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1.
Urology ; 135: 171-172, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31589882

RESUMO

OBJECTIVE: To demonstrate how bladder ultrasound can be useful in completing morcellation during difficult Holmium Laser Enucleation of the Prostate (HoLEP). As HoLEP has emerged as a standard of care for the treatment of benign prostatic hyperplasia, multiple studies have reported the potentially catastrophic complication of bladder injury during morcellation. This video aims to assist any urologist performing HoLEP by providing step-by-step instruction for using ultrasound to complete morcellation safely. METHODS: Enucleation is performed using a 26-French continuous flow scope, off-set laser bridge with a laser stabilization catheter, and a 550 µm holmium laser fiber. Once the median and lateral lobes have been enucleated, the outer sheath is removed and the nephroscope is inserted to facilitate morcellation. Under dual inflow irrigation, the Piranha morcellator (Richard Wolf, Knittlingen, Germany) is introduced and set to the manufacturer's recommended settings of 1500 rpm. A 3.5-MHz convex abdominal ultrasound transducer (Hitachi Prosound Alpha 7; Hitachi Aloka Medical America, Wallingford, CT) under B-mode is used to visualize the bladder, predominantly in the sagittal orientation. Morcellation proceeds under simultaneous ultrasound and direct cystoscopic guidance. RESULTS: The distended bladder is visualized concurrently with the ultrasound and via the nephroscope as the Piranha engages the adenoma and begins morcellation. Once the adenoma is engaged, the operator then drops their hands to place the morcellator in the center of the bladder. Ultrasound provides real-time feedback as to the location of the morcellator in relation to the adenoma and bladder. CONCLUSION: This video highlights the use of intraoperative bladder ultrasound as a visual aid to assist during the morcellation portion of HoLEP. This proof of concept demonstrates that ultrasound can be an additional tool to utilize during difficult cases when cystoscopic visualization during morcellation is limited.


Assuntos
Complicações Intraoperatórias/prevenção & controle , Terapia a Laser/métodos , Morcelação/métodos , Prostatectomia/métodos , Bexiga Urinária/diagnóstico por imagem , Humanos , Complicações Intraoperatórias/etiologia , Terapia a Laser/efeitos adversos , Terapia a Laser/instrumentação , Lasers de Estado Sólido/efeitos adversos , Lasers de Estado Sólido/uso terapêutico , Masculino , Morcelação/efeitos adversos , Morcelação/instrumentação , Estudo de Prova de Conceito , Próstata/diagnóstico por imagem , Próstata/cirurgia , Prostatectomia/efeitos adversos , Prostatectomia/instrumentação , Hiperplasia Prostática/cirurgia , Ultrassonografia , Bexiga Urinária/lesões
2.
Taiwan J Obstet Gynecol ; 58(3): 423-427, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31122536

RESUMO

OBJECTIVES: To evaluate the feasibility and safety of two-port myomectomy using bag-contained manual morcellation compared to three-port myomectomy using power morcellation. MATERIAL AND METHODS: A retrospective chart review was conducted for 428 cases of either two-port or three-port laparoscopic myomectomy performed by single operator in the university hospital between January 2011 and December 2016. RESULTS: The cohorts of three-port myomectomy with power morcellation was consisted of two hundred and forty-eight patients. One hundred and eighty patients underwent two-port myomectomy with manual morcellation in contained bag. Two-port group showed shorter hospital stay (5.16 ± 1.39 d vs. 4.83 ± 1.19 d, p = 0.001), less estimated blood loss (61.8 ± 58.2 mL vs. 50.2 ± 52.4 mL, p = 0.001), and higher hemoglobin level at postoperative day 1 (10.7 ± 1.17 g/dL vs. 11.0 ± 1.14 g/dL, p = 0.028) with statistical significance. Morcellation time (25.8 ± 9.30 min vs. 18.9 ± 10.11 min, p = 0.001) and total operative time (82.4 ± 30.19 min vs. 76.4 ± 25.47 min, p = 0.047) were also significantly shorter in two-port group. There were no identified spillages of fibroids, ruptures of specimen bag during manual morcellation in two-port myomectomy. In both groups, there were no cases of leiomyosarcoma diagnosed postoperatively. CONCLUSION: Two-port laparoscopic myomectomy with bag-contained manual morcellation is a feasible and safe alternative for three-port with power morcellation. Its surgical outcomes were shown to be superior to conventional laparoscopic myomectomy according to our study but further evaluation in near future is needed.


Assuntos
Leiomioma/cirurgia , Morcelação/instrumentação , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Duração da Cirurgia , Estudos Retrospectivos
3.
Urol Int ; 103(1): 95-101, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30917381

RESUMO

INTRODUCTION: The DrillCutTM morcellator is marketed for its fast and highly efficient removal of prostatic tissue and a higher level of patient safety. However, a paucity of publications has looked into its actual efficacy and safety. The aim of our study was to evaluate its ex vivo and in vivo efficiency and to compare its results with other devices presented in the literature. PATIENTS AND METHODS: We conducted a prospective pilot study on patients who underwent holmium laser enucleation of the prostate (HoLEP) from 2017 to 2018 using the Top-Down technique. Enucleated adenomas were morcellated using the DrillCutTM morcellator. We collected both preoperative and operative data. Operative data included the enucleated adenoma weight and operative time. Various morcellator parameters were collected including morcellation time and efficiency. We recorded the encountered complications and device malfunction. Ex vivo characteristics were evaluated in terms of morcellation speed and aspiration power. RESULTS: Sixty consecutive patients with a median age of 72.8 years were included. The enucleated adenoma was retrieved in 12.5 min (4-58). The median resected prostatic weight was 90 g (44-242). The DrillCutTM efficiency was calculated as 6.46 g/min (2.7-15). Only one patient had a simple bladder mucosal injury. Device malfunction was encountered in 4 patients (6.6%) due to blockage of the morcellator blades. The ex vivo aspiration speed was 52 s/L, while the morcellation power was 14 g/2 min. CONCLUSION: Our results showed that the DrillCut morcellator was effective and safe in managing our patients post-HoLEP. The DrillCutTM has better ex vivo morcellation power but modest aspiration speed in comparison to other morcellators.


Assuntos
Terapia a Laser/métodos , Morcelação/instrumentação , Próstata/fisiopatologia , Próstata/cirurgia , Adenoma/fisiopatologia , Adenoma/cirurgia , Idoso , Idoso de 80 Anos ou mais , Hólmio , Humanos , Lasers de Estado Sólido , Masculino , Pessoa de Meia-Idade , Morcelação/métodos , Segurança do Paciente , Projetos Piloto , Estudos Prospectivos , Neoplasias da Próstata/fisiopatologia , Neoplasias da Próstata/cirurgia , Resultado do Tratamento
4.
Int J Surg ; 62: 22-27, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30639472

RESUMO

PURPOSE: To evaluate the feasibility of using contained endobags (Morsafe®) in the retrieval of the specimen during laparoscopic surgeries in presumably benign myomatous pathology. MATERIAL AND METHODS: We conducted a retrospective single center case - control study on 239 patients, between 01.05.2014 and 31.12.2017 for uterine myomata, presumed to be benign. The analyzed parameters were the method for contained specimen retrieval, the time of bag manipulation, practicability of action and the perioperative complications rate. The present work has been reported in accordance with the STROCSS criteria and guidelines [1]. RESULTS: the main laparoscopic interventions were myomectomy (n = 148 cases) and LASH (laparoscopic supracervical hysterectomy) (n = 68 cases), LASH with bilateral salpingectomy (n = 7), LASH and bilateral adnexectomy (n = 3), LTH (laparoscopic total hysterectomy) (n = 3), LTH and bilateral adnexectomy (n = 1), radical LTH with lymphonodectomy (n = 2), LTH with bilateral salpingectomy (n = 1) and adenomyomectomy (n = 6). In 3 cases using contained closed bags, there was an evidence of malignancy in the pathological sections: leiomyosarcoma (n = 1) and endometrial carcinoma (n = 2). There were no adverse events and no intra - or postoperative bag - induced complications. Regarding the intraoperative duration, the time of bag introduction was about 7 min, and morcellation approximately 12 min. CONCLUSION: in - bag morcellation through endobag (Morsafe®) proved to be a safe laparoscopic method in retrieval of myomatous tissue, potentially reducing the risk of dissemination and thereby improving the patients' safety avoiding spreading of benign disease and malignancy, but preserving the benefits of minimally invasive surgery. The advantages concerned not only the operating time and costs, but also the safety aspects in case of malignancy. As the system can help to reduce risk of cell dissemination it could also reduce the risk in case of occult malignancy.


Assuntos
Leiomioma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Idoso , Estudos de Viabilidade , Feminino , Humanos , Histerectomia/instrumentação , Histerectomia/métodos , Laparoscopia/efeitos adversos , Laparoscopia/instrumentação , Laparoscopia/métodos , Leiomiossarcoma/cirurgia , Pessoa de Meia-Idade , Morcelação/efeitos adversos , Morcelação/instrumentação , Duração da Cirurgia , Estudos Retrospectivos , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/instrumentação , Adulto Jovem
5.
J Endourol ; 32(12): 1136-1141, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30343610

RESUMO

INTRODUCTION: Morcellation of the adenoma after laser enucleation of the prostate (LEP) is both time-consuming and prone to complications. We have designed a novel polyethylene sack (ProSac) to improve the morcellation process following LEP. Both silicone and cadaver models were utilized to evaluate the safety and efficacy of ProSac. METHODS: The inanimate model used tissue-mimicking silicone to accurately approximate bladder volume and compliance. The second model was developed using a fresh cadaver. Heat-fixed chicken breast was used to mimic enucleated prostatic adenoma. Morcellation of the simulated adenoma tissue was tested in both models with and without the ProSac. Morcellated tissue was removed from the filter, desiccated, and weighed after each run to establish morcellation efficiency. Visual inspection was used to evaluate for mucosal injury or bladder perforation. A hydromanometer was placed in the cadaveric bladder to measure bladder pressure. RESULTS: The device was able to capture up to 30 g of tissue with good closure while maintaining good distention and visualization during morcellation. In the silicone model, morcellation efficiency with the device was 4.6 g/minute, while efficiency without the device was 2.6 g/minute (p = 0.03). In the cadaveric model, mean entrapment time was 22 ± 11 seconds. Morcellation efficiency with the device was 2.1 g/minute when excluding entrapment time and 1.9 g/minute including entrapment time. Without the ProSac, morcellation efficiency was 1.2 g/minute (p = 0.05). In both models, multiple mucosal injuries occurred without the device, while none occurred with the device. Bladder pressure was similar between study arms. CONCLUSIONS: The ProSac is a novel device that can provide additional safety during adenoma morcellation. It may also achieve clinically and statistically significant improvement in morcellation efficiency without increasing bladder pressure.


Assuntos
Adenoma/diagnóstico por imagem , Adenoma/cirurgia , Morcelação/instrumentação , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Urológicos , Animais , Cadáver , Galinhas , Endoscopia , Desenho de Equipamento , Humanos , Terapia a Laser , Masculino , Modelos Biológicos , Segurança do Paciente , Polietileno , Hiperplasia Prostática/cirurgia , Silicones , Bexiga Urinária
6.
Curr Opin Obstet Gynecol ; 30(4): 243-251, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29939852

RESUMO

PURPOSE OF REVIEW: Submucosal uterine leiomyomas are a common benign pelvic tumor that can cause abnormal uterine bleeding and may contribute to infertility and miscarriage. Hysteroscopic myomectomy is the treatment of choice to alleviate bleeding from these myomas and to normalize the uterine cavity. This review discusses the techniques and recent evidence for hysteroscopic myomectomy and examines the two primary surgical tools employed today: the bipolar resectoscope and hysteroscopic mechanical morcellator. RECENT FINDINGS: Hysteroscopic myomectomy has been a popular treatment for symptomatic submucosal fibroids for decades; it is a minimally invasive, low-cost, low-risk procedure, and is associated with high patient satisfaction. There have been rapid advances in the surgical technology available for this procedure. Both the bipolar resectoscope and the hysteroscopic mechanical morcellator are appropriate tools to remove submucosal myomas. Although the hysteroscopic morcellators have been associated with shortened operative time and a decreased learning curve, the data are limited for their use on type 2 fibroids. The strength of the bipolar resectoscope lies in its ability to resect deeper type 2 fibroids. SUMMARY: The evidence suggests that no one technique should be used for all patients, but rather a choice of technique should be taken on a case-by-case basis, depending on the myoma number, size, type, and location. Gynecologists must become knowledgeable about each of these techniques and their associated risks to safely offer these surgeries to their patients.


Assuntos
Histeroscopia/métodos , Hemorragia Uterina/cirurgia , Miomectomia Uterina/métodos , Embolia Aérea/prevenção & controle , Feminino , Humanos , Histeroscopia/instrumentação , Cuidados Intraoperatórios , Morcelação/instrumentação , Duração da Cirurgia , Cuidados Pré-Operatórios , Miomectomia Uterina/instrumentação , Vasopressinas/uso terapêutico
7.
Urology ; 111: 54-58, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29030074

RESUMO

OBJECTIVE: To evaluate operating room (OR) costs associated with the 2 available morcellators in the United States in a matched cohort and to determine benign prostatic hyperplasia surgeon's morcellator preference. MATERIALS AND METHODS: Patients from 2013, the last year our institution exclusively used the VersaCut device, were matched 1:1 with the most recent patient cohort, utilizing the Wolf Piranha morcellator. Cost of morcellation including the expense of OR time and disposable instrument costs were calculated. A survey to the Endourological Society e-mail listserv was sent to determine morcellator preference. RESULTS: We identified 142 patients who underwent holmium laser enucleation of the prostate in 2013. When compared with the VersaCut group, morcellation efficiency (4.4 vs 7.0 g/min, P <.01) and expense of OR time ($1420.80 vs $992.21, P <.005) both favored the Piranha morcellator system even when the costs of disposable instruments were factored into the analysis ($1338.81 vs $1637.50, P <.05). A total of 126 urologists responded to the survey. Of these, 56 (44.5%) perform transurethral prostate enucleations, which included 48 (86%) holmium. More endourologists use the VersaCut (n = 33, 59%) than the Piranha (n = 24, 43%) morcellator. Qualities that impacted the preference of morcellator included the preferred device is safer, faster, easier to use, reusable, and less expensive. CONCLUSION: We identified a significant improved efficiency and improved cost savings utilizing the Piranha morcellator even when controlling for disposable costs. Of the endourologists who responded to the survey, less than half perform transurethral enucleation. Morcellator preference is largely based on safety, efficiency, and ease of use, whereas cost and reusablility were of lesser importance.


Assuntos
Custos e Análise de Custo , Morcelação/economia , Morcelação/instrumentação , Padrões de Prática Médica , Hiperplasia Prostática/cirurgia , Urologia , Estudos de Coortes , Desenho de Equipamento , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Procedimentos Cirúrgicos Urológicos Masculinos/economia
8.
Curr Opin Obstet Gynecol ; 30(1): 69-74, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29194076

RESUMO

PURPOSE OF REVIEW: This review was written in an effort to describe the evolution of power morcellation equipment from their creation to their current state. In addition, this review addresses the continuously evolving equipment involved with power morcellation and looks to describe where the field is headed in the future. In addition, recent professional and federal recommendations have changed the way power morcellation is being approached and has led to the development of contained morcellation systems, which, although in their infancy, are also being proven to be well tolerated options. RECENT FINDINGS: This article will review the most current research on electronic power morcellation and the multiple attempts to prove superiority from the many different types of equipment, and also the many different approaches to morcellation. In addition, with the adaptation to contained morcellation, this review will cover research focused on optimizing a containment system and the techniques involved. SUMMARY: In summary, this review is aimed at describing many of the currently available power morcellation products and contained morcellation systems in an effort to allow physicians to understand the different options available, and to discuss well tolerated, effective, and clinically proven techniques that can lead to improved surgical outcomes in the future.


Assuntos
Desenho de Equipamento/história , Morcelação/história , Morcelação/instrumentação , Contraindicações de Procedimentos , Diagnóstico Tardio/história , Desenho de Equipamento/tendências , Feminino , Doenças dos Genitais Femininos/história , Doenças dos Genitais Femininos/cirurgia , Neoplasias dos Genitais Femininos/diagnóstico , Neoplasias dos Genitais Femininos/história , Neoplasias dos Genitais Femininos/cirurgia , História do Século XX , História do Século XXI , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Laparoscopia/efeitos adversos , Laparoscopia/tendências , Morcelação/efeitos adversos , Morcelação/tendências , Segurança do Paciente , Estados Unidos , United States Food and Drug Administration
10.
Curr Opin Obstet Gynecol ; 30(1): 81-88, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29251674

RESUMO

PURPOSE OF REVIEW: To review the data-derived prevalence rates for occult leiomyosarcoma (LMS), and outcomes for women who have these tumors inadvertently morcellated. RECENT FINDINGS: In 2014, the Food and Drug Administration presented data showing the prevalence rates of occult LMS at 2.02/1000 surgeries for presumed benign fibroids. They also attributed poorer outcomes for women undergoing power morcellation of these tumors. Two more recent meta-analyses have shown much lower rates, as low as one in 8300 surgeries when including only prospective studies, and one in 1428 surgeries when including both prospective and retrospective studies. When looking at outcomes, both studies show no difference in outcomes when comparing power or any other type of morcellation. The most recent data suggest that even intact removal has no advantage when looking at mortality rates. SUMMARY: Prevalence of occult LMS remains quite rare, but outcomes after intact removal or any type of morcellation appear to be no different.


Assuntos
Medicina Baseada em Evidências , Complicações Intraoperatórias/etiologia , Leiomioma/cirurgia , Leiomiossarcoma/cirurgia , Morcelação/efeitos adversos , Complicações Pós-Operatórias/etiologia , Contraindicações de Procedimentos , Diagnóstico Tardio , Diagnóstico Diferencial , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/mortalidade , Complicações Intraoperatórias/prevenção & controle , Leiomioma/diagnóstico , Leiomiossarcoma/diagnóstico , Leiomiossarcoma/epidemiologia , Leiomiossarcoma/mortalidade , Metanálise como Assunto , Morcelação/instrumentação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Prevalência , Reprodutibilidade dos Testes , Taxa de Sobrevida , Estados Unidos/epidemiologia , United States Agency for Healthcare Research and Quality , United States Food and Drug Administration
11.
Curr Opin Obstet Gynecol ; 30(1): 89-95, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29232257

RESUMO

PURPOSE OF REVIEW: As the Food and Drug Administration raised concern over the power morcellator in 2014, the field has seen significant change, with patients and physicians questioning which procedure is safest and most cost-effective. The economic impact of these decisions is poorly understood. RECENT FINDINGS: Multiple new technologies have been developed to allow surgeons to continue to afford patients the many benefits of minimally invasive surgery while minimizing the risks of power morcellation. At the same time, researchers have focused on the true benefits of the power morcellator from a safety and cost perspective, and consistently found that with careful patient selection, by preventing laparotomies, it can be a cost-effective tool. SUMMARY: Changes since 2014 have resulted in new techniques and technologies to allow these minimally invasive procedures to continue to be offered in a safe manner. With this rapid change, physicians are altering their practice and patients are attempting to educate themselves to decide what is best for them. This evolution has allowed us to refocus on the cost implications of new developments, allowing stakeholders the opportunity to maximize patient safety and surgical outcomes while minimizing cost.


Assuntos
Doenças dos Genitais Femininos/cirurgia , Custos de Cuidados de Saúde , Histerectomia/economia , Morcelação/economia , Miomectomia Uterina/economia , Atitude do Pessoal de Saúde , Atitude Frente a Saúde , Contraindicações de Procedimentos , Análise Custo-Benefício , Diagnóstico Tardio/efeitos adversos , Diagnóstico Tardio/economia , Diagnóstico Tardio/tendências , Feminino , Doenças dos Genitais Femininos/economia , Neoplasias dos Genitais Femininos/diagnóstico , Neoplasias dos Genitais Femininos/economia , Neoplasias dos Genitais Femininos/cirurgia , Custos de Cuidados de Saúde/tendências , Humanos , Histerectomia/efeitos adversos , Histerectomia/instrumentação , Histerectomia/tendências , Complicações Intraoperatórias/economia , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Complicações Intraoperatórias/terapia , Laparoscopia/efeitos adversos , Laparoscopia/economia , Laparoscopia/tendências , Morcelação/efeitos adversos , Morcelação/instrumentação , Morcelação/tendências , Duração da Cirurgia , Segurança do Paciente/economia , Estados Unidos , United States Food and Drug Administration , Miomectomia Uterina/efeitos adversos , Miomectomia Uterina/instrumentação , Miomectomia Uterina/tendências
12.
Curr Opin Obstet Gynecol ; 30(1): 65-68, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29232258

RESUMO

PURPOSE OF REVIEW: Controversy exists surrounding extraction of tissue in gynecologic surgery using morcellators following cases of disseminated uterine cancers discovered after the use of electromechanical morcellators. This chapter traces the history of tissue extraction in gynecology and reviews the evolving scientific data and opinions regarding the future of morcellation. RECENT FINDINGS: Since the initial Food and Drug Administration warning about morcellation in 2014, subsequent studies do not support the Food and Drug Administration's high incidence of occult uterine cancer. Current research continues, focusing on methods of contained tissue morcellation, both laparoscopically and vaginally. SUMMARY: Minimally invasive surgical techniques have revolutionized gynecology, drastically reducing the need for open procedures. To maximize patient safety while preserving the rapid recovery and low morbidity of laparoscopic and vaginal approaches, optimal methods of tissue extraction need to be developed and promulgated.


Assuntos
Doenças dos Genitais Femininos/cirurgia , Morcelação/história , Morcelação/instrumentação , Contraindicações de Procedimentos , Diagnóstico Tardio , Feminino , Doenças dos Genitais Femininos/história , História do Século XIX , História do Século XX , História do Século XXI , Humanos , Histerectomia/efeitos adversos , Histerectomia/história , Histerectomia/instrumentação , Histerectomia/tendências , Laparoscopia/efeitos adversos , Laparoscopia/tendências , Morcelação/efeitos adversos , Morcelação/tendências , Segurança do Paciente , Medição de Risco , Estados Unidos , United States Food and Drug Administration , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/história , Neoplasias Uterinas/cirurgia
14.
Obstet Gynecol ; 130(5): 1057-1063, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-29016511

RESUMO

OBJECTIVE: To evaluate the association between the U.S. Food and Drug Administration (FDA) communication discouraging use of power morcellators on changes in surgical practice for women with uterine leiomyomas. METHODS: This is a cross-sectional study using data from 2013 to 2014 in the Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgical Databases from Arizona, Florida, Kentucky, and New Jersey. Women with a diagnosis of leiomyomas who underwent hysterectomy or myomectomy were included in the analysis. Multivariable models were used to assess changes in the proportion of hysterectomies performed laparoscopically, vaginally, or by laparotomy in the 15 months before the FDA safety communication in April 2013 (January 2013 to March 2014) to the 9 months after the FDA communication (April to December 2014). Changes in the proportion of women who underwent myomectomy compared with hysterectomy were also evaluated during this time period. RESULTS: There were 77,637 hysterectomy and myomectomy cases analyzed from states with both inpatient and ambulatory surgery data; 59% of patients were outpatients. Overall, there was a 4% (95% CI 3.2-4.8%) decrease in the use of laparoscopic hysterectomy for treatment of uterine leiomyomas from 62% of all hysterectomies before the FDA communication on morcellation to 58% afterward. Changes in surgical practice were more pronounced in the inpatient compared with outpatient setting; inpatient laparoscopic hysterectomy decreased by 7% (95% CI 6.1-7.9%) from 24% to 17% of all hysterectomies with an accompanying increase in abdominal hysterectomy of 8% (95% CI 6.7-8.6%) from 71% to 79%. There were no significant changes in the proportion of women with leiomyomas who underwent myomectomy compared with hysterectomy. CONCLUSION: The FDA communication discouraging the use of power morcellators was associated with a decline in laparoscopy to perform hysterectomy, particularly in the inpatient setting. There was no change in the selection of myomectomy compared with hysterectomy for leiomyoma treatment after the FDA communication.


Assuntos
Histerectomia/tendências , Laparoscopia/tendências , Leiomioma/cirurgia , Morcelação/instrumentação , Retirada de Dispositivo Médico Baseada em Segurança , Miomectomia Uterina/tendências , Neoplasias Uterinas/cirurgia , Adulto , Arizona , Estudos Transversais , Bases de Dados Factuais , Feminino , Florida , Humanos , Histerectomia/instrumentação , Histerectomia/métodos , Kentucky , Laparoscopia/métodos , Pessoa de Meia-Idade , Análise Multivariada , New Jersey , Estados Unidos , United States Food and Drug Administration , Miomectomia Uterina/instrumentação , Miomectomia Uterina/métodos
15.
Eur J Obstet Gynecol Reprod Biol ; 215: 41-44, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28599164

RESUMO

OBJECTIVE: This study was a quality improvement project investigating patterns of hysterectomy practice including changes in surgical techniques and patient outcomes after manufacturer withdrawal of a laparoscopic power morcellator from our hospitals in July 2014. STUDY DESIGN: This time-series pre and post retrospective review examined data from electronic health records, comparing one year when a laparoscopic power morcellator was available (Year 1, mid-2013 to mid-2014) to one year after withdrawal (Year 2, mid-2014 to mid-2015). Data were from patients of 8 gynecologists in a multispecialty group associated with a large, integrated care and coverage delivery system in Washington State. Analyzed were 100 patients for Year 1 and 133 patients for Year 2. Analysis was by two-sided chi-square tests comparing practice patterns and outcomes in the two years. RESULTS: For hysterectomy route, no significant difference was seen between Years 1 and 2 in percent surgeries that were abdominal or laparoscopic (including robotic). For minimally invasive hysterectomies, significantly more transvaginal hysterectomies were performed in Year 2 (22%) than Year 1 (14%) (p<0.05). In Year 2, no laparoscopic supracervical hysterectomies occurred, with total laparoscopic or vaginal hysterectomies performed instead. Transvaginal uterus morcellation increased from 13% in Year 1 to 24% in Year 2 (p<0.05). Bilateral salpingectomies increased in Year 2 as well (p<0.05). Among patient factors, estimated blood loss, surgical site infection, total operative time, and hospital length of stay were not significantly different between Years 1 and 2. Body mass index, race/ethnicity, and age did not differ between years. No patients had occult uterine sarcoma. CONCLUSION: Surgical practice patterns changed for our group of 8 gynecologists in the year after a laparoscopic power morcellator was withdrawn. Though open hysterectomies did not increase, no laparoscopic supracervical hysterectomies were performed. Total laparoscopic and vaginal hysterectomies and bilateral salpingectomies increased, with reliance on transvaginal uterine tissue-removal techniques. Patient outcomes including surgical infections, length of surgery, estimated blood loss and total hospital stay did not change. Our results suggest that experienced vaginal surgeons can adapt to removal of important surgical equipment and continue to provide minimally invasive hysterectomies without compromising patient outcomes and safety.


Assuntos
Histerectomia/instrumentação , Laparoscopia/instrumentação , Morcelação/instrumentação , Feminino , Humanos , Histerectomia/métodos , Laparoscopia/métodos , Tempo de Internação , Morcelação/métodos , Padrões de Prática Médica , Melhoria de Qualidade , Estudos Retrospectivos , Útero/cirurgia , Vagina/cirurgia
16.
Urology ; 106: 173-177, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28532766

RESUMO

OBJECTIVE: To compare the morcellation efficiency of the Wolf Piranha oscillating morcellator with the Lumenis VersaCut reciprocating morcellator. MATERIALS AND METHODS: After institutional review board approval, we conducted a retrospective analysis of patients undergoing holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia. The first 41 cases of HoLEP with morcellation performed with the oscillating morcellator were matched by weight of resected tissue to 41 control patients from our historic data set who underwent morcellation with the reciprocating system. The primary outcome of interest was morcellation efficiency. We also evaluated surgeon experience level to assess for a learning curve with the oscillating morcellator. RESULTS: The 41 patients from each group were comparable in terms of age, prostate size, continuation of aspirin, and catheter status. The oscillating morcellation efficiency was nearly double that of the reciprocating morcellator (8.6 g/min [range: 3.0-18.3] vs 3.8 g/min [range: 0.9-10.1], P <.0001). Mean resected weights for cases with the oscillating and reciprocating instruments were 69 g (range: 17-224 g) and 69 g (range: 17-213 g), respectively (P = .9). The total operative time and complication rates did not significantly differ. For the oscillating system, morcellation efficiency for cases performed by staff alone was 9.8 g/min compared with 8.1 g/min when trainees were involved (P = .2), and there was no correlation between morcellation efficiency and number of cases performed (R = 0.01). CONCLUSION: The oscillating morcellation system resulted in a morcellation efficiency double that of the reciprocating system for tissue retrieval after HoLEP. Achieving efficiency with the oscillating system was not associated with a significant learning curve and was not impacted by trainee involvement.


Assuntos
Terapia a Laser/métodos , Lasers de Estado Sólido/uso terapêutico , Curva de Aprendizado , Morcelação/instrumentação , Hiperplasia Prostática/cirurgia , Ressecção Transuretral da Próstata/métodos , Urologia/educação , Idoso , Educação de Pós-Graduação em Medicina/métodos , Desenho de Equipamento , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Morcelação/educação , Estudos Retrospectivos , Ressecção Transuretral da Próstata/educação
17.
Surg Technol Int ; 30: 215-220, 2017 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-28537350

RESUMO

The treatment of intrauterine masses, such as endometrial polyps and leiomyomas, has undergone a technological revolution in the past few decades. Gynecologists may now choose from a variety of unipolar and bipolar resectoscopes as well as an assortment of both mechanical and bipolar hysteroscopic morcellators. We present a comparison of these technologies to better practitioners understanding of the strengths and limitations of these devices.


Assuntos
Procedimentos Cirúrgicos em Ginecologia , Histeroscopia , Morcelação , Doenças Uterinas/cirurgia , Útero/cirurgia , Desenho de Equipamento , Feminino , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Histeroscopia/instrumentação , Histeroscopia/métodos , Leiomioma/cirurgia , Morcelação/instrumentação , Morcelação/métodos , Pólipos/cirurgia
18.
JSLS ; 21(1)2017.
Artigo em Inglês | MEDLINE | ID: mdl-28352146

RESUMO

BACKGROUND AND OBJECTIVES: The well-known advantages of minimally invasive surgery make the approach well suited for hysterectomy and other gynecological procedures. The removal of specimens excised during surgery has been a challenge that has been answered by the use of power morcellation. With this study we sought to assess the feasibility of power morcellation within a specimen bag. METHODS: This was a retrospective cohort study including patients from a private practice in suburban Chicago, Illinois, who underwent contained electromechanical power morcellation during a laparoscopic or robot-assisted hysterectomy or myomectomy from May 2014 through December 2015. Contained power morcellation was performed with the Espiner EcoSac 230 (Espiner Medical Ltd., North Somerset, United Kingdom) specimen bag. Descriptive statistics were performed for both categorical and continuous data. RESULTS: Of the 187 procedures performed, 73.8% were myomectomies, and 26.2% were hysterectomies. The patients' mean age was 40 (range, 25-54) years and mean body mass index was 28.7 (range, 17.3-57.6). The average specimen weight was 300 g, with the largest weighing 2134 g. Estimated blood loss averaged 98.4 mL. The postoperative admission rate was 12.3%, most of which were due to nausea and urinary retention. Seventeen patients (9.1%) had postoperative complications, most of which were minor, and 4 (2.1%) were readmitted. There were no bag failures or complications that were due to the use of the specimen bag or to power morcellation. CONCLUSIONS: Performing electromechanical power morcellation within the Espiner EcoSac 230 specimen bag was successfully performed in 187 patients with no bag-related complications. This method of contained power morcellation is feasible, reliable, and reproducible, even for a large specimen.


Assuntos
Histerectomia/métodos , Laparoscopia/métodos , Morcelação/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Miomectomia Uterina/métodos , Adulto , Estudos de Viabilidade , Feminino , Humanos , Histerectomia/instrumentação , Pessoa de Meia-Idade , Morcelação/métodos , Estudos Retrospectivos , Miomectomia Uterina/instrumentação
20.
Surg Endosc ; 31(1): 494-500, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27194256

RESUMO

BACKGROUND: Electromechanical power morcellation is an important tool of modern laparoscopy. Recent reports on the spread of previously undetected malignancy by power morcellation indicate the need for additional protective devices to reduce this risk. We conducted a study to obtain the first data concerning the safety of an endobag with three closable ports during morcellation and subsequent bag extraction under in vitro conditions, mimicking the settings in our operating theater. The second purpose of the study was to establish a minimal width of the skin incision necessary to safely extract the sealed bag after morcellation. METHODS: The morcellation test was carried out on 11 stained porcine muscle tissue samples with one additional sample as a control. The insufflation pressure was set at 12 mmHg. After filling the endobag with blue dye solution, an additional extraction test was conducted by pulling the closed bag through a template with apertures of various diameters. For each opening, a series of ten bag extractions was carried out. RESULTS: No loss of solid material or fluid was recorded during the morcellation test. The extraction test showed a loss of fluid for template openings smaller than 18 mm. The force necessary to extract the bag was inversely related to the width of the aperture. CONCLUSIONS: The data suggest that under the evaluated conditions, the use of a closable morcellation bag can considerably improve the patient's safety during morcellation. Further studies are necessary to evaluate the influence of the bag on operating time, intervention costs and complications.


Assuntos
Histerectomia/instrumentação , Laparoscopia/instrumentação , Leiomioma/cirurgia , Modelos Anatômicos , Morcelação/instrumentação , Miomectomia Uterina/instrumentação , Neoplasias Uterinas/cirurgia , Animais , Feminino , Histerectomia/métodos , Insuflação , Laparoscopia/métodos , Leiomioma/complicações , Leiomioma/patologia , Morcelação/métodos , Duração da Cirurgia , Projetos Piloto , Segurança , Sarcoma/complicações , Sarcoma/patologia , Suínos , Miomectomia Uterina/métodos , Neoplasias Uterinas/complicações , Neoplasias Uterinas/patologia
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