MRI Evaluation of Uterine Masses for Risk of Leiomyosarcoma: A Consensus Statement.

Laparoscopic myomectomy, a common gynecologic operation in premenopausal women, has become heavily regulated since 2014 following the dissemination of unsuspected uterine leiomyosarcoma (LMS) throughout the pelvis of a physician treated for symptomatic leiomyoma. Research since that time suggests a higher prevalence than previously suspected of uterine LMS in resected masses presumed to represent leiomyoma, as high as one in 770 women (0.13%). Though rare, the dissemination of an aggressive malignant neoplasm due to noncontained electromechanical morcellation in laparoscopic myomectomy is a devastating outcome. Gynecologic surgeons' desire for an evidence-based, noninvasive evaluation for LMS is driven by a clear need to avoid such harms while maintaining the availability of minimally invasive surgery for symptomatic leiomyoma. Laparoscopic gynecologists could rely upon the distinction of higher-risk uterine masses preoperatively to plan oncologic surgery (ie, potential hysterectomy) for patients with elevated risk for LMS and, conversely, to safely offer women with no or minimal indicators of elevated risk the fertility-preserving laparoscopic myomectomy. MRI evaluation for LMS may potentially serve this purpose in symptomatic women with leiomyomas. This evidence review and consensus statement defines imaging and disease-related terms to allow more uniform and reliable interpretation and identifies the highest priorities for future research on LMS evaluation.

Less is more: clinical impact of decreasing pneumoperitoneum pressures during robotic surgery.

The objective of this study was to investigate the effects of decreasing insufflation pressure during robotic gynecologic surgery. The primary outcomes were patient-reported postoperative pain scores and length of stay. Secondary outcomes include surgical time, blood loss, and intraoperative respiratory parameters. This is a retrospective cohort study of patients undergoing robotic surgery for benign gynecologic conditions by a single minimally invasive surgeon at an academic hospital between 2014 and 2017. Patients were categorized by the maximum insufflation pressure reached during the surgery as either 15, 12, 10, or 8 mmHg. Continuous variables were compared using analysis of variance and χ2 test was used for categorical variables. 598 patients were included in this study with no differences in age, BMI, race, prior abdominal surgeries, or specimen weight between the four cohorts. When comparing cohorts, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs. 3.8, p ≤ 0.001), and hospital length of stay (449 vs 467 vs 351 vs. 317 min, p ≤ 0.001). There were no differences in duration of surgery (p = 0.31) or blood loss (p = 0.09). Lower operating pressures were correlated with significantly lower peak inspiratory pressures (p < 0.001) and tidal volumes (p < 0.001). Surgery performed at lower-pressure pneumoperitoneum (≤ 10 mmHg) is associated with lower postoperative pain scores, shorter length of stay, and improved intraoperative respiratory parameters without increased duration of surgery or blood loss. Operating at lower insufflation pressures is a low-cost, reversible intervention that should be implemented during robotic surgery as it results in the improved pain scores and shorter hospital stays.

The role of imaging as a guide to the surgical treatment of endometriosis.

Minimally invasive surgery for complex endometriosis requires preoperative planning that intimately connects the gynecologic surgeon to the radiologist. Understanding the surgeon's perspective to endometriosis treatment facilitates a productive relationship that ultimately benefits the patient. We examine minimally invasive surgery for endometriosis and the key radiologic information which enable the surgeon to successfully negotiate patient counseling, preoperative planning, and an interdisciplinary approach to surgery.

Robot-Assisted Myomectomy for Large Uterine Myomas: A Single Center Experience.

Objective. To determine if robot-assisted myomectomy (RAM) is feasible for women with large uterine myomas. Methods. Retrospective review of one gynecologic surgeon's RAM cases between May 2010 and July 2013. Large uterine myomas, defined as the largest myoma ≥9 cm by preoperative magnetic resonance imaging, was age- and time-matched to controls with the largest myoma <9 cm. Primary surgical outcomes compared were operative time and estimated blood loss (EBL). Results. 207 patients were included: 66 (32%) patients were in the ≥9 cm group, while 141 (68%) patients were in the <9 cm group. There was a statistically significant increase in the operative time (130 min versus 92 min) and EBL (100 mL versus 25 mL) for the ≥9 cm group compared to the <9 cm group. Ten (4.8%) patients had the largest myoma measuring ≥15 cm, and 11 (5.3%) patients had a specimen weight >900 gm, of which no major adverse outcomes were observed. All patients in the study cohort were discharged on the same day after surgery. Conclusion. RAM is a feasible surgical approach for patients with myomas ≥9 cm. Patients with large myomas undergoing RAM are also candidates for same-day discharge after surgery.

Learning curve analysis of the first 100 robotic-assisted laparoscopic hysterectomies performed by a single surgeon.

OBJECTIVE: To review the first 100 cases of robotic-assisted hysterectomy performed by an individual surgeon. METHODS: A retrospective cohort study of the first 100 consecutive patients who underwent robotic-assisted hysterectomy by a newly trained minimally invasive gynecologic surgeon was conducted. Demographic factors and short-term surgical outcome variables were abstracted from medical records. We examined univariate associations and performed multivariable modeling with linear regression, and modeled the learning curve for total operative time using power-law function. RESULTS: Mean age was 46 years; mean body mass index was 27.8 kg/m(2). Median operative time was 120 minutes; median estimated blood loss was 100mL. On multivariable analysis, case number (ß -0.296; P<0.005) and uterine weight (ß 0.330; P<0.005) independently predicted operative time, while uterine weight (ß 0.387; P<0.005) independently predicted estimated blood loss. The point at which the slope of the case number-operative time curve crosses -1.0 is at case 28 when uncontrolled and at case 24 when controlled for other factors. CONCLUSION: There was a significantly decreased operative time for robotic-assisted hysterectomies performed later in the surgeon's learning curve. Surgical proficiency, as measured by operative time, seemed to be attained after 20-30 cases.

Comparison of morbidity associated with laparoscopic myomectomy and hysterectomy for the treatment of uterine leiomyomas.

OBJECTIVE: To compare short-term morbidity and quality of life after laparoscopic hysterectomy (LH) and laparoscopic myomectomy (LM) for the treatment of symptomatic uterine leiomyomas. METHOD: We performed a prospective, observational study of women who were eligible for both surgical procedures. After informed consent was obtained, each participant was asked to complete the SF-12v2 Health Survey before surgery and to repeat it seven days and 28 days after surgery. Data on short-term morbidities, such as operative time, blood loss, length of hospital stay, and surgical complications, were collected by an obstetrician-gynaecologist. Women who underwent LH were compared by non-parametric statistical analyses with those who underwent LM. RESULTS: Sixty-one women were recruited between January 1 and December 31, 2008, including 40 who underwent LM and 21 LH. Women who underwent LH were older, had higher parity, and were less likely to have infertility than those who chose LM. Median LH operative time of 223 minutes (IQR 214 to 241) was slightly longer than for LM (188 minutes, IQR 154 to 239; P = 0.02). However, we found no difference between the two groups in terms of SF-12v2 fluctuation, blood loss, hospital stay, and short-term complications. CONCLUSION: Laparoscopic myomectomy is a viable alternative to laparoscopic hysterectomy for women with symptomatic leiomyomas who want conservative surgery. The procedures have similar morbidity and impact on quality of life.

Controlled ovarian hyperstimulation and gestational surrogacy in a patient with lung transplant: a case report.

BACKGROUND: Cystic fibrosis (CF) is one of the most common genetic disorders that can often lead to chronic pulmonary disease. Patients with respiratory failure due to CF may achieve a good quality of life after lung transplant, and many will desire to have children. CASE: A 26-year-old, nulliparous female with CF and double lung transplant presented for fertility treatment. She was successfully treated with controlled ovarian hyperstimulation and gestational surrogacy. CONCLUSION: Controlled ovarian hyperstimulation and gestational surrogacy is a safe option for patients with lung transplant to have a genetic child.

Coexistence of endometriosis in women with symptomatic leiomyomas.

OBJECTIVE: To investigate the coexistence of endometriosis in women presenting with symptomatic leiomyomas. DESIGN: Retrospective study. SETTING: Tertiary university medical center. PATIENT(S): We reviewed the medical records of 131 patients who underwent laparoscopic myomectomy or hysterectomy. All patients were consented for possible concomitant diagnosis and treatment of endometriosis. INTERVENTION(S): All patients underwent laparoscopic myomectomy or hysterectomy. MAIN OUTCOME MEASURE(S): The main outcome measure of the study was the presence or absence of endometriosis. RESULT(S): Of the 131 patients, 113 were diagnosed with endometriosis and fibroids, while 18 were diagnosed with fibroids alone. Patients with fibroids were on average 4.0 years older than those with endometriosis and fibroids (41 vs. 45). Patients with both diagnoses were also more likely to present with pelvic pain and nulliparity than those with fibroids alone. CONCLUSION(S): An overwhelming majority of patients with symptomatic fibroids were also diagnosed with endometriosis. Overlooking the concomitant diagnosis of endometriosis in these women may lead to suboptimal treatment of the patients. Further studies are needed to evaluate the impact of surgical treatments on symptom resolution.

Ovarian stimulation for fertility preservation in patients with cancer.

OBJECTIVE: To evaluate controlled ovarian hyperstimulation (COH) in women with cancer compared with healthy women. DESIGN: A retrospective cohort study. SETTING: Academic assisted reproductive technology (ART) program. PATIENT(S): Fifty women undergoing oocyte retrieval before cancer treatment and 50 age-matched controls. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number of oocytes and matured oocytes retrieved, number of fertilized oocytes, days of stimulation, dose of gonadotropins. RESULT(S): There were no significant differences in the number of oocytes retrieved (13 vs. 11.5), the number of matured oocytes retrieved (9.7 vs. 9.6), and the number of oocytes fertilized (7.4 vs. 6.8). However, the patients with cancer had a longer duration of stimulation (10.5 vs. 9.0 days) and higher total dose of gonadotropins (4,174 IU vs. 3,416 IU). CONCLUSION(S): In our study, reasonable ovarian response was achieved by women with cancer with increased doses of gonadotropins and a longer duration of stimulation.

Endometriosis of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy.

STUDY OBJECTIVE: We aim to describe the clinical characteristics and the principles of combined laparoscopic and thoracoscopic management of women with diaphragmatic endometriosis at our institution. DESIGN: Case series (Canadian Task Force Classification II2). SETTING: Tertiary care referral center. PATIENTS: Four women with diaphragmatic endometriosis. INTERVENTIONS: Laparoscopy and thoracoscopy. MEASUREMENTS: We retrospectively reviewed the charts of 4 consecutive women with diaphragmatic endometriosis who underwent laparoscopy and thoracoscopy from June 2008 through September 2008. MAIN RESULTS: Four patients underwent a combination of laparoscopy for treatment of abdominopelvic endometriosis and thoracoscopy for treatment of diaphragmatic endometriosis. All patients had a history of chest pain. Three had a history of pelvic pain. Two had a history of catamenial hemothorax or pneumothorax. Two had been previously diagnosed with endometriosis, and three had a history of hormonal pharmacotherapy. All underwent laparoscopy and thoracoscopy without complications. All had uneventful recoveries. At nine-month follow-up, all patients were free of chest pain, and one patient had recurring pelvic pain. CONCLUSIONS: To the best of our knowledge, this constitutes the only reported series of patients with endometriosis who underwent a procedure systematically combining both laparoscopy and thoracoscopy for treatment of abdominopelvic and thoracic disease. It confirms that combined laparoscopic and thoracoscopic diagnosis and management of diaphragmatic endometriosis is reasonable. The inferior aspect of the diaphragm should be evaluated in all patients undergoing laparoscopy for endometriosis. Concomitant thoracoscopy should be considered for all patients with history of catamenial hemopneumothorax, cyclic chest or shoulder pain, or cyclic dyspnea. The aim of treatment should be to remove endometriotic lesions, to provide symptomatic relief, and to avoid recurrence. The use of these minimally invasive techniques may reduce the need for laparotomy or thoracotomy in affected patients.