Patient Understanding of Uterine Fibroids and the Different Surgical Approaches to Hysterectomy.

Objective: The purpose of this study was to assess understanding of the hysterectomy procedure and uterine fibroids among women in a general gynecology clinic. Materials and Methods: This was an anonymous cross-sectional survey. We adapted and pilot tested a survey instrument designed to assess understanding of the hysterectomy procedure and of uterine fibroids. The final version of the survey consisted of basic demographic questions, followed by 28 knowledge questions (Canadian Task Force Classification II-2). The survey was disseminated to women in the waiting room of one of our gynecology clinics. The patient population included women 18 years and older. Results: The mean age of respondents was 33.5 years old. In total, 69.5% of the respondents had at least some college education. In the group of questions related to different types of hysterectomies, the most poorly answered question was "Which type of hysterectomy has the highest risk of damage to the bladder?" Less than 40% of the respondents were able to identify a laparoscopic and robotic hysterectomy based on a written description. Of questions about uterine fibroids, the most poorly answered question was whether cancer that looks like fibroids is common, with >90% of the respondents incorrectly thinking that cancer that resembled fibroids is common. More than half of respondents did not know what a fibroid is. Conclusions: In this analysis of the understanding of the hysterectomy procedure and fibroids among an educated population, overall understanding was poor. Specific areas where knowledge was particularly poor were the different ways of doing a hysterectomy and uterine fibroids.

Comparative Thermal Effects of J-Plasma®, Monopolar, Argon, and Laser Electrosurgery in a Porcine Tissue Model.

INTRODUCTION: The objective of this study was to understand how J-Plasma® (Bovie Medical Corporation, Clearwater, Florida) surgical energy compares to monopolar, argon beam, and CO2 laser devices in terms of depth of penetration and lateral thermal spread in a porcine tissue model. MATERIALS AND METHODS: Using a porcine animal model, we applied the thermal energy of the J-Plasma® laser, Bovie Monopolar Pencil™ (Bovie Medical Corporation, Clearwater, Florida), argon beam coagulator, and CO2 laser to porcine small bowel, bladder, and peritoneal tissues at equivalent settings. Tissue was excised and sent to pathology for histologic evaluation. Primary outcome was depth of penetration and lateral thermal spread. RESULTS: When applied to peritoneum tissue, CO2 laser had the greatest lateral thermal spread at 2.99mm, while the argon beam had the lowest at just under 1.5mm. With regard to depth of penetration, the monopolar pencil had the highest while J-Plasma® had the lowest. When applied to bladder tissue, the argon beam was associated with the greatest lateral thermal spread (3.1mm) as compared to the other three devices (all less than 1mm). In terms of depth of penetration of bladder tissue, J-Plasma® again had the lowest value, while the monopolar pencil had the highest. When applied to small intestine tissue, the argon beam had the greatest lateral spread (3.51mm), while J-Plasma® had the lowest (less than 1mm). Regarding depth of penetration of small intestine tissue, argon beam had the highest value at 1.8mm compared to the other three devices (all below 0.6mm). CONCLUSION: Consistent with our previous study, J-Plasma® had minimal lateral and depth spread when applied to various tissue types. J-Plasma® performed better or similar when compared to monopolar, argon beam, and laser electrosurgical devices. Further studies in-vivo are needed to evaluate safety and surgical application of the J-Plasma® device.

Temporal Trends in the Uptake and Continuation of the Etonogestrel Implant in a Large Private Practice Setting.

OBJECTIVE: To assess temporal trends in the uptake and continuation of the etonogestrel subdermal implant in a large private practice setting. METHODS: This was a retrospective cohort study based on billing records from a large multispecialty private practice in Las Vegas, Nevada. We looked at women of all ages seeking long-acting reversible contraception (LARC) between January 1, 2013, and December 31, 2016. The main outcome measure was uptake of the etonogestrel subdermal implant, expressed as a fraction of all insertions of LARC across four calendar years (2013-2016). The Kaplan-Meier method was used to estimate 12-month continuation stratified by year of insertion. RESULTS: There were 3477 total LARC insertions across the 4-year study period. In unadjusted analyses, the uptake of the etonogestrel implant increased from 3.0% of LARC insertions in 2013 to 9% in 2016 among women aged 30 years and older. For women younger than 30 years, the uptake of the implant stayed stable from 2013 to 2015 (22.8%, 21.7%, and 22.4%, respectively), but increased to 30.9% in 2016. We modeled the uptake of the implant as a function of year of insertion adjusted for age (continuous) and insurance status (private vs. Medicaid), and we stratified the models by age (younger than 30 years, 30 years, and older than 30 years). The positive association between year of insertion and uptake of the implant was significantly stronger for women aged 30 years and older, compared to women younger than 30 years. There was a progressive decrease in the 12-month continuation of implant from 2013 (95.7%) to 2015 (57.7%). CONCLUSIONS: In this large private practice setting, among women aged 30 years and older, we observed a threefold increase in the uptake of the subdermal implant from 2013 to 2016. We also observed a significant decrease in the 12-month continuation of the implant over time. Further studies of implant uptake and continuation in the private practice setting are needed.

Thermal Effect of J-Plasma® Energy in a Porcine Tissue Model: Implications for Minimally Invasive Surgery.

OBJECTIVE: To evaluate tissue effect of J-Plasma® (Bovie Medical Corporation, Clearwater, Florida) in porcine liver, kidney, muscle, ovarian, and uterine tissue blocks. DESIGN: Prospective study utilizing porcine tissue blocks to evaluate the thermal spread of J-Plasma® device on liver, kidney, muscle, ovarian, and uterine tissue at various power settings, gas flow, and exposure times. MATERIALS AND METHODS: J-Plasma® helium was used in porcine liver, kidney, and muscle tissue at 20%, 50%, and 100% power, and 1 L/min, 3 L/min, and 5 L/min gas flow at one, five, and 10-second intervals. J-Plasma® was then used in ovarian and uterine tissue at maximum power and gas flow settings in intervals of one, five, 10, and 30 seconds. Histologic evaluation of each tissue was then performed to measure thermal spread. RESULTS: Regardless of tissue type, increased power setting, gas flow rate, and exposure time correlated with greater depth of thermal spread in liver, kidney, and muscle tissue. J-Plasma® did not exceed 2 mm thermal spread on liver, kidney, muscle, ovarian, and uterine tissue, even at a maximum setting of 100% power and 5 L/min gas flow after five seconds. Prolonged exposure to J-Plasma® of up to 30 seconds resulted in increased length and width of thermal spread of up to 12 mm, but did not result in significantly increased depth at 2.84 mm. CONCLUSIONS: The J-Plasma® helium device has minimal lateral and depth of thermal spread in a variety of tissue types and can likely be used for a multitude of gynecologic surgical procedures. However, further studies are needed to demonstrate device safety in a clinical setting.

The McCarus-Volker ForniSee®: A Novel Trans-illuminating Colpotomy Device and Uterine Manipulator for Use in Conventional and Robotic-Assisted Laparoscopic Hysterectomy.

PURPOSE: The purpose of this paper is to introduce a novel trans-illuminating culdotomy and uterine manipulator device. MATERIALS AND METHODS: The study was a prospective, non-randomized, non-blinded observational clinical study involving 50 female patients undergoing total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LSH) for benign indications. The surgeries were performed from March through May 2012 at two institutions. The primary study objectives were to demonstrate the safety and adequate clinical performance of the uterine manipulator device and to illustrate its potential widespread future use in minimally invasive gynecologic procedures. RESULTS: Average patient age was 45.1 years and, of the 50 patients, 33 had undergone previous intra-abdominal surgery. There were no reports of adverse events, difficulty with placement of the instrument, multiple attempts at placement, or difficulty with uterine manipulation. There was only one device-related uterine perforation, and pneumoperitoneum was maintained in all cases during culdotomy. Vaginal tissue left on subjects was less than 5mm. Overall, there were no ureteral injuries, there were two reported incidental cystotomies, and average blood loss was 99.0cc. Postoperative courses were normal for all patients, with only two reported postoperative complications: a possible vaginal cuff abscess and a 2cm vaginal mucosal cuff separation. CONCLUSIONS: The McCarus-Volker ForniSee® (LSI Solutions, Inc., Victor, New York) is a novel trans-illuminating culdotomy device and uterine manipulator that is safe, efficient, functional, and easy to use. Trans-illumination additionally delineates and enhances identification of critical anatomic planes, such as the vesicovaginal junction and cervicovaginal junction.