Impact of prior hysterectomy on surgical outcomes for laparoscopic adnexal surgery.

BACKGROUND: Adnexal surgery is believed to be more complex in patients with prior hysterectomy; however, there is little data regarding surgical outcomes. Understanding of individualized risks improves counseling, informed consent, and preoperative planning. METHODS: We performed a retrospective cohort study with a control group; we evaluated 744 patients undergoing laparoscopic adnexal surgery at an academic tertiary care center from 2011 to 2015. Comparisons were made using Chi square, Fisher's exact, or Wilcoxon-rank sum tests. We used log-binomial regression to calculate risk ratio and 95% confidence interval. RESULTS: Patients with prior hysterectomy were more likely to have intraoperative or postoperative complications at the time of laparoscopic adnexal surgery when compared to patients without prior hysterectomy [17.7% vs. 10.2%, p = 0.02, risk ratio (RR) 1.7, 95% confidence interval (CI) 1.1-2.7]. Patients with prior hysterectomy were four times more likely to have intraoperative complications (3.2% vs. 0.8%, p = 0.047, RR 4.0, 95% CI 1.1-14.7), and five times more likely to have conversion to laparotomy (5.6% vs. 1.1%, p = 0.004, RR 5.0, 95% CI 1.8-14.0). Patients with prior hysterectomy were more likely to need additional procedures, including lysis of adhesions (69.4% vs. 26.0%, p < 0.001), ureterolysis (15.3% vs. 4.8%, p < 0.001), and cystoscopy (28.2% vs. 8.1%, p < 0.001). They had longer operative time [101.5 min (IQR 59.5-135.0) vs. 78.0 min (IQR 53.0-109.0, p < 0.001)], and were less likely to have outpatient surgery (56.5% vs. 84.8%, p < 0.01). Postoperative complications were also more common (15.3% vs. 9.4%, p = 0.046). CONCLUSIONS: Patients with prior hysterectomy were 70% more likely to have a complication at the time of laparoscopic adnexal surgery than patients without hysterectomy. Increased risk of complications in subsequent adnexal surgery may influence the informed consent process or decisions regarding ovarian conservation. Awareness of potential need for additional surgical procedures may guide availability of equipment, choice of operating site, or referral to an advanced pelvic surgeon.

Structured vs narrative reporting of pelvic MRI for fibroids: clarity and impact on treatment planning.

OBJECTIVES: To evaluate clarity and usefulness of MRI reporting of uterine fibroids using a structured disease-specific template vs. narrative reporting for planning of fibroid treatment by gynaecologists and interventional radiologists. METHODS: This is a HIPAA-compliant, IRB-approved study with waiver of informed consent. A structured reporting template for fibroid MRIs was developed in collaboration between gynaecologists, interventional and diagnostic radiologists. The study population included 29 consecutive women who underwent myomectomy for fibroids and pelvic MRI prior to implementation of structured reporting, and 42 consecutive women with MRI after implementation of structured reporting. Subjective evaluation (on a scale of 1-10, 0 not helpful; 10 extremely helpful) and objective evaluation for the presence of 19 key features were performed. RESULTS: More key features were absent in the narrative reports 7.3 ± 2.5 (range 3-12) than in structured reports 1.2 ± 1.5 (range 1-7), (p < 0.0001). Compared to narrative reports, gynaecologists and radiologists deemed structured reports both more helpful for surgical planning (p < 0.0001) (gynaecologists: 8.5 ± 1.2 vs. 5.7 ± 2.2; radiologists: 9.6 ± 0.6 vs. 6.0 ± 2.9) and easier to understand (p < 0.0001) (gynaecologists: 8.9 ± 1.1 vs. 5.8 ± 1.9; radiologists: 9.4 ± 1.3 vs. 6.3 ± 1.8). CONCLUSION: Structured fibroid MRI reports miss fewer key features than narrative reports. Moreover, structured reports were described as more helpful for treatment planning and easier to understand. KEY POINTS: • Structured reports missed only 1.2 ± 1.5 out of 19 key features, as compared to narrative reports that missed 7.3 ± 2.5 key features for planning of fibroid treatment. • Structured reports were more helpful and easier to understand by clinicians. • Structured template can provide essential information for fibroids treatment planning.

Impact of Cystectomy on Ovarian Reserve: Review of the Literature.

Ovarian cysts are common in the reproductive age. Pathologic cysts such as endometriomas and dermoids often require surgical intervention if symptomatic. Laparoscopic cystectomy is the first-line treatment for these cysts and is associated with better pain control and less recurrence than drainage or cyst ablation procedures. There has been an emerging concern about the effect of ovarian cystectomy on ovarian reserve with some evidence of short-term and long-term reduction in ovarian reserve. Certain cyst characteristics (endometrioma pathology, large cyst size, bilateral presentation) are associated with a greater decline in ovarian reserve after cystectomy. The impact of surgery on ovarian reserve can be minimized by selecting the appropriate surgery for the patient, careful tissue handling, and limited use of electrosurgery. Patients should be counseled on the risks of surgery on reproductive potential, and the management plan should be individualized to the patient's symptoms and reproductive goals.

Vaginal Hysterectomy for Treatment of Cervical Ectopic Pregnancy.

BACKGROUND: Cervical ectopic pregnancy can lead to catastrophic hemorrhage, and may be managed conservatively with intra-amniotic methotrexate (MTX), systemic MTX, or both; surgical evacuation with or without balloon tamponade; and uterine artery embolization. However, some patients require hysterectomy, which has traditionally been performed abdominally. CASE: A 39-year-old parous woman was diagnosed with cervical ectopic pregnancy at an estimated 7 1/7 weeks of gestation. Her ß-hCG level remained at 29,433 milli-international units/mL, and the gestational sac persisted on ultrasonography after first intra-amniotic then multidose systemic MTX treatment. After a review of other fertility-sparing procedures, she chose definitive treatment with hysterectomy because she did not desire future childbearing. She underwent a successful vaginal hysterectomy, a novel approach for this condition. CONCLUSION: Vaginal hysterectomy can be performed successfully for treatment of cervical ectopic pregnancy in patients who have completed childbearing and for whom conservative treatment has failed.

First-trimester cystic hygroma: relationship of nuchal translucency thickness and outcomes.

OBJECTIVE: To estimate the relationship between nuchal translucency thickness and abnormal karyotype, major congenital anomaly, perinatal loss, and composite abnormal outcome in fetuses with first-trimester nuchal cystic hygroma. METHODS: We performed a retrospective cohort study of first-trimester fetuses with ultrasound-diagnosed nuchal cystic hygroma collected over a 10-year period. RESULTS: There were 944 first-trimester fetuses with nuchal cystic hygroma. A karyotype abnormality occurred in 54.9% (400 of 729) of fetuses. A major congenital anomaly occurred in 28.8% (61 of 212) of fetuses with a normal karyotype. Perinatal loss occurred in 39% (115 of 295) of fetuses not electively terminated. Overall, an abnormal outcome occurred in 86.6% (543 of 627) of fetuses. After adjusting for potential confounders, every 1-mm increase in nuchal translucency thickness increased the odds of an abnormal karyotype by 44% (adjusted odds ratio [OR] 1.44, 95% confidence interval [CI] 1.29-1.60, P<.001), the odds of major congenital anomaly by 26% (adjusted OR 1.26, 95% CI, 1.08-1.47, P=.003), the odds of perinatal loss by 47% (adjusted OR 1.47, 95% CI 1.07-2.02, P=.019), and the odds of a composite abnormal outcome by 77% (adjusted OR 1.77, 95% CI 1.15-2.74, P=.01). CONCLUSION: First-trimester nuchal cystic hygroma is associated with high rates of karyotype abnormality, major congenital anomaly, perinatal loss, and abnormal outcome. As the thickness of the nuchal translucency increases, the odds of abnormal karyotype, major congenital anomaly, perinatal loss, and abnormal outcome increase.