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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.
In Vivo ; 33(5): 1393-1401, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31471384

RESUMO

Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.


Assuntos
Leiomioma/cirurgia , Morcelação , Animais , Gerenciamento Clínico , Prática Clínica Baseada em Evidências , Feminino , Humanos , Incidência , Leiomioma/diagnóstico , Leiomioma/epidemiologia , Leiomiossarcoma/diagnóstico , Leiomiossarcoma/epidemiologia , Leiomiossarcoma/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Morcelação/efeitos adversos , Morcelação/métodos , Melhoria de Qualidade , /epidemiologia
3.
Tokai J Exp Clin Med ; 44(3): 54-58, 2019 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-31448397

RESUMO

INTRODUCTION: After a FDA recommendation in April 2014, power morcellation (PM) in laparoscopic myomectomy (LM) has become less common. We now collect a myoma using manual morcellation (MM) from a wound in the umbilical region. In this study, we compared the PM and MM methods. METHODS: The subjects were 69 patients who underwent LM from April 2013 to March 2016 using PM (n = 37) or MM (n = 32). With PM, the myoma was collected using a 4-hole 12-mm parallel trocar in the left lower abdomen. Using MM, an EZ ACCESSTM (2-cm skin incision) was placed on the umbilical region, and the myoma was put in a collection purse and guided into the access hole for MM using scissors under direct vision. RESULTS: None required allogeneic transfusion or a transition to open surgery, and had surgical or post surgical complications. At multiple linear regression analysis, which was adjusted by age, body mass index, and intraoperative blood loss, significant difference was not observed in operation time between the PM and MM groups. CONCLUSION: Manual morcellation was found to be a safe method for collection of myoma that prevents scattering of tissues and does not prolong the operation time.


Assuntos
Laparoscopia/métodos , Leiomioma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Fatores Etários , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Índice de Massa Corporal , Feminino , Humanos , Duração da Cirurgia , Análise de Regressão , Estudos Retrospectivos
4.
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
5.
Clín. investig. ginecol. obstet. (Ed. impr.) ; 46(1): 15-20, ene.-mar. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-182626

RESUMO

Objetivo: Evaluar e identificar aquellas variables relacionadas con la tasa de éxito en el manejo con el histeroscopio de energía mecánica Truclear System 5.0(R) de los restos ovulares retenidos. Material y métodos: Estudio descriptivo prospectivo realizado en el Hospital de Igualada con periodo de inclusión de enero del 2015 a diciembre del 2016. Incluye a todas aquellas pacientes con diagnóstico de restos ovulares a las que se les realizó en el quirófano una histeroscopia diagnóstico-terapéutica con el histeroscopio de energía mecánica Truclear System 5.0(R). Resultados: Se incluyeron un total de 42 pacientes de las cuales se excluyeron 12 por no cumplir los criterios de inclusión. De las 30 pacientes analizadas, 21 (70%) presentaban pérdidas discontinuas en el momento del diagnóstico, mientras que 9 (30%) permanecían asintomáticas. La morcelación completa de los restos se consiguió en el 77% de las pacientes (23). No hubo ninguna complicación evidente intraoperatoria ni en el postoperatorio inmediato. Conclusiones: La resección selectiva histeroscópica con energía mecánica parece ser un buen método terapéutico para la retención de los restos ovulares, con unos porcentajes de éxito del 77%. Esta técnica nos ofrece una alternativa al tradicional legrado uterino evacuador que minimiza los riesgos y complicaciones que supone un acto quirúrgico invasivo para la paciente. Se plantea, como futura hipótesis de trabajo, la seguridad y el beneficio en la realización de la histeroscopia ambulatoria en todas aquellas pacientes con restos ovulares que cumplan unos criterios específicos


Objective: To evaluate and identify the variables related to the success rate in managing patients diagnosed with retained products of conception, by using the Truclear System 5.0(R) Hysteroscopic Morcellator, which is powered by mechanical energy. Materials and methods: A descriptive prospective study was performed at Hospital de Igualada, with the inclusion period lasting from January 2015 to December 2016. The study included all patients diagnosed with retained products of conception who underwent diagnostic and therapeutic hysteroscopy with the Truclear System 5.0(R) Hysteroscopic Morcellator, which uses mechanical energy. Results: A total of 42 patients were included, of whom 12 were excluded because they did not meet the inclusion criteria. Of the 30 patients analysed, 21 (70%) had low abnormal uterine bleeding at the time of diagnosis and 9 (30%) remained asymptomatic. The complete removal of the remains was achieved in 77% of the patients (23). There were no evident complications either during or immediately after surgery. Conclusions: Hysteroscopic selective resection with mechanical energy seems to be a good therapeutic method for retained products of conception, achieving a success rate of 77%. This technique offers an alternative to traditional dilatation and legrado, minimising the risks and complications involved in invasive surgical procedures for patients. Further studies are needed to evaluate the safety of and benefit in performing hysteroscopy on an outpatient basis in all patients with retained products of conception who meet specific criteria


Assuntos
Humanos , Feminino , Adulto , Morcelação/métodos , Histeroscopia/métodos , Placenta Retida/cirurgia , Estudos Prospectivos , Histeroscópios
6.
Prog. obstet. ginecol. (Ed. impr.) ; 62(1): 51-54, ene.-feb. 2019. ilus
Artigo em Espanhol | IBECS | ID: ibc-184895

RESUMO

Introducción: La leiomiomatosis peritoneal diseminada (LPD) es una entidad rara que se caracteriza por la presencia de múltiples nódulos de músculo liso a nivel de la superficie peritoneal de la cavidad abdominopélvica. Presenta una fisiopatología poco conocida, siendo más frecuente en mujeres en edad reproductiva. Caso clínico: Se presenta el caso de una paciente con leiomiomatosis peritoneal diseminada con antecedente de histerectomía por útero polimiomatoso y morcelación intraabdominal de la pieza quirúrgica. Conclusiones: La leiomiomatosis peritoneal diseminada (LPD) es una entidad rara con pocos casos reportados en la literatura. Se postula un origen iatrogénico por la persistencia de fragmentos de mioma dentro de la cavidad abdominopélvica tras morcelación, factor a tener presente en aquellas pacientes sometidas a miomectomias o histerectomías


Introduction: Leiomyomatosis peritonealis disseminata (LPD) is characterized by multiple smooth muscle nodules in the peritoneal surface of the abdominopelvic cavity. The exact pathophysiology is unclear, being more frequent in women of reproductive age. Case report: A case of peritoneal dissemination after laparoscopic hysterectomy with subsequent intraabdominal morcellation in a patient with a polymyatomic uterus is presented. Conclusions: Leiomyomatosis peritonealis disseminata (LPD) is a rare entity with few cases reported in the literature. An iatrogenic origin is postulated by the persistence of myoma fragments within the abdominopelvic cavity after the morcelation. Factor to take into account in those patients undergoing myomectomies or hysterectomies


Assuntos
Humanos , Feminino , Adulto , Leiomiomatose/patologia , Leiomioma/cirurgia , Histerectomia/métodos , Morcelação/métodos , Cavidade Peritoneal/patologia , Miomectomia Uterina/métodos , Complicações Pós-Operatórias , Laparoscopia/métodos
7.
Int J Surg ; 62: 28-33, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30654144

RESUMO

OBJECTIVE: To identify the superior surgical procedure for endometrial polypectomy based on network meta-analysis. METHOD: Literature retrieval was conducted in globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating the clinical effects of respective surgical procedure for endometrial polypectomy. Surgical parametric data, including operative time, success rates and complications, were quantitatively pooled and estimated based on the Bayesian theorem. The values of surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated and ranked by various procedures. Node-splitting analysis was performed to test the inconsistency of the main results and publication bias was assessed by examining funnel-plot symmetry. RESULTS: After a detailed review, 8 RCTs containing 5 different procedures were finally included for network meta-analysis. The results indicated that hysteroscopic morcellation possessed the highest possibility of revealing best clinical effects on operative time (SUCRA, 0.49), success rate (SUCRA, 0.90) and complications (SUCRA, 0.50). Moreover, node-splitting analysis and funnel-plot symmetries illustrated no inconsistency or obvious publication bias in the current study. CONCLUSIONS: Current evidence demonstrated that hysteroscopic morcellation showed optimal potential superior clinical effects for endometrial polypectomy compared to other procedures. However, high-quality large sample trials are still expected, and new investigations on other relative procedures in this field should be included in the future.


Assuntos
Neoplasias do Endométrio/cirurgia , Morcelação/métodos , Pólipos/cirurgia , Teorema de Bayes , Feminino , Humanos , Histeroscopia/efeitos adversos , Histeroscopia/métodos , Morcelação/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos
8.
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
9.
Surg Innov ; 26(1): 72-76, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30047311

RESUMO

OBJECTIVE: To evaluate clinical and operative outcomes of transvaginal extraction (TVE) and contained power morcellation (CPM) for myoma retrieval after laparoscopic myomectomy. MATERIALS AND METHODS: Prospective data from 35 consecutive cases using CPM were compared with retrospective data of all cases using TVE from December 2014 to January 2017. Patients were matched 1:1 based on myoma diameter. A total of 62 women were included in the final analysis. Specimen retrieval was performed using the TVE or CPM within an insufflated isolation bag. RESULTS: Age, body mass index, mode of prior obstetric delivery, history of previous abdominal surgery, indication for myomectomy, and the myoma(s) characteristics were similar between groups. Retrieval time was significantly shorter in the TVE group compared with the CPM group: 10 minutes (3-15 minutes) versus 17 minutes (14-42 minutes); P < .001. Time required for placement of the instruments was 9.7 minutes for the isolation bag and 0.5 minutes for the vaginal extractor. Additional analgesic administration for pain relief was necessary in 13 patients (42%) in the TVE group and 23 patients (72%) in the CPM group ( P = .01). Total cost of the hospital stay was significantly higher in the CPM group compared with the TVE group ( P < .001). Estimated blood loss and duration of hospital stay were similar between groups. CONCLUSION: Both CPM and TVE can be used for safe retrieval of large myomas that are removed laparoscopically. Compared with CPM, TVE was associated with a shorter retrieval time, less postoperative pain, and less hospital costs.


Assuntos
Laparoscopia/métodos , Leiomioma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Perda Sanguínea Cirúrgica , Estudos de Coortes , Feminino , Humanos , Laparoscopia/efeitos adversos , Leiomioma/patologia , Tempo de Internação , Pessoa de Meia-Idade , Morcelação/efeitos adversos , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Duração da Cirurgia , Prognóstico , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Carga Tumoral , Miomectomia Uterina/efeitos adversos , Neoplasias Uterinas/patologia , Vagina/cirurgia
10.
J Robot Surg ; 13(2): 209-214, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29907929

RESUMO

Clinical practice has drastically changed following the 2014 U.S. Food and Drug Administration (FDA) warning statement regarding power morcellation during laparoscopic hysterectomy and myomectomy. Despite investigation into alternative tissue extraction techniques, there remain a paucity of data associated with contained manual morcellation techniques. The goal of this study was to investigate the associated perioperative outcomes of contained manual morcellation compared to power morcellation in women undergoing robotic myomectomy. Performing manual morcellation (n = 38) resulted in a 21-min decrease in mean operative time (105.4 ± 42.2 vs 126.1 ± 44.1 min, p = 0.02) compared to power morcellation (n = 62). Women were younger (33 vs 36 years, p = 0.03) in the manual morcellation group, with all other patient demographics being similar. Median specimen weight (82 vs 104 g, p = 0.13), number of fibroids removed (2 vs 1, p = 0.16), estimated blood loss (10 vs 50 mL, p = 0.25), and post-operative morphine equivalents administered (5.57 ± 4.57 vs 5.29 ± 4.39, p = 0.76) were similar. The same-day discharge rate was not significantly different between the groups (86 vs 90%, p = 0.74). Linear regression modeling identified specimen weight, number of fibroids removed, and use of power morcellation as significant contributors to surgical time. Contained manual morcellation during robotic myomectomy is associated with a significant decrease in surgical time when compared to power morcellation, with similar post-operative narcotic administration and length of stay.


Assuntos
Laparoscopia/métodos , Morcelação/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Miomectomia Uterina/métodos , Adulto , Feminino , Humanos , Tempo de Internação , Morfina/administração & dosagem , Entorpecentes/administração & dosagem , Duração da Cirurgia , Cuidados Pós-Operatórios/estatística & dados numéricos , Resultado do Tratamento
11.
J Minim Invasive Gynecol ; 26(1): 175-177, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30098413

RESUMO

We report a case of a pyomyoma in which in-bag morcellation allowed for a total laparoscopic hysterectomy instead of laparotomy, which has been recognized as the standard of care to avoid the spread of infection from morcellation. A 45-year-old multiparous woman presented with sepsis, pelvic pain, and leukocytosis at 1 month after undergoing uterine artery embolization for symptomatic uterine leiomyoma. Pelvic computed tomography scan revealed a 9-cm suspected pyomyoma. A total hysterectomy was performed using a laparoscopic approach with in-bag morcellation. The intervention was successful, and the postoperative course was uneventful. The patient was discharged on postoperative day 1 and was well at 2 months after surgery.


Assuntos
Leiomioma/cirurgia , Morcelação/métodos , Embolização da Artéria Uterina/métodos , Neoplasias Uterinas/cirurgia , Feminino , Humanos , Histerectomia/métodos , Laparoscopia/métodos , Laparotomia , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Complicações Pós-Operatórias
12.
J Minim Invasive Gynecol ; 26(5): 856-864, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30170179

RESUMO

STUDY OBJECTIVE: Conventional laparoscopic myomectomy (CLM) and robotic-assisted myomectomy (RAM) are limited in the number and size of myomas that can be removed, whereas abdominal myomectomy (AM) is associated with increased complications and morbidity. Here we evaluated the surgical outcomes of these myomectomy techniques compared with those of laparoscopic-assisted myomectomy (LAM), a hybrid approach that combines laparoscopy and minilaparotomy with bilateral uterine artery occlusion or ligation to control blood loss. DESIGN: Retrospective chart review (Canadian Task Force classification II-1). SETTING: Suburban community hospital. PATIENTS: Women age ≥18 years with nonmalignant indications. INTERVENTION: A total of 1313 consecutive CLMs, RAMs, AMs, and LAMs performed between January 2011 and December 2013. MEASUREMENTS AND MAIN RESULTS: Our review included 163 CLMs (12%), 156 RAMs (12%), 686 AMs (52%), and 308 LAMs (23%). Although the average number, size, and total weight of leiomyomas removed were comparable in the LAM and AM groups (9.1, 8.13 cm, and 391 g, respectively, vs 9.0, 7.5 cm, and 424 g; p < .0001), the number and weight of myomas were significantly greater in those 2 groups compared with the CLM and RAM groups (2.9 and 217 g, respectively, and 2.9 and 269 g; p < .0001). The intraoperative complication rate was highest in the RAM group, and the postoperative complication rate was highest in the AM group, both of which were approximately 3 times greater than the rates in the LAM group. There was no statistically significant difference in postoperative complication rates between the CLM and LAM groups. CONCLUSION: LAM with uterine artery occlusion/ligation is a viable approach for removing large tumor loads while minimizing blood loss and precluding the need for power morcellation.


Assuntos
Artéria Uterina/cirurgia , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Registros Eletrônicos de Saúde , Feminino , Humanos , Complicações Intraoperatórias/cirurgia , Laparoscopia/métodos , Laparotomia/métodos , Leiomioma/cirurgia , Ligadura , Pessoa de Meia-Idade , Morcelação/métodos , Mioma/cirurgia , Complicações Pós-Operatórias/cirurgia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Oclusão Terapêutica
13.
World J Urol ; 37(7): 1315-1320, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30350017

RESUMO

OBJECTIVE: This study sought to compare the incidental prostate cancer (iPCa) detection rate between pathological specimens from green laser enucleation of the prostate (GreenLEP) and open simple prostatectomy (OSP). MATERIALS AND METHODS: In two institutions, the charts of all consecutive patients who underwent OSP between January 2005 and December 2010 were retrospectively reviewed, and the data of all consecutive patients who underwent GreenLEP with tissue morcellation between July 2013 and January 2018 were also collected. Preoperative demographics and pathological findings were recorded. iPCa detection rate was retrospectively compared between the GreenLEP and OSP groups in a propensity score model, including all predetermined variables: Age, preoperative PSA level and prostate volume. RESULTS: Of 738 patients, 402 were included in the propensity-score matching analysis, and they were equally distributed among groups. The overall iPCa detection rates were similar in both groups (9.9% vs. 8.5%; p = 0.73), and there were no statistically significant differences in terms of tumour stage, Gleason score or the rate of clinically significant iPCa, although the number of cassettes analysed was significantly higher in the morcellation group than in the OSP group. No predictive factors for iPCa were identified. CONCLUSIONS: The results of the present study suggest that the mechanical morcellation of large glands had no influence on iPCa detection. Compared with a specimen from standard OSP, a large morcellated tissue sample allows adequate pathological evaluation and does not alter a pathologist's ability to detect iPCa.


Assuntos
Achados Incidentais , Morcelação/métodos , Prostatectomia/métodos , Hiperplasia Prostática/cirurgia , Neoplasias da Próstata/patologia , Ressecção Transuretral da Próstata/métodos , Obstrução Uretral/cirurgia , Idoso , Humanos , Terapia a Laser , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Hiperplasia Prostática/complicações , Neoplasias da Próstata/diagnóstico , Obstrução Uretral/etiologia
14.
J Minim Invasive Gynecol ; 26(5): 809-810, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30315895

RESUMO

STUDY OBJECTIVE: To achieve tissue containment and extraction for numerous and large myomas in the complex minimally invasive difficult myomectomy setting via a surgical tutorial including technical pointers and suggestions DESIGN: A step-by-step explanation of the .surgery using video (instructive video) (Canadian Task Force classification III). Institutional review board approval was not required for this study. SETTING: George Washington University Hospital, Washington, DC. PATIENTS: Multiple patients with a high number or large size of leiomyomata. INTERVENTIONS: Four reproducible techniques that enable the minimally invasive gynecologic surgeon to perform complex tissue containment and extraction: MEASUREMENTS AND MAIN RESULTS: One of the main challenges encountered with minimally invasive myomectomy procedures includes myoma containment and extraction. Given the potential risks for leiomyomatosis and the spread of leiomyosarcoma, the Food and Drug Administration banned electromechanical morcellation device usage [1]. After implementation of the ban and fueled by the increasing size and number of myomas removed through minimally invasive techniques, tissue containment and extraction are becoming increasingly challenging. This shift is partly reflected by the number of complications attributable to surgeon experience [2,3]. With the increase in the number of myomas removed during a minimally invasive myomectomy, the risk of myoma retention in the abdominal cavity is amplified. Also, the increase in the myoma size removed through minimally invasive surgery renders tissue extraction through contained, extracorporeal, manual morcellation more challenging [2-5]. Inefficiencies in tissue containment and extraction could potentially be hazardous to the patient's safety and detrimental to the operating room efficiency, and the AAGL Practice Report on tissue extraction emphasizes that the use of specimen retrieval pouches should be investigated further [2-6]. Patients underwent uncomplicated complex minimally invasive myomectomy. CONCLUSION: Mastering these reproducible techniques maximizes patient safety and operating room efficiency during minimally invasive myomectomy procedures.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , District of Columbia , Feminino , Humanos , Laparoscopia/métodos , Leiomiomatose/cirurgia , Leiomiossarcoma/cirurgia , Morcelação/efeitos adversos , Morcelação/métodos , Mioma/cirurgia , Reprodutibilidade dos Testes , Gravação em Vídeo
15.
Minim Invasive Ther Allied Technol ; 28(4): 220-226, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30293473

RESUMO

Introduction: In this study we evaluate the influence of longitudinal and transverse length of prostate size measured on the magnetic resonance imaging (MRI) scan on the overall outcomes of HoLEP. Material and methods: The patients were divided into two groups based on the shape of the prostate. Group 1 had a longitudinal shape with a longitudinal diameter greater than the transverse diameter, whereas group 2 had an oval shape with a transverse diameter greater than the longitudinal diameter. The pre-operative, peri-operative and the one-month post-operative data along with the urinary parameters were then evaluated. Results: The two groups were comparable with regard to their pre-operative values. While the median lobe enucleation time and morcellation time showed no difference, group 1 showed a significantly shorter (p < 0.01) operative time for lateral lobe enucleation, lower laser energy usage and better enucleation efficiency. However, there was no difference in the median lobe enucleation time, morcellation time, haemoglobin drop, duration of urethral catheterization and hospital stay. The groups were also comparable with regard to the improvement in urinary parameters and complications. Conclusion: Prostate shape plays a significant role in the surgical treatment of BPH.


Assuntos
Terapia a Laser/métodos , Morcelação/métodos , Duração da Cirurgia , Próstata/anatomia & histologia , Hiperplasia Prostática/cirurgia , Ressecção Transuretral da Próstata/métodos , Cateterismo Urinário/métodos , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos , Resultado do Tratamento
16.
Eur J Obstet Gynecol Reprod Biol ; 230: 85-89, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30245442

RESUMO

OBJECTIVES: Our objective is to investigate the prevalence, pathology and prognosis of uterine sarcomas in laparoscopic hysterectomy/myomectomy with electric power morcellation for presumed leiomyomas. STUDY DESIGN: We retrospectively reviewed patients with laparoscopic power morcellation (LPM) for presumed leiomyomas in a Chinese tertiary institution by chart review from September 1, 2013 to December 31, 2016. RESULTS: Twenty-four in 4478 patients (0.54%) with LPM for presumed leiomyomas had unexpected cancers. The patients showed the highest frequency of occult cancers (10/375, 2.6%) at 51-60 years and lowest (0/255) before 30 years. The pathology included 14 endometrial stromal sarcomas (ESS) (low-grade 12 and high-grade 2), 9 leiomyosarcomas, and 1 malignant mixed mesodermal tumor. The patients underwent abdominal re-exploration including total hysterectomy with bilateral salpingo-oophorectomy and staging surgery. Three patients were at advanced FIGO stage (IIIb-IVb) and 21 at stage I. Seven patients recurred within 1-25 (mean 6.29) months including 5 leiomyosarcomas, 1 high-grade and 1 low-grade ESS. Four recurrent patients with leiomyosarcomas and one with high-grade ESS died of disease in 1-3 months. Seventeen patients had no relapse and were alive for 6-41 (mean 24) months. CONCLUSIONS: Our study suggests that patients with LPM for presumed leiomyomas appear to have a considerable risk of unexpected cancers. Moreover, morcellation is potentially associated with adverse prognosis in patients with high-grade sarcomas. Informed consent on unexpected cancers that should be discussed before morcellation.


Assuntos
Laparoscopia/efeitos adversos , Leiomioma/cirurgia , Morcelação/efeitos adversos , Sarcoma/epidemiologia , Miomectomia Uterina/efeitos adversos , Neoplasias Uterinas/epidemiologia , Neoplasias Uterinas/cirurgia , Adolescente , Adulto , Idoso , China/epidemiologia , Feminino , Humanos , Histerectomia/efeitos adversos , Histerectomia/métodos , Laparoscopia/métodos , Pessoa de Meia-Idade , Morcelação/métodos , Prevalência , Estudos Retrospectivos , Sarcoma/etiologia , Miomectomia Uterina/métodos , Neoplasias Uterinas/etiologia , Adulto Jovem
17.
Surg Endosc ; 32(10): 4357-4362, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29987561

RESUMO

BACKGROUND: To assess potential risks of new surgical procedures and devices before their introduction into daily practice, a prospective risk inventory (PRI) is a required step. This study assesses the applicability of the Health Failure Mode and Effects Analysis (HFMEA) as part of a PRI of new technology in minimally invasive gynecologic surgery. METHODS: A reference case was defined of a patient with presumed benign leiomyoma undergoing a laparoscopic hysterectomy or myomectomy including in-bag power morcellation; however, pathology defined a stage I uterine leiomyosarcoma. Using in-bag morcellation as a template, a HFMEA was performed. All steps of the in-bag morcellation technique were identified. Next, the possible hazards of these steps were explored and possible measures to control these hazards were discussed. RESULTS: Five main steps of the morcellation process were identified. For retrieval bags without openings to accommodate instruments inside the bag, 120 risks were identified. Of these risks, 67 should be eliminated. For containment bags with openings 131 risks were identified of which 68 should be eliminated. Of the 10 causes most at risk to cause spillage, two can be eliminated by using appropriate bag materials. Myomectomy appears to be more at risk for residual tissue spillage compared to total hysterectomy. CONCLUSION: The HFMEA has provided important new insights regarding potential weaknesses of the in-bag morcellation technique, particularly with respect to hazardous steps in the morcellation process as well as requirements that bags should meet. As such, this study has shown HFMEA to be a valuable method that identifies and quantifies potential hazards of new technology.


Assuntos
Histerectomia/métodos , Laparoscopia/métodos , Leiomiossarcoma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Feminino , Análise do Modo e do Efeito de Falhas na Assistência à Saúde , Humanos , Estudos Prospectivos
18.
Eur J Cancer ; 101: 62-68, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30025231

RESUMO

BACKGROUND: There is concern but no solid evidence that morcellation during laparoscopic or vaginal hysterectomy may cause abdominal spread and thereby impaired prognosis of incidental uterine sarcomas. OBJECTIVE: Our purpose was to compare survival among patients with uterine sarcomas who underwent hysterectomy with or without morcellation to test the hypothesis that morcellation impairs prognosis. STUDY DESIGN: We identified all women in Norway diagnosed with uterine sarcoma between 1953 and 2012 through national registries and retrieved data on surgical technique and morcellation by evaluation of patient files. Patients were categorised into abdominal, laparoscopic or vaginal hysterectomy with or without morcellation. Vaginal and laparoscopic hysterectomies were introduced in 1991; our main comparison is from 1991 to 2012. We compared age-adjusted disease-specific survival of sarcoma patients treated with or without morcellation and calculated age-adjusted hazard ratios (HRs) and subdistribution HR (accounting for competing risk) with 95% confidence intervals (CIs). RESULTS: Among 1367 patients with uterine sarcoma between 1953 and 2012 in Norway, 653 were diagnosed after 1991, and 23 of these patients (3.5%) underwent morcellation. Uterine sarcoma prevalence was 3.6 per 1000 laparoscopic hysterectomies. Mean follow-up was 6.0 years in the morcellated group and 6.9 years in the non-morcellated group. The risk of dying from uterine sarcoma after morcellation was 1.5 per 1000 procedures. Sarcoma mortality was higher in the morcellated group than in the non-morcellated group (age-adjusted HR 1.90, CI 1.05-3.44; multivariate HR, 2.50, 95% CI 0.57-10.9). Age-adjusted 10-year uterine sarcoma survival was 32.2% for women treated with morcellation compared with 57.2% for non-morcellated group (difference 25.5%; CI -55.7 to 18.1). All-cause 10-year survival was 32.2% in the morcellated group and 44.1% in the non-morcellated group (difference 11.9%; CI -40.9 to 32.7). CONCLUSION: Our results strengthen the evidence that morcellation during hysterectomy in patients with incidental uterine sarcoma may cause impaired survival. These results can guide shared decision-making in clinical practice.


Assuntos
Histerectomia/métodos , Morcelação/métodos , Sarcoma/cirurgia , Neoplasias Uterinas/cirurgia , Útero/cirurgia , Adulto , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Noruega/epidemiologia , Prevalência , Prognóstico , Estudos Retrospectivos , Sarcoma/epidemiologia , Neoplasias Uterinas/epidemiologia , Útero/patologia
19.
J Minim Invasive Gynecol ; 25(7): 1266-1273, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29631012

RESUMO

STUDY OBJECTIVE: To examine whether peritoneal washings during laparoscopic-assisted myomectomy with in-bag manual tissue extraction can contain spilled leiomyoma cell sheets. DESIGN: Retrospective observational study (Canadian Task Force classification II-2). SETTING: Departments of Obstetrics and Gynecology and Diagnostic Pathology at a general hospital. PATIENTS: Twenty-four women. INTERVENTIONS: Hysterotomy followed by complete enucleation by blunt and sharp dissection was performed. Enucleated myomas were placed into a retriever bag and extracted through a suprapubic or umbilical mini-laparotomic incision by manual morcellation with a surgical scalpel. A histological examination was performed to identify the dispersed leiomyoma cell sheets in trapped tissues on the surface of a defoaming sponge equipped in the reservoir of an intraoperative red blood cell salvage device, which was used to collect peritoneal washing fluid along with blood. MEASUREMENTS AND MAIN RESULTS: Bag rupture was not observed in any case; however, apparent leiomyoma cell sheets were identified in 20 of 24 cases (83.3%). No devices or procedures that were used for myomectomy could completely prevent leiomyoma cells from appearing in the peritoneal washing fluid. CONCLUSION: Even when careful in-bag tissue extraction of myomas was performed in laparoscopic-assisted myomectomy, dispersion of leiomyoma cell was identified in most cases. Further study is needed to show that the feasibility of rigorous washing to reduce the potential risk of leiomyoma cell dissemination.


Assuntos
Laparoscopia , Leiomioma/patologia , Morcelação , Cavidade Peritoneal/patologia , Miomectomia Uterina/métodos , Neoplasias Uterinas/patologia , Adulto , Feminino , Humanos , Laparoscopia/métodos , Leiomioma/cirurgia , Morcelação/métodos , Projetos Piloto , Estudos Retrospectivos , Neoplasias Uterinas/cirurgia
20.
JAMA Surg ; 153(6): e180141, 2018 06 20.
Artigo em Inglês | MEDLINE | ID: mdl-29641835

RESUMO

Importance: In November 2014, the US Food and Drug Administration (FDA) issued a black box warning against the use of power morcellation for excision of uterine fibroids to decrease the risk of disseminating malignant cells and worsening survival outcomes of patients with unexpected malignant neoplasms. After the FDA statement was issued, studies showed decreased rates of minimally invasive surgery and increased rates of open abdominal hysterectomy. However, there are limited and controversial data on the association of these changed rates with 30-day hysterectomy complications. Objective: To assess changes in the rates of 30-day major and minor complications of hysterectomy for benign gynecologic indications following the FDA-issued statement. Design, Setting, and Participants: This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database and included 603 hospitals participating between January 1, 2013, and December 31, 2015. Thirty-day posthysterectomy complications were compared before and after the FDA-issued warning. Women who underwent hysterectomy for benign gynecologic indications (n = 75 487), including hysterectomies with indication of uterine fibroids (n = 25 571), were included. Complication rates and procedure distributions between the periods were compared with χ2 tests and multivariable logistic regression controlling for patient and operative factors. Main Outcomes and Measures: Major and minor 30-day complication rates before (from 2013 through the first quarter of 2014) and after (from the fourth quarter of 2014 through 2015) the FDA-issued warning. Results: Of 75 487 women (mean [SD] age, 47.8 [10.7] years) who underwent hysterectomy for benign gynecologic indications, 32 186 (42.6%) were treated before and 43 301 (57.4%) after the FDA-issued warning. Non-Hispanic white women comprised most (59.4%) of the total population, followed by African American women (15.1%). Overall, major and minor complications remained stable before and after the FDA-issued warning. By contrast, among a subset of 25 571 women (33.9%) who underwent hysterectomy for uterine fibroids, major complications significantly increased after the FDA-issued warning from 1.9% to 2.4% (adjusted odds ratio [OR], 1.23; 95% CI, 1.04-1.47; P = .02), and minor complications significantly increased from 2.7% to 3.3% (adjusted OR, 1.21; 95% CI, 1.04-1.40; P = .01). In this subgroup, the rate of open abdominal surgery increased from 37.2% to 43.0%, and the rate of minimally invasive surgery (total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, and laparoscopic-assisted vaginal hysterectomy) decreased from 56.1% to 49.7% (P < .001). Conclusions and Relevance: Major and minor 30-day complication rates among women undergoing hysterectomy for uterine fibroids increased following the FDA-issued statement. This increased risk corresponding with a decreased use of minimally invasive surgery should be balanced against the potential harms of morcellation during a shared decision-making process between clinician and patient. Regulatory bodies and medical societies should consider these findings when issuing relevant communications.


Assuntos
Rotulagem de Medicamentos , Histerectomia/efeitos adversos , Histerectomia/estatística & dados numéricos , Leiomioma/cirurgia , Morcelação/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Neoplasias Uterinas/cirurgia , Adulto , Feminino , Humanos , Histerectomia/métodos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Morcelação/efeitos adversos , Morcelação/métodos , Estudos Retrospectivos , Estados Unidos , United States Food and Drug Administration
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