Evaluation of Positioning Devices for Optimization of Outcomes in Laparoscopic and Robotic-Assisted Gynecologic Surgery.

In this review, we evaluate techniques, devices, and equipment for patient positioning and their effect on patient outcomes, such as cephalad slide and neuropathy, in laparoscopic and robotic-assisted gynecologic surgery. We conducted a systematic review by searching MEDLINE, Embase, and Cochrane Library for relevant articles published over a 15-year period. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. Seven articles, including 3 randomized controlled trials and 4 case series, were included in our analysis. Four studies evaluated cephalad patient slide. In 2 randomized controlled trials (n = 103), the mean slide with various devices (i.e., memory foam, bean bag with shoulder braces, egg crate, and gel pad) ranged from 1.07 ± 1.93 cm to 4.5 ± 4.0 cm. The use of a bean bag with shoulder supports/braces was associated with minimal slide, with a median slide of 0 cm (range, 0-2 cm) in a retrospective series and with mean slide of 1.07 ± 1.93 cm in a randomized controlled trial (vs memory foam). No conclusive effect of body mass index on slide could be identified. Five studies evaluating the incidence of neuropathy found an overall incidence of 0.16% and no differences among slide-preventing devices. The minimal slide described across studies supports the conclusion that any of the currently used devices and techniques for safe patient positioning are within reason. The low overall incidence of neuropathy is also reassuring. Best evidence recommendations cannot be made for a specific device or technique; our findings suggest the importance of strict adherence to the basic tenets of safe patient positioning to minimize slide and prevent nerve injury.

Operative Outcomes of Opportunistic Bilateral Salpingectomy at the Time of Benign Hysterectomy in Low-Risk Premenopausal Women: A Systematic Review.

Opportunistic bilateral salpingectomy (OBS) is gaining momentum as a potential strategy for preventing epithelial ovarian cancer (EOC). OBS has been associated with a 40% to 65% decrease in the incidence of EOC when performed at the time of benign hysterectomy in patients at population-level risk for EOC. Current data suggest minimal disadvantage or "cost" to the patient and system from this practice in terms of estimated blood loss (EBL), operative time, length of hospital stay, ovarian reserve depletion, and complications attributable to OBS. These costs merit additional scrutiny in comparison with potential benefits before OBS can be adopted or recommended universally as a preventative strategy. This systematic review identifies 10 comparative studies (8 cohorts and 2 randomized controlled studies) ranging from 19 to 425 180 patients that cumulatively demonstrate a small to no increase in operative time and no additional EBL, hospital stay, or complications attributable to OBS at the time of benign hysterectomy. We anticipate that more widespread adoption of OBS will necessarily incorporate more difficult salpingectomies, thus potentially increasing the time, EBL, and complications associated with this practice in large studies. This consideration should be weighed into discussions of whether salpingectomy at the time of hysterectomy would ever be considered mandatory (or failure to perform OBS be considered negligent) and may have to be considered for fair reimbursement for any additional time and risk of this surgical step. Given the available evidence of benefit, further randomized controlled trials for salpingectomy versus no salpingectomy at the time of hysterectomy are unlikely to be feasible and may be unethical. Going forward, additional large prospective cohorts with historical control subjects will be valuable in assessing the additional costs of universal OBS at the time of benign hysterectomy.

Complications in robotic-assisted gynecologic surgery according to case type: a 6-year retrospective cohort study using Clavien-Dindo classification.

STUDY OBJECTIVE: To estimate the risk of postoperative complications in robotic-assisted gynecologic surgery according to case type. STUDY DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Mayo Clinic Arizona. PATIENTS: All 1155 patients who underwent robotic-assisted gynecologic surgery between March 2004 and December 2009 were included. Patients were primarily white (94.3%), with a mean (SD) age of 51.5 (15.4) years, and were overweight, with body mass index (BMI) of 27.2 (6.8). INTERVENTIONS: Risk of complications, overall and according to Clavien-Dindo grade, and incidence of specific complications were analyzed. Robotic-assisted gynecologic surgical procedures were categorized postoperatively according to case type as benign simple (e.g., oophorectomy, simple hysterectomy) in 552 (47.8%) patients, benign complex (e.g., excision of invasive endometriosis) in 262 (22.7%), urogynecologic in 121 (10.5%), and oncologic in 220 (19.1%). MEASUREMENTS AND MAIN RESULTS: Intraoperative complications occurred in 3.2% of patients. Postoperative complications of any type occurred in 18.4% of patients. Conversion to laparotomy was necessary in 2.7%. Urologic complications were more common in urogynecologic cases (5.8%) as compared with benign simple (0.5%), benign complex (2.7%), and oncologic (3.2%). Bleeding complications were most common in oncologic cases (5%). Clavien-Dindo grade ≥ 3 complications occurred in 5.2% of patients overall, and were >3-fold likely to occur in benign complex, urogynecologic, and oncologic cases than in benign simple cases. When adjusted for age, BMI, estimated blood loss, operative time, length of stay, and previous pelvic surgery, complications were nearly twice as common for benign complex (odds ratio [OR] 1.7; 95% confidence interval [CI], 1.1-2.7), urogynecologic (OR 1.9; 95% CI, 1.0-3.4), and oncologic (OR 1.9; 95% CI, 1.1-3.1) cases as for benign simple cases, although weakly significant. Case type, BMI, estimated blood loss, and length of stay remained important factors in predicting postoperative complications. CONCLUSION: The incidence of complications in robotic-assisted gynecologic surgery varies according to case type. Defining the role of patient and surgical variables such as case type in the occurrence of complications may help in identification of cases with increased risk, to improve patient counseling and surgical outcome.

Preventing slide in Trendelenburg position: randomized trial comparing foam and gel pads.

To compare patient slide in Trendelenburg position using egg-crate foam or gel pad. This randomized trial compared slide on friction pads during Trendelenburg position for robotic and laparoscopic gynecologic procedures in 61 patients at the Mayo Clinic Florida between March 11, 2010 and May 31, 2011. Data was analyzed using Student's t test with significance defined as p ≤ 0.05. There was no significant difference in mean slide according to pad type (foam 3.0 ± SD 2.1 cm; gel 4.5 ± SD 4.0 cm, p = 0.08). Minor complaints occurred in 10 % of patients, and did not differ by group (p = 0.4). Most complaints (98 %) were transient shoulder or neck pain. A single patient had both transient right hand numbness and right lateral thigh paresthesia. We assessed outcomes by chart review from the inpatient care and postoperative evaluation notes (mean 44 ± SD 17 days), and by review of any intervening notes that occurred before the study's end (mean 345 ± SD 116 days). Trendelenburg-related slide is equivalent on either egg-crate foam or gel pad.

Leiomyoma-related hospitalization and surgery: prevalence and predicted growth based on population trends.

OBJECTIVE: To estimate leiomyoma-related inpatient care in the United States for 2007 with predictions for the ensuing 40 years. STUDY DESIGN: We used the 2007 Nationwide Inpatient Sample to estimate hospitalizations and inpatient surgeries for uterine leiomyoma in US women 15 to 54 years. We used the US Census Bureau population projections to predict leiomyoma-related inpatient care through 2050. RESULTS: In 2007, 355,135 women were hospitalized for leiomyoma (rate = 42 per 10,000 women-years). Black women had increased rates of hospitalization, hysterectomy, and myomectomy (relative risk, 3.5, 2.4, 6.8, respectively) compared with white women. Leiomyoma-related hospitalizations are predicted to increase 23% (to 437,874) between 2007 and 2050, with 20% and 31% increases in leiomyoma-related hysterectomies and myomectomies. CONCLUSION: Leiomyoma-related inpatient care and major surgery remains substantial despite advances in less invasive treatment options. Given population growth, the projected burden of leiomyoma-related inpatient care will increase significantly by 2050, differentially impacting black vs white women.

Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.

OBJECTIVE: To estimate the incidence and characteristics of patients with vaginal cuff dehiscence after robotic cuff closure. METHODS: We reviewed medical records from March 2004 to December 2008 of all patients with vaginal cuff dehiscence after a robotic simple and radical hysterectomy, trachelectomy, and upper vaginectomy using the robotic da Vinci Surgical System. RESULTS: Twenty-one of 510 patients were identified with vaginal cuff dehiscence (incidence 4.1%, 95% confidence interval 2.3-5.8%). In nine patients, the robotic procedure was performed for a gynecologic malignancy. Coitus was the triggering event in 10 patients. Patients most commonly presented with vaginal bleeding and sudden gush of watery vaginal discharge. Bowel evisceration was associated in six patients. Median time to presentation was 43 days or 6.1 weeks. Nineteen cases were repaired through a vaginal approach and one combined vaginal and laparoscopic. Three of 21 patients experienced a repeat dehiscence and required a second repair. CONCLUSION: Vaginal cuff dehiscence should be considered in patients with vaginal bleeding and sudden watery discharge after robotic cuff closure. The incidence is similar as previously reported for laparoscopic procedures. Contributing factors remain unknown but thermal effect and vaginal closure technique probably play major roles. LEVEL OF EVIDENCE: III.

Management of Bartholin duct cysts and abscesses: a systematic review.

OBJECTIVE: To review systematically the literature, published in English, on recurrence and healing after treatment of Bartholin duct cysts and abscesses. DATA SOURCES: We searched PubMed, EMBASE, CINAHL, LILACS, Web-of-science, the Cochrane database, and POPLINE from 1982 until May 2008. We searched the internet, hand-searched reference lists, and contacted experts and authors of relevant papers to detect all published and unpublished studies. METHODS OF STUDY SELECTION: We included any study with at least 10 participants, addressing either frequency of recurrence or healing time after treatment of Bartholin duct cyst or abscess. We followed MOOSE (meta-analysis of observational studies in epidemiology) guidelines. Of 532 articles identified, 24 studies (5 controlled trials, 2 cohort studies, and 17 case series) met all inclusion criteria. Study size ranged between 14 and 200 patients. TABULATION, INTEGRATION, AND RESULTS: The interventions included: (1) Silver nitrate gland ablation, (2) cyst or abscess fenestration, ablation, or excision using carbon dioxide (CO(2)) laser, (3) marsupialization, (4) needle aspiration with or without alcohol sclerotherapy, (5) fistulization using a Word catheter, Foley catheter, or Jacobi ring, (6) gland excision, and (7) incision and drainage followed by primary suture closure. The reported frequency of recurrence varied from 0% to 38%. There was no recurrence after marsupialization in available studies. Recurrence after other treatments varied, and was most common after aspiration alone. Healing generally occurred in 2 weeks or less. CONCLUSION: There are multiple treatments for Bartholin duct cysts and abscesses. A review of the literature failed to identify a best treatment approach. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to identify seven different treatments for Bartholin duct cysts or abscesses, contrast treatment choice complications and recurrence risks for the different options for treatment of Bartholin duct cysts or abscesses, and point out the limited quality and quantity of data upon which to choose best practices.

Hysterectomy rates in the United States, 2003.

OBJECTIVE: To estimate hysterectomy rates by type of hysterectomy and to compare age, length of stay, and regional variation in type of hysterectomy performed for benign indications. METHODS: We conducted a cross-sectional analysis of national discharge data using the 2003 Nationwide Inpatient Sample. These data represent a 20% stratified sample of U.S. hospitals. Women aged 16 years or older who underwent a hysterectomy were identified by International Classification of Diseases, 9th Revision, Clinical Modification procedure codes. We extracted data regarding age, race, diagnoses codes, length of stay, and hospital characteristics. Using 2000 National Census data and weighted data analysis for cluster sampling, we calculated hysterectomy rates. RESULTS: In 2003, 602,457 hysterectomies were performed, for a rate of 5.38 per 1,000 women-years. Of the 538,722 hysterectomies for benign disease (rate 4.81 per 1,000 women-years), the abdominal route was the most common (66.1%), followed by vaginal (21.8%) and laparoscopic (11.8%) routes. Mean ages (+/-standard deviation) differed among hysterectomy types (abdominal 44.5+/-0.1 years, vaginal 48.2+/-0.2 years, and laparoscopic 43.6+/-0.3 years, P<.001). Mean lengths of stay (+/-standard deviation) were also different (3.0+/-0.03 days, 2.0+/-0.03 days, 1.7+/-0.03 days, respectively, P<.001). The hysterectomy rate was highest in the South (5.92 per 1,000 women-years) and lowest in the Northeast (3.33 per 1,000 women-years). CONCLUSION: Despite a shorter length of stay, vaginal and laparoscopic hysterectomies remain far less common than abdominal hysterectomy for benign disease. LEVEL OF EVIDENCE: III.

Cesarean delivery on maternal request: maternal and neonatal outcomes.

OBJECTIVE: To review systematically the evidence about maternal and infant outcomes of cesarean delivery on maternal request and planned vaginal delivery. DATA SOURCES: We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles through dual review using a priori inclusion criteria. METHODS OF STUDY SELECTION: We included English language studies published from 1990 to June 2005 that compared the key reference group (cesarean delivery on maternal request or proxies) and planned vaginal delivery. TABULATION, INTEGRATION, AND RESULTS: We identified 54 articles for maternal and infant outcomes. Virtually no studies exist on cesarean delivery on maternal request, so the knowledge base rests on indirect evidence from proxies with unique and significant limitations. Most studies compared outcomes by actual routes of delivery, resulting in variable relevance to planned routes of delivery. Primary cesarean delivery on maternal request and planned vaginal delivery likely differ with respect to individual outcomes; for instance, risks of urinary incontinence and maternal hemorrhage were lower with planned cesarean, whereas the risk of neonatal respiratory morbidity was higher and maternal length of stay was longer with planned cesarean delivery. However, our comprehensive assessment, across many outcomes, suggests no major differences between primary cesarean delivery on maternal request and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. If a woman chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing frequency. CONCLUSION: The evidence is significantly limited by its minimal relevance to primary cesarean delivery on maternal request. Future research requires developing consensus about terminology, creating a minimum data set for cesarean delivery on maternal request, improving study design and statistical analyses, attending to major outcomes and their special measurement issues, assessing both short- and long-term outcomes with better measurement strategies, dealing better with confounders, and considering the value or utility of different outcomes.

Cesarean delivery on maternal request.

OBJECTIVES: The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed the evidence on the trend and incidence of cesarean delivery (CD) in the United States and in other developed countries, maternal and infant outcomes of cesarean delivery on maternal request (CDMR) compared with planned vaginal delivery (PVD), factors affecting the magnitude of the benefits and harms of CDMR, and future research directions. DATA SOURCES: We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles to examine against a priori inclusion criteria. We included studies published from 1990 to the present, written in English. Studies had to include comparison between the key reference group (CDMR or proxies) and PVD. REVIEW METHODS: A primary reviewer abstracted detailed data on key variables from included articles; a second senior reviewer confirmed accuracy. RESULTS: We identified 13 articles for trends and incidence of CD, 54 for maternal and infant outcomes, and 5 on modifiers of CDMR. The incidence of CDMR appears to be increasing. However, accurately assessing either its true incidence or trends over time is difficult because currently CDMR is neither a well-recognized clinical entity nor an accurately reported indication for diagnostic coding or reimbursement. Virtually no studies exist on CDMR, so the knowledge base rests chiefly on indirect evidence from proxies possessing unique and significant limitations. Furthermore, most studies compared outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with respect to individual outcomes for either mothers or infants. However, our comprehensive assessment, across many different outcomes, suggests that no major differences exist between primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. Given the limited data available, we cannot draw definitive conclusions about factors that might influence outcomes of planned CDMR versus PVD. CONCLUSIONS: The evidence is significantly limited by its minimal relevance to primary CDMR. Future research requires developing consensus about terminology for both delivery routes and outcomes; creating a minimum data set of information about CDMR; improving study design and statistical analyses; attending to major outcomes and their special measurement issues; assessing both short- and long-term outcomes with better measurement strategies; dealing better with confounders; and considering the value or utility of different outcomes.

Teaching residents coding and documentation: effectiveness of a problem-oriented approach.

OBJECTIVE: We sought to assess the effectiveness of a problem-oriented approach to teaching residents accurate coding and documentation of ambulatory gynecology visits. STUDY DESIGN: This was a pilot before-and-after study. Nine resident volunteers underwent 4 individual instructional sessions on coding and documentation with a trained faculty member over 6 weeks. Outcomes were assessed by comparing the appropriateness of procedure and diagnostic codes billed in participant continuity clinic prior to and in the 6 to 9 months following the intervention. RESULTS: Following the intervention, participants demonstrated an increase in the accuracy of coding the correct category of the evaluation and management service, an increase in the appropriate use of modifiers, and a decline in undercoding errors. CONCLUSION: Problem-oriented interactive learning appears to be an effective method of teaching residents proper coding and documentation.

Reclosure of the disrupted laparotomy wound: a systematic review.

OBJECTIVE: To review systematically all prospective, randomized trials published in English quantifying the success of reclosure of the disrupted laparotomy wound. DATA SOURCES: The MEDLINE/PubMed, EMBASE, CINAHL, and Cochrane databases were searched from 1966 to 2004. References were hand-searched and their authors contacted to identify all published and unpublished eligible studies. METHODS OF STUDY SELECTION: We included all prospective, randomized trials measuring successful reclosure of disrupted laparotomy wounds in human subjects. Studies with fascial disruption, subfascial abscess, or ongoing contamination were excluded. Of over 2,098 potentially relevant articles, 8 were included, incorporating 348 patients. TABULATION, INTEGRATION, AND RESULTS: Two authors determined study inclusion. One investigator abstracted data, and a second checked for accuracy. The main outcome was successful healing after wound reclosure. Timing of reclosure, utility of antibiotics, and reclosure techniques were also analyzed. Successful healing after reclosure ranged between 81% and 100%. Failed healing included both superficial wound separation and reaccumulation of abscess. No serious morbidity or mortality was reported. Compared with healing by secondary intention, reclosure resulted in faster healing times (16-23 days versus 61-72 days), and in the one study that evaluated it, 6.4 fewer office visits. The optimal timing and technique for reclosure and the utility of antibiotics were inconclusive. CONCLUSION: Reclosure of disrupted laparotomy wounds was successful in over 80% of patients. Failed reclosure resulted in no life-threatening complications. Reclosure of disrupted laparotomy wounds is safe and decreases healing times.

Vulvar melanoma: a report of 20 cases and review of the literature.

BACKGROUND: Vulvar melanoma is the second most common vulvar malignancy and represents a significant women's health issue. OBJECTIVE: To report experience with 21 cases of vulvar melanoma in 20 patients and to review the literature about the condition. METHODS: Parameters retrospectively reviewed included age at diagnosis, family history of melanoma, location on the vulva, atypical nevi, Breslow depth, ulceration status, histologic pattern, presenting signs and symptoms, and the results of sentinel lymph node biopsy. Molecular characterization of the melanocortin type 1 receptor was performed in 1 patient. RESULTS: A family history of cutaneous melanoma was present in 15% of cases. The mean Breslow depth was 2.8 mm (range, 0.0-11.0 mm). Ten patients successfully underwent sentinel lymph node biopsy, results of which were positive in 2 (20%). Reported for the first time is that one patient had a germline mutation in the melanocortin type 1 receptor. CONCLUSION: Vulvar and cutaneous melanoma behave similarly despite their unique pathogeneses. Sentinel lymph node biopsy can be performed successfully for vulvar melanoma.

Vulvar melanoma: review of diagnosis, staging, and therapy.

OBJECTIVES: To update, assimilate, and bridge the contemporary literature on vulvar and cutaneous melanoma regarding diagnosis, staging, and therapy to provide a useful clinical reference for managing and counseling for affected patients. MATERIALS AND METHODS: A computerized search for reports in the literature up to June 2003 was carried out using PubMed and MEDLINE databases. Multidisciplinary involvement was used in evaluating the available data and formulating conclusions. RESULTS: More than 300 reports were reviewed. Diagnosis, staging, and therapy aspects of vulvar melanoma are summarized. CONCLUSIONS: Vulvar melanoma represents a subtype of cutaneous melanoma, with similar prognostic and staging factors. The most recent American Joint Committee on Cancer staging system for cutaneous melanoma is applicable to vulvar melanoma. Sentinel lymph node biopsy is reliable for staging the regional lymph node basin for vulvar melanoma. Standardized documentation of clinical and histopathologic parameters is needed to standardize grouping of cases for future comparison studies.