The role of minimally invasive gynecologic surgeons in the era of subspecialties: when to refer and consult.

PURPOSE OF REVIEW: Minimally invasive gynecologic surgery (MIGS) is a subspecialty focus of obstetrics and gynecology with focused expertise on complex benign gynecologic disorders. To date, no formal recommendations have been made in defining a referral system for MIGS. This article reviews the evidence regarding common disorders and procedures and their outcomes, and posits a basis for MIGS referral. RECENT FINDINGS: In instances where intraoperative and perioperative features may pose clinical challenges to the surgeon and ultimately the patient, the literature suggests the following scenarios may have adverse outcomes, and therefore, benefit from the skills of MIGS subspecialists: fibroids - at least five myomas, myoma size at least 9 cm, and suspected myoma weight at least 500 g; endometriosis - presence of endometrioma(s), suspected stage III/IV endometriosis, and requirement for advanced adjunct procedures; hysterectomy - uteri at least 250 g or 12 weeks estimated size, at least three prior laparotomies, obesity, and complex surgical history with suspected adhesive disease. SUMMARY: A referral system for MIGS subspecialists has proven benefits for both the gynecologic surgical community as well as the patients and their outcomes. This article provides evidence for collaboration with MIGS especially as it relates to leiomyomatous uteri, endometriosis, and complex hysterectomies.

The Patient Acceptable Symptom State in Female Urinary Incontinence.

OBJECTIVE: The objective of this study is to characterize an acceptable health state, using the patient acceptable symptom state (PASS) question, in adult women with urinary incontinence. METHODS: This is a prospective multicenter cohort study determining PASS thresholds from condition-specific measures using an electronic research platform in English-speaking women seeking nonsurgical treatment of urinary incontinence between March 2019 and May 2020. Exclusions included pregnancy, isolated overactive bladder, and pelvic organ prolapse greater than stage II. The cohort was described and then grouped based on achievement of PASS. The PASS thresholds were determined using the 75th percentile and univariate regression methods. Multivariable regression modeling was used to understand the influence of covariates on PASS achievement. RESULTS: The study was completed by 100 (80%) of the 125 enrolled subjects. Of these, 45% (n = 45) achieved PASS after a median of 7 weeks of treatment (range, 6-13 weeks). The corresponding questionnaire score for PASS was estimated to be 6 for the Incontinence Severity Index, 3 for the Patient Global Impression of Severity and Improvement, 37.5 using the Urinary Distress Inventory 6, and 33.3 using the Incontinence Impact Questionnaire 7. Increasing age was independently associated with achieving PASS after adjusting for treatment adherence and outcomes scores (adjusted odds ratio, 1.05 [95% confidence interval, 1.01-1.10]; P = 0.02). CONCLUSIONS: PASS was achieved in 45% of women after conservative treatment of urinary incontinence. PASS offers a new perspective for analysis and interpretation of outcome measures used in pelvic floor disorders and can serve as a reference for future research and clinical care pathways.

Renal Hilum Injury with Veress Needle.

Introduction: Since the advent of laparoscopy, the ideal first-port entry technique has not yet been determined. Use of the Veress needle at Palmer's point, although safe in practice under skilled physicians, is not without risk of complications. Case Description: A female patient with prior abdominal surgeries underwent a laparoscopic surgery for a nonmalignant indication. Intraoperative complications included hemodynamic instability and gross hematuria. The patient was ultimately stabilized, and imaging after the case revealed a hematoma formation around the left kidney with evidence of renal hilar injury. Discussion: The laparoscopic surgeon must be aware that blind Veress needle entry has inherent risk for injury of retroperitoneal structures including the renal system. Particularly if hemodynamic instability is noted after abdominal entry at any site, physicians should have a low threshold for investigation, including by laparotomy if necessary.

Risk Factors for Polypropylene Midurethral Sling Extrusion: A Case-Control Study.

OBJECTIVE: To identify risk factors associated with surgical revision of midurethral sling (MUS) due to mesh extrusion. MATERIALD AND METHODS: This is a case-control study identifying women who underwent primary surgical revision of polypropylene MUS for vaginal mesh extrusion from 2001 to 2016. Cases of surgical revision were compared to a randomly selected control group in a 1:5 ratio. Patient demographics and clinical characteristics were compared and multivariate logistic regression modeling was performed to analyze the relationships between risk factors and vaginal mesh extrusion. RESULTS: In total, 64 cases were identified and compared to 400 controls. The average subject was 51.7 years old (range, 30-78) with a body mass index (BMI) of 27.9 kg/m2 (range, 23.6-30.2) at the time of surgical revision. The median time to MUS revision was 318 days (interquartile range, 144-1355 days). Surgical revision was associated with current smokers (odds ratio [OR] = 5.43 [95% confidence interval [CI] 2.86, 10.31]), a BMI under 30 kg/m2 (OR = 4.37 [95% CI = 2.05, 9.36]), age under 55 years (OR = 2.02, [95% CI = 1.13, 3.61]), a retropubic sling (OR = 2.10 [95% CI = 1.14, 3.88]), and fibromyalgia (OR = 3.33 [95% CI 1.12, 9.95]). CONCLUSION: Smoking status, age under 55 years, BMI below 30 kg/m2, fibromyalgia, and retropubic approach were factors associated with surgical revision of MUS due to vaginal mesh extrusion. These findings may improve counseling and patient selection.

Robotic Repair of Supratrigonal Vesicovaginal Fistula with Sigmoid Epiploica Interposition.

INTRODUCTION AND HYPOTHESIS: In the United States, vesicovaginal fistula (VVF) most often results from gynecologic surgery causing significant morbidity and distress to both the patient and surgeon. The use of tissue interposition at time of primary repair has been advocated to decrease the risk of recurrence. The aim of this study is to describe our experience with interposition of sigmoid epiploica during robotic extravesical repair of supratrigonal VVF. METHODS: This is a retrospective case series from June 2015 to September 2016. Features of the surgical technique include 1) cystoscopic ureteral catheterization, 2) cannulation of the fistula, 3) mobilization of the bladder from the vagina, 4) removal of the epithelialized edges of the fistulous tract, 5) single-layer closure of the vagina, 6) tension-free layered closure of the bladder, 7) retrograde fill of the bladder to ensure water-tight repair, 8) interposition of sigmoid epiploica appendage(s), and 9) prolonged bladder drainage with indwelling transurethral catheter. RESULTS: In total, 5 women underwent successful robotic VVF repair with epiploic appendage interposition. Mean surgical time was 218 minutes with an average console time of 147 minutes and an estimated blood loss of 49 mL. Most the patients were discharged to home on postoperative day 1 with no untoward effects due to the epiploica interposition. There have been no recurrences to date. CONCLUSIONS: Robotic repair of VVF with sigmoid epiploica interposition is efficient and well tolerated. Use of this technique may increase the number of patients eligible for tissue interposition.

Influence of Morbid Obesity on Surgical Outcomes in Robotic-Assisted Gynecologic Surgery.

Objective: The aim of this research was to estimate the impact of body mass index (BMI) on surgical outcomes in patients undergoing robotic-assisted gynecologic surgery. Materials and Methods: This study was a retrospective review of prospectively collected cohort data for a consecutive series of patients undergoing gynecologic robotic surgery in a single institution. BMI, expressed as kg/m2, was abstracted from the medical charts of all patients undergoing robotic hysterectomy. Data on estimated blood loss (EBL), hemoglobin (Hb) drop, procedure time, length of hospital stay, uterine weight, pain-medication use, and complications were also extracted. Results: Two hundred and eighty-one patients underwent robotic operations. Types of procedures were total hysterectomy with or without adnexal excision, and total hysterectomies with lymphadenectomies. Eighty-four patients who were classified as morbidly obese (BMI>35) were compared with 197 patients who had a BMI of<35 (nonmorbidly obese). For patients with BMI<35, and BMI>35, the mean BMI was 27.1 and 42.5 kg/m2 (p<0.05), mean age was 49 and 50 (p=0.45), mean total operative time was 222 and 266 minutes (p<0.05), console time 115 and 142 minutes (p<0.05), closing time (from undocking until port-site fascia closure) was 30 and 41 minutes (p<0.05), EBL was 67 and 79 mL (p=0.27), Hb drop was 1.6 and 1.4 (p=0.28), uterine weight was 196.2 and 227 g (p=0.52), pain-medication use 93.7 and 111 mg of morphine (p=0.46), and mean length of stay was 1.42 and 1.43 days (0.9), all respectively. No statistically significant difference was noted between the 2 groups for EBL, Hb drop, LOS, uterine weight, pain-medication use, or complications. The only statistically significant difference was seen in operating times and included docking, console, closing, and procedure times. There were no perioperative mortalities. Morbidity occurred in 24 patients (8%). In the morbidly obese group, there were 6 complications (7%) and, in the nonmorbidly obese group, there were 18 complications (9%). Conclusions: Morbid obesity does not appear to be associated with an increased risk of morbidity in patients undergoing robotically assisted gynecologic surgery. Morbid obesity is associated with increased procedure time, but otherwise appears to have no difference in outcomes. Robotic surgery offered an ideal approach, allowing minimally invasive surgery in these technically challenging patients, with no significant increase in morbidity. J GYNECOL SURG 30:81).

Risk for advanced-stage endometrial cancer in surgical specimens from patients with complex endometrial hyperplasia with atypia.

OBJECTIVES: To determine the incidence of endometrial cancer in patients undergoing hysterectomy for atypical complex endometrial hyperplasia and to study the risk of advanced endometrial cancer that may be associated with extra-uterine disease. METHODS: A retrospective chart review was performed of the records of all women who underwent hysterectomy for a preoperative diagnosis of complex hyperplasia with atypia from two teaching hospitals between 1999 and 2006. Demographic and clinical variables were collected and analyzed for the 80 patients identified by the initial screening methods. RESULTS: After screening and exclusions, 66 women with a preoperative diagnosis of atypical complex hyperplasia who subsequently underwent a hysterectomy were identified. Eleven of the 66 patients with atypical complex hyperplasia had a diagnosis of endometrial carcinoma in the hysterectomy specimens (17%). No endometrial cancer patient was staged greater than stage 1B or had greater than grade 2 disease. The patients with endometrial cancer were older (p < 0.05). Evidence of myometrial invasion was found in 63% (7/11) of the cancer cases, but all were less than 50% of the myometrium. CONCLUSION: Endometrial cancer found at the time of hysterectomy for complex hyperplasia with atypia may be associated with less advanced disease.

Prediction of proteinuria and microalbuminuria in diabetic pregnancies with a random single void.

OBJECTIVE: To determine whether a single urine specimen could effectively replace the 24 hour (24-h) urine collection in screening for microalbuminuria and proteinuria in pregnant women with pregestational diabetes. MATERIALS AND METHODS: A total of 42 pregnant women with pregestational diabetes mellitus were involved in the eventual analysis. Demographic and clinical variables were collected and analyzed. Urinary Protein (P) to Creatinine (Cr) ratio and microalbumin (MA) to Cr ratios were measured for the spot sample, and the total P, total MA, and serum Cr were measured for the 24-h urine sample. Analysis was done using linear regression and the Pearson correlation coefficient (r). RESULTS: Mean maternal age was 30.8 years, and the mean gestational age at collection was 19.8 weeks. A strong correlation exists between the spot MA to Cr value and 24-h MA, with an r = 0.81 (P < 0.0001). The association between the spot P to Cr ratio and 24-h urinary P was not as strong, r = 0.58 (P < 0.0001). CONCLUSIONS: A strong association between spot MA to Cr ratio and 24-h urinary microalbuminuria may suggest a predictive role for random urine assessment of MA in pregnant pregestational diabetic patients. However, based on our data, the spot P to Cr ratio may be inadequate for assessing proteinuria in pregestational diabetic pregnancies.

Pregnancy in a woman with uterine procidentia: a case report.

BACKGROUND: Uterine prolapse in pregnancy is rare and can either occur during pregnancy or be present before the pregnancy. We present a case of a successful pregnancy in a patient with preexisting uterine procidentia. CASE: A 44-year-old woman with a history of complete uterine prolapse presented with an unplanned pregnancy. Upon initial presentation at 15 weeks she had uterine prolapse with cervical elongation that protruded 10 cm past the introitus. The prolapse persisted until about 30 weeks, during which it was conservatively managed with bed rest, knee-chest positions and local treatment of the desiccated cervix with emollients. The patient had an uncomplicated vaginal delivery and underwent a vaginal hysterectomy, anterior-posterior repair and a sacrospinous ligament fixation a few months later. CONCLUSION: Uterine prolapse in pregnant women with preexisting prolapse will probably resolve in the third trimester without treatment. An otherwise uncomplicated course and a vaginal delivery can be expected.

Decreased maternal serum inhibin-A in pregestational diabetic women: implication for adjustment.

OBJECTIVE: To evaluate the effect of maternal pregestational diabetes on serum dimeric inhibin-A (DIA), 1 of the 4 markers of the quadruple screen. STUDY DESIGN: The data were collected retrospectively from women with singleton pregnancies who had a quadruple screen drawn at 15-20 weeks of gestation in 2004-2006. A total of 84 women with pregestational diabetes were identified and their DIA values were compared with those of 100 nondiabetic pregnant women. We compared the mean multiples of the median (MoM) for DIA levels among diabetics, among nondiabetics and between the 2 types of diabetics. We also measured the degree of correlation between the quadruple screen markers and glycosylated hemoglobin (HbA1C). RESULTS: The corrected mean MoM for DIA levels among diabetic patients was 0.85 (95% CI, 0.77-0.95) vs. 1.0 (95% CI, 0.93-1.09) in the nondiabetic control group (p = 0.02). The mean MoMfor DIA levels did not appear to differ between type 1 and type 2 diabetes, and there does not appear to be a correlation between the quadruple screen markers and HbA1C. CONCLUSION: The DIA levels among pregestational diabetic women are lower than in the nondiabetic population, suggesting a need for adjustment.

Triplet gestation outcomes in relation to maternal prepregnancy body mass index and weight gain.

OBJECTIVE: To study prepregnancy maternal body mass index (BMI) and overall maternal weight gain in triplet gestations in relation to maternal and newborn outcomes. STUDY DESIGN: This was a retrospective study of birth certificate data of all live-born triplet gestations occurring between 1999 and 2003 in an eight-county region in New York. An analysis of computerized birth certificate data for variables related to pregnancy and newborn outcomes was conducted, looking at neonatal birth weight, neonatal gestational age, and the occurrence of the maternal pregnancy complications of gestational diabetes, gestational hypertension, and preeclampsia. RESULTS: In 56 triplet gestations studied, the prepregnancy BMI was not associated with mean newborn birth weights and gestational age at delivery. The total maternal weight gain was associated with increasing mean birth weight and higher gestational age at delivery. Pregnancy complications in triplet pregnancies of gestational diabetes and gestational hypertension were associated with prepregnancy BMI, but not maternal weight gain. CONCLUSION: For triplet gestations, a normal prepregnancy BMI and a total gestational weight gain of at least 15.9 - 20.5 kg (35 - 45 lb) are associated with fewer pregnancy complications.