Risk factors for trachelectomy following supracervical hysterectomy.

INTRODUCTION: We identified risk factors for trachelectomy after supracervical hysterectomy (SCH) due to persistence of symptoms. MATERIAL AND METHODS: A retrospective case-control study in a university-affiliated hospital. Seventeen women who underwent a trachelectomy following SCH for nonmalignant indications between June 2002 and October 2014 were compared with 68 randomly selected women (controls) who underwent a SCH within the same time period. Demographics and clinical characteristics were compared between the study and control groups. Univariate analysis identified potential risk factors for trachelectomy following SCH. Univariate logistic regression models predicted which patients would have a trachelectomy following SCH. RESULTS: The occurrence of trachelectomy following SCH during the study period was 0.9% (17/1892). The study group was younger than the control group (mean age 38 ± 6 years vs. 44 ± 5 years; p < 0.001). Patients who had a history of endometriosis [odds ratio (OR) 6.23, 95% CI 1.11-40.5, p = 0.038] had increased risk for trachelectomy. Pathology diagnosed endometriosis only among women in the study group. Preoperative diagnosis of abnormal uterine bleeding (OR 0.22, 95% CI 0.06-0.075, p = 0.016), anemia (OR 0.12, 95% CI 0.01-0.53; p = 0.003), and fibroid uterus (OR 0.24, 95% CI 0.07-0.82, p = 0.024) reduced the risk for future trachelectomy. CONCLUSION: Young age and endometriosis are significant risk factors for trachelectomy following SCH.

Adnexal Torsion in Postmenopausal Women: Clinical Presentation and Risk of Ovarian Malignancy.

STUDY OBJECTIVE: To investigate the clinical presentation, operative outcome, and incidence of malignancy in postmenopausal women who were diagnosed with adnexal torsion. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary university-affiliated hospital. PATIENTS: Postmenopausal women diagnosed with adnexal torsion between 1995 and 2014 (study group) were reviewed and compared with 220 premenopausal patients diagnosed with adnexal torsion during the same time period. INTERVENTION: Demographic data, clinical signs and symptoms, and intra- and postoperative characteristics were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS: During the study period 44 postmenopausal women were diagnosed with adnexal torsion. Continuous dull pain was the most common presenting symptom in the postmenopausal group (57%), whereas acute-onset sharp pain was the predominant symptom in the premenopausal group (86%). The time interval from admission to surgery was significantly longer in the postmenopausal group (24 vs 6 hours, p < .001). Laparoscopic surgery was performed in 84.5% of the cases in the premenopausal group, whereas it was carried out in only 50% of cases in the postmenopausal group (p < .001). Four women in the postmenopausal group were diagnosed with malignancy, whereas only 1 case of malignancy was found in the premenopausal group (9% vs .4%, respectively; p = .003). CONCLUSIONS: Adnexal torsion in postmenopausal women is an uncommon event with a unique presentation. Because ovarian malignancy is not an uncommon finding in this group of patients, preparation for more extensive surgery should be contemplated.

Personnel-itis: a myth or a pathology? A retrospective analysis of obstetrical and perinatal outcomes for physicians and nurses.

OBJECTIVE: To evaluate whether medical personnel differ from the general population in obstetrical and perinatal outcomes. MATERIALS AND METHODS: The participants comprised 46 physicians and 116 nurses employed at one medical center who gave birth in its maternity hospital. General medical and obstetrical data on their latest ("index") pregnancy and delivery were extracted from real-time computerized patient files. The control group included 162 women who gave birth during the same period in the same hospital. RESULTS: The study group had significantly more deliveries, cesarean sections, and terminations of pregnancy prior to the index pregnancy. The medical personnel conceived significantly more often with assisted reproductive technologies (ART) (18.8% vs. 8% for controls, P<0.05), and had significantly more obstetrical complications, i.e., premature contractions, gestational diabetes mellitus, preeclamptic toxemia, and 2nd/3rd trimester bleeding or chorioamnionitis (42.5% vs. 29% for controls, P<0.05). The rate of vaginal birth after cesarean delivery (VBAC) was lower in the study group (22.2% vs. 33.3% for controls, P=0.03). There was no difference in gestational age at delivery, birth weight, or adverse neonatal outcome. CONCLUSIONS: Medical personnel utilized ART more frequently and had more pregnancy complications as well as a lower incidence of VBAC than non-personnel. Neonatal outcomes were similar for both groups.

Risk factors, symptoms, and treatment of ovarian torsion in children: the twelve-year experience of one center.

OBJECTIVE: To assess risk factors, clinical findings and mode of diagnosis and treatment in premenarchal children with surgically verified ovarian torsion (OT). STUDY DESIGN: A retrospective case review (Canadian Task Force Classification II-2). SETTING: Teaching and research hospital, a tertiary center. PATIENTS: Premenarchal children with surgically verified OT. INTERVENTIONS: Patients underwent either laparoscopy or laparotomy. RESULTS: Twenty-two cases of OT in 20 premenarchal girls (median age 12 years) were identified. Three cases involved recurrent torsion after detorsion without cystectomy. The main presenting symptoms were sudden pain and vomiting. Six patients underwent Doppler examinations, and all demonstrated an abnormal flow. Seventeen interventions were by laparoscopy. Conservative management, mainly detorsion with additional cyst drainage or cystectomy, was performed in 19 cases (86.4%). Oophoropexy was performed in 3 cases (13.6%). Pathologic examination demonstrated 5 simple cysts and 1 dermoid cyst. CONCLUSIONS: Ovarian torsion in premenarchal girls usually presents with intermittent abdominal pain and abdominal tenderness. Other signs and symptoms are nonspecific. When performed, Doppler imaging may assist in diagnosing ovarian torsion in children. Detorsion followed by cystectomy may prevent recurrence.

Comparison of adnexal torsion between pregnant and nonpregnant women.

OBJECTIVE: The purpose of this study was to compare clinical manifestations, treatment, and pregnancy outcome of adnexal torsion in pregnant and nonpregnant women. STUDY DESIGN: We conducted a retrospective case-control study in the Departments of Gynecology at 2 tertiary centers between 1999-2008. Forty-one pregnant and 77 nonpregnant women with surgically proved adnexal torsion were assessed. RESULTS: Recurrence rate of torsion was 19.5% in pregnant women and 9.1% in control subjects; 73% of pregnant women conceived through assisted reproductive technologies. Doppler blood flow was falsely normal in 61% of pregnant women and in 45% of nonpregnant women; 83.3% of pregnant women delivered at term. Laparoscopic detorsion was the main surgical procedure. CONCLUSION: Presentation of adnexal torsion is similar in pregnant and nonpregnant women. Past assisted reproductive technology is an important risk factor in pregnancy. Doppler blood flow has a high false-negative rate and should not outweigh clinical suspicion. Although pregnancy outcome is favorable, the high rate of recurrence raises the issue of surgical fixation at the first episode.

The impact of a wireless audio system on communication in robotic-assisted laparoscopic surgery: A prospective controlled trial.

BACKGROUND: Robotic surgery presents a challenge to effective teamwork and communication in the operating theatre (OR). Our objective was to evaluate the effect of using a wireless audio headset device on communication, efficiency and patient outcome in robotic surgery. METHODS AND FINDINGS: A prospective controlled trial of team members participating in gynecologic and urologic robotic procedures between January and March 2015. In the first phase, all surgeries were performed without headsets (control), followed by the intervention phase where all team members used the wireless headsets. Noise levels were measured during both phases. After each case, all team members evaluated the quality of communication, performance, teamwork and mental load using a validated 14-point questionnaire graded on a 1-10 scale. Higher overall scores indicated better communication and efficiency. Clinical and surgical data of all patients in the study were retrieved, analyzed and correlated with the survey results. The study included 137 procedures, yielding 843 questionnaires with an overall response rate of 89% (843/943). Self-reported communication quality was better in cases where headsets were used (113.0 ± 1.6 vs. 101.4 ± 1.6; p < .001). Use of headsets reduced the percentage of time with a noise level above 70 dB at the console (8.2% ± 0.6 vs. 5.3% ± 0.6, p < .001), but had no significant effect on length of surgery nor postoperative complications. CONCLUSIONS: The use of wireless headset devices improved quality of communication between team members and reduced the peak noise level in the robotic OR.

Long-term outcomes for different vaginal cuff closure techniques in robotic-assisted laparoscopic hysterectomy: A randomized controlled trial.

OBJECTIVE: This randomized controlled trial aimed to evaluate the outcomes of different vaginal cuff closure techniques in robotic-assisted total laparoscopic hysterectomy. STUDY DESIGN: Ninety women undergoing robotic-assisted total laparoscopic hysterectomy for benign disease were randomized to three vaginal cuff closure techniques: running 2.0 V-Lock™ (Arm 1), 0 Vicryl™ figure-of-eight (Arm 2), and running 0 Vicryl™ with Lapra-Ty® (Arm 3). Patients' records were reviewed for age, body mass index, smoking status and relevant co-morbidities. Operative times for vaginal closure and total length of surgery, estimated blood loss, and peri-operative complications were collected. Patients were evaluated at 2 and 6 weeks post-operatively, and interviewed 1year following surgery by a telephone survey. Outcomes evaluated were vaginal cuff dehiscence, pain, dyspareunia and bleeding. RESULTS: The study arms did not differ with respect to estimated blood loss (50mL in each arm; p=0.34), median vaginal cuff closure time (14.5, 12 and 13min, respectively; p=0.09) or readmission (p=0.55). In the 1-year follow-up (54/90 respondents; 60%), there were no significant differences among study arms for vaginal bleeding, cuff infection or dyspareunia. Only women belonging to arm 3 reported vaginal pain (0%, 0% and 23%, respectively; p=0.01). No cases of vaginal cuff dehiscence were observed. CONCLUSIONS: The type of closure technique has no significant impact on patient outcomes. In the absence of a clear advantage of one technique over the others, the decision regarding the preferred method to close the vaginal cuff in robotic-assisted total laparoscopic hysterectomy should be based on surgeons' preference and cost effectiveness.

Quality of Communication in Robotic Surgery and Surgical Outcomes.

BACKGROUND AND OBJECTIVES: Robotic surgery has introduced unique challenges to surgical workflow. The association between quality of communication in robotic-assisted laparoscopic surgery and surgical outcomes was evaluated. METHODS: After each gynecologic robotic surgery, the team members involved in the surgery completed a survey regarding the quality of communication. A composite quality-of-communication score was developed using principal component analysis. A higher composite quality-of-communication score signified poor communication. Objective parameters, such as operative time and estimated blood loss (EBL), were gathered from the patient's medical record and correlated with the composite quality-of-communication scores. RESULTS: Forty robotic cases from March through May 2013 were included. Thirty-two participants including surgeons, circulating nurses, and surgical technicians participated in the study. A higher composite quality-of-communication score was associated with greater EBL (P = .010) and longer operative time (P = .045), after adjustment for body mass index, prior major abdominal surgery, and uterine weight. Specifically, for every 1-SD increase in the perceived lack of communication, there was an additional 51 mL EBL and a 31-min increase in operative time. The most common reasons reported for poor communication in the operating room were noise level (28/36, 78%) and console-to-bedside communication problems (23/36, 64%). CONCLUSION: Our study demonstrates a significant association between poor intraoperative team communication and worse surgical outcomes in robotic gynecologic surgery. Employing strategies to decrease extraneous room noise, improve console-to-bedside communication and team training may have a positive impact on communication and related surgical outcomes.

Robotic Trachelectomy After Supracervical Hysterectomy for Benign Gynecologic Disease.

BACKGROUND AND OBJECTIVES: A renewed interest in the supra cervical approach to hysterectomy has created a cohort of patients with a retained cervix at risk of persistent symptoms requiring a subsequent trachelectomy. The objective of this study was to evaluate the efficacy of robotic trachelectomy after a previous supracervical hysterectomy. METHODS: This is a retrospective chart review of women who had robotic trachelectomy after supracervical hysterectomy for benign gynecologic disease from January 2009 through October 2014. RESULTS: Eleven patients underwent robotic trachelectomy for benign conditions during the observed period. Prior supracervical hysterectomy had been performed for pelvic pain (8/11, 73%), abnormal uterine bleeding (7/11, 64%), and dysmenorrhea (5/11, 45%). In 10 of 11 patients, the symptoms leading to robotic trachelectomy were the same as those leading to supracervical hysterectomy. The time from hysterectomy to recurrence of symptoms ranged from 0.5 to 26 months (median, 6), whereas the time interval from previous surgery to robotic trachelectomy ranged from 1 to 57 months (median, 26). Mean age and body mass index at robotic trachelectomy were 42 ± 5.4 years and 32 ± 6.1 kg/m(2). Mean length of surgery was 218 ± 88 minutes (range, 100-405). There was 1 major postoperative complication involving bladder perforation and subsequent vesicovaginal fistula (VVF). Endometriosis was seen in 27% of pathologic specimens and cervicitis in another 27%; 45% showed normal tissue histology. In 6 (55%) cases, symptoms leading to trachelectomy resolved completely after surgery, and the other 5 (45%) patients reported a significant improvement. CONCLUSIONS: Although trachelectomy can be a challenging surgery, our experience suggests that the robotic approach may be a valuable means of achieving safe and reproducible outcomes.

Effects of Fatigue on Residents' Performance in Laparoscopy.

BACKGROUND: The influence of fatigue on residents' performance in laparoscopy was prospectively assessed through a computer-based virtual reality simulation (VRS) model. STUDY DESIGN: Twenty-six residents (14 novices, 12 experienced) were recruited. In the first stage, each participant was initially tested on 8 VRS-based tasks. In the second, run-in stage, each resident had 8 hours of hands-on practice of the specific tasks chosen. Finally, participants were evaluated before and after 24 hours on call. For each task, a set of parameters reflecting proficiency, efficacy, and safety were documented. RESULTS: In most of the tasks assessed, sleep deprivation had a significant deleterious effect on the performance of residents, both in terms of efficiency (time to complete the task), and safety (errors). These observations were more pronounced among novices. For example, in camera manipulation at a 30-degree angle, the total time to complete the task was slower after sleep deprivation (novices: sleep deprivation = 136 seconds, control = 119 seconds; experienced: sleep deprivation = 112 seconds, control = 103 seconds; p = 0.03). Moreover, accuracy rates were lower after sleep deprivation: in the "grasping and clipping" task, a lower accuracy rate after sleep deprivation was noted (novices: sleep deprivation = 82.8%, control = 87.9%; experienced: sleep deprivation = 87.6%, control = 90.8%; p = 0.05). CONCLUSIONS: In this prospectively controlled study we observed reduced efficiency and safety in the performance of residents after sleep deprivation. Using an innovative study design, we eliminated the learning curve bias. Compared with novices, experienced residents performed relatively better after a night shift, and this may be attributed to better adaptation to sleep deprivation.

Second-dose methotrexate in ectopic pregnancies: the role of beta human chorionic gonadotropin.

OBJECTIVE: To evaluate the role of ß-hCG levels on days 1, 4, and 7 after methotrexate as predictors for second-dose requirement and success. DESIGN: Retrospective cohort study. SETTING: Tertiary university-affiliated hospital. PATIENT(S): A total of 1,703 patients were admitted because of ectopic pregnancy. Four hundred nine received methotrexate, of whom 73 women required a second dose. INTERVENTION(S): The "single-dose" methotrexate protocol with 50 mg/m(2) was administered to patients with progressing ectopic pregnancy. Surgical intervention was performed in cases of methotrexate second-dose treatment failure. MAIN OUTCOME MEASURE(S): Methotrexate second-dose requirement and success according to ß-hCG levels on days 1, 4 and 7. RESULT(S): Second-dose methotrexate was successful in 58 patients (79.4%, success group), whereas 15 patients (20.6%) failed treatment and required surgical intervention (failure group). The medians of ß-hCG levels on days 1, 4, and 7 were significantly higher in the "failure group" (1,601 vs. 2,844, 2,164 vs. 3,225, and 1,915 vs. 3,745 mIU/mL, respectively). Logistic regression analysis demonstrated that day-1 ß-hCG levels were the only significant independent variable for second-dose treatment outcome. The receiver operating characteristic curve for ß-hCG levels on day 1 was 0.727, and at a cutoff value of 2,234 mIU/mL the sensitivity and specificity reached the optimum for treatment success (77.5% and 73.3%, respectively). CONCLUSION(S): Day-1 ß-hCG levels were the only predictors for methotrexate second-dose requirement and treatment success. The cutoff value of ß-hCG on day 1 with the optimal treatment results was found to be 2,234 mIU/mL.

Laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum.

OBJECTIVE: To compare the safety and feasibility of operative laparoscopy versus laparotomy in women with ruptured ectopic pregnancy and massive hemoperitoneum. METHODS: In a retrospective cohort study at a university-affiliated medical center, records of women with ruptured ectopic pregnancy and massive hemoperitoneum (>800mL) were reviewed. RESULTS: Sixty women were diagnosed with ruptured ectopic pregnancy and massive hemoperitoneum: 48 underwent emergency laparoscopy; 12 underwent emergency laparotomy. There was no difference in hemodynamic status at presentation between the groups. Median operating time was significantly shorter in the laparoscopy group (50minutes [range, 43-63minutes] vs 60minutes [range, 60-72minutes]; P=0.01). Median intra-abdominal blood loss was significantly greater in the laparotomy group (1500mL [range, 1400-2000mL] vs 1000mL [range, 800-1200mL]; P=0.002). There was no difference between the groups regarding treatment with blood products, perioperative complications, and hospitalization period. CONCLUSION: In patients with ruptured ectopic pregnancy and massive hemoperitoneum, laparoscopy is feasible and safe, with significantly shorter operating times compared with laparotomy. While the mode of surgery should be based on the surgeon's experience and preference, the significantly lower hemoperitoneum volume associated with laparoscopy may be a reflection of shorter operating times and quicker hemorrhage control.

Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence.

OBJECTIVE: To report our clinical experience in adnexal torsion. STUDY DESIGN: A retrospective case review of surgically proven adnexal torsion. RESULTS: 216 cases were identified. Mean age was 29±12. Twenty-two were premenarchal, 59 had ovarian stimulation, 48 were pregnant (with a median gestational age of 7 weeks) and 14 were post-menopausal. The most common risk factor was a previous history of adnexal torsion. The main clinical features were sudden, intermittent pain. Forty-five percent of Doppler examinations demonstrated normal flow: premenarchal and postmenopausal patients had higher rates of abnormal flow, compared to pregnant patients or after ovarian stimulation. Median time from admission to diagnosis was 6 h. Laparoscopy was conducted in 81.0% of the cases, and laparotomy in the rest. Twenty-three cases of recurrent torsion were documented. The majority of these events occurred following detorsion only. An enlarged ovary was found in 77 cases, dermoid cyst in 8 cases, and one case was malignant. Sixty eight-cases underwent detorsion, in 82 cases a combined detorsion and cystectomy or fenestration were performed and 43 patients underwent partial or total adnexectomy. Adnexal fixation was conducted in 21 cases. Cyst drainage or cystectomy significantly reduced the chance of retorsion by 50% and 75%, respectively, compared to detorsion only. CONCLUSION: Ovarian stimulation and early pregnancy are predisposing factors for ovarian torsion. Doppler flow studies may be a helpful diagnostic tool among premenarchal and post-menopausal women. Cystectomy should be considered in order to reduce the risk of retorsion.

"Watchful waiting" in ectopic pregnancies: a balance between reduced success rates and less methotrexate.

Many cases of ectopic pregnancy will spontaneously resolve, so that "watchful waiting" and ß-hCG follow-up will separate true viable ectopic pregnancies from spontaneously resolving ectopic pregnancies. Withholding methotrexate in patients with spontaneously resolving ectopic pregnancies and administering it in only true viable ectopic pregnancies will no doubt decrease published success rates for this therapy.