Diagnosis of gynecologic malignancy after the treatment of presumed benign fibroid disease with interventional radiology procedures: a retrospective cohort study.

OBJECTIVE: To ascertain the finding of future diagnosis of malignancy in women who undergo nonsurgical treatment for uterine fibroid disease with interventional radiology (IR) procedures. DESIGN: Mixed-methods retrospective cohort study. SETTING: Two tertiary care academic hospitals in Boston, Massachusetts. PATIENT(S): A total of 491 women who underwent radiologic intervention for fibroids between 2006 and 2016. INTERVENTION(S): Uterine artery embolization or high-intensity focused ultrasound ablation. MAIN OUTCOME MEASURE(S): Subsequent surgical interventions and diagnosis of gynecologic malignancy after the IR procedure. RESULT(S): During the study period, 491 women underwent treatment of fibroids with IR procedures; follow-up information was available for 346 cases. The mean age was 45.3 ± 4.8 years, and 69.7% were between the ages of 40 and 49 years. Regarding ethnicity, 58.9% of patients were white, and 26.1% were black. The most common symptoms were abnormal uterine bleeding (87%), pelvic pressure (62.3%), and pelvic pain (60.9%). A total of 106 patients underwent subsequent surgical treatment of fibroids. Of the 346 patients who had follow-up, 4 (1.2%) were diagnosed with leiomyosarcoma after their interventional treatment for fibroids. An additional 2 cases of endometrial adenocarcinoma and 1 case of a premalignant lesion of the endometrium were noted. CONCLUSION(S): The proportion of patients who went on to be diagnosed with leiomyosarcoma after conservative IR treatments appears to be higher than previously reported. A thorough preprocedural workup and patient counseling regarding the possibility of underlying uterine malignancy should be undertaken.

Laparoscopic Abdominal Cerclage.

Cervical insufficiency is a well-established cause of infant morbidity and mortality. Recommended treatment of cervical insufficiency includes a procedure in which a stitch, termed a cerclage, is placed around the cervix to keep it closed. Abdominal cerclage is the preferred approach for patients with refractory cervical insufficiency or anatomic limitations to vaginal cerclage placement. Laparoscopic abdominal cerclage has many benefits over an open approach and has been increasingly performed over the last 20 years due to surgeon skillset and improved neonatal survival compared with repeat vaginal cerclage. Laparoscopic abdominal cerclage is a highly effective, well-tolerated surgical treatment of selected patients.

Surgical Outcomes of a Combined Surgical Approach for Apical Prolapse Repair.

Introduction We aimed to evaluate the safety, efficacy and surgical outcomes of combined laparoscopic/vaginal prolapse repair by two surgeons. Material and Methods A retrospective chart review of all patients (n = 135) who underwent apical prolapse repair from February 2009 to December 2012 performed in a collaborative manner by a Minimally Invasive Gynecologic Surgeon and a Urogynecologist. Demographic data (age, body mass index [BMI], race, gravidity, parity) and surgical information (estimated blood loss, operative time, intraoperative complications, readmission and reoperation rates, presence of postoperative infection) were collected. Results The majority of patients were postmenopausal (58.91%), multiparous (mean parity = 2.49) and overweight (mean BMI = 27.71). Nearly 20% had previous prolapse surgery. The most common surgical procedure was laparoscopic supracervical hysterectomy (LSH) with sacrocervicopexy (59.26%), and the most common vaginal repair was of the posterior compartment (78.68%). The median operative time was 149 minutes (82-302), and the estimated blood loss was 100 mL (10-530). Five intra-operative complications, five readmissions and four reoperations were noted. Performance of a concomitant hysterectomy did not affect surgical or anatomical outcomes. Conclusion Combination laparoscopic/vaginal prolapse repair by two separate surgeons seems to be an efficient option for operative management.

Surgical Outcomes of a Combined Surgical Approach for Apical Prolapse Repair / Resultados cirúrgicos de uma abordagem cirúrgica combinada para a correção do prolapso apical

Abstract Introduction We aimed to evaluate the safety, efficacy and surgical outcomes of combined laparoscopic/vaginal prolapse repair by two surgeons. Material and Methods A retrospective chart review of all patients (n =135) who underwent apical prolapse repair from February 2009 to December 2012 performed in a collaborative manner by a Minimally Invasive Gynecologic Surgeon and a Urogynecologist. Demographic data (age, body mass index [BMI], race, gravidity, parity) and surgical information (estimated blood loss, operative time, intraoperative complications, readmission and reoperation rates, presence of postoperative infection) were collected. Results The majority of patients were postmenopausal (58.91%), multiparous (mean parity =2.49) and overweight (mean BMI =27.71). Nearly 20% had previous prolapse surgery. The most common surgical procedure was laparoscopic supracervical hysterectomy (LSH) with sacrocervicopexy (59.26%), and the most common vaginal repair was of the posterior compartment (78.68%). The median operative time was 149 minutes (82-302), and the estimated blood loss was 100 mL (10-530). Five intraoperative complications, five readmissions and four reoperations were noted. Performance of a concomitant hysterectomy did not affect surgical or anatomical outcomes. Conclusion Combination laparoscopic/vaginal prolapse repair by two separate surgeons seems to be an efficient option for operative management.

Resumo Introdução Objetivamos avaliar a segurança, eficácia e desfechos cirúrgicos da via laparoscópica e vaginal combinadas para a correção do prolapso feitos por dois cirurgiões. Métodos Um estudo retrospectivo com análise de prontuário foi realizado em todos os pacientes (n =135) que foram submetidos a correção de prolapso apical de fevereiro de 2009 a dezembro de 2012 de maneira concomitante por um laparoscopista e um uroginecologista. Dados demográficos (idade, índice de massa corporal [IMC], raça, número de gestações e partos) e cirúrgicos (perda sanguínea estimada, tempo operatório, complicações intraoperatórias, taxas de readmissão e reoperação, e presença de infecção pós-operatória) foram analisados. Resultados Operfil da paciente operada era pertencente à pós-menopausa (58,91%), ser multípara (paridade média =2,49) e com sobrepeso (IMC médio =27,71). Aproximadamente 20% havia feito cirurgia prévia para prolapso. O procedimento cirúrgico mais realizado foi a histerectomia supracervical laparoscópica (HSL) com sacrocervicopexia (59,6%); o reparo vaginal mais encontrado foi o para defeito de compartimento posterior (78,68%). O tempo operatório mediano foi de 149 minutos (82-302), e a perda sanguínea estimada foi de 100 ml (10-530). Cinco complicações pós-operatórias, cinco readmissões e quatro reoperações foram encontradas. A realização de uma histerectomia em concomitância aos demais procedimentos não afetou os desfechos cirúrgicos ou anatômicos. Conclusão O reparo combinado do prolapso pela via laparoscópica e vaginal por dois cirurgiões em concomitância aparenta ser uma opção eficiente para o manejo operatório.

Sexual function after hysterectomy and myomectomy.

Sexual function after hysterectomy and myomectomy is a controversial topic and influenced by several factors. With regard to hysterectomy, there is not a consensus whether the removal of the cervix will modify sexual function after surgery, and patients who choose to preserve their cervix should be counseled about the possibility of continued vaginal bleeding and the need for continued pap smear surveillance after surgery. In most studies, hysterectomy has been found to improve sexual function because usually patients have symptoms that indicated the surgery, such as abnormal uterine bleeding and pelvic pain, and as these symptoms cease, they report an improvement in their sexual life. In regards to myomectomy, literature is scarce, however few studies have shown an improvement in sexual function due to the same reasons as hysterectomy. For purposes of research, it is important to standardize sexual questionnaires when performing studies about this outcome. It is also important to emphasize that during discussion of your patient, sexual outcomes should be addressed and that the surgeon should consider all patients' personal, religious, and cultural background during the decision-making process because it will minimize patient's disappointment if she develops a negative response after surgery.

Inhibition of HIV transmission in human cervicovaginal explants and humanized mice using CD4 aptamer-siRNA chimeras.

The continued spread of the HIV epidemic underscores the need to interrupt transmission. One attractive strategy is a topical vaginal microbicide. Sexual transmission of herpes simplex virus type 2 (HSV-2) in mice can be inhibited by intravaginal siRNA application. To overcome the challenges of knocking down gene expression in immune cells susceptible to HIV infection, we used chimeric RNAs composed of an aptamer fused to an siRNA for targeted gene knockdown in cells bearing an aptamer-binding receptor. Here, we showed that CD4 aptamer-siRNA chimeras (CD4-AsiCs) specifically suppress gene expression in CD4⁺ T cells and macrophages in vitro, in polarized cervicovaginal tissue explants, and in the female genital tract of humanized mice. CD4-AsiCs do not activate lymphocytes or stimulate innate immunity. CD4-AsiCs that knock down HIV genes and/or CCR5 inhibited HIV infection in vitro and in tissue explants. When applied intravaginally to humanized mice, CD4-AsiCs protected against HIV vaginal transmission. Thus, CD4-AsiCs could be used as the active ingredient of a microbicide to prevent HIV sexual transmission.

Increasing minimally invasive hysterectomy: effect on cost and complications.

OBJECTIVE: In a 3-year period, the main mode of access for hysterectomy at Brigham and Women's Hospital changed from abdominal to laparoscopic. We estimated potential effects of this shift on perioperative outcomes and costs. METHODS: We compared the perioperative outcomes and the cost of care for all hysterectomies performed in 2006 and 2009 at an urban academic tertiary care center using the χ² test or Fisher's exact test for categorical variables and two-sided Student's t test for continuous variables. A multivariate regression analysis was also performed for the major perioperative outcomes across the study groups. Cost data were gathered from the hospital's billing system; the remainder of data was extracted from patients' medical records. RESULTS: This retrospective study included 2,133 patients. The total number of hysterectomies performed remained stable (1,054 procedures in 2006 compared with 1,079 in 2009) but the relative proportions of abdominal and laparoscopic cases changed markedly during the 3-year period (64.7% to 35.8% for abdominal, P<.001; and 17.7% to 46% for laparoscopic cases, P<.001). The overall rate of intraoperative complications and minor postoperative complications decreased significantly (7.2% to 4%, P<.002; and 18% to 5.7%, P<.001, respectively). Operative costs increased significantly for all procedures aside from robotic hysterectomy, although no significant change was noted in total mean costs. CONCLUSION: A change from majority abdominal hysterectomy to minimally invasive hysterectomy was accompanied by a significant decrease in procedure-related complications without an increase in total mean costs.

Intramyometrial injection of vasopressin in laparoscopic supracervical hysterectomy.

STUDY OBJECTIVE: To investigate the effectiveness of vasopressin in reducing blood loss in laparoscopic supracervical hysterectomy (LSH). DESIGN: Retrospective chart analysis (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: In all, 143 women who had LSH for benign gynecologic disease. INTERVENTIONS: Laparoscopic supracervical hysterectomy. MEASUREMENTS AND MAIN RESULTS: From January 2001 through December 2006, 143 patients were identified who had consecutive, successful LSH performed by different gynecologic laparoscopists. There were no exclusion criteria. The patients were divided into 2 groups based on whether intramyometrial vasopressin injection was used intraoperatively to reduce blood loss; 77 (54%) patients received intramyometrial vasopressin injection and 66 (46%) did not. The 2 groups were compared with regard to blood loss, operating time, uterine weight, hospital stay, concomitant salpingo-oophorectomy, perioperative complications, and patient characteristics including age, gravity, parity, body mass index, surgical history, and number of cesarean deliveries. No difference existed in the first postoperative day decrease in hemoglobin between the vasopressin and control group (2.3 +/- 0.9 vs 2.1 +/- 1.2 g/dL, respectively, p = .56). No significant difference existed between the groups with respect to operating time (146.9 +/- 52.6 vs 131.9 +/- 42.8 min, p = .07) or uterine weight (145.4 +/- 121.8 vs 119.5 +/- 66.9 g, p = .14). All other parameters and patient characteristics were similar between the 2 groups except for the duration of hospital stay. Patients who received intramyometrial vasopressin injection experienced a slightly longer duration of hospital stay (1.4 +/- 0.7 vs 1.1 +/- 0.4 days, p = .02). CONCLUSION: Our study does not support the routine use of intramyometrial vasopressin injection during LSH to reduce blood loss.

Assessing the learning curve for laparoscopic supracervical hysterectomy.

OBJECTIVE: We assessed the learning curve for laparoscopic supracervical hysterectomy. METHODS: This was a prospective cohort study. We analyzed the first 60 consecutive laparoscopic supracervical hysterectomy procedures performed by a team of 2 gynecological laparoscopic surgeons between May 2001 and July 2006 to examine whether a learning curve exists as defined by a decrease in operating time and complications as the sequence increased. Based on previous reports, we defined the first 30 laparoscopic supracervical hysterectomies as "early" cases and the subsequent cases as "late" cases. RESULTS: The mean operating time for laparoscopic supracervical hysterectomy was significantly reduced from 166 minutes to 142.3 minutes (P < or = 0.05) between the early and the late cases. The mean first postoperative day drop in hemoglobin between the early and the late cases was from 2.4 gm/dL to 2.0 gm/dL (P = 0.08). Two complications occurred in the series: one delayed bowel injury in the early cases and one conversion to laparotomy due to a cystotomy in the late cases. No difference existed between the early and the late patients regarding age, parity, body mass index, uterine weight, previous abdominal surgery, or hospital stay. There was an overall linear correlation between the operating time and uterine weight (R = 0.384). CONCLUSION: There is a learning curve for laparoscopic supracervical hysterectomy. After gaining experience in performing 30 cases, the operating time is significantly reduced. The operation can be performed safely during the learning period.

Delayed spontaneous expulsion of a cervical ectopic pregnancy: a case report.

Cervical ectopic pregnancy is an uncommon event. Modern diagnostic and treatment options provide an opportunity for conservative treatment of this condition. A case of a profuse hemorrhage associated with delayed spontaneous expulsion of a cervical ectopic pregnancy is described, and the management is discussed. In this patient, the cervical ectopic pregnancy was treated successfully using systemic methotrexate and selective uterine artery embolization. The patient returned 1 week later with spontaneous expulsion of the ectopic pregnancy associated with profuse hemorrhage. The bleeding subsided following tamponade using a transcervical Foley catheter. We conclude that conservative treatment of cervical ectopic pregnancy is feasible, with careful posttreatment surveillance.