2 uteri showed no evidence of endometrial malignancy in the endometrial cavity, whereas serous EIC was present only in areas of adenomyosis. Clinicopathologic data including characterized immunohistochemical stainings and p53 gene sequence analysis are presented and clinical significance is discussed.

In vivo imaging of ovarian tissue using a novel confocal microlaparoscope.

OBJECTIVE: The objective of the study was to develop a clinical confocal microlaparoscope for imaging ovary epithelium in vivo with the long-term objective of diagnosing cancer in vivo. STUDY DESIGN: A confocal microlaparoscope was developed and used to image the ovaries of 21 patients in vivo using fluorescein sodium and acridine orange as the fluorescent contrast agents. RESULTS: The device was tested in vivo and demonstrated to be safe and function as designed. Real-time cellular visualization of ovary epithelium was demonstrated. CONCLUSION: The confocal microlaparoscope represents a new type of in vivo imaging device. With its ability to image cellular details in real time, it has the potential to aid in the early diagnosis of cancer. Initially the device may be used to locate unusual regions for guided biopsies. In the long term, the device may be able to supplant traditional biopsies and allow the surgeon to identify early-stage ovarian cancer.

Pilot study of the prospective identification of changes in cognitive function during chemotherapy treatment for advanced ovarian cancer.

Change in cognitive function is increasingly being recognized as an adverse outcome related to chemotherapy treatment. These changes need not be severe to impact patient functional ability and quality of life. The primary goal of this study was to determine if there is evidence of changes in the cognitive function domains of attention, processing speed, and response time among women with newly diagnosed advanced ovarian cancer who receive chemotherapy. Eligible patients were women diagnosed with stage III-IV epithelial ovarian or primary peritoneal cancer who had not yet received chemotherapy but who were prescribed a minimum of six cycles (courses) of chemotherapy treatment. Cognitive function was assessed by a computerized, Web-based assessment (attention, processing speed, and reaction time) and by patient self-report. Cognitive function was assessed at three time points: prior to the first course (baseline), course three, and course six. Medical records were reviewed to abstract information on chemotherapy treatment, concomitant medications, and blood test results (e.g., hemoglobin, CA-125). Of the 27 eligible participants, 92% and 86% demonstrated cognitive impairments from baseline to course three and from baseline to course six of chemotherapy, respectively. Impairment was detected in two or more cognitive domains among 48% (12 of 25) and 41% (9 of 22) of participants at course three and course six of chemotherapy, respectively. This study shows evidence of decline in cognitive function among women being treated for ovarian cancer. There is a need for additional, prospective research to better understand the impact of chemotherapy on cognitive function among ovarian cancer patients so that effective preventive and treatment strategies can be developed.

Laparoscopic optical coherence tomography imaging of human ovarian cancer.

OBJECTIVES: Ovarian cancer is the fourth leading cause of cancer-related death among women in the US largely due to late detection secondary to unreliable symptomology and screening tools without adequate resolution. Optical coherence tomography (OCT) is a recently emerging imaging modality with promise in ovarian cancer diagnostics, providing non-destructive subsurface imaging at imaging depths up to 2 mm with near-histological grade resolution (10-20 microm). In this study, we developed the first ever laparoscopic OCT (LOCT) device, evaluated the safety and feasibility of LOCT, and characterized the microstructural features of human ovaries in vivo. METHODS: A custom LOCT device was fabricated specifically for laparoscopic imaging of the ovaries in patients undergoing oophorectomy. OCT images were compared with histopathology to identify preliminary architectural imaging features of normal and pathologic ovarian tissue. RESULTS: Thirty ovaries in 17 primarily peri- or post-menopausal women were successfully imaged with LOCT: 16 normal, 5 endometriosis, 3 serous cystadenoma, and 4 adenocarcinoma. Preliminary imaging features developed for each category reveal qualitative differences in the homogeneous character of normal post-menopausal ovary, the ability to image small subsurface inclusion cysts, and distinguishable features for endometriosis, cystadenoma, and adenocarcinoma. CONCLUSIONS: We present the development and successful implementation of the first laparoscopic OCT probe. Comparison of OCT images and corresponding histopathology allowed for the description of preliminary microstructural features for normal ovary, endometriosis, and benign and malignant surface epithelial neoplasms. These results support the potential of OCT both as a diagnostic tool and an imaging modality for further evaluation of ovarian cancer pathogenesis.

Mucinous adenocarcinoma of the endometrium with metastasis to the clitoral glans after pelvic exenteration for radiation resistant vaginal cuff recurrence.

Mucinous adenocarcinoma of the endometrium (MACE) is a rare subtype of endometrial adenocarcinoma that often presents a significant diagnostic challenge due to its variation from the conventional morphologic appearance of endometrioid epithelium. This case report is of a woman who has survived 4 years after pelvic exenteration and subsequent vulvectomy for recurrent MACE.

A Novel Treatment for Massive Hemorrhage after Maternal Trauma in Pregnancy.

Background Trauma in pregnancy can lead to life-threatening hemorrhage. Conventional treatments of hemorrhage include medical and surgical management. However, if these measures fail uterine compression is an option to control bleeding. We present a case where this management was employed. Case A patient presented at 36 weeks of gestation with multiple injuries after a motor vehicle collision and experienced disseminated intravascular coagulation (DIC). The use of a Bakri balloon in combination with external compression with Coban, a sterile self-adherent bandage, after delivery temporized her bleeding and allowed her to become stable for further management. Conclusion When other measures fail and a hysterectomy is considered unsafe, the combination of internal and external uterine compression is an option.

Complete resolution of Paget disease of the vulva with imiquimod cream.

Extra mammary Paget disease (EMPD) is a neoplastic disease of apocrine gland bearing skin. Surgical excision is the standard of care for EMPD; however, it is accompanied by recurrence in more than 60% of the patients. Recently, imiquimod cream has been reported to induce complete responses in primary or recurrent EMPD. We report on 2 women with vulva EMPD who achieved biopsy-confirmed resolution of their disease after topical application of imiquimod 5% cream.

Vaginal Mesh Removal Outcomes: Eight Years of Experience at an Academic Hospital.

OBJECTIVES: The purpose of this study is to describe the clinical history leading up to and the outcomes after vaginal mesh removal surgery at an academic hospital. METHODS: A retrospective case series of patients who underwent vaginal mesh removal from 2008 to 2015 was conducted. Demographics, clinical history, physical examination, pre- and postoperative symptoms, and number and type of reoperations were abstracted. RESULTS: Between February 2008 and November 2015, 83 patients underwent vaginal mesh removal surgery at our hospital. The median time interval from initial mesh placement to removal was 58 months (range, 0.4-154 months). The most common preoperative symptoms were vaginal pain (n = 52, 62%), dyspareunia (n = 46, 55%), and pelvic pain (n = 42, 50%). Intraoperative complications were infrequent (n = 3, 4%). Of patients presenting for follow-up within 4 to 6 weeks postoperatively, the most common symptoms were urinary incontinence (n = 15, 28%), vaginal pain (n = 7, 13%), buttock pain (n = 5, 9%), and urinary tract infection (n = 5, 9%). There were no identifiable risk factors to predict which patients would have persistent postoperative symptoms or who would require more than 1 mesh removal surgery. After vaginal mesh removal, 29 patients (35%) required 1 or more reoperations, with 3 being the highest number of reoperations per patient. The total number of reoperations was 43, with a total of 63 individual procedures performed. Forty-four percent (n = 28) of the procedures were graft removals, 40% (n = 25) were pelvic organ prolapse surgeries (only native tissue repairs), and 16% (n = 10) were stress incontinence surgeries. More than 1 procedure was performed in 49% (n = 21) of the reoperations. CONCLUSIONS: Vaginal mesh removal surgery is safe; however, some patients require more than 1 procedure, and the risk factors for reoperations are unclear.

Multispectral fluorescence imaging of human ovarian and fallopian tube tissue for early-stage cancer detection.

With early detection, 5-year survival rates for ovarian cancer exceed 90%, yet no effective early screening method exists. Emerging consensus suggests over 50% of the most lethal form of the disease originates in the fallopian tube. Twenty-eight women undergoing oophorectomy or debulking surgery provided informed consent for the use of surgical discard tissue samples for multispectral fluorescence imaging. Using multiple ultraviolet and visible excitation wavelengths and emissions bands, 12 fluorescence and 6 reflectance images of 47 ovarian and 31 fallopian tube tissue samples were recorded. After imaging, each sample was fixed, sectioned, and stained for pathological evaluation. Univariate logistic regression showed cancerous tissue samples had significantly lower intensity than noncancerous tissue for 17 image types. The predictive power of multiple image types was evaluated using multivariate logistic regression (MLR) and quadratic discriminant analysis (QDA). Two MLR models each using two image types had receiver operating characteristic curves with area under the curve exceeding 0.9. QDA determined 56 image type combinations with perfect resubstituting using as few as five image types. Adaption of the system for future in vivo fallopian tube and ovary endoscopic imaging is possible, which may enable sensitive detection of ovarian cancer with no exogenous contrast agents.

Validation of referral guidelines for women with pelvic masses.

OBJECTIVE: Guidelines for referring women with pelvic masses suspicious for ovarian cancers to gynecologic oncologists have been published jointly by Society of Gynecologic Oncologists (SGO) and the American College of Obstetricians and Gynecologists (ACOG). They are based on patient age, CA 125 level, physical findings, imaging study results, and family history. Although the guidelines are evidence-based, their predictive value in distinguishing cancers from benign masses is unknown. METHODS: Chart review for factors included in the guidelines of surgically evaluated women with pelvic masses at 7 tertiary care centers during a 12-month interval was performed. This information was used to estimate the predictive values of the SGO and ACOG guidelines in identifying patients with malignant pelvic masses. RESULTS: A total of 1,035 patients were identified, including 318 (30.7%) with primary malignancies of the ovary, fallopian tube, or peritoneum. Seventy-seven were younger than 50 years old (premenopausal group), and 240 were 50 years old or older (postmenopausal group). Fifty additional patients (4.8%) had cancers metastatic to the ovaries, and the remaining 667 (64.4%) had benign masses. The referral guidelines captured 70% of the ovarian cancers in the premenopausal group and 94% of the ovarian cancers in the postmenopausal group. The positive predictive value was 33.8% for the premenopausal group and 59.5% for the postmenopausal group, whereas the negative predictive values were more than 90% for both groups. Elevated CA 125 level was the single best predictor of malignancy in both groups. CONCLUSION: The SGO and ACOG referral guidelines effectively separate women with pelvic masses into 2 risk categories for malignancy. This distinction permits a rational approach for referring high-risk patients to a gynecologic oncologist for management.

Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening.

Human papillomavirus (HPV) DNA testing was recently approved by the Food and Drug Administration for use as an adjunct to cytology for cervical cancer screening. To help provide guidance to clinicians and patients when using HPV DNA testing as an adjunct to cervical cytology for screening, a workshop was cosponsored by the National Institutes of Health-National Cancer Institute, American Society of Colposcopy and Cervical Pathology (ASCCP), and American Cancer Society. Consensus was reached based on a literature review, expert opinion, and unpublished results from large ongoing screening studies. The conclusions of the workshop were that HPV DNA testing may be added to cervical cytology for screening in women aged 30 years or more. Women whose results are negative by both HPV DNA testing and cytology should not be rescreened before 3 years. Women whose results are negative by cytology, but are high-risk HPV DNA positive, are at a relatively low risk of having high-grade cervical neoplasia, and colposcopy should not be performed routinely in this setting. Instead, HPV DNA testing along with cervical cytology should be repeated in these women at 6 to 12 months. If test results of either are abnormal, colposcopy should then be performed. This guidance should assist clinicians in utilizing HPV DNA testing in an effective manner, while minimizing unnecessary evaluations and treatments.

Folate, vitamin B12, and homocysteine status. findings of no relation between human papillomavirus persistence and cervical dysplasia.

OBJECTIVES: Human papillomavirus (HPV) infections are the cause of most, if not all, cervical cancers. Women consistently positive for oncogenic type HPV infections have a greater risk of developing cervical dysplasia compared with women transiently infected. HPV infection alone appears to be insufficient to produce disease, suggesting that other cofactors may be needed. Folate, vitamin B12, and homocysteine, through their role in DNA methylation, may be involved in cervical neoplasia. METHODS: This study examined the associations between HPV persistence and circulating folate, vitamin B12, and homocysteine levels among 91 low-income Hispanic women. Further, the relation of these nutrients to cervical pathology was evaluated. HPV status was determined at two visits approximately 3 mo apart. RESULTS: Adjusted mean circulating concentrations of folate, vitamin B12, and homocysteine were not statistically different between women with two positive HPV tests, one positive test, or two negative HPV tests. No association was observed between tertiles of folate, vitamin B12, or homocysteine and HPV persistence risk. Further, adjusted mean levels of these nutrients were not statistically different between cytologic grades. CONCLUSIONS: Results from this small study did not support a role for folate, vitamin B12, or homocysteine in HPV persistence or cervical dysplasia.

Thin-layer cytology and histopathology in the evaluation of abnormal uterine bleeding.

OBJECTIVE: To compare thin-layer endometrial cytology to endometrial biopsy and surgical pathology in women with abnormal uterine bleeding. STUDY DESIGN: We performed a prospective study of 103 women. Patients underwent endometrial cytologic evaluation using an endometrial brush, followed by either endometrial biopsy, hysteroscopy with dilation and curettage, or hysterectomy, as clinically indicated. Test performance characteristics and adequacy of cytology and endometrial biopsy were assessed. Ki-67 immunocytochemical expression was evaluated in a random subset of 60 specimens. RESULTS: Cytologic sampling demonstrated a sensitivity of 78%, a specificity of 96%, a positive predictive value of 78% and a negative predictive value of 96% for the detection of endometrial abnormalities. The unsatisfactory rate of uterine cytology was 15% as compared to 26% for endometrial biopsy. Of adenocarcinoma cases, 83% expressed Ki-67, as compared to 30% in benign cases. CONCLUSION: Endometrial cytology may be useful in the detection of endometrial hyperplasia and neoplasia and provides adequate material for the assessment of Ki-67.