The impact of metronidazole on pain persistence after fertility-sparing endometriosis surgery: METROFERT randomized study.

BACKGROUND: Recent studies have shown that a disrupted microbiome is associated with endometriosis. Despite endometriosis affecting 1 in 10 reproductive-aged women, there is a lack of innovative and nonhormonal long-term effective treatments. Studies have reported an approximately 20-37.5% persistence of pain after fertility-sparing endometriosis surgery. Metronidazole has been shown to decrease inflammatory markers and the size of endometriosis lesions in animal studies. OBJECTIVE: To determine if modulating the microbiome with oral metronidazole for 14 days after fertility-sparing endometriosis surgery decreases pain persistence postoperatively. STUDY DESIGN: This was a randomized, multicenter, placebo-controlled, double-blind trial. Individuals 18-50 years old were prospectively randomized to placebo versus oral metronidazole for 14 days immediately after endometriosis fertility-sparing excision surgery. The primary outcome was binary, subjective pain persistence at six weeks postoperatively. Secondary outcomes of quality of life, sexual function, and endometriosis-associated pain scores according to the Endometriosis Health Profile-5, Female Sexual Function Index, and a visual analog scale. RESULTS: 152 participants were approached from October 2020 to October 2023 to enroll in the study. 64 participants were excluded either because they did not meet inclusion or exclusion criteria or because they declined to participate. 88 participants were randomized in a 1:1 ratio to receive either the oral placebo or metronidazole after endometriosis excision surgery. 18.2% of participants were lost to follow-up or discontinued treatment and this was not significantly different between the two arms, yielding a final cohort of 72 participants. Baseline demographics of the two study groups were similar. There was no statistically significant improvement in the primary outcome of binary subjective pain persistence between the metronidazole group compared to placebo (84% vs 88%, p=0.74) at 6 weeks postoperatively. Further, no significant differences between treatments were detected in the secondary outcomes. CONCLUSION: A postoperative 14-day regimen of oral metronidazole immediately after fertility-sparing endometriosis surgery was not associated with any significant differences between treatment groups in the in the persistence of endometriosis-related pain symptoms compared to placebo at 6 weeks.

Postoperative Complications of Appendectomy in Gynecologic Laparoscopic Surgery for Benign Indications.

OBJECTIVE: To assess whether concomitant appendectomy in patients who undergo laparoscopic surgery for benign gynecologic indications is associated with increased rates of complications in the 30-day postoperative period. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent laparoscopic surgery by a gynecologist. Patients were excluded if they underwent open abdominal surgeries, bowel resections, urogynecologic surgeries, or if diagnoses of cancer or appendicitis were present. There were 246,987 patients included in the population cohort from 2010 to 2020. Demographic information and postoperative outcomes of patients who underwent concomitant appendectomy were compared with patients who did not undergo appendectomy. A matched cohort was created by computing propensity scores, and outcomes were again compared between groups. All patients undergoing appendectomy were 1:1 matched to a unique patient who did not undergo appendectomy using a greedy matching based on the propensity score calculated from demographic and surgical characteristics. RESULTS: A total of 1,760 patients (0.7%) underwent concomitant appendectomy. There was an 8.0% complication rate in the appendectomy group, compared with 5.5% in the group of those without appendectomy ( P <.001), and this was similar to the results in the propensity-matched sample. Patients who underwent appendectomy had significantly higher rates of readmission (4.3% vs 2.3%), which remained significant in the propensity-matched sample. There were no differences in the rates of postoperative thromboembolic events, blood transfusion, or reoperation. CONCLUSION: Patients who are undergoing concomitant appendectomy have an increased risk of any complication and hospital readmission. Additional studies may be conducted to identify patients with optimal risk benefit profiles when considering performing concomitant appendectomy at time of gynecologic surgery.

Alternatives to excisional therapy: a clinical review of our current options to conservatively manage symptomatic leiomyomas.

PURPOSE OF REVIEW: This article provides a clinical review of the alternatives to traditional excisional surgical therapies for uterine leiomyomas, such as myomectomy or hysterectomy. RECENT FINDINGS: In this review, currently available hormonal medications will be briefly discussed. Then, nonhormonal medical therapy will be addressed with respect to mechanism of action, safety, and efficacy. Finally, the risk-benefit profile of nonexcisional procedures for management of leiomyomas will be addressed. SUMMARY: This provides an update on the information available for more conservative options for symptomatic leiomyoma management.

Comparison of Industry-Leading Energy Devices for Use in Gynecologic Laparoscopy: Articulating ENSEAL versus LigaSure Energy Devices.

STUDY OBJECTIVE: To compare 2 laparoscopic bipolar electrosurgical devices used in total laparoscopic hysterectomy (TLH). An articulating advanced bipolar device (ENSEAL G2; Ethicon Endo-Surgery, Cincinnati, OH) and an electrothermal bipolar vessel sealer (LigaSure; Medtronic, Minneapolis, MN) were analyzed for differences in surgeon perception of ease of instrument use and workload using the NASA Raw Task Load Index (RTLX) scale. A second objective was to examine differences in operative time, estimated blood loss (EBL), and perioperative complication rates between the 2 devices. DESIGN: Single-institution, single-blinded, randomized controlled trial (Canadian Task Force classification I). SETTING: Division of Minimally Invasive Gynecologic Surgery in a university hospital. PATIENTS: Eligibility required planned TLH, over age 18 years, and able to give informed consent; exclusions were stage III or IV endometriosis, known gynecologic malignancy, and early decision for conversion to laparotomy. One hundred seventy-eight patients screened, 142 enrolled, 2 withdrew, and 140 completed the study. Patients were followed 1 month postoperatively. INTERVENTIONS: Preoperative randomization to articulating advanced bipolar device or electrothermal bipolar vessel sealer to be used during TLH. MEASUREMENTS AND MAIN RESULTS: At the end of each hysterectomy the primary surgeon completed an ergonomic assessment tool, the RTLX. Results were analyzed to detect differences in workload between the 2 devices. For each case the time to ligation of the bilateral uterine arteries, EBL, and complications (including device failure, blood transfusion, or other injury) were recorded. Statistical analysis was performed using the t test for normally distributed data, χ2 test for categorical data, and Mann-Whitney U-test for nonparametric data. There were no differences in age, body mass index, parity, prior surgery, uterine weight, race, indication, pathology, and comorbidities between the 2 groups. A statistically significant increase in RTLX scores (p < .0001), device failures (p = .0031), and time to ligation of bilateral uterine arteries (p = .0281) was noted in the articulating device group. No significant differences in EBL or complication rates were noted between the groups. CONCLUSIONS: The articulating advanced bipolar device was shown to have a statistically significant increase in surgeon-perceived workload and rate of device failure when used in TLH; however, clinical and surgical outcomes were equivalent.

Systematic Review of Topical Hemostatic Agent Use in Minimally Invasive Gynecologic Surgery.

BACKGROUND AND OBJECTIVES: To perform a systematic review of articles evaluating hemostatic effectiveness and peri-operative outcomes when topical hemostatic agents (HA) are used in minimally invasive gynecologic surgeries (MIGS) for benign conditions. METHODS: Studies published through March 31, 2017 were retrieved through PubMed, EMBASE, Cochrane, and ClinicalTrials.gov to identify all eligible studies. No studies were excluded based on publish date. All comparative studies or case series with >10 participants reporting use of at least one topical HA in MIGS for benign conditions were included as long as full-text articles were available and written in English. Studies were excluded if surgery was done for malignancy or completed via an open approach. Articles that included multiple surgical subspecialties were excluded if data related to MIGS was unable to be isolated. Evaluation for eligibility and data extraction was performed by three independent reviewers. Quality of evidence was also assessed by each reviewer. RESULTS: From 132 articles, a total of 8 studies were included in this systematic review. We found that use of fibrin sealant decreased time to hemostasis, postoperative hemoglobin drop, and estimated blood loss (EBL) compared with bipolar energy and reduced the overall operative time in laparoscopic myomectomy. When fibrin sealant use at time of myomectomy was compared to bipolar energy there was no significant difference in the rate of postoperative complications. Furthermore, there was less of a decrease in anti-Mullerian hormone (AMH) level when a thrombin-gelatin matrix was used compared to bipolar energy on ovarian tissue. CONCLUSION: Application of topical HA in MIGS can reduce operative time, blood loss, and ameliorate damage to ovarian function. However, more data needs to be gathered for use of HA during different types of gynecologic procedures (adnexal surgery, myomectomy, and hysterectomy) to provide better quality evidence to guide their use.

Adnexal masses requiring reoperation in women with previous hysterectomy with or without adnexectomy.

OBJECTIVES: To characterize the etiologies of adnexal masses requiring reoperation in women with prior hysterectomy and to compare incidence and pathology of these masses based upon whether total, partial or no adnexectomy was performed at time of hysterectomy. In addition, the average time interval between hysterectomy and reoperation for a pelvic mass is ascertained. STUDY DESIGN: A single-institution, retrospective review spanning 10 years. Using pertinent ICD-9 and CPT codes, women with a history of hysterectomy who underwent a subsequent surgery for an adnexal or pelvic mass were identified. RESULTS: Over ten years, 250 women returned for gynecologic surgery due to a pelvic mass after prior hysterectomy. Most had undergone hysterectomy only (76%). 64.8% of these women had masses of ovarian origin, 12.4% were tubal in origin, 20% of masses involved both the ovary and tube and a small proportion arose from non-gynecologic processes. 18% of these women had a malignancy; 80% were ovarian and 6.7% originated from the fallopian tube. Patients having had a prior hysterectomy and bilateral salpingectomy returned soonest (p<0.0001) and patients with malignant masses returned after the longest time intervals (HR 0.41, p<0.0001). CONCLUSIONS: The majority of adnexal masses requiring reoperation after hysterectomy are gynecologic in origin, benign, and arise from the ovary. Women returning with malignant masses after hysterectomy present after longer time intervals.

Identifying the Rate-Limiting Step in Total Laparoscopic Hysterectomy in a Training Hospital.

STUDY OBJECTIVE: To identify the lengthiest step of total laparoscopic hysterectomy (TLH) in a teaching hospital and to determine which clinical factors affect the duration of this step. SETTING: The University of Louisville Hospital. DESIGN: Single institution retrospective case series. METHODS AND MAIN RESULTS: This is a retrospective chart and video review that included 135 benign, elective TLHs performed at The University of Louisville. TLH was divided into 5 steps: (1) insertion of laparoscopic ports and adhesiolysis to restore normal anatomy; (2) identification of the ureter and resection of adnexal structures to transection of the round ligament; (3) transection of the round ligament to transection of the uterine artery; (4) lateralization of the uterine vessel pedicle to completion of colpotomy; and (5) completion of vaginal cuff closure. The random intercept and slope model was used to identify the lengthiest step of TLH, and the backward elimination procedure was used to evaluate which clinical factors affected this step. Mean ± SD total length of TLH was 81 ± 30 min. The lengthiest step was colpotomy, with a mean duration of 24 ± 13 min. Uterine weight significantly increased the length of time required for colpotomy (p = .001). The primary energy source (ultrasonic scalpel vs monopolar hook) used to perform colpotomy did not influence the length of time (p = .539 vs p = .583). Uterine weight (p < .001) and adhesiolysis (p = .003) significantly increased the total time of TLH. CONCLUSIONS: At a teaching institution where surgeries are performed by residents and fellows, colpotomy is the lengthiest step of TLH and is influenced by uterine weight. This finding may reflect the training levels of the surgeons performing these cases and the learning curve associated with a challenging surgical skill. Further research should focus on simulation models and/or tools for colpotomy that may result in greater efficiency in the operating room.

Stepwise approach to laparoscopic hysterectomy: evaluation of technique and cost benefit.

This article examines factors associated with performing a laparoscopic hysterectomy in a stepwise fashion and addresses the technique and cost effectiveness of this procedure compared with abdominal hysterectomy. We review techniques of the laparoscopic hysterectomy as well difficulties that may be encountered throughout the procedure. The hysterectomy is profiled in a method that provides a reproducible system that allows surgeons to increase their surgical numbers and comfort level. When assessing cost-benefit analysis, the cost of hysterectomy is primarily influenced by the operative time, length of hospital stay, equipment, and complications. Robotic and laparoscopic hysterectomy had the highest mean hospital charges. The laparoscopic approach to hysterectomy provides better rates of recovery, length of stay, and hospital cost. The use of the stepwise approach to hysterectomy may allow surgeons to readily perform the procedure and also identify areas and techniques that need improvement. Regardless of age, body mass index (BMI), comorbities, and other nonclinical factors, the laparoscopic hysterectomy compared with abdominal hysterectomy and vaginal hysterectomy has been shown to be better for the patient's recovery and quality of life.

Laparoscopy in pregnancy and the pediatric patient.

Minimally invasive surgery is now standard of care for many procedures in pediatric gynecology. Laparoscopy has been well documented to produce faster recovery,decreased postoperative pain, and because of smaller incisions, a better cosmetic result. These are important when considering an active pediatric patient. Although a laparoscopic approach to endometriosis, adnexal masses, and ovarian torsion are well supported in the literature in the pediatric patient, more data are needed with regard to SILS in younger patients. Laparoscopy seems to be a better approach to oopheropexy in children undergoing radiation, and in resection of certain mullerian anomalies; however, the numbers are low.Similarly in pregnant patients, laparoscopy provides for shorter recovery times,decrease analgesic use and shorter hospital stays. Concerns about poor fetal outcomes in surgery during pregnancy for non gynecologic problems have been brought to light; however, the evidence indicates that these outcomes can be attributed to the nature of the underlying disease and not the surgical approach. With regard to pneumoperitoneum the effect of CO2 insufflation on fetal physiology and long-term outcomes remains unclear, and will continue to be an issue of controversy until larger studies are published.With both the pediatric and pregnant populations, laparoscopic complications can be diminished when performed by skilled surgeons with strict adherence to good technical principles. The advantages of laparoscopy are great, and this approach should be considered in pediatric and pregnant patients.

Global endometrial ablation.

Abnormal uterine bleeding (AUB) is a significant health problem for many women. Surgical treatment of AUB often follows failed attempts with first-line medical therapy. Hysterectomy, while being a definitive treatment, is a major surgical procedure with potential for significant complications and economic costs. Endometrial ablation was developed as an alternative to hysterectomy. The first-generation endometrial ablation devices required extensive training and experience to be performed effectively and safely. As a result, newer ablative devices were developed addressing the need for less technical knowledge and improved safety. Since 1997, the United States FDA has approved 5 global endometrial ablation devices for treatment of AUB attributable to benign causes. This review will focus on the technical aspects of these second- generation devices and their applications for treatment of AUB.