Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review.

OBJECTIVE: To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint. DATA SOURCES: PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible. METHODS OF STUDY SELECTION: This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy. TABULATION, INTEGRATION, AND RESULTS: The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss. CONCLUSION: Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021233300.

Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries. DATA SOURCES: PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included. METHODS: Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals. RESULTS: Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures. CONCLUSION: Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications: A Systematic Review.

OBJECTIVE: To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications. DATA SOURCES: A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal. METHODS OF STUDY SELECTION: All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible. TABULATION, INTEGRATION, AND RESULTS: We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent. CONCLUSION: Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD 42018093099.

Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System.

OBJECTIVE: To examine trends in minimally invasive hysterectomy and power morcellation use over time and associated clinical characteristics. METHODS: We conducted a trend analysis and retrospective cohort study of all women 18 years of age and older undergoing hysterectomy for benign conditions at Kaiser Permanente Northern California collected from electronic health records. Generalized estimating equations and Cochran-Armitage testing were used to assess the primary outcomes, hysterectomy incidence, and proportion of hysterectomies by surgical route and power morcellation. Logistic regression analysis was used to assess secondary outcomes, clinical characteristics, and complications associated with surgical route. RESULTS: There were 31,971 hysterectomies from 2008 to 2015; the incidence decreased slightly from 2.86 (95% confidence interval [CI] 2.85-2.87) to 2.60 (95% CI 2.59-2.61) per 1,000 women (P<.001). Minimally invasive hysterectomies increased from 39.8% to 93.1%, almost replacing abdominal hysterectomies entirely (P<.001). Vaginal hysterectomies decreased slightly from 26.6% to 23.4% (P<.001). The proportion of nonrobotic laparoscopic hysterectomies with power morcellation increased steadily from 3.7% in 2008 to a peak of 11.4% in 2013 and decreased to 0.02% in 2015 (P<.001). Robot-assisted laparoscopic hysterectomies remained a small proportion of all hysterectomies comprising 7.8% of hysterectomies in 2015. Women with large uteri (greater than 1,000 g) were more likely to receive abdominal hysterectomies than minimally invasive hysterectomy (adjusted relative risk 11.62, 95% CI 9.89-13.66) and laparoscopic hysterectomy with power morcellation than without power morcellation (adjusted relative risk 5.74, 95% CI 4.12-8.00). Laparoscopic supracervical hysterectomy was strongly associated with power morcellation use (adjusted relative risk 43.89, 95% CI 37.55-51.31). CONCLUSION: A high minimally invasive hysterectomy rate is primarily associated with uterine size and can be maintained without power morcellation.

Adverse events associated with pelvic organ prolapse surgeries that use implants.

OBJECTIVE: To estimate the rate of vaginal implant exposure associated with biologic grafts and permanent mesh used for pelvic organ prolapse (POP) surgery, to describe treatments used for these complications, and to estimate response rates to these treatments. The secondary aims were to describe the operative and perioperative complications. METHODS: This was a retrospective analysis of female members of Kaiser Permanente Southern and Northern California and Hawaii who underwent POP surgeries with biologic grafts and permanent mesh between September 2008 and May 2010. Inpatient and outpatient electronic medical records were reviewed for postoperative adverse events. RESULTS: During the 21-month period, 1,282 women, mean age of 62 years (±10 standard deviation), median parity of 3 (interquartile range 2-4), and median body mass index of 28 (interquartile range 24-30) underwent prolapse repairs with 1,484 implants with a mean follow-up time of 358 days (±276 standard deviation). Vaginal exposures occurred more often with permanent mesh (53/847 [6%]) than biologic grafts (10/637 [1.6%]) (P<.001). Resolution of vaginal exposure after the first treatment occurred in 24 of 63 (38%), whereas 39 of 63 (62%) required multiple treatments. Surgical excision was performed in 20 of 63 (32%) exposures. Permanent mesh exposures were more likely to require surgical excision (20/53 [38%]) than biologic graft exposures (zero of 10) (P=.02). CONCLUSION: Vaginal exposure occurred more frequently with permanent mesh than biologic graft, may require multiple treatments, and occasionally require surgical excision. LEVEL OF EVIDENCE: : II.

Perioperative complications and reoperations after incontinence and prolapse surgeries using prosthetic implants.

OBJECTIVE: To estimate the perioperative complication and reoperation rates associated with slings and prolapse repairs using mesh and biologic grafts. METHODS: Analysis of all female members of Kaiser Permanente Southern and Northern California and Hawaii who underwent sling procedures or pelvic organ prolapse surgeries using implanted grafts or mesh between September 1, 2008, and May 31, 2010. Physicians' Current Procedural Terminology Coding System, 4th edition, International Classification of Diseases, 9th Revision, and surgical implant logs were used to identify the procedures performed, implants used, perioperative complications, and readmissions and reoperations within 12 months of the index surgery. RESULTS: During the 21-month period, 4,142 women (mean age 57 years [standard deviation 12.2], median parity 3 [interquartile range 1-4], median body mass index 28 [interquartile range 25-32]) underwent 3,747 (71%) slings and 1,508 (29%) prolapse repair procedures using implanted prostheses. Trocar-related bladder perforations (51 of 3,747 [1.4%]) occurred more commonly than urethral perforations (2 of 3,747 [0.05%]) in sling procedures (P<.001). There were no trocar-related injuries for prolapse repair kit procedures. Mesh-related reoperations after sling procedures were performed for voiding dysfunction or urinary retention (49 of 3,747 [1.3%]), vaginal mesh erosion (30 of 3,747 [0.8%]), and urethral erosion (3 of 3,747 [0.08%]). Reoperations after prolapse procedures were performed more often for vaginal mesh erosion (29 of 858 [3%]) than for biologic graft infection (2 of 650 [0.3%]; P=.01) and were performed more commonly after anterior (19 of 307 [6%]) compared with apical (9 of 487 [2%]) or posterior vaginal mesh repairs (1 of 64 [2%]; P=.018). CONCLUSION: Reoperations for mesh-related complications occurred most often after transvaginal mesh placement in the anterior vagina.

Surgical education for the twenty-first century: beyond the apprentice model.

Traditionally, surgery has been taught by an apprentice model, where the learner imitates the actions of a skilled mentor. Although effective, this model is inefficient because it requires learners to be exposed to a large number of surgeries performed by a limited number of dedicated teaching faculty. In addition, competence is proved with subjective evaluations. Because of changes in modern medical practice, specifically reimbursement issues, resident work hour restrictions, and need for reliable and valid credentials, the critical components of the apprentice model are eroding. A paradigm shift is needed in modern surgical education.

Histologic evaluation of human cadaveric fascia lata in a rabbit vagina model.

The purpose of this study was to evaluate the histologic response of human cadaveric fascia lata after vaginal implantation. Freeze-dried, gamma-irradiated cadaveric fascia lata from three lots was implanted between the rectovaginal membrane and vaginal epithelium in New Zealand white rabbits. Rabbits were killed at 2, 4, 8, and 12 weeks after implantation. At necropsy, gross findings were described and specimens for routine cultures were taken. Histologic evaluation determined graft integrity, neovascularization, inflammatory response, and host tissue incorporation. Nine rabbits were available for histologic analysis and 14 for gross and microbiologic analysis. Vaginal erosions occurred with three grafts. The remainder were adherent to the surrounding tissues. Erosion was associated with bacterial colonization of the graft. Autolysis of one graft occurred at 4 weeks. Over time, the inflammatory response decreased and neovascularization increased; by 12 weeks, the graft collagen was replaced by host collagen. Cadaveric fascia lata serves as scaffolding for host tissue incorporation with replacement by host collagen.

Further characterization of the supine empty stress test for predicting low valsalva leak point pressures.

The aim of this study is to determine if the diagnostic accuracy of the supine empty stress test (SEST) differs depending on the volume of residual urine. We performed a review of all patients who were diagnosed with stress urinary incontinence (SUI) via multi-channel urodynamics including valsalva leak point determinations (VLPP). A SEST was performed and the residual urine recorded via catheterization. The test-specific indices of the SEST for the prediction of low VLPP (defined as <60 cm H(2)0) were determined for varying residual volumes. Ninety-nine patients were included. Regardless of residual volume, low sensitivities, specificities and positive predictive values were demonstrated. Sensitivity and positive predictive values were further reduced and negative predictive values were improved slightly with higher residual volume. The highest negative predictive value was 89% at a residual volume of greater than 10 mL. Residual urine volume has minimal impact on the utility of the SEST.

Electrochemical recognition of analytes using quaternary ammonium binaphthyl salts.

The electrooxidation of quaternary ammonium binaphthyl salts is shown to proceed by a quasi-reversible one-electron process. The oxidation of an aza-crown ether substituted binaphthyl salt is affected by the presence of lithium and sodium ions in solution and there is shown to be a linear relationship between the limiting current for the process and the concentration of Li+ and Na+. The electrochemistry of the binaphthyl salt is also shown to be affected by the addition of organic cations to the solution, showing that these receptors could form the basis of analytical devices which could be made specific to a range of analytes.

Changes in tensile strength of cadaveric human fascia lata after implantation in a rabbit vagina model.

PURPOSE: We determined changes in tensile properties after vaginal implantation of human cadaveric fascia lata. MATERIALS AND METHODS: Baseline tensile properties were determined for freeze-dried, gamma irradiated human cadaveric fascia lata from 3 separate lots. Fascial strips (2 x 0.5 cm.) from 2 lots were implanted between the rectovaginal membrane and vaginal mucosa in New Zealand white rabbits. The strips were excised en bloc 12 weeks after implantation. Tensile property measurements were repeated and compared with pre-implantation values. RESULTS: Pre-implantation interlot and intralot variability in baseline tensile properties was significant. After implantation there was an approximate 90% decrease in tensile strength from baseline values. There was no gross evidence of graft autolysis. CONCLUSIONS: The decrease in tensile strength of cadaveric fascial graft was significant after implantation in this model.

Does hysterectomy without adnexectomy in patients with prior tubal interruption increase the risk of subsequent hydrosalpinx?

OBJECTIVE: Our purpose was to examine the hypothesis that hysterectomy without adnexectomy after tubal interruption is associated with the development of hydrosalpinx. STUDY DESIGN: In this case-control study, patients with a pathologic diagnosis of hydrosalpinx were compared with a group of patients undergoing adnexectomy without a hydrosalpinx. The incidence of prior tubal interruption followed by hysterectomy in the two groups was compared. RESULTS: There was a statistically significant association between the development of hydrosalpinx and a history of hysterectomy after tubal interruption. Nine of 38 cases and 2 of 45 controls had a history of tubal interruption (odds ratio 6.67, P =.019). CONCLUSIONS: Patients undergoing hysterectomy who have had a tubal interruption may be at risk for the development of hydrosalpinx because this combination of procedures results in a segment of tube that is blocked at both ends. If further study bears out this association, consideration should be given to performing salpingectomy at the time of hysterectomy even if the ovaries are being left behind.

Electrochemical recognition of chiral species using quaternary ammonium binaphthyl salts.

The use of ephedrine-substituted quaternary ammonium binaphthyl salts as molecular receptors is demonstrated. The electrochemical oxidation of the receptor is affected by the binding of an analyte in solution. The binding site on the binaphthyl salt has been determined using computer modeling and confirmed using 1D and 2D NMR studies. It is shown that the sensitivity of the receptor is related to the size of the analyte. Axially chiral binaphthyl salts are shown to bind chiral analytes in a different manner and this is demonstrated using lactic and mandelic acid. The presence of a polar functional group on the analyte is also shown to have an effect on the guest-host interaction.

Surgical management of stress urinary incontinence: consideration for an algorithmic approach.

Stress urinary incontinence is defined as the symptomatic loss of urine related to increases in intra-abdominal pressure. A variety of nonsurgical therapies with varying degrees of effectiveness and patient acceptance are available. If nonsurgical therapies fail, then multiple surgical options exist, including retropubic urethropexy, bulking agents, pubovaginal slings, and sling variants. A surgical algorithm based on the amount of anterior vaginal wall prolapse (including urethrovesical mobility) and urethral sphincter function utilizing these procedures is reported herein.

Variability of reported techniques for performance of the pubovaginal sling procedure.

The aim of this study was to determine the commonly used techniques for sling surgery. A questionnaire was distributed to the attendees at the 20th Annual Scientific Meeting of the American Urogynecologic Society. Techniques addressed included the type and length of the graft material, the fixation point, and the methods of sling tensioning. Type of training and monthly surgical volume was also determined. Sixty-five gynecologic and urologic surgeons responded to the survey, the majority of whom were fellowship-trained urogynecologists (68%). The median monthly operative experience was 8 anti-incontinence procedures, including 3.5 pubovaginal slings. There was wide inter-respondent variability in all techniques except fixation point. There was also large intra-respondent variability in sling technique: 42% reported the use of differing graft materials, 19% noted using differing graft lengths, and 19% employed variable tensioning methods. Type of training and operative experience did not predict surgical technique(s) or consistency. Our conclusion was that there is wide variability in the techniques of sling performance.

Perioperative changes in serum creatinine after gynecologic surgery.

OBJECTIVE: The purpose of this study was to prospectively determine the normal range of postoperative changes in serum creatinine levels when bilateral ureteral patency was confirmed by cystoscopy. STUDY DESIGN: A total of 187 consecutive patients who had undergone major gynecologic surgery were evaluated prospectively. All patients had undergone perioperative cystoscopy to evaluate for ureteral patency, and creatinine levels had been determined before and 24 hours after surgery. RESULTS: The mean change in serum creatinine level was 0.01 mg/dL, and the changes for the central 95% ranged from -0.2 to 0.3 mg/dL. With a previously defined cutoff value of an increase of >0.2 mg/dL after operation to indicate ureteral obstruction, specificity and negative predictive values (when compared with cystoscopic findings) were 98% and 100%, respectively. CONCLUSION: Creatinine levels change minimally during the immediate postoperative period in the absence of ureteral compromise. If bilateral ureteral patency was demonstrated after operation in our population, creatinine level elevations were always <0.3 mg/dL.

Laparoscopic versus open Burch retropubic urethropexy: comparison of morbidity and costs when performed with concurrent vaginal prolapse repairs.

OBJECTIVE: The purpose of this study was to determine the morbidity and cost that are associated with laparoscopic and open Burch retropubic urethropexy when they are performed with concurrent vaginal prolapse repairs. STUDY DESIGN: We conducted a retrospective study of all patients who had undergone laparoscopic (n = 76) or open (n = 143) Burch retropubic urethropexy with at least 1 concurrent vaginal repair for symptomatic prolapse. We compared demographic data, level of prolapse, operative and postoperative details, medical and surgical histories, complications, and hospital charges. RESULTS: The group with open retropubic urethropexy had an older age, greater degree of prolapse, fewer concurrent hysterectomies, and a greater number of vaginal procedures than the group with laparoscopic retropubic urethropexy. There were minimal differences in complications and no differences in the estimated blood loss, operative time, hemoglobin change, hospitalization, or hospital charges between the 2 groups. CONCLUSION: Traditional benefits of laparoscopic retropubic urethropexy were not apparent when vaginal prolapse repairs were performed.