Association Between Power Morcellation and Mortality in Women With Unexpected Uterine Cancer Undergoing Hysterectomy or Myomectomy.

PURPOSE: Despite concerns that power morcellation may adversely affect prognosis of patients with occult uterine cancer, empirical evidence has been limited and inconclusive. In this study, we aimed to determine whether uncontained power morcellation at the time of hysterectomy or myomectomy is associated with increased mortality risk in women with occult uterine cancer. METHODS: By linking statewide hospital discharge records with cancer registry data in New York, we identified 843 women with occult endometrial carcinoma and 334 women with occult uterine sarcoma who underwent a hysterectomy or myomectomy for presumed benign indications during the period October 1, 2003, through December 31, 2013. Within this cohort, we compared disease-specific and all-cause mortality of women who underwent laparoscopic supracervical hysterectomy/laparoscopic myomectomy (LSH/LM), a surrogate indicator for uncontained power morcellation, with women who underwent supracervical abdominal hysterectomy and total abdominal hysterectomy (TAH), which did not involve power morcellation. Multivariable Cox regressions and propensity score method were used to adjust for patient characteristics. RESULTS: Among women with occult uterine sarcoma, LSH/LM was associated with a higher risk for disease-specific mortality than TAH (adjusted hazard ratio [aHR], 2.66, 95% CI, 1.11 to 6.37; adjusted difference in 5-year disease-specific survival, -19.4%, 95% CI, -35.8% to -3.1%). In the subset of women with leiomyosarcoma, LSH/LM was associated with an increased risk for disease-specific mortality compared with supracervical abdominal hysterectomy (aHR, 3.64, 95% CI, 1.50 to 8.86; adjusted difference in 5-year disease-specific survival, -31.2%, 95% CI, -50.0% to -12.3%) and TAH (aHR, 4.66, 95% CI, 1.97 to 11.00; adjusted difference in 5-year disease-specific survival, -37.3%, 95% CI, -54.2% to -20.3%). Among women with occult endometrial carcinoma, there was no significant association between surgical approach and disease-specific mortality. CONCLUSION: Uncontained power morcellation was associated with higher mortality risk in women with occult uterine sarcoma, especially in those with occult leiomyosarcoma.

Comparison of 30-day Complication Rates between Laparoscopic Myomectomy and Total Laparoscopic Hysterectomy for the Treatment of Uterine Leiomyoma in Women Older Than Age 40.

STUDY OBJECTIVE: To evaluate whether there are differences in complication rates between laparoscopic myomectomy (LM) and total laparoscopic hysterectomy (TLH) for the treatment of uterine leiomyoma in perimenopausal women. DESIGN: A retrospective cohort study using 1:2 propensity score matching (Canadian Task Force classification II-2). SETTING: American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: Women between the ages of 40 and 60 years undergoing surgical laparoscopic surgery for uterine leiomyoma between the years 2010 and 2016. INTERVENTIONS: Women were stratified to either LM or TLH at a ratio of 1:2 using propensity score matching. Descriptive statistics were reported as means with standard deviations. Pairwise analysis using the Student t test and chi-square test was performed where appropriate. Multivariable logistic regression was used to identify factors associated with the presence of a complication. MEASUREMENTS AND MAIN RESULTS: After propensity score matching, there were 631 myomectomies and 1262 hysterectomies. The operating time was slightly longer for LM compared with TLH (166.8 ± 90.3 minutes vs 157.9 ± 70.9 minutes, p = .03). The overall complication rate was 6.3%. There were no differences in complications between the LM and TLH groups (5.9% vs 6.6%, p = .54). Urinary tract infections were more common in the TLH group (2.3% vs 0.6%, p = .01). There were no other differences in the rates of specific complications between the 2 groups. On logistic regression, wound class greater than 3 was most strongly associated with a risk of complications (adjusted odds ratio [aOR] = 8.89; 95% confidence interval [CI], 1.28-15.87). Other variables associated with an increased risk of complications were conversion to hysterectomy (aOR = 5.91; 95% CI, 1.7-9.63), total operating time (aOR = 1.05; 95% CI, 1.02-1.07), and length of stay over 1 day (aOR = 3.67; 95% CI, 2.31-5.8). CONCLUSION: LM is not associated with an increased risk of complications compared with TLH in women over the age of 40 years undergoing treatment for uterine leiomyomata.

Recurrence after robotic myomectomy: is it associated with use of GnRH agonist?

Gonadotropin-releasing hormone (GnRH) agonist therapy is used before myomectomy to decrease the size of the fibroids, but its association with fibroid recurrence postoperatively remains unsettled. We undertook a retrospective study of robotic-assisted myomectomy (RM) patients at our academic medical center to determine symptomatic recurrence and reoperation rates in those who did versus did not receive preoperative GnRH therapy. Only patients, who had their index myomectomy at least 2 years prior to the chart review, were included in this study. Of 118 RM patients identified between January 2005 and December 2009, 17 patients (14.4 %) had symptomatic recurrence as early as 5 months to as late as 30 months postoperatively. The symptomatic recurrence group had significantly higher preoperative GnRH use (35 vs 9 % non-recurrence; p = 0.009). A total of 7.6 % of all patients underwent reoperation. GnRH agonist use was significantly higher in the reoperation group (56 vs 9 % no reoperation; p = 0.002). Cavity entry during the initial surgery was also more frequent in the reoperation group (56 vs 20 %; p = 0.030), whereas the presence of multiple fibroids, size of the largest leiomyoma, and uterine volume were not statistically different between groups. Our study is among the earliest to report RM reoperation rates in patients receiving preoperative GnRH therapy, showing that the role of GnRH agonist therapy to shrink myomas may not be beneficial when measured against risk of disease recurrence.

Comparison of Survival Outcomes in Women with Unsuspected Uterine Malignancy Diagnosed After Laparotomic Versus Laparoscopic Myomectomy: A National, Population-Based Study.

PURPOSE: The primary objective of our study was to investigate the effect of morcellation on overall survival in women with unsuspected uterine malignancy (UUM) diagnosed after myomectomy by comparing women who underwent laparotomic myomectomy to those who underwent laparoscopic myomectomy. The secondary objective was to estimate the incidence of UUM diagnosed after myomectomy. METHODS: We analyzed the mortality and incidence of women with UUM diagnosed after myomectomy using data from the national health insurance database between 2009 and 2013. To extract women with or without UUM diagnosed after myomectomy, we used diagnosis (C54.X) and procedure codes. We used the indicator of suspicion of death to verify deaths. RESULTS: During the study period, among the study population of approximately 23 million women per year, 102144 women underwent myomectomy. Of them, 69955 and 32085 women were enrolled onto the laparotomic and laparoscopic groups, respectively. In each group, the numbers of women with UUM diagnosed after myomectomy were 76 and 50, respectively. The incidences of UUM and UUM excluding endometrial cancer, respectively, were 0.1, 0.15 % (p = 0.046) and 0.05, 0.07 % (p = 0.147) in each group, respectively. The overall 3-year survival rates for patients with UUM and UUM excluding endometrial cancer were 97.6 ± 0.2 % (n = 23), 91.5 ± 0.5 % (n = 12); and 93.8 ± 0.6 % (n = 8), 93.8 ± 0.6 % (n = 5) in each group, respectively. Additionally, there were no statistically significant differences between the groups with respect to overall survival of women with UUM with or without endometrial cancer (log-rank test; p = 0.14) (time-dependent Cox regression model; p = 0.93). CONCLUSIONS: There was no difference in the overall survival of women with UUM with or without endometrial cancer between groups. The incidence of UUM with or without endometrial cancer diagnosed after myomectomy was quite low.

MAUDE: analysis of robotic-assisted gynecologic surgery.

STUDY OBJECTIVE: To evaluate the adverse events encountered during robotic gynecologic surgery, as reported to the FDA MAUDE database from January 2006 to December 2012. DESIGN: Database search (Canadian Task Force classification III). INTERVENTION: A search of the FDA MAUDE database was performed by brand name "da Vinci" and manufacturer "Intuitive Surgical." Reports reflecting gynecologic procedures either by description or procedure name were included. A record of reports was kept to ensure that no duplicates were added. The date and type of event (operator-related error, technical system failure, or surgical injuries attributed to use of the robot) and the clinical outcome were recorded. MEASUREMENTS AND MAIN RESULTS: Twenty-six percent of reported events (n = 73) resulted in injury, and 8.5% (n = 24) resulted in death. Of note, although adnexal procedures were performed in <3% of the cohort, they accounted for 20% of the fatalities. Twenty-one percent of injuries were attributed to operator-related error, and 14% to technical system failure; 65% were not directly related to use of the robot. Fifteen deaths were reported during planned hysterectomy. Four of those were due to injury to a major blood vessel (iliac artery in 3, and aorta in 1), although a detailed description of how the injury occurred was absent from the event description. CONCLUSION: It is important to continue to evaluate the occurrence of injuries during robot-assisted surgery in an effort to identify unique challenges associated with this advanced technology.