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1.
Radiology ; 311(1): e232191, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38591980

RESUMEN

Endometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often has a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists frequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing techniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, establishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and makes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients.


Asunto(s)
Endometriosis , Humanos , Femenino , Endometriosis/diagnóstico por imagen , Consenso , Diagnóstico Tardío , Ultrasonografía , Radiólogos
2.
J Minim Invasive Gynecol ; 31(2): 71-83.e17, 2024 02.
Artículo en Inglés | MEDLINE | ID: mdl-37931893

RESUMEN

OBJECTIVE: No consensus currently exists regarding patient-reported outcome measure (PROM) instruments. This structured review was conducted to identify the PROMs used by randomized controlled trials (RCTs) that evaluated surgical treatment in patients with endometriosis. DATA SOURCES: Two parallel searches were conducted by a medical librarian using Ovid MEDLINE, Ovid Embase, and Cochrane Library for RCTs published from 2000 to July 2022. One search focused on studies reporting quality of life (QoL), and the second search focused on studies reporting pain and sexual, bowel, and bladder function. METHOD OF STUDY SELECTION: During the title and abstract screening and reference check, 600 results were identified on PROMs relating to QoL and 465 studies on PROMs relating to pain and sexual, bowel, and/or bladder function and an evaluation of 17 and 12 studies conducted, respectively. The inclusion criteria involved selecting RCTs that focused on surgical intervention and assessing QoL, pain, and sexual, bowel, and/or bladder function using PROMs. TABULATION, INTEGRATION, AND RESULTS: Covidence software was used to organize and identify duplicate articles through screening. We developed a data extraction form to collect key information about each included study, as well as the pertinent PROMs used in the study. Assessment of the risk of bias of each study was also performed. A total of 19 studies were identified involving 2089 participants and a total of 16 PROMs used across the studies; 9 of 19 studies (47%) were rated as having a low risk of bias. There were no high-risk studies identified in this review. CONCLUSION: This study identified a large number of RCTs in surgical treatment of endometriosis that used various PROMs to assess QoL, pain, and bladder, bowel, and sexual function. The PROMs used by high-quality RCTs for QoL include Endometriosis Health Profile-30, Endometriosis Health Profile-5, Short-Form 36, Short-Form 12, and EQ-5D; for bowel-related symptoms Knowles-Eccersley-Scott-Symptom Questionnaire, Gastrointestinal Quality of Life Index, and Cleveland Clinic Fecal Incontinence Severity Scoring System/Wexner; for bladder-related function Bristol Female Lower Urinary Tract Symptoms, International Prostate Symptom Score, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and Urinary Symptom Profile; and finally for sexual function Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire and Sexual Activity Questionnaire. Unlike other domains, only one tool (visual analog scale) was the dominant PROM used for the assessment of pain. In addition, the use of more than one PROM in each study to assess different aspects of patient's health and pain symptoms did not become prevalent until after 2015.


Asunto(s)
Endometriosis , Prolapso de Órgano Pélvico , Incontinencia Urinaria , Masculino , Femenino , Humanos , Endometriosis/cirugía , Ensayos Clínicos Controlados Aleatorios como Asunto , Dolor , Calidad de Vida , Medición de Resultados Informados por el Paciente
3.
J Obstet Gynaecol Can ; 46(6): 102456, 2024 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-38588946

RESUMEN

OBJECTIVES: Venous thromboembolism (VTE) occurs in 0.4%-0.7% of benign hysterectomies. Pelvic vascular compression secondary to fibroids may elevate VTE risk. We aimed to evaluate the incidence and timing of VTE among individuals undergoing hysterectomy for fibroids and other benign indications. METHODS: Retrospective cohort study of patients who underwent a hysterectomy for fibroid and non-fibroid indications from January 2015 to December 2021. Main outcome measure was VTE consisting of pulmonary embolism or deep venous thrombosis diagnosed during 3 periods: (1) preoperative (1 year before surgery until day before surgery), (2) early postoperative (surgery date through 6 weeks after surgery), and (3) late postoperative (6 weeks to 1 year after surgery). Demographics, comorbidities, surgical characteristics, and VTE rates were compared by indication. RESULTS: A total of 263 844 individuals with fibroids and 203 183 without were identified. In total, 1.1% experienced VTE. On multivariable regression (adjusted demographic confounders and route of surgery), the presence of fibroids was associated with increased odds of preoperative (adjusted odds ratio [aOR] 1.12; 95% CI 1.03-1.22, P = 0.011) and reduced odds of late postoperative VTE (aOR 0.81; 95% CI 0.73-0.91, P < 0.001). For individuals with fibroids, uterine weight ≥250 g and undergoing laparotomy were independently associated with preoperative (aOR 1.29; 95% CI 1.09-1.52, P = 0.003 and aOR 2.32; 95% CI 2.10-2.56, P < 0.001) and early postoperative VTE (aOR 1.32; 95% CI 1.08-1.62, P = 0.006 and aOR 1.72; 95% CI 1.50-1.96, P < 0.001). CONCLUSIONS: Patients with fibroids were at increased odds of having VTE 1 year before hysterectomy. For those with fibroids, elevated uterine weight and laparotomy were associated with greater risk of preoperative and early postoperative VTEs.


Asunto(s)
Histerectomía , Leiomioma , Complicaciones Posoperatorias , Neoplasias Uterinas , Tromboembolia Venosa , Humanos , Femenino , Histerectomía/efectos adversos , Estudios Retrospectivos , Leiomioma/cirugía , Leiomioma/complicaciones , Tromboembolia Venosa/epidemiología , Tromboembolia Venosa/etiología , Persona de Mediana Edad , Adulto , Neoplasias Uterinas/cirugía , Neoplasias Uterinas/complicaciones , Complicaciones Posoperatorias/epidemiología , Factores de Riesgo , Estados Unidos/epidemiología , Incidencia , Estudios de Cohortes
4.
Am J Obstet Gynecol ; 227(2): 311.e1-311.e7, 2022 08.
Artículo en Inglés | MEDLINE | ID: mdl-35490792

RESUMEN

BACKGROUND: The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared with 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh the procedural complications and the potential for subsequent surgical menopause against future ovarian pathology or cancer. OBJECTIVE: We aimed to determine if performing unilateral salpingo-oophorectomy is a more cost-effective strategy for the prevention of death than surveillance for asymptomatic endometriomas. STUDY DESIGN: We created a cost-effectiveness model using TreeAge Pro (TreeAge Software Inc; Williamstown, MA) with a lifetime horizon. Our hypothetical cohort included premenopausal patients with 2 ovaries who did not desire fertility. Those diagnosed with asymptomatic endometrioma underwent either unilateral salpingo-oophorectomy or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (± hormone replacement therapy) if the contralateral ovary is removed. We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. The costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio of Δ costs / Δ deaths with a willingness-to-pay threshold of $11.6 million as the value of a statistical life. Multiple 1-way sensitivity analyses were performed to evaluate model robustness. RESULTS: Our model demonstrated that unilateral salpingo-oophorectomy is associated with improved outcomes compared with surveillance, with fewer deaths (0.28% vs 1.50%) and fewer cases of ovarian cancer (0.42% vs 2.96%). However, it costs more than sonographic surveillance at $6403.43 vs $5381.39 per case of incidental endometrioma. The incremental cost-effectiveness ratio showed that unilateral salpingo-oophorectomy costs $83,773.77 per death prevented and $40,237.80 per case of ovarian cancer prevented. As both values were well below the willingness-to-pay threshold, unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy. If unilateral salpingo-oophorectomy were chosen over surveillance for premenopausal patients with incidental endometriomas, 1 diagnosis of ovarian cancer would be prevented in every 40 patients and 1 death averted in every 82 patients. We performed 1-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions. CONCLUSION: Unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy compared with surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. It incurs fewer deaths and fewer cases of ovarian cancer with costs below the national willingness-to-pay thresholds.


Asunto(s)
Endometriosis , Neoplasias Ováricas , Anciano , Carcinoma Epitelial de Ovario , Análisis Costo-Beneficio , Endometriosis/patología , Endometriosis/cirugía , Femenino , Humanos , Medicare , Neoplasias Ováricas/patología , Salpingooforectomía/métodos , Estados Unidos
5.
J Minim Invasive Gynecol ; 29(1): 119-127, 2022 01.
Artículo en Inglés | MEDLINE | ID: mdl-34265441

RESUMEN

STUDY OBJECTIVES: To examine the effectiveness of endometrial sampling for preoperative detection of uterine leiomyosarcoma in women undergoing hysterectomy, identify factors associated with missed diagnosis, and compare the outcomes of patients who had a preoperative diagnosis with those of patients who had a missed diagnosis. DESIGN: Retrospective cohort study using linked data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry from 2003 to 2015. SETTING: Inpatient and outpatient encounters at civilian hospitals and ambulatory surgery centers in New York State. PATIENTS: Women with uterine leiomyosarcoma who underwent a hysterectomy and a preoperative endometrial sampling within 90 days before the hysterectomy. INTERVENTIONS: Endometrial sampling. MEASUREMENTS AND MAIN RESULTS: A total of 79 patients with uterine leiomyosarcoma met the sample eligibility criteria. Of these patients, 46 (58.2%) were diagnosed preoperatively, and 33 (41.8%) were diagnosed postoperatively. Patients in the 2 groups did not differ significantly in age, race/ethnicity, bleeding symptoms, or comorbidities assessed. In multivariable regression analysis, women who had endometrial sampling performed with hysteroscopy (compared with women who had endeometrial sampling performed without hysteroscopy) had a higher likelihood of preoperative diagnosis (adjusted risk ratio [aRR] 3.03; 95% confidence interval [CI], 1.43-6.42). Patients with localized stage (vs distant stage) or tumor size >11 cm (vs <8 cm) were less likely to be diagnosed preoperatively (aRR 0.50; 95% CI, 0.28-0.89, and aRR 0.54; 95% CI, 0.30-0.99, respectively). Supracervical hysterectomy was not performed in any of the patients whose leiomyosarcoma was diagnosed preoperatively compared with 21.2% of the patients who were diagnosed postoperatively (p = .002). CONCLUSION: Endometrial sampling detected leiomyosarcoma preoperatively in 58.2% of the patients. The use of hysteroscopy with endometrial sampling improved preoperative detection of leiomyosarcoma by threefold. Patients with a missed diagnosis had a higher risk of undergoing suboptimal surgical management at the time of their index surgery.


Asunto(s)
Neoplasias Endometriales , Leiomiosarcoma , Neoplasias Uterinas , Neoplasias Endometriales/cirugía , Endometrio , Femenino , Humanos , Histerectomía , Leiomiosarcoma/diagnóstico , Leiomiosarcoma/cirugía , Estudios Retrospectivos , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/cirugía
6.
J Minim Invasive Gynecol ; 29(2): 274-283.e1, 2022 02.
Artículo en Inglés | MEDLINE | ID: mdl-34438045

RESUMEN

STUDY OBJECTIVE: To determine the incidence of perioperative coronavirus disease (COVID-19) in women undergoing benign gynecologic surgery and to evaluate perioperative complication rates in patients with active, previous, or no previous severe acute respiratory syndrome coronavirus 2 infection. DESIGN: A multicenter prospective cohort study. SETTING: Ten institutions in the United States. PATIENTS: Patients aged >18 years who underwent benign gynecologic surgery from July 1, 2020, to December 31, 2020, were included. All patients were followed up from the time of surgery to 10 weeks postoperatively. Those with intrauterine pregnancy or known gynecologic malignancy were excluded. INTERVENTIONS: Benign gynecologic surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the incidence of perioperative COVID-19 infections, which was stratified as (1) previous COVID-19 infection, (2) preoperative COVID-19 infection, and (3) postoperative COVID-19 infection. Secondary outcomes included adverse events and mortality after surgery and predictors for postoperative COVID-19 infection. If surgery was delayed because of the COVID-19 pandemic, the reason for postponement and any subsequent adverse event was recorded. Of 3423 patients included for final analysis, 189 (5.5%) postponed their gynecologic surgery during the pandemic. Forty-three patients (1.3% of total cases) had a history of COVID-19. The majority (182, 96.3%) had no sequelae attributed to surgical postponement. After hospital discharge to 10 weeks postoperatively, 39 patients (1.1%) became infected with severe acute respiratory syndrome coronavirus 2. The mean duration of time between hospital discharge and the follow-up positive COVID-19 test was 22.1 ± 12.3 days (range, 4-50 days). Eleven (31.4% of postoperative COVID-19 infections, 0.3% of total cases) of the newly diagnosed COVID-19 infections occurred within 14 days of hospital discharge. On multivariable logistic regression, living in the Southwest (adjusted odds ratio, 6.8) and single-unit increase in age-adjusted Charlson comorbidity index (adjusted odds ratio, 1.2) increased the odds of postoperative COVID-19 infection. Perioperative complications were not significantly higher in patients with a history of positive COVID-19 than those without a history of COVID-19, although the mean duration of time between previous COVID-19 diagnosis and surgery was 97 days (14 weeks). CONCLUSION: In this large multicenter prospective cohort study of benign gynecologic surgeries, only 1.1% of patients developed a postoperative COVID-19 infection, with 0.3% of infection in the immediate 14 days after surgery. The incidence of postoperative complications was not different in those with and without previous COVID-19 infections.


Asunto(s)
COVID-19 , Pandemias , Adolescente , Prueba de COVID-19 , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Embarazo , Estudios Prospectivos , Estudios Retrospectivos , SARS-CoV-2 , Resultado del Tratamiento , Estados Unidos/epidemiología
7.
J Minim Invasive Gynecol ; 28(3): 710-720, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33348012

RESUMEN

OBJECTIVE: Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy. DATA SOURCES: PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered. METHODS OF STUDY SELECTION: The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence. TABULATION, INTEGRATION, AND RESULTS: A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11-0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13-1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00-3.88). CONCLUSION: There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation.


Asunto(s)
Histerectomía/efectos adversos , Laparoscopía/efectos adversos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Dehiscencia de la Herida Operatoria/prevención & control , Técnicas de Sutura/estadística & datos numéricos , Enfermedades Vaginales/prevención & control , Femenino , Humanos , Histerectomía/métodos , Incidencia , Laparoscopía/métodos , Factores de Riesgo , Procedimientos Quirúrgicos Robotizados/métodos , Dehiscencia de la Herida Operatoria/epidemiología , Dehiscencia de la Herida Operatoria/etiología , Resultado del Tratamiento , Reino Unido/epidemiología , Enfermedades Vaginales/epidemiología , Enfermedades Vaginales/etiología
8.
Am J Obstet Gynecol ; 223(5): 762-763, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32693094

RESUMEN

Vaginal hysterectomy rates in the United States are decreasing, despite it being the recommended hysterectomy route for benign hysterectomy by multiple societies. Visualization issues are a known barrier to a medical student learning in the operating room, and it is likely that this also extends to resident training. In addition, vaginal surgery can be taxing on both the surgeons and assistants, with high rates of musculoskeletal work disorders reported in vaginal surgeons. The use of a camera is integral to endoscopic surgery, and table-mounted retractor systems have been used for decades in open surgery. We bring these 2 features into vaginal surgery, that is, using a table-mounted camera system and a table-mounted vaginal retractor. When used together as demonstrated in this video, these tools can improve visualization and may improve ergonomics for the entire surgical team, including learners, during vaginal surgery.


Asunto(s)
Ergonomía , Histerectomía Vaginal/instrumentación , Equipo Quirúrgico , Terminales de Computador , Femenino , Procedimientos Quirúrgicos Ginecológicos/instrumentación , Procedimientos Quirúrgicos Ginecológicos/métodos , Humanos , Histerectomía Vaginal/métodos , Vagina/cirugía
9.
J Minim Invasive Gynecol ; 27(4): 883-891, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31238150

RESUMEN

STUDY OBJECTIVE: To validate the algorithm for selective bowel surgery based on preoperative imaging by comparing the perioperative outcomes of patients who undergo each type of bowel surgery for deep bowel disease, and secondarily to evaluate the incidence, factors, and subsequent outcomes when the actual procedure performed deviated from the preoperative surgical plan. DESIGN: Retrospective study comparing 3 surgical interventions in an intention-to-treat analysis. SETTING: Tertiary care hospital. PATIENTS: Women with significant pain (visual analog scale [VAS] >7) who were diagnosed with bowel endometriosis from preoperative imaging and underwent laparoscopic surgery for bowel endometriosis at a large referral center between 2014 and 2017. INTERVENTION: Laparoscopic shaving, disc resection, or full-segment resection and reanastomosis of bowel endometriosis. MEASUREMENTS AND MAIN RESULTS: A total of 172 patients (mean age, 36.6 ± 5.2 years) underwent bowel surgery for endometriosis (n = 30 shaving, 71 disc, and 71 segmental resection). Total operative time was similar in the 3 group, but the mean length of hospital stay was longer in the segmental group (5.3 ± 1.0 days) compared with the disc group (4.6 ± 0.9 days) and the shaving group (3.8 ± 1.5 days) (p = .001). The surgical procedure was performed as planned according to the clinical algorithm in 86.5% of patients. Adherence to the proposed clinical algorithm resulted in a low incidence of overall complications (8.7% of total complications, 4.6% of minor complications, and 3.5% of major complications). The incidence of minor complications was higher in the segmental group (9.9%) compared with the discoid group (1.4%) and the shaving group (0%) (p = .0236), whereas the incidence of major complications were similar across the 3 groups (3.3%, 2.8%, and 4.2%, respectively; p = .899). There was a significantly higher frequency of pseudomembranous colitis in the segmental resection group (7 patients; 9.9%) compared with the discoid group (n = 1; 1.4%) and shaving group (0%) (p = .04). Owing to discrepancies between preoperative imaging and intraoperative findings after dissection and mobilization, deviation from the planned procedure occurred in a total of 25 of 172 cases (14.5%), with a less extensive procedure actually performed in 21 of 25 (84%) of the deviated cases. One of the 4 cases (25%) that involved a more extensive procedure resulted in a major complication of rectovaginal fistula. CONCLUSION: Selective bowel resection algorithm provides a systematic approach to the surgical management of patients with bowel endometriosis. Adherence to the surgical plan according to the preoperative imaging and criteria outlined in the algorithm can be accomplished in the majority of patients; however, the surgical team should be aware that upstaging or downstaging may be required, depending on the intraoperative findings. When feasible, the team should opt for a less extensive procedure to avoid complications associated with more radical surgery.


Asunto(s)
Endometriosis , Laparoscopía , Enfermedades del Recto , Adulto , Algoritmos , Endometriosis/complicaciones , Endometriosis/diagnóstico por imagen , Endometriosis/cirugía , Femenino , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Enfermedades del Recto/complicaciones , Enfermedades del Recto/diagnóstico por imagen , Enfermedades del Recto/cirugía , Estudios Retrospectivos , Resultado del Tratamiento
10.
J Minim Invasive Gynecol ; 27(2): 332-343, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31377454

RESUMEN

STUDY OBJECTIVE: To systematically review the literature regarding the efficacy of high-intensity focused ultrasound (HIFU) in reducing adenomyotic lesions, patients' pain and bleeding symptoms, and the impact on patients' quality of life. DATA SOURCE: A search was performed through PubMed/MEDLINE and Cochrane databases. METHODS OF STUDY SELECTION: All available studies published in the English language in the last 10 years that evaluated the effects of HIFU for adenomyosis. TABULATION, INTEGRATION, AND RESULTS: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A meta-analysis was performed on data from homogeneous studies. Pooled results from the meta-analysis showed that after HIFU treatment for adenomyosis, a large effect was observed in reducing the uterine volume at 12 months (standard mean difference [SMD] = 0.85), a significant reduction in dysmenorrhea at 3 months (SMD = 1.83) and 12 months (SMD = 2.37), and a significant improvement in quality of life at 6 months (SMD = 3.0) and 12 months (SMD = 2.75). Adverse reactions after HIFU were reported in 55.9% of patients. CONCLUSION: This review suggests a potential benefit for HIFU in the treatment of adenomyosis-related symptoms; however, findings of the meta-analysis were based on fewer, nonuniform studies, which did not equally account for each specific symptom/parameter across the board. Results showed there appears to be a potential of HIFU in the treatment of adenomyosis-related symptoms. To date, there are no comparative and randomized clinical trials comparing the HIFU technique with other conservative treatment options. As yet, there are insufficient data regarding fertility and pregnancy outcomes.


Asunto(s)
Adenomiosis/terapia , Ultrasonido Enfocado de Alta Intensidad de Ablación/métodos , Adenomiosis/epidemiología , Adenomiosis/patología , Adulto , Dismenorrea/epidemiología , Dismenorrea/terapia , Femenino , Fertilidad/fisiología , Ultrasonido Enfocado de Alta Intensidad de Ablación/efectos adversos , Humanos , Embarazo , Resultado del Embarazo/epidemiología , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto/estadística & datos numéricos , Resultado del Tratamiento
11.
J Minim Invasive Gynecol ; 27(6): 1405-1413, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31812614

RESUMEN

STUDY OBJECTIVE: To compare the feasibility of opportunistic bilateral salpingectomy (OBS) at the time of vaginal hysterectomy (VH) for benign disease in patients with and without relative contraindications (RCs) to the vaginal approach and to evaluate the factors that contribute to the inability to perform OBS. DESIGN: Retrospective chart review. SETTING: Tertiary medical center. PATIENTS: Women undergoing hysterectomy for benign indications between November 2014 and October 2017 who were consented for either VH with or without removal of tube(s) and/or bilateral salpingectomy. INTERVENTIONS: RCs to the vaginal approach are defined as lack of prolapse (cervix high, cervix not visualized, cervix tucked underneath pubis, or minimal descent), enlarged uterus (≥250 g or a size of a ≥12-week uterus), nulliparity, obesity (body mass index ≥30 kg/m2), previous cesarean section (CS), known adhesions, and known adnexal pathologic condition. MEASUREMENTS AND MAIN RESULTS: A total of 258 patients underwent VH and attempted to undergo OBS within the study period; of these, 112 patients (43.4%) had no RC, and 146 patients (56.6%) had ≥1 RCs. Overall, successful salpingectomy was performed in 86.8% of patients. There was no significant difference in the rate of success in patients without or with ≥1 RCs (84.9% vs 89%, p = .15). Salpingectomy was unsuccessful in 13.2% of patients (n = 34). In a multivariable logistic regression analysis, the odds of unsuccessful OBS were 3.83 times higher in patients without prolapse (confidence interval [CI], 0.99-14.76; p = .051), 2.71 times higher in patients with obesity (CI, 1.23-5.94; p = .013), and 3.07 times higher in patients with previous CS (CI, 1.17-8.08; p = .023) as compared to patients without any relative contraindications. An enlarged uterus was associated with successful salpingectomy (odds ratio, 0.28; 95% CI, 0.08-0.94; p = .039) compared with a normal-sized uterus. When excluding enlarged uterus, patients with 2 to 3 RCs had 11.24 and 6.8 higher odds of an unsuccessful OBS than patients with no (CI, 3.73-33.87; p <.001) and 1 RC (CI, 2.36-19.63; p <.001), respectively. There were no differences in postoperative stay or rates of readmission among patients with or without successful salpingectomy at the time of VH. CONCLUSION: OBS is associated with a high overall rate of success in patients with and without traditional RCs to VH. Lack of prolapse, obesity, and previous CS were associated with failed attempt at salpingectomy. Patients with ≥2 RCs to VH should be counseled about the high likelihood of failed salpingectomy.


Asunto(s)
Contraindicaciones de los Procedimientos , Enfermedades de los Genitales Femeninos/cirugía , Histerectomía Vaginal/efectos adversos , Salpingectomía/métodos , Adulto , Estudios de Factibilidad , Femenino , Enfermedades de los Genitales Femeninos/epidemiología , Humanos , Histerectomía/efectos adversos , Histerectomía/métodos , Histerectomía/estadística & datos numéricos , Persona de Mediana Edad , Embarazo , Estudios Retrospectivos , Salpingectomía/efectos adversos , Salpingectomía/estadística & datos numéricos , Resultado del Tratamiento
12.
J Minim Invasive Gynecol ; 27(6): 1316-1323, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31669552

RESUMEN

STUDY OBJECTIVE: To evaluate bowel function (changes in stool caliber, sensation of incomplete evacuation, stooling frequency, and rectal bleeding) and urinary function (dysuria and retention) after segmental resection in patients with bowel endometriosis. DESIGN: Retrospective study. SETTING: Tertiary hospital. PATIENTS: A total of 413 (mean age = 33.6 ± 5.1 years) of reproductive aged women, with bowel endometriosis that underwent segmental bowel resection of the rectosigmoid from 2005 to 2018, without history of prior bowel surgery, without existing or history of malignancy. INTERVENTIONS: Laparoscopic segmental bowel resection performed by the same team and with the same technique. MEASUREMENTS AND MAIN RESULTS: Data collected from the patients' records included length of resected segment, distance of the lesion from the anal verge, and complications. Information on intestinal and urinary function was obtained from a questionnaire applied before the surgery and at 2, 6, and 12 months after the surgery. There was a significant increase in the incidence of stool thinning and rectal bleeding 2 months after surgical procedure; these symptoms decreased significantly over time. The incidence of urinary symptoms decreased significantly over time after surgery. The length of the bowel segment resected was not associated with the postoperative symptoms, but the rectosigmoid lesion was significantly closer to the anal verge in patients with rectal bleeding and urinary symptoms. There was no association between the length of intestinal segment resected and the frequency of stooling. At 6 months, patients who had a decreased frequency of stooling underwent a resection closer to the anal verge (9.7 cm) in comparison with the ones with unchanged or increase frequency of stooling (10.1 cm and 10.7 cm, respectively; p <.05). CONCLUSION: Patient complaints on bowel and urinary alterations after segmental resection were transient with significant improvement over time up to 12 months. Bowel and urinary symptoms were not associated with the size of the bowel segment resected, whereas rectal bleeding at 2 months after surgery was significantly associated with the distance from anal verge. Segmental resection was also associated with a great improvement in constipation at 12 months postoperative.


Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Endometriosis/cirugía , Complicaciones Posoperatorias/rehabilitación , Enfermedades del Recto/cirugía , Enfermedades del Sigmoide/cirugía , Adulto , Colon/cirugía , Colon Sigmoide/cirugía , Estreñimiento/epidemiología , Estreñimiento/etiología , Estreñimiento/rehabilitación , Defecación/fisiología , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Endometriosis/epidemiología , Femenino , Hemorragia Gastrointestinal/epidemiología , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/rehabilitación , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Hemorragia Posoperatoria/epidemiología , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/rehabilitación , Enfermedades del Recto/epidemiología , Recto/cirugía , Estudios Retrospectivos , Enfermedades del Sigmoide/epidemiología , Factores de Tiempo
13.
J Minim Invasive Gynecol ; 26(7): 1234-1252.e1, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31039407

RESUMEN

STUDY OBJECTIVE: Hysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify nonhormonal interventions, perioperative surgical interventions, and devices to minimize blood loss at the time of hysterectomy for leiomyoma. DATA SOURCES: Librarian-led search of Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases from 1946 to 2018 with hand-guided updates. METHODS OF STUDY SELECTION: Included studies reported on keywords of hysterectomy, leiomyoma, and operative blood loss/postoperative hemorrhage/uterine bleeding/metrorrhagia/hematoma. The review excluded a comparison of route of hysterectomy, morcellation, vaginal cuff closure, hormonal medications, vessel sealing devices for vaginal hysterectomy, and case series with <10 patients. TABULATION, INTEGRATION, AND RESULTS: Surgical blood loss, postoperative hemoglobin (Hb) drop, hemorrhage, transfusion, and major and minor complications were analyzed and aggregated in meta-analyses for comparable studies in each category. A total of 2016 unique studies were identified, 33 of which met the inclusion criteria, and 22 were used for quantitative synthesis. The perioperative use of misoprostol in abdominal hysterectomy (AH) was associated with a lower postoperative Hb drop (0.59 g/dL; 95% confidence interval [CI], 0.39-0.79; p < .01) and blood loss (-96.43 mL; 95% CI, -153.52 to -39.34; p < .01) compared with placebo. Securing the uterine vessels at their origin in laparoscopic hysterectomy (LH) was associated with decreased intraoperative blood loss (-69.07 mL; 95% CI, -135.20 to -2.95; p = .04) but no significant change in postoperative Hb (0.24 g/dL; 95% CI, -0.31 to 0.78; p = .39) compared with securing them by the uterine isthmus. Uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with standard ligation (-27.72 mL; 95% CI, -35.07 to -20.38; p < .01). The postoperative Hb drop was not significantly different with a bipolar electrosurgical device versus suturing in AH (0.26 g/dL; 95% CI, -0.19 to 0.71; p = .26). There was no significant difference between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the Hb drop (0.02 g/dL; 95% CI, -0.15 to 0.20; p = .79) or blood loss (-50.88 mL; 95% CI, -106.44 to 4.68; p = .07) in LH. Blood loss in LH was not decreased with the LigaSure (Medtronic, Minneapolis, MN) impedance monitoring EBVS compared with competing EBVS systems monitoring impedance or temperature (2.00 mL; 95% CI, -8.09 to 12.09; p = .70). No significant differences in hemorrhage, transfusion, or major complications were noted for all interventions. CONCLUSION: Perioperative misoprostol in AH led to a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines) although the clinical benefit is likely limited. Remaining interventions, although promising, had at best low-quality evidence to support their use at this time. Larger and rigorously designed randomized trials are needed to establish the optimal set of perioperative interventions for use in hysterectomy for leiomyomas.


Asunto(s)
Pérdida de Sangre Quirúrgica/prevención & control , Histerectomía , Leiomioma/cirugía , Atención Perioperativa/métodos , Neoplasias Uterinas/cirugía , Femenino , Humanos , Resultado del Tratamiento
14.
J Minim Invasive Gynecol ; 26(2): 244-252.e1, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30176363

RESUMEN

In this review, we evaluate techniques, devices, and equipment for patient positioning and their effect on patient outcomes, such as cephalad slide and neuropathy, in laparoscopic and robotic-assisted gynecologic surgery. We conducted a systematic review by searching MEDLINE, Embase, and Cochrane Library for relevant articles published over a 15-year period. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. Seven articles, including 3 randomized controlled trials and 4 case series, were included in our analysis. Four studies evaluated cephalad patient slide. In 2 randomized controlled trials (n = 103), the mean slide with various devices (i.e., memory foam, bean bag with shoulder braces, egg crate, and gel pad) ranged from 1.07 ± 1.93 cm to 4.5 ± 4.0 cm. The use of a bean bag with shoulder supports/braces was associated with minimal slide, with a median slide of 0 cm (range, 0-2 cm) in a retrospective series and with mean slide of 1.07 ± 1.93 cm in a randomized controlled trial (vs memory foam). No conclusive effect of body mass index on slide could be identified. Five studies evaluating the incidence of neuropathy found an overall incidence of 0.16% and no differences among slide-preventing devices. The minimal slide described across studies supports the conclusion that any of the currently used devices and techniques for safe patient positioning are within reason. The low overall incidence of neuropathy is also reassuring. Best evidence recommendations cannot be made for a specific device or technique; our findings suggest the importance of strict adherence to the basic tenets of safe patient positioning to minimize slide and prevent nerve injury.


Asunto(s)
Procedimientos Quirúrgicos Ginecológicos/instrumentación , Laparoscopía/instrumentación , Posicionamiento del Paciente/instrumentación , Procedimientos Quirúrgicos Robotizados/instrumentación , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Procedimientos Quirúrgicos Ginecológicos/métodos , Humanos , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/prevención & control , Laparoscopía/efectos adversos , Laparoscopía/métodos , Posicionamiento del Paciente/efectos adversos , Posicionamiento del Paciente/métodos , Seguridad del Paciente , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Resultado del Tratamiento
16.
J Minim Invasive Gynecol ; 25(2): 257-264, 2018 02.
Artículo en Inglés | MEDLINE | ID: mdl-28864044

RESUMEN

Adenomyosis is characterized by the presence of ectopic foci of endometrial glandular tissue and/or stroma within the myometrium. The diagnosis of adenomyosis is traditionally made through histologic evaluation of the postsurgical specimen. More recently, imaging with transvaginal ultrasound (TVUS) has been used for the preoperative diagnosis of adenomyosis. As yet, there is no consensus regarding the best imaging feature or combination thereof for the nonsurgical diagnosis of adenomyosis. This study systematically evaluated the literature in the last 10 years to determine the accuracy of 2-dimensional (2D) TVUS, different imaging features, enhancing methods such as 3-dimensional (3D) TVUS, elastography and color Doppler in the nonsurgical diagnosis of adenomyosis. A total of 8 studies were included. Pooled sensitivity and specificity for 2D TVUS for the diagnosis of adenomyosis for all combined imaging characteristics was 83.8% and 63.9%, respectively. Pooled sensitivity for 355 total patients with use of imaging feature of heterogeneous myometrium with 2D TVUS was highest (86.0%), and pooled specificity for 283 total patients with use of globular uterus was highest (78.1%). After including the "question mark" sign with other TVUS features, higher sensitivity and specificity, of 92% and 88%, respectively, were noted. For 3D TVUS, pooled sensitivity and specificity for all combined imaging characteristics was 88.9% and 56.0%, respectively. Poor definition of junctional zone showed the highest pooled sensitivity (86%) and the highest pooled specificity (56.0%) for the diagnosis of adenomyosis with 3D TVUS. There was no improvement in overall accuracy in 3D TVUS compared with 2D TVUS. Preliminary results of TVUS with color Doppler showed a high sensitivity and specificity for the differentiation between adenomyosis and myomas (95.6% and 93.4%, respectively). Also, TVUS elastography in 1 study showed an improvement in specificity (82.9%) compared with 2D TVUS (63.9%), albeit with comparable sensitivity. Larger studies are needed to advance our understanding of the different types of adenomyosis and their clinical impact.


Asunto(s)
Adenomiosis/dietoterapia , Ultrasonografía/métodos , Adenomiosis/patología , Diagnóstico por Imagen de Elasticidad/métodos , Femenino , Humanos , Imagenología Tridimensional/métodos , Miometrio/diagnóstico por imagen , Sensibilidad y Especificidad
17.
J Minim Invasive Gynecol ; 29(4): 453-454, 2022 04.
Artículo en Inglés | MEDLINE | ID: mdl-35176507
18.
J Minim Invasive Gynecol ; 24(2): 218-229, 2017 02.
Artículo en Inglés | MEDLINE | ID: mdl-27988392

RESUMEN

Opportunistic bilateral salpingectomy (OBS) is gaining momentum as a potential strategy for preventing epithelial ovarian cancer (EOC). OBS has been associated with a 40% to 65% decrease in the incidence of EOC when performed at the time of benign hysterectomy in patients at population-level risk for EOC. Current data suggest minimal disadvantage or "cost" to the patient and system from this practice in terms of estimated blood loss (EBL), operative time, length of hospital stay, ovarian reserve depletion, and complications attributable to OBS. These costs merit additional scrutiny in comparison with potential benefits before OBS can be adopted or recommended universally as a preventative strategy. This systematic review identifies 10 comparative studies (8 cohorts and 2 randomized controlled studies) ranging from 19 to 425 180 patients that cumulatively demonstrate a small to no increase in operative time and no additional EBL, hospital stay, or complications attributable to OBS at the time of benign hysterectomy. We anticipate that more widespread adoption of OBS will necessarily incorporate more difficult salpingectomies, thus potentially increasing the time, EBL, and complications associated with this practice in large studies. This consideration should be weighed into discussions of whether salpingectomy at the time of hysterectomy would ever be considered mandatory (or failure to perform OBS be considered negligent) and may have to be considered for fair reimbursement for any additional time and risk of this surgical step. Given the available evidence of benefit, further randomized controlled trials for salpingectomy versus no salpingectomy at the time of hysterectomy are unlikely to be feasible and may be unethical. Going forward, additional large prospective cohorts with historical control subjects will be valuable in assessing the additional costs of universal OBS at the time of benign hysterectomy.


Asunto(s)
Histerectomía/métodos , Neoplasias Glandulares y Epiteliales , Neoplasias Ováricas , Salpingectomía , Carcinoma Epitelial de Ovario , Trompas Uterinas/patología , Trompas Uterinas/cirugía , Femenino , Humanos , Neoplasias Glandulares y Epiteliales/epidemiología , Neoplasias Glandulares y Epiteliales/patología , Neoplasias Glandulares y Epiteliales/cirugía , Evaluación de Procesos y Resultados en Atención de Salud , Neoplasias Ováricas/epidemiología , Neoplasias Ováricas/patología , Neoplasias Ováricas/cirugía , Ajuste de Riesgo , Salpingectomía/efectos adversos , Salpingectomía/métodos
19.
J Minim Invasive Gynecol ; 24(2): 203-204, 2017 02.
Artículo en Inglés | MEDLINE | ID: mdl-27932268

RESUMEN

STUDY OBJECTIVE: To show a step-by-step laparoscopic approach for excision of an ovarian endometrioma following surgical principles for safety and maximal preservation of ovarian function. DESIGN: Video. Medical management of ovarian endometriomas is not recommended. Operative laparoscopy is the treatment of choice. Although considered a simple procedure, ovarian cystectomy requires a precise and correct technique in order to preserve ovarian function. SETTING: A private hospital. PATIENT: An asymptomatic, 27-year-old woman with ultrasound imaging suggesting a 6.2 × 5.4 cm left endometrioma. Additional findings of endometriotic implants were noted in the posterior aspect of the left broad ligament, retrocervical region, Douglas pouch, and left round ligament. INTERVENTIONS: After trocar insertion, standard inspection of the pelvic cavity with identification of endometriosis lesions and adhesions was performed. The endometrioma was drained with direct trocar puncture to avoid spillage of the endometriotic contents. Cyst aspiration and saline cleaning were executed. After drainage, a cold cut was performed at the puncture site for better identification of the cyst capsule. Through gentle traction and countertraction, the capsule was peeled from the ovarian cortex, preserving as much ovarian tissue as possible followed by careful hemostasis with a bipolar instrument. The ovary is fixed, anatomy re-established, and concomitant pelvic endometriosis resected. We aim for complete surgical excision in order to avoid leaving disease behind. The ovarian edges were reapproximated using simple interrupted stitches. MEASUREMENTS AND MAIN RESULTS: The total procedure time was 40 minutes. CONCLUSION: Laparoscopic endometrioma stripping offers an effective option for ovarian endometriosis treatment, reducing recurrence and being reproducible by gynecologic surgeons after proper training.


Asunto(s)
Endometriosis/cirugía , Laparoscopía/métodos , Enfermedades del Ovario/cirugía , Ovariectomía/métodos , Enfermedades de los Anexos/complicaciones , Enfermedades de los Anexos/cirugía , Adulto , Fondo de Saco Recto-Uterino/patología , Fondo de Saco Recto-Uterino/cirugía , Drenaje , Endometriosis/complicaciones , Femenino , Humanos , Laparoscopía/efectos adversos , Laparoscopía/normas , Recurrencia Local de Neoplasia/cirugía , Enfermedades del Ovario/complicaciones , Ovariectomía/normas , Ovario/cirugía , Enfermedades Peritoneales/complicaciones , Enfermedades Peritoneales/cirugía , Adherencias Tisulares/cirugía
20.
J Minim Invasive Gynecol ; 24(3): 353-363, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28027973

RESUMEN

Borderline ovarian tumors (BOTs) have a low malignant potential and occur most often in young women. Its preoperative diagnosis can improve surgical strategy and reproductive approach. This study systematically reviews the literature for the accuracy of transvaginal ultrasound (TVUS), magnetic resonance (MRI), and computed tomography (CT) in the diagnostic of BOTs. We conducted a search in PubMed/Medline of articles in English from the last 5 years and included 14 studies for systematic review, 9 of them in the meta-analysis. The pooled sensibility and specificity was respectively 77.0% and 83.0% for TVUS (5 studies) and 85% and 74% for MRI (4 studies) in differentiating benign from malignant BOTs. CT and positron emission tomography (PET)-CT techniques were heterogeneous between studies, so a meta-analysis was not performed for the 4 studies on CT and PET-CT. However, these 4 studies have also shown a high accuracy in differentiating BOTs from malignant ovarian cancers.


Asunto(s)
Cistoadenofibroma/diagnóstico , Neoplasias Ováricas/diagnóstico , Cistoadenofibroma/patología , Femenino , Humanos , Imagen por Resonancia Magnética/métodos , Neoplasias Ováricas/patología , Tomografía de Emisión de Positrones/métodos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X/métodos , Ultrasonografía/métodos
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