PROJECT PREVENT: a randomized controlled trial of preoperative vaginal metronidazole to decrease patient issues and infections after hysterectomy.

Objectives: To evaluate if vaginal metronidazole for 5 days before hysterectomy decreases postoperative infections and patient issues. Design: This randomized trial compared vaginal metronidazole for 5 days before a scheduled hysterectomy to no intervention. Sample size calculation was based on a 20% difference in issues and infection (30% incidence and 10% in the intervention arm) with 80% power and an alpha error of 0.05 and indicated 62 subjects needed in each arm. Setting: Outpatient gynecology clinics at a single academic institution. Participants: 154 subjects were screened for eligibility between July 2020 and September 2022. 133 underwent hysterectomy including 68 subjects (51.1%) randomized to the metronidazole and 65 (48.9%) controls. Overall, the population was racially and ethnically diverse. There was no significant difference in characteristics between the two groups. Interventions: Vaginal metronidazole for 5 days before hysterectomy. Main outcome measures: Postoperative patient issues and documented postoperative infections at 4-8 weeks after surgery. Results: There was no difference in the composite rate of patient-reported issues and/or documented postoperative infection (53/133 (39.8%) with no difference between groups (29/68 (42.6%) vs 24/65 (36.9%), p=0.50). There was no difference in patient-reported issues which was 51/133 (38.3%) with no difference between groups (28/68 (41.2%) vs 23/65 (33.8%), p=0.49) or in documented infections with a rate of 25/133 (18.8%) with no significant difference between groups (15/68 (22.0%) vs 10/65 (15.4%), p=0.33). In the intervention arm, the compliance rate was 73.5% for all 5 days of vaginal metronidazole, and a per-protocol analysis was performed which resulted in no significant difference between groups. Conclusions: There is insufficient evidence to suggest a significant benefit of preoperative vaginal metronidazole to prevent surgical site infections and postoperative patient issues in patients undergoing hysterectomy. Trial registration number: ClinicalTrials.gov, NCT04478617.

Response of an Obstetric Unit during the Coronavirus Disease of 2019 (COVID-19) Pandemic: Experiences from a Tertiary Care Center.

Objective To describe our experiences in preparing our obstetric unit in Westchester County, New York, during the COVID-19 (coronavirus disease of 2019) pandemic. We focus on describing our timeline, continuously evolving actions, observations, and challenges. Methods With guidance from the New York State Department of Health (NYSDOH), our institutional epidemiologist, and key multidisciplinary faculty members, we evaluated emerging national data as well as expert opinions to identify issues and challenges to create action plans. Results We created and modified policies for our patients presenting for obstetrical care on the labor and delivery unit to accommodate their unique needs during this pandemic. Conclusion The COVID-19 pandemic has posed many unique challenges. Balancing communication, risks of infection to providers, patient autonomy and rights, and resources for testing and personal protective equipment were among the valuable lessons learnt. We have shared our experiences and described our observations and challenges in Westchester County, New York.

An unusual foreign body aspiration requiring an unusual retrieval technique.

Foreign body aspiration during medical procedures has been reported in the literature. These iatrogenic incidents could be related to instruments malfunction or to accidental occurrences during medical treatment. In this paper, we present a report of a woman coming for a laparoscopic abdominal hysterectomy who developed intraoperative bronchospasm. In an attempt to administer aerosolized albuterol, the resident anesthesia provider fractured the Luer-lock tip of the 60-cc syringe, which he was using to hold the albuterol nebulizer. The plastic tip was dislodged into the endotracheal tube (ETT). On further inspection with a fiberoptic instrument the plastic tip was located loosely adherent to the distal part of the ETT and was held in place by the moisture, which had precipitated in the distal tube. An intraoperative consult with interventional pulmonary medicine was obtained after unsuccessfully attempting to retrieve the foreign body with a grasper. The syringe tip was then removed using a Fogarty balloon catheter that was threaded through the hole of the plastic tip.

The roles and limitations of robotic surgery for obese endometrial cancer patients: a common challenge in gynecologic oncology.

In the United States, the epidemic of obesity is readily apparent in women diagnosed with endometrial cancer, the most common gynecologic malignancy. Overall, the benefits of minimally invasive surgery and its oncologic outcomes are similar among laparoscopy and robotic approaches. However, in stratifying obese patients by BMI, more data is needed on morbidly obese patients and their candidacy for robotic surgery along with the technical challenges of staging procedures. Cost analysis studies targeted specifically to the obese and morbidly obese patient is needed to further justify efforts at promoting robotic surgery in this patient population.

Routine cystoscopy after robotic gynecologic oncology surgery.

BACKGROUND AND OBJECTIVES: Our aim was to determine whether the use of routine cystoscopy increases lower urinary tract injury detection (bladder and/or ureter) after robotic surgery performed by gynecologic oncologists. METHODS: A retrospective chart review of patients who presented for robotic hysterectomy from 2009-2012 was performed at 2 separate academic medical centers, one that performed routine cystoscopy and one that did not. Statistical analysis was performed with t tests and χ2 tests. RESULTS: We identified 140 cases without cystoscopy and 109 cases with routine cystoscopy. There were no intraoperative or postoperative urinary injuries detected in either group. There were no significant differences in age and body mass index. In the non-cystoscopy group, a larger specimen size (P<.001), less blood loss (P=.013), and a longer mean operative time were observed (P<.0001). In the routine cystoscopy group, more lymphadenectomies were performed with hysterectomy (P=.007) and more patients underwent hysterectomy for ovarian cancer (P=.0192). There were no differences in surgical indications or secondary procedures including bilateral salpingo-oophorectomy, radical hysterectomy, ureterolysis, and pelvic organ prolapse-related procedures. The minimum follow-up period was 30 days in both groups. CONCLUSION: Routine use of cystoscopy did not appear to affect the detection rate of intraoperative lower urinary tract injury during robotic gynecologic surgery because this rate was zero in both groups. However, cystoscopy is relatively simple to perform and can be efficiently incorporated into robotic surgery to avoid the severe morbidity and possible litigation surrounding a urinary tract injury.

Malignant transformation of endometriosis in a cesarean section abdominal wall scar: a case report.

BACKGROUND: Endometriosis occurring in a cesarean section abdominal wall scar is reported at a rate of 0.03-0.45%. Malignant transformation of this type of endometriosis is exceptionally rare. CASE: A 51-year-old, G3P2012, Black woman presented with a lump in her cesarean section abdominal wall scar that was increasing in size. Biopsy of the mass revealed metastatic adenocarcinoma with poorly differentiated, nonmucinous ovarian primary. She received 3 cycles of neoadjuvant chemotherapy and underwent an interval debulking with the final pathology showing malignant transformation of endometriosis within her abdominal wall scar. She then completed radiotherapy to the area and is disease-free 6 months later. CONCLUSION: Our combination of neoadjuvant chemotherapy and excision of the mass with negative margins followed by adjuvant radiotherapy is a feasible treatment option.

Rare large cell neuroendocrine tumor of the endometrium: A case report and review of the literature.

INTRODUCTION: Large cell neuroendocrine carcinoma (LCNEC) of the endometrium is a rare malignancy with an aggressive course. Although data is limited to case reports, the prognosis appears to be poor, similar to other type II uterine cancers. A total of 12 cases of LCNEC of the uterus have been published to date. PRESENTATION OF CASE: A 71 year-old woman presented with postmenopausal vaginal bleeding. Endometrial biopsy was non-diagnostic for LCNEC. She underwent surgical debulking and staging of a 22cm endometrial tumor with omental metastasis and positive lymph nodes. Her final FIGO stage was IVB. DISCUSSION: We summarize all prior case reports of LCNEC of the endometrium and discuss the definition, presentation, imaging and surgical management. The pathology with immunohistochemical review, adjuvant therapy and prognosis of LCNEC of the endometrium are also reviewed. CONCLUSION: Pathologic findings and immunohistochemistry are essential in making a diagnosis of LCNEC of the endometrium. Primary debulking and surgical staging is typically performed, but if a diagnosis of LCNEC can be made preoperatively with immunohistochemistry, surgeons should consider neoadjuvant chemotherapy due to its high grade histology and aggressive course. Otherwise adjuvant chemotherapy is usually given. Even with early stage disease, the prognosis seems poor. Due to the rarity of this aggressive malignancy, more data is needed to establish incidence.

Two cases of post-coital vaginal cuff dehiscence with small bowel evisceration after robotic-assisted laparoscopic hysterectomy.

INTRODUCTION: Vaginal cuff dehiscence following robotic surgery is uncommon. Published reports of vaginal cuff dehiscence following robotic surgery are increasing, but the true incidence is unknown. PRESENTATION OF CASE: Case 1. A 45 year old female had sexual intercourse and presented with a vaginal cuff dehiscence complicated by small bowel evisceration 4 months after RA-TLH. Case 2. A 44 year old female had sexual intercourse and presented with a vaginal cuff dehiscence with small bowel evisceration 6 weeks after RA-TLH. DISCUSSION: We discuss the rate of vaginal cuff dehiscence by mode of hysterectomy, surgical and non-surgical risk factors that may contribute to vaginal cuff dehiscence, and proposed preventative methods at the time of RA-TLH to reduce this complication. CONCLUSION: Vaginal cuff dehiscence with associated evisceration of intraabdominal contents is a potentially severe complication of hysterectomy. We recommend counseling patients who undergo RA-TLH to abstain from vaginal intercourse for a minimum of 8-12 weeks.

Abdominal wall port site metastasis after robotically staged endometrial carcinoma: A case report.

INTRODUCTION: The incidence of port-site metastasis following robotic-assisted laparoscopic hysterectomy is unknown. PRESENTATION OF CASE: We present a case of a 78-year-old female diagnosed with an incidental grade 3 endometrial adenocarcinoma on a final hysterectomy specimen. She subsequently underwent a robotic staging surgery with a gynecologic oncologist where nodal pathology was found to be negative; her final stage was 1B. One year following diagnosis, she developed a recurrence on her abdominal wall at the former port-sites with concomitant vaginal cuff recurrence. DISCUSSION: We hypothesize possible modes of metastasis and present limited published data to date on port site metastasis following robotic hysterectomy for endometrial cancer. CONCLUSION: This is the second reported case of port-site metastasis following robotic surgery for endometrial cancer.

Hemoglobin A1c and the relationship to stage and grade of endometrial cancer.

OBJECTIVES: To determine if elevated markers of poor glycemic control (HgA1c and fasting glucose levels) in patients surgically staged for type I endometrial cancer is related to a higher stage or higher grade at the time of diagnosis. Also, to assess if these markers impact overall survival. METHODS: A retrospective chart review was performed from January 2000 to June 2010 at three academic medical centers. Patients were included if they underwent surgical staging and had HgA1c drawn within 3 months before surgery. Demographic data, fasting blood glucose levels and overall survival data were also obtained. RESULTS: Eighty-two patients fitting the inclusion criteria were identified during the study period. There was a strong positive correlation between HgA1c and fasting glucose. There was no statistical difference with regard to stage alone, grade alone, or when stratified together with regard to HgA1c or fasting glucose levels. There was a trend toward increased mean HgA1c across increasing stages, but this was not statistically significant. Diabetes, HgA1c and tumor grade did not affect overall survival, but advanced stage was a poor prognostic measure for overall survival. CONCLUSIONS: Elevated preoperative HgA1c has a trend toward a higher stage at the time of diagnosis. Advanced stage is a poor prognostic measure for overall survival.

FIGO staging for carcinosarcoma: can the revised staging system predict overall survival?

OBJECTIVES: The purpose of this study is to detect differences in overall survival between the 1988 FIGO staging and current staging of uterine carcinosarcomas to determine if revised 2009 staging accurately predicts actual patient survival. METHODS: From 1988 until 2010, patients with uterine carcinosarcoma were retrospectively identified from tumor registry records. Patients were grouped in both broad stages (1-4) and all FIGO substages in order to detect differences. Time-dependent receiver operating characteristic curves (ROC) were generated to predict death before the end of the second year post-diagnosis for both the new and revised system. Kaplan Meier estimated median survival time was utilized to compare actual patient survival. RESULTS: Of 112 patients with carcinosarcoma, 37 patients (33%) had FIGO Stage I disease, 15 patients (13.4%) had Stage II disease, 36 patients (32%) were diagnosed as Stage III, and 24 patients (21.4%) had Stage IV disease. 106 of 112 (94.6%) patients underwent lymphadenectomy (pelvic +/- para-aortic). Four patients (3.6%) were downstaged when utilizing broad staging criteria: 2 patients were downstaged from Stage II to I, and 2 patients were downstaged from Stage III to Stage I and II respectively. When looking at substage, the area under the ROC was 0.67 for the former staging system, and 0.65 for the revised staging. Kaplan-Meier estimated median survival time post-diagnosis was 610 days (95% CI [478,930]). CONCLUSION: Based upon our reclassification of 112 patients with uterine carcinosarcoma, the revised FIGO staging system does not predict survival more accurately than former staging. Carcinosarcoma has an overall poor prognosis and better indicators of survival are needed.

Hydronephrosis as a prognostic indicator of survival in advanced cervix cancer.

OBJECTIVE: To determine whether hydronephrosis is an independent prognostic indicator of survival among patients with advanced cervical carcinoma. Moreover, we wanted to demonstrate the relationship between unilateral and bilateral hydronephrosis and overall survival. METHODS: Retrospective analysis of 197 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical carcinoma or higher treated between 1990 and 2007 was conducted. Inclusion criteria were clinical staging according to FIGO criteria, standardized radiation treatment and cisplatin-based chemosensitization regimens. Associations between hydronephrosis and covariates-age, race, histopathologic diagnosis, pelvic sidewall involvement, stage, nodal involvement, and Gynecologic Oncology Group/Eastern Cooperative Oncology Group performance status (PS)-were determined. Statistical analysis including Kaplan-Meier, log-rank test, proportional hazards regression, Fisher exact test, and Mann-Whitney test were used where appropriate, with P < 0.05 considered significant. RESULTS: Of 143 included patients, 73 patients had no hydronephrosis (HN), 39 patients had unilateral HN, and 31 patients had bilateral HN. Twenty-nine patients (40%) with no HN died compared to 24 patients (61.5%) with unilateral HN and 21 patients (67.7%) with bilateral HN. Median time to death was significantly shorter for patients with unilateral HN (27 months; 95% confidence interval [CI], 10-48) and bilateral HN (12 months; 95% CI, 6-23) versus patients without HN (68 months; 95% CI, 39-∞; P < 0.001). Unadjusted hazard ratio (HR) for HN (both unilateral and bilateral) was 2.4 (95% CI, 1.5-3.8); P < 0.001. Of potential covariates evaluated, PS and sidewall involvement were significantly associated with HN (P = 0.021 and P = 0.014, respectively). Proportional hazards regression revealed that controlling for use of radiation, chemotherapy, and for PS, HN was still significantly associated with poor prognosis (HR unilateral HN = 2.0, 95% CI, 1.2-3.5; HR bilateral HN = 3.2, 95% CI, 1.7-6.0); P ≤ 0.001. CONCLUSION: Hydronephrosis is an independent poor prognostic indicator of survival in patients with advanced cervical cancer. Bilateral hydronephrosis compared to unilateral involvement confers a worse overall prognosis. Additional studies are needed to determine if FIGO staging should be amended.

Microsatellite instability and DNA methylation of endometrial tumors and clinical features in young women compared with older women.

INTRODUCTION: Molecular genetic changes in endometrial cancers are important to identify possible family cancer syndromes and thus, to facilitate appropriate screening. Most studies in this regard have focused primarily on young women. We have assayed cancers for microsatellite instability (MSI) and DNA methylation from a large group of patients younger than 50 years and a comparable group of older women. We obtained personal and medical histories of the patients and their family cancer histories. METHODS: The Bethesda panel of markers was used for the detection of MSI. Methylation status of mismatch repair genes was ascertained using the methylation-specific DNA detection kit SALSA MS-MLPA No. ME011. RESULTS: There were 101 patients younger than 50 years and 112 older women. The 2 age groups did not differ in the percentage of patients who were obese, carried a diagnosis of diabetes, or previously had another cancer. The younger patients were more likely to be nulliparous, whereas the older patients were more likely to have hypertension. Among the younger group, 21 (20.8%) tumors revealed MSI, and 13 (61.9%) of these were unmethylated. For the older women, 35 (31.2%) had MSI tumors, and only 6 (17.1%) of these were unmethylated. Young women with a family history of a hereditary nonpolyposis colorectal cancer-related cancer were more likely to have a tumor revealing MSI and no methylation, but family history was less helpful in older women in this regard. CONCLUSION: We did not find personal risk factors or a history of an additional cancer to be different between the 2 age groups. The combination of MSI testing and DNA methylation studies resulted in the identification of presumptive hereditary nonpolyposis colorectal cancer syndrome in approximately 13% of women with endometrial cancer presenting at age younger than 50 years and in approximately 5% of older women. Family history was more helpful with younger women than with older women.