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AAGL Global Congress of Minimally Invasive Gynecology 2013
Two-thirds of women with uterine pathology got pregnant after combined procedure
NATIONAL HARBOR, MD. – More than two-thirds of 30 women with infertility related to uterine pathology achieved pregnancy after a single surgery that combined both hysteroscopy and laparoscopy, a study showed.
"After treatment, many of these patients can achieve pregnancy spontaneously without the use of assisted reproductive technology, and significant cost savings are achieved if the procedures are done at the same time," said Dr. Chris J. Allphin, a gynecologist at the Eastern Idaho Regional Medical Center, Idaho Falls.
The single procedure cost an average of $15,000 less than having sequential procedures.
Dr. Allphin reported a retrospective study of 30 patients treated since 2007 for infertility due to ultrasound-confirmed uterine pathology; 13 women had a uterine septum and 17 had leiomyomata.
Two surgeons simultaneously performed the procedures. Septae were diagnosed laparoscopically and treated with hysteroscopic metroplasty. Leiomyomata were diagnosed laparoscopically and treated with either a hysteroscopic or laparoscopic myomectomy.
Of the 30 patients, 21 women (70%) became pregnant and 5 women conceived twice. Fourteen pregnancies (66%) – including one set of twins – were conceived without assisted reproduction techniques. Four were the result of intrauterine insemination. There were seven in vitro fertilization pregnancies, Dr. Allphin reported at the meeting sponsored by AAGL.
Younger women achieved the best pregnancy rates, with 82% of those younger than 35 years conceiving. The rate was 62% among those aged 35-40 years and 60% in those older than 40 years.
The average cost of having the laparoscopy and hysteroscopy at different admissions is $38,256. The average cost of the dual procedure at a single admission was $23,185. "Thirty patients having the dual procedure saved the system $450,000," according to Dr. Allphin.
Of the nine patients who did not conceive, two had no antral follicles at return to the fertility specialist, two had attempted one in vitro fertilization cycle and then discontinued treatment, one had two intrauterine insemination cycles and then discontinued treatment, three continue to go through in vitro fertilization cycles, and one has postponed trying to conceive.
Dr. Allphin said he had no relevant financial disclosures.
NATIONAL HARBOR, MD. – More than two-thirds of 30 women with infertility related to uterine pathology achieved pregnancy after a single surgery that combined both hysteroscopy and laparoscopy, a study showed.
"After treatment, many of these patients can achieve pregnancy spontaneously without the use of assisted reproductive technology, and significant cost savings are achieved if the procedures are done at the same time," said Dr. Chris J. Allphin, a gynecologist at the Eastern Idaho Regional Medical Center, Idaho Falls.
The single procedure cost an average of $15,000 less than having sequential procedures.
Dr. Allphin reported a retrospective study of 30 patients treated since 2007 for infertility due to ultrasound-confirmed uterine pathology; 13 women had a uterine septum and 17 had leiomyomata.
Two surgeons simultaneously performed the procedures. Septae were diagnosed laparoscopically and treated with hysteroscopic metroplasty. Leiomyomata were diagnosed laparoscopically and treated with either a hysteroscopic or laparoscopic myomectomy.
Of the 30 patients, 21 women (70%) became pregnant and 5 women conceived twice. Fourteen pregnancies (66%) – including one set of twins – were conceived without assisted reproduction techniques. Four were the result of intrauterine insemination. There were seven in vitro fertilization pregnancies, Dr. Allphin reported at the meeting sponsored by AAGL.
Younger women achieved the best pregnancy rates, with 82% of those younger than 35 years conceiving. The rate was 62% among those aged 35-40 years and 60% in those older than 40 years.
The average cost of having the laparoscopy and hysteroscopy at different admissions is $38,256. The average cost of the dual procedure at a single admission was $23,185. "Thirty patients having the dual procedure saved the system $450,000," according to Dr. Allphin.
Of the nine patients who did not conceive, two had no antral follicles at return to the fertility specialist, two had attempted one in vitro fertilization cycle and then discontinued treatment, one had two intrauterine insemination cycles and then discontinued treatment, three continue to go through in vitro fertilization cycles, and one has postponed trying to conceive.
Dr. Allphin said he had no relevant financial disclosures.
NATIONAL HARBOR, MD. – More than two-thirds of 30 women with infertility related to uterine pathology achieved pregnancy after a single surgery that combined both hysteroscopy and laparoscopy, a study showed.
"After treatment, many of these patients can achieve pregnancy spontaneously without the use of assisted reproductive technology, and significant cost savings are achieved if the procedures are done at the same time," said Dr. Chris J. Allphin, a gynecologist at the Eastern Idaho Regional Medical Center, Idaho Falls.
The single procedure cost an average of $15,000 less than having sequential procedures.
Dr. Allphin reported a retrospective study of 30 patients treated since 2007 for infertility due to ultrasound-confirmed uterine pathology; 13 women had a uterine septum and 17 had leiomyomata.
Two surgeons simultaneously performed the procedures. Septae were diagnosed laparoscopically and treated with hysteroscopic metroplasty. Leiomyomata were diagnosed laparoscopically and treated with either a hysteroscopic or laparoscopic myomectomy.
Of the 30 patients, 21 women (70%) became pregnant and 5 women conceived twice. Fourteen pregnancies (66%) – including one set of twins – were conceived without assisted reproduction techniques. Four were the result of intrauterine insemination. There were seven in vitro fertilization pregnancies, Dr. Allphin reported at the meeting sponsored by AAGL.
Younger women achieved the best pregnancy rates, with 82% of those younger than 35 years conceiving. The rate was 62% among those aged 35-40 years and 60% in those older than 40 years.
The average cost of having the laparoscopy and hysteroscopy at different admissions is $38,256. The average cost of the dual procedure at a single admission was $23,185. "Thirty patients having the dual procedure saved the system $450,000," according to Dr. Allphin.
Of the nine patients who did not conceive, two had no antral follicles at return to the fertility specialist, two had attempted one in vitro fertilization cycle and then discontinued treatment, one had two intrauterine insemination cycles and then discontinued treatment, three continue to go through in vitro fertilization cycles, and one has postponed trying to conceive.
Dr. Allphin said he had no relevant financial disclosures.
AT THE AAGL GLOBAL CONGRESS
Major finding: Fourteen pregnancies (66%) – including one set of twins – were conceived without assisted reproduction techniques.
Data source: A retrospective study of 30 patients.
Disclosures: Dr. Allphin said he had no relevant financial disclosures.
Laparoscopic hysterectomy appears less painful than robotic surgery
WASHINGTON – Patients who underwent a robotically assisted laparoscopic hysterectomy required significantly more postoperative analgesia than did those who had a conventional laparoscopic hysterectomy.
The findings of a retrospective review may help determine which procedure to go with, when postoperative pain is an important recovery factor, Dr. Megan Wasson said at a meeting sponsored by the AAGL.
Dr. Wasson, a fourth-year ob.gyn. resident at the Christiana Care Health System in Wilmington, Del., reviewed the postoperative analgesic requirements of 353 women who underwent minimally invasive hysterectomy for benign conditions at the facility from 2009 to 2012.
Among the group, 116 had a conventional procedure – 78 had a laparoscopic-assisted supracervical hysterectomy and 38 had a total laparoscopic hysterectomy. Robotically assisted hysterectomy was performed for 237 women – three of these were supracervical hysterectomies and 234 were total hysterectomies.
Because patients received different kinds of pain medication, Dr. Wasson and her colleagues converted all of the pain treatment to oxycodone equivalents.
While the oral oxycodone equivalent intake was not significantly different between the groups, the parenteral oxycodone equivalent was higher (14 mg vs. 26 mg). When both oral and parenteral were combined, the total oxycodone equivalent was 28 mg in the laparoscopic group and almost 38 mg in the robotically assisted group – a significant difference.
Women who had conventional laparoscopic surgery were significantly younger than those who had the robotically assisted surgery (42 vs. 46 years). Significantly more black than white women had laparoscopic surgery (51% vs.14%), while significantly more white women had robotically assisted surgery (83% vs. 41%). There were no differences in the rate of prior cesarean section, laparotomy, or laparoscopy.
The uterus was significantly larger in the laparoscopic group (281 g vs. 203 g). Significantly fewer of these women also had a concomitant salpingo-oophorectomy (25% vs. 29%). In the laparoscopic group, intraoperative blood loss was significantly less (131 mL vs. 170 mL), as was hemoglobin decrease (1.68 g/dL vs. 2.26 g/dL). The composite port size was significantly smaller (25.8 mm vs. 41.6 mm). Total procedure time was similar (176 vs. 170 minutes).
Dr. Wasson had no financial declarations.
WASHINGTON – Patients who underwent a robotically assisted laparoscopic hysterectomy required significantly more postoperative analgesia than did those who had a conventional laparoscopic hysterectomy.
The findings of a retrospective review may help determine which procedure to go with, when postoperative pain is an important recovery factor, Dr. Megan Wasson said at a meeting sponsored by the AAGL.
Dr. Wasson, a fourth-year ob.gyn. resident at the Christiana Care Health System in Wilmington, Del., reviewed the postoperative analgesic requirements of 353 women who underwent minimally invasive hysterectomy for benign conditions at the facility from 2009 to 2012.
Among the group, 116 had a conventional procedure – 78 had a laparoscopic-assisted supracervical hysterectomy and 38 had a total laparoscopic hysterectomy. Robotically assisted hysterectomy was performed for 237 women – three of these were supracervical hysterectomies and 234 were total hysterectomies.
Because patients received different kinds of pain medication, Dr. Wasson and her colleagues converted all of the pain treatment to oxycodone equivalents.
While the oral oxycodone equivalent intake was not significantly different between the groups, the parenteral oxycodone equivalent was higher (14 mg vs. 26 mg). When both oral and parenteral were combined, the total oxycodone equivalent was 28 mg in the laparoscopic group and almost 38 mg in the robotically assisted group – a significant difference.
Women who had conventional laparoscopic surgery were significantly younger than those who had the robotically assisted surgery (42 vs. 46 years). Significantly more black than white women had laparoscopic surgery (51% vs.14%), while significantly more white women had robotically assisted surgery (83% vs. 41%). There were no differences in the rate of prior cesarean section, laparotomy, or laparoscopy.
The uterus was significantly larger in the laparoscopic group (281 g vs. 203 g). Significantly fewer of these women also had a concomitant salpingo-oophorectomy (25% vs. 29%). In the laparoscopic group, intraoperative blood loss was significantly less (131 mL vs. 170 mL), as was hemoglobin decrease (1.68 g/dL vs. 2.26 g/dL). The composite port size was significantly smaller (25.8 mm vs. 41.6 mm). Total procedure time was similar (176 vs. 170 minutes).
Dr. Wasson had no financial declarations.
WASHINGTON – Patients who underwent a robotically assisted laparoscopic hysterectomy required significantly more postoperative analgesia than did those who had a conventional laparoscopic hysterectomy.
The findings of a retrospective review may help determine which procedure to go with, when postoperative pain is an important recovery factor, Dr. Megan Wasson said at a meeting sponsored by the AAGL.
Dr. Wasson, a fourth-year ob.gyn. resident at the Christiana Care Health System in Wilmington, Del., reviewed the postoperative analgesic requirements of 353 women who underwent minimally invasive hysterectomy for benign conditions at the facility from 2009 to 2012.
Among the group, 116 had a conventional procedure – 78 had a laparoscopic-assisted supracervical hysterectomy and 38 had a total laparoscopic hysterectomy. Robotically assisted hysterectomy was performed for 237 women – three of these were supracervical hysterectomies and 234 were total hysterectomies.
Because patients received different kinds of pain medication, Dr. Wasson and her colleagues converted all of the pain treatment to oxycodone equivalents.
While the oral oxycodone equivalent intake was not significantly different between the groups, the parenteral oxycodone equivalent was higher (14 mg vs. 26 mg). When both oral and parenteral were combined, the total oxycodone equivalent was 28 mg in the laparoscopic group and almost 38 mg in the robotically assisted group – a significant difference.
Women who had conventional laparoscopic surgery were significantly younger than those who had the robotically assisted surgery (42 vs. 46 years). Significantly more black than white women had laparoscopic surgery (51% vs.14%), while significantly more white women had robotically assisted surgery (83% vs. 41%). There were no differences in the rate of prior cesarean section, laparotomy, or laparoscopy.
The uterus was significantly larger in the laparoscopic group (281 g vs. 203 g). Significantly fewer of these women also had a concomitant salpingo-oophorectomy (25% vs. 29%). In the laparoscopic group, intraoperative blood loss was significantly less (131 mL vs. 170 mL), as was hemoglobin decrease (1.68 g/dL vs. 2.26 g/dL). The composite port size was significantly smaller (25.8 mm vs. 41.6 mm). Total procedure time was similar (176 vs. 170 minutes).
Dr. Wasson had no financial declarations.
AT THE AAGL GLOBAL CONGRESS
Major finding: Women who had a robotically assisted hysterectomy needed significantly more postoperative pain medication than did those who had a conventional laparoscopic hysterectomy.
Data source: The retrospective review included 353 women.
Disclosures: Dr. Wasson had no financial disclosures.
Surgery may benefit elderly women with endometrial cancer
NATIONAL HARBOR, MD. – Surgery is a safe option for elderly women who have endometrial cancer, significantly extending life with a low rate of surgical complications, findings from a small study showed.
A review of 68 women aged 75-94 years found that those who underwent surgery lived about 2 years longer than those who didn’t, Dr. Eloise Chapman-Davis reported at a meeting sponsored by the AAGL.
"Age, multiple comorbidities, high-risk endometrial histology, and stage alone should not exclude elderly patients from surgical treatment options," said Dr. Chapman-Davis, a gynecologic oncologist at Tufts Medical Center, Boston. "Survival may be improved in patients with endometrial cancer who undergo surgery as a part of their treatment."
The women in the current study were treated for endometrial cancer from 2005 to 2012. The first analysis broke the cohort down into those who had surgery (55) and those who did not. Significantly more women in the surgery group were younger than 80 years (85% vs. 45% of the nonsurgery group).
Stage 3 cancer was present in 16% of the surgical group and in 8% of the nonsurgical group. Stage 4 cancer was present in 3% of the surgical group and 31% of the nonsurgical group.
There were no significant differences in baseline comorbidities, including hypertension, diabetes, and pulmonary and coronary artery disease.
Every woman in the nonsurgical group underwent chemotherapy and 46% had radiation. In the surgical group, 20% had radiation and 20%, chemotherapy.
Surgical management changed over the course of the study. The facility implemented robotic surgery in 2009; after 2011, only one patient had laparotomy. The oldest patient who underwent open surgery was 87 years; the oldest patient who had robotic surgery was 94 years.
The surgical group was divided into those who had open (36) and robotic hysterectomies (19). Node sampling was significantly greater in the open group for both pelvic (83% vs. 53%) and aortic nodes (61% vs. 5%).
Robotic surgery took significantly longer than open surgery (mean, 196 vs. 137 minutes). However, blood loss was significantly less in the robotic surgery group (113 vs. 287 mL). Four patients in the open group needed more than 2 U of blood, and one patient lost more than 1,000 mL of blood.
In the robotic group, there was one conversion to open surgery, one cardiac event, and one ileus. In the open group, there were six cardiac events and six cases of prolonged ileus. The mean length of stay was 2 days in the robotic group and 6 days in the open group – a significant difference.
Age did not significantly affect survival. By 3.5 years, 60% of those up to age 79 years and 60% of those 80 and older were still living. Treatment, however, did exert a significant effect. The mean survival of patients who had no surgery was 3 years, compared with about 4 years for those who did have surgery.
The study did not address any survival differences between open and robotic procedures.
Dr. Chapman-Davis said she had no relevant financial disclosures.
NATIONAL HARBOR, MD. – Surgery is a safe option for elderly women who have endometrial cancer, significantly extending life with a low rate of surgical complications, findings from a small study showed.
A review of 68 women aged 75-94 years found that those who underwent surgery lived about 2 years longer than those who didn’t, Dr. Eloise Chapman-Davis reported at a meeting sponsored by the AAGL.
"Age, multiple comorbidities, high-risk endometrial histology, and stage alone should not exclude elderly patients from surgical treatment options," said Dr. Chapman-Davis, a gynecologic oncologist at Tufts Medical Center, Boston. "Survival may be improved in patients with endometrial cancer who undergo surgery as a part of their treatment."
The women in the current study were treated for endometrial cancer from 2005 to 2012. The first analysis broke the cohort down into those who had surgery (55) and those who did not. Significantly more women in the surgery group were younger than 80 years (85% vs. 45% of the nonsurgery group).
Stage 3 cancer was present in 16% of the surgical group and in 8% of the nonsurgical group. Stage 4 cancer was present in 3% of the surgical group and 31% of the nonsurgical group.
There were no significant differences in baseline comorbidities, including hypertension, diabetes, and pulmonary and coronary artery disease.
Every woman in the nonsurgical group underwent chemotherapy and 46% had radiation. In the surgical group, 20% had radiation and 20%, chemotherapy.
Surgical management changed over the course of the study. The facility implemented robotic surgery in 2009; after 2011, only one patient had laparotomy. The oldest patient who underwent open surgery was 87 years; the oldest patient who had robotic surgery was 94 years.
The surgical group was divided into those who had open (36) and robotic hysterectomies (19). Node sampling was significantly greater in the open group for both pelvic (83% vs. 53%) and aortic nodes (61% vs. 5%).
Robotic surgery took significantly longer than open surgery (mean, 196 vs. 137 minutes). However, blood loss was significantly less in the robotic surgery group (113 vs. 287 mL). Four patients in the open group needed more than 2 U of blood, and one patient lost more than 1,000 mL of blood.
In the robotic group, there was one conversion to open surgery, one cardiac event, and one ileus. In the open group, there were six cardiac events and six cases of prolonged ileus. The mean length of stay was 2 days in the robotic group and 6 days in the open group – a significant difference.
Age did not significantly affect survival. By 3.5 years, 60% of those up to age 79 years and 60% of those 80 and older were still living. Treatment, however, did exert a significant effect. The mean survival of patients who had no surgery was 3 years, compared with about 4 years for those who did have surgery.
The study did not address any survival differences between open and robotic procedures.
Dr. Chapman-Davis said she had no relevant financial disclosures.
NATIONAL HARBOR, MD. – Surgery is a safe option for elderly women who have endometrial cancer, significantly extending life with a low rate of surgical complications, findings from a small study showed.
A review of 68 women aged 75-94 years found that those who underwent surgery lived about 2 years longer than those who didn’t, Dr. Eloise Chapman-Davis reported at a meeting sponsored by the AAGL.
"Age, multiple comorbidities, high-risk endometrial histology, and stage alone should not exclude elderly patients from surgical treatment options," said Dr. Chapman-Davis, a gynecologic oncologist at Tufts Medical Center, Boston. "Survival may be improved in patients with endometrial cancer who undergo surgery as a part of their treatment."
The women in the current study were treated for endometrial cancer from 2005 to 2012. The first analysis broke the cohort down into those who had surgery (55) and those who did not. Significantly more women in the surgery group were younger than 80 years (85% vs. 45% of the nonsurgery group).
Stage 3 cancer was present in 16% of the surgical group and in 8% of the nonsurgical group. Stage 4 cancer was present in 3% of the surgical group and 31% of the nonsurgical group.
There were no significant differences in baseline comorbidities, including hypertension, diabetes, and pulmonary and coronary artery disease.
Every woman in the nonsurgical group underwent chemotherapy and 46% had radiation. In the surgical group, 20% had radiation and 20%, chemotherapy.
Surgical management changed over the course of the study. The facility implemented robotic surgery in 2009; after 2011, only one patient had laparotomy. The oldest patient who underwent open surgery was 87 years; the oldest patient who had robotic surgery was 94 years.
The surgical group was divided into those who had open (36) and robotic hysterectomies (19). Node sampling was significantly greater in the open group for both pelvic (83% vs. 53%) and aortic nodes (61% vs. 5%).
Robotic surgery took significantly longer than open surgery (mean, 196 vs. 137 minutes). However, blood loss was significantly less in the robotic surgery group (113 vs. 287 mL). Four patients in the open group needed more than 2 U of blood, and one patient lost more than 1,000 mL of blood.
In the robotic group, there was one conversion to open surgery, one cardiac event, and one ileus. In the open group, there were six cardiac events and six cases of prolonged ileus. The mean length of stay was 2 days in the robotic group and 6 days in the open group – a significant difference.
Age did not significantly affect survival. By 3.5 years, 60% of those up to age 79 years and 60% of those 80 and older were still living. Treatment, however, did exert a significant effect. The mean survival of patients who had no surgery was 3 years, compared with about 4 years for those who did have surgery.
The study did not address any survival differences between open and robotic procedures.
Dr. Chapman-Davis said she had no relevant financial disclosures.
AT THE AAGL GLOBAL CONGRESS
Major finding: Elderly women who had surgery for endometrial cancer lived about 1 year longer than those who did not have surgery.
Data source: A retrospective study of 68 women.
Disclosures: Dr. Chapman-Davis said she had no relevant financial disclosures.
Laparoscopic radical trachelectomy preserves fertility potential
WASHINGTON – Laparoscopic radical trachelectomy can be performed safely in well-selected patients with early cervical cancer who wish to preserve their fertility.
In a small retrospective analysis of 10 women, potential fertility was preserved in 8 women, Dr. Rene Pareja said at the AAGL Global Congress.
By 12 months, no pregnancies had been achieved, reported Dr. Pareja of the Instituto de Cancerología–Clinica las Américas (IDC) in Medellin, Colombia. However, conception should be possible for those who desire to have a child, he said at the meeting sponsored by AAGL.
Patients in the series were treated from 2009 to 2013. All had stage IB1 disease. In nine women, the lesion was less than 2 cm; in one woman, it was 3 cm. Half of the cancers were squamous, and the other half were adenocarcinomas.
All 10 patients underwent a minimally invasive radical trachelectomy. The mean surgical time was 240 minutes, with an estimated blood loss of 100 cc. There were no transfusions and no conversions to open surgery. One cystotomy was repaired laparoscopically. The mean hospital stay was 2 days.
Surgeons recovered a mean of 16 nodes from each patient (range, 10-24); none of these were positive. Four women had no residual disease. One had a positive endocervical margin on pathology; she underwent a hysterectomy. None of the patients required either chemotherapy or radiation therapy.
In addition to the hysterectomy, there were four postoperative complications: one necrosis of the right uterine cornua, one ureterovaginal fistula, and two lymphocysts.
At a mean follow-up of 12 months, there have been no cancer recurrences. One patient is attempting to conceive, although she has not yet done so.
The extant literature supports Dr. Pareja’s experience of laparoscopic radical trachelectomy. Since 2003, the procedure has been reported in 150 patients. Among these, there have been 38 pregnancies, 13 miscarriages, and 20 live births. Dr. Pareja did not say what percentage of women in these studies were attempting to conceive, however.
Five patients reported in the literature have had recurrent cancer and three have died, although Dr. Pareja did not mention whether these deaths were related to the cancers.
So far, the safety and obstetrical outcomes of his patients compare well with those reported in other forms of cervical cancer surgery. Among the 150 reported cases of laparoscopic radical trachelectomy, the relapse rate was 3.3% and death rate 2.9%. The total pregnancy rate was 25% and the delivery rate 13%.
Among the 1,088 reported cases of vaginal radical trachelectomy, there was a 4% relapse rate and 2.9% death rate. The total pregnancy rate was 24% and the delivery rate 28%.
Among the 485 reported cases of abdominal radical trachelectomy, the relapse rate was 3.8% and the death rate 0.4%. The pregnancy rate was 16% and the delivery rate 11%.
Dr. Pareja had no financial disclosures.
WASHINGTON – Laparoscopic radical trachelectomy can be performed safely in well-selected patients with early cervical cancer who wish to preserve their fertility.
In a small retrospective analysis of 10 women, potential fertility was preserved in 8 women, Dr. Rene Pareja said at the AAGL Global Congress.
By 12 months, no pregnancies had been achieved, reported Dr. Pareja of the Instituto de Cancerología–Clinica las Américas (IDC) in Medellin, Colombia. However, conception should be possible for those who desire to have a child, he said at the meeting sponsored by AAGL.
Patients in the series were treated from 2009 to 2013. All had stage IB1 disease. In nine women, the lesion was less than 2 cm; in one woman, it was 3 cm. Half of the cancers were squamous, and the other half were adenocarcinomas.
All 10 patients underwent a minimally invasive radical trachelectomy. The mean surgical time was 240 minutes, with an estimated blood loss of 100 cc. There were no transfusions and no conversions to open surgery. One cystotomy was repaired laparoscopically. The mean hospital stay was 2 days.
Surgeons recovered a mean of 16 nodes from each patient (range, 10-24); none of these were positive. Four women had no residual disease. One had a positive endocervical margin on pathology; she underwent a hysterectomy. None of the patients required either chemotherapy or radiation therapy.
In addition to the hysterectomy, there were four postoperative complications: one necrosis of the right uterine cornua, one ureterovaginal fistula, and two lymphocysts.
At a mean follow-up of 12 months, there have been no cancer recurrences. One patient is attempting to conceive, although she has not yet done so.
The extant literature supports Dr. Pareja’s experience of laparoscopic radical trachelectomy. Since 2003, the procedure has been reported in 150 patients. Among these, there have been 38 pregnancies, 13 miscarriages, and 20 live births. Dr. Pareja did not say what percentage of women in these studies were attempting to conceive, however.
Five patients reported in the literature have had recurrent cancer and three have died, although Dr. Pareja did not mention whether these deaths were related to the cancers.
So far, the safety and obstetrical outcomes of his patients compare well with those reported in other forms of cervical cancer surgery. Among the 150 reported cases of laparoscopic radical trachelectomy, the relapse rate was 3.3% and death rate 2.9%. The total pregnancy rate was 25% and the delivery rate 13%.
Among the 1,088 reported cases of vaginal radical trachelectomy, there was a 4% relapse rate and 2.9% death rate. The total pregnancy rate was 24% and the delivery rate 28%.
Among the 485 reported cases of abdominal radical trachelectomy, the relapse rate was 3.8% and the death rate 0.4%. The pregnancy rate was 16% and the delivery rate 11%.
Dr. Pareja had no financial disclosures.
WASHINGTON – Laparoscopic radical trachelectomy can be performed safely in well-selected patients with early cervical cancer who wish to preserve their fertility.
In a small retrospective analysis of 10 women, potential fertility was preserved in 8 women, Dr. Rene Pareja said at the AAGL Global Congress.
By 12 months, no pregnancies had been achieved, reported Dr. Pareja of the Instituto de Cancerología–Clinica las Américas (IDC) in Medellin, Colombia. However, conception should be possible for those who desire to have a child, he said at the meeting sponsored by AAGL.
Patients in the series were treated from 2009 to 2013. All had stage IB1 disease. In nine women, the lesion was less than 2 cm; in one woman, it was 3 cm. Half of the cancers were squamous, and the other half were adenocarcinomas.
All 10 patients underwent a minimally invasive radical trachelectomy. The mean surgical time was 240 minutes, with an estimated blood loss of 100 cc. There were no transfusions and no conversions to open surgery. One cystotomy was repaired laparoscopically. The mean hospital stay was 2 days.
Surgeons recovered a mean of 16 nodes from each patient (range, 10-24); none of these were positive. Four women had no residual disease. One had a positive endocervical margin on pathology; she underwent a hysterectomy. None of the patients required either chemotherapy or radiation therapy.
In addition to the hysterectomy, there were four postoperative complications: one necrosis of the right uterine cornua, one ureterovaginal fistula, and two lymphocysts.
At a mean follow-up of 12 months, there have been no cancer recurrences. One patient is attempting to conceive, although she has not yet done so.
The extant literature supports Dr. Pareja’s experience of laparoscopic radical trachelectomy. Since 2003, the procedure has been reported in 150 patients. Among these, there have been 38 pregnancies, 13 miscarriages, and 20 live births. Dr. Pareja did not say what percentage of women in these studies were attempting to conceive, however.
Five patients reported in the literature have had recurrent cancer and three have died, although Dr. Pareja did not mention whether these deaths were related to the cancers.
So far, the safety and obstetrical outcomes of his patients compare well with those reported in other forms of cervical cancer surgery. Among the 150 reported cases of laparoscopic radical trachelectomy, the relapse rate was 3.3% and death rate 2.9%. The total pregnancy rate was 25% and the delivery rate 13%.
Among the 1,088 reported cases of vaginal radical trachelectomy, there was a 4% relapse rate and 2.9% death rate. The total pregnancy rate was 24% and the delivery rate 28%.
Among the 485 reported cases of abdominal radical trachelectomy, the relapse rate was 3.8% and the death rate 0.4%. The pregnancy rate was 16% and the delivery rate 11%.
Dr. Pareja had no financial disclosures.
AT THE AAGL GLOBAL CONGRESS
Major finding: A laparoscopic radical trachelectomy preserved fertility in 8 of 10 women with early cervical cancer, with no recurrences at a mean follow-up of 12 months.
Data source: A retrospective study involving 10 women.
Disclosures: Dr. Pareja had no financial disclosures.
Single-incision sling may help stress urinary incontinence
NATIONAL HARBOR, MD. – After 12 months, an adjustable, single-incision sling significantly improved clinical and quality of life measures associated with stress urinary incontinence in women.
The Altis sling decreased the Urinary Distress Index (UDI) from a mean of 55 to a mean of 10, Dr. Douglas Van Drie said at a meeting sponsored by the AAGL. The Incontinence Impact Questionnaire (ILQ-7) showed similar improvements at the interim assessment of the device’s 2-year safety and efficacy study.
The study was sponsored by Coloplast, which makes the sling, with input and monitoring by the Food and Drug Administration. Altis was approved in November 2012 based on an investigational device exemption study, which included implant data. The FDA efficacy requirement was a 50% decrease in pad weight by 6 months.
According to the company website, "Altis is a unique, minimally invasive sling that combines integrated two-way tensioning with lightweight sling material to provide strength, security, and adjustability."
Physicians are divided on their thoughts about a single-incision sling, said Dr. Van Drie, a urogynecologist in group practice in Grand Rapids, Mich. "Those [physicians] who use them are advocates for their safety and simplicity, and the ability to insert them in the office. They have been adopted in different areas of the world as an option for doing simplified, less costly incontinence surgery. The argument against is questions about their staying power – will the effect hold up long term?" he said.
Even though the Altis is a single-incision sling, it has a "very secure" anchoring system, Dr. Van Drie said. The anchor not only goes into the obturator internus, but into the membrane and the obturator externus.
The study involved 113 women, with a mean age of 54 years. Their histories included stress incontinence with hypermobility (81%), without hypermobility (19%), mixed incontinence (37%), and overactive bladder (5%).
Most of the procedures were performed during an inpatient hospital stay (59%); however, 24% were performed at an ambulatory surgical center and 17%, in the physician’s office. General anesthesia was used in 52%, spinal in 3%, and local in 45%.
At 12 months, 90% of patients had at least a 50% reduction in pad weight, and 90% had a negative cough stress test result. The UDI decreased by a mean of 46 points, and the IIQ-7 score, by a mean of 47 points.
There were 11 device-related failures in eight patients. These included one each of urinary retention, urinary tract infection, decreased urine stream, dyspareunia, inflammation, worsening of overactive bladder, and voiding dysfunction. There were four mesh extrusions (3.5%), all less than 3 cm. Two patients with extrusion were smokers, and one was diabetic.
Serious adverse events occurred in three patients: One with a hematoma, one patient who needed transfer to the operating room because of anxiety during repair of a 2-mm mesh extrusion, and one patient whose adverse event was changed to a severe adverse event when she moved out of the study. There were no unanticipated device effects, Dr. Van Drie noted.
Dr. Van Drie is a consultant for Coloplast and has received research money and grants from the company.
NATIONAL HARBOR, MD. – After 12 months, an adjustable, single-incision sling significantly improved clinical and quality of life measures associated with stress urinary incontinence in women.
The Altis sling decreased the Urinary Distress Index (UDI) from a mean of 55 to a mean of 10, Dr. Douglas Van Drie said at a meeting sponsored by the AAGL. The Incontinence Impact Questionnaire (ILQ-7) showed similar improvements at the interim assessment of the device’s 2-year safety and efficacy study.
The study was sponsored by Coloplast, which makes the sling, with input and monitoring by the Food and Drug Administration. Altis was approved in November 2012 based on an investigational device exemption study, which included implant data. The FDA efficacy requirement was a 50% decrease in pad weight by 6 months.
According to the company website, "Altis is a unique, minimally invasive sling that combines integrated two-way tensioning with lightweight sling material to provide strength, security, and adjustability."
Physicians are divided on their thoughts about a single-incision sling, said Dr. Van Drie, a urogynecologist in group practice in Grand Rapids, Mich. "Those [physicians] who use them are advocates for their safety and simplicity, and the ability to insert them in the office. They have been adopted in different areas of the world as an option for doing simplified, less costly incontinence surgery. The argument against is questions about their staying power – will the effect hold up long term?" he said.
Even though the Altis is a single-incision sling, it has a "very secure" anchoring system, Dr. Van Drie said. The anchor not only goes into the obturator internus, but into the membrane and the obturator externus.
The study involved 113 women, with a mean age of 54 years. Their histories included stress incontinence with hypermobility (81%), without hypermobility (19%), mixed incontinence (37%), and overactive bladder (5%).
Most of the procedures were performed during an inpatient hospital stay (59%); however, 24% were performed at an ambulatory surgical center and 17%, in the physician’s office. General anesthesia was used in 52%, spinal in 3%, and local in 45%.
At 12 months, 90% of patients had at least a 50% reduction in pad weight, and 90% had a negative cough stress test result. The UDI decreased by a mean of 46 points, and the IIQ-7 score, by a mean of 47 points.
There were 11 device-related failures in eight patients. These included one each of urinary retention, urinary tract infection, decreased urine stream, dyspareunia, inflammation, worsening of overactive bladder, and voiding dysfunction. There were four mesh extrusions (3.5%), all less than 3 cm. Two patients with extrusion were smokers, and one was diabetic.
Serious adverse events occurred in three patients: One with a hematoma, one patient who needed transfer to the operating room because of anxiety during repair of a 2-mm mesh extrusion, and one patient whose adverse event was changed to a severe adverse event when she moved out of the study. There were no unanticipated device effects, Dr. Van Drie noted.
Dr. Van Drie is a consultant for Coloplast and has received research money and grants from the company.
NATIONAL HARBOR, MD. – After 12 months, an adjustable, single-incision sling significantly improved clinical and quality of life measures associated with stress urinary incontinence in women.
The Altis sling decreased the Urinary Distress Index (UDI) from a mean of 55 to a mean of 10, Dr. Douglas Van Drie said at a meeting sponsored by the AAGL. The Incontinence Impact Questionnaire (ILQ-7) showed similar improvements at the interim assessment of the device’s 2-year safety and efficacy study.
The study was sponsored by Coloplast, which makes the sling, with input and monitoring by the Food and Drug Administration. Altis was approved in November 2012 based on an investigational device exemption study, which included implant data. The FDA efficacy requirement was a 50% decrease in pad weight by 6 months.
According to the company website, "Altis is a unique, minimally invasive sling that combines integrated two-way tensioning with lightweight sling material to provide strength, security, and adjustability."
Physicians are divided on their thoughts about a single-incision sling, said Dr. Van Drie, a urogynecologist in group practice in Grand Rapids, Mich. "Those [physicians] who use them are advocates for their safety and simplicity, and the ability to insert them in the office. They have been adopted in different areas of the world as an option for doing simplified, less costly incontinence surgery. The argument against is questions about their staying power – will the effect hold up long term?" he said.
Even though the Altis is a single-incision sling, it has a "very secure" anchoring system, Dr. Van Drie said. The anchor not only goes into the obturator internus, but into the membrane and the obturator externus.
The study involved 113 women, with a mean age of 54 years. Their histories included stress incontinence with hypermobility (81%), without hypermobility (19%), mixed incontinence (37%), and overactive bladder (5%).
Most of the procedures were performed during an inpatient hospital stay (59%); however, 24% were performed at an ambulatory surgical center and 17%, in the physician’s office. General anesthesia was used in 52%, spinal in 3%, and local in 45%.
At 12 months, 90% of patients had at least a 50% reduction in pad weight, and 90% had a negative cough stress test result. The UDI decreased by a mean of 46 points, and the IIQ-7 score, by a mean of 47 points.
There were 11 device-related failures in eight patients. These included one each of urinary retention, urinary tract infection, decreased urine stream, dyspareunia, inflammation, worsening of overactive bladder, and voiding dysfunction. There were four mesh extrusions (3.5%), all less than 3 cm. Two patients with extrusion were smokers, and one was diabetic.
Serious adverse events occurred in three patients: One with a hematoma, one patient who needed transfer to the operating room because of anxiety during repair of a 2-mm mesh extrusion, and one patient whose adverse event was changed to a severe adverse event when she moved out of the study. There were no unanticipated device effects, Dr. Van Drie noted.
Dr. Van Drie is a consultant for Coloplast and has received research money and grants from the company.
AT THE AAGL GLOBAL CONGRESS
Major finding: After receiving a single-incision incontinence sling, 90% of women had significant improvements in clinical and quality of life measures related to stress urinary incontinence.
Data source: A prospective study of 113 women.
Disclosures: Coloplast sponsored the study. Dr. Van Drie is a consultant for Coloplast and has received research money and grants from the company.
Patients report long-lasting benefit of thermal balloon endometrial ablation
NATIONAL HARBOR, MD. – A thermal balloon endometrial ablation provided long-lasting benefit to women with dysmenorrhea, with 86% saying the benefits lasted for up to 11 years, and 82% reporting that they needed no further treatment for the condition.
"Patient satisfaction with [the device] is high," Vinod Kumar, Ph.D., said at a meeting sponsored by the AAGL. "It appears to be an effective option for women with symptoms of heavy menstrual bleeding and a robust alternative to hysterectomy."
Dr. Kumar of the University Hospitals Birmingham, England, presented follow-up data of up to 11 years on a cohort of 192 women who responded to a mailed survey after undergoing thermal balloon endometrial ablation with the Gynecare ThermaChoice III Uterine Balloon Therapy System.
In the cohort, 18 patients were 10-11 years postprocedure; 82 were 5-10 years postprocedure; and 92 were up to 5 years postprocedure.
They were a mean of 44 years when ablation was performed. Most (77%) had a normal uterus; 15% had an intramural fibroid; 2% a submucosal fibroid of less than 3 cm; and 3%, a polyp. The findings were undisclosed for the remainder. Uterine size was more than 10 cm in 74%.
With a mean follow-up of 30 months, 56% reported amenorrhea. Flow was lighter than before the procedure in 39% of the women, and unchanged or worse in 5%. Of the 44% who still had menstrual bleeding, length of bleeding was less than 3 days in 14%, 3-5 days in 14%, 6-7 days in 9%, and more than 8 days in 7%.
Most women (86%) reported less pain or no pain at follow-up. For 9%, there was no pain change; the rest reported a worsening of pain.
The majority of women (86%) reported that the clinical benefit had been maintained over time.
No further treatment was necessary in 82% of the group. Four women received a levonorgestrel intrauterine device. Nine were using medical therapy, including hormone therapy. One woman had a repeat endometrial ablation, and 20 had hysterectomy.
Most women (86%) reported that they were either satisfied or very satisfied with the procedure.
Dr. Kumar had no financial disclosures.
NATIONAL HARBOR, MD. – A thermal balloon endometrial ablation provided long-lasting benefit to women with dysmenorrhea, with 86% saying the benefits lasted for up to 11 years, and 82% reporting that they needed no further treatment for the condition.
"Patient satisfaction with [the device] is high," Vinod Kumar, Ph.D., said at a meeting sponsored by the AAGL. "It appears to be an effective option for women with symptoms of heavy menstrual bleeding and a robust alternative to hysterectomy."
Dr. Kumar of the University Hospitals Birmingham, England, presented follow-up data of up to 11 years on a cohort of 192 women who responded to a mailed survey after undergoing thermal balloon endometrial ablation with the Gynecare ThermaChoice III Uterine Balloon Therapy System.
In the cohort, 18 patients were 10-11 years postprocedure; 82 were 5-10 years postprocedure; and 92 were up to 5 years postprocedure.
They were a mean of 44 years when ablation was performed. Most (77%) had a normal uterus; 15% had an intramural fibroid; 2% a submucosal fibroid of less than 3 cm; and 3%, a polyp. The findings were undisclosed for the remainder. Uterine size was more than 10 cm in 74%.
With a mean follow-up of 30 months, 56% reported amenorrhea. Flow was lighter than before the procedure in 39% of the women, and unchanged or worse in 5%. Of the 44% who still had menstrual bleeding, length of bleeding was less than 3 days in 14%, 3-5 days in 14%, 6-7 days in 9%, and more than 8 days in 7%.
Most women (86%) reported less pain or no pain at follow-up. For 9%, there was no pain change; the rest reported a worsening of pain.
The majority of women (86%) reported that the clinical benefit had been maintained over time.
No further treatment was necessary in 82% of the group. Four women received a levonorgestrel intrauterine device. Nine were using medical therapy, including hormone therapy. One woman had a repeat endometrial ablation, and 20 had hysterectomy.
Most women (86%) reported that they were either satisfied or very satisfied with the procedure.
Dr. Kumar had no financial disclosures.
NATIONAL HARBOR, MD. – A thermal balloon endometrial ablation provided long-lasting benefit to women with dysmenorrhea, with 86% saying the benefits lasted for up to 11 years, and 82% reporting that they needed no further treatment for the condition.
"Patient satisfaction with [the device] is high," Vinod Kumar, Ph.D., said at a meeting sponsored by the AAGL. "It appears to be an effective option for women with symptoms of heavy menstrual bleeding and a robust alternative to hysterectomy."
Dr. Kumar of the University Hospitals Birmingham, England, presented follow-up data of up to 11 years on a cohort of 192 women who responded to a mailed survey after undergoing thermal balloon endometrial ablation with the Gynecare ThermaChoice III Uterine Balloon Therapy System.
In the cohort, 18 patients were 10-11 years postprocedure; 82 were 5-10 years postprocedure; and 92 were up to 5 years postprocedure.
They were a mean of 44 years when ablation was performed. Most (77%) had a normal uterus; 15% had an intramural fibroid; 2% a submucosal fibroid of less than 3 cm; and 3%, a polyp. The findings were undisclosed for the remainder. Uterine size was more than 10 cm in 74%.
With a mean follow-up of 30 months, 56% reported amenorrhea. Flow was lighter than before the procedure in 39% of the women, and unchanged or worse in 5%. Of the 44% who still had menstrual bleeding, length of bleeding was less than 3 days in 14%, 3-5 days in 14%, 6-7 days in 9%, and more than 8 days in 7%.
Most women (86%) reported less pain or no pain at follow-up. For 9%, there was no pain change; the rest reported a worsening of pain.
The majority of women (86%) reported that the clinical benefit had been maintained over time.
No further treatment was necessary in 82% of the group. Four women received a levonorgestrel intrauterine device. Nine were using medical therapy, including hormone therapy. One woman had a repeat endometrial ablation, and 20 had hysterectomy.
Most women (86%) reported that they were either satisfied or very satisfied with the procedure.
Dr. Kumar had no financial disclosures.
AT THE AAGL GLOBAL CONGRESS
Major finding: After up to 11 years of follow-up, 86% of women who had a thermal balloon endometrial ablation said they were satisfied with the procedure, and 82% had needed no further treatment.
Data source: The findings were from a follow-up study of 192 women.
Disclosures: Dr. Kumar had no financial disclosures.
Bowel resection for endometriosis restores fertility in many women
NATIONAL HARBOR, MD. – Pregnancy occurred in more than half of infertile women who had a segmental laparoscopic bowel resection for endometriosis.
Of 155 women, 96 (62%) conceived after the surgery. Most of these pregnancies (71 of 96; 74%) were spontaneous, Dr. Rosa Maria Neme reported at a meeting sponsored by AAGL.
The prospective study included women treated during 2009-2012 at the University of São Paulo, Brazil, said Dr. Neme, director of the university’s endometriosis center. The patients were a mean of 32 years old.
Most (92%) had bowel symptoms, including pain during defecation, diarrhea and constipation, abdominal bloating, and dyschezia. Endometriosis-related symptoms were present in all, and included dysmenorrhea, nonmenstrual pelvic pain and dyspareunia, tenesmus, cyclic rectal bleeding, lower back pain, and asthenia.
An associated infertility was present in 62% (155), with a mean duration of 18 months. Most patients (78%) had already undergone some form of fertility treatment before surgery and 69% had undergone a previous surgery for pelvic pain.
All of the patients had a torus bowel resection. A number of other procedures also were performed during the surgery, including extensive ureterolysis (80%), ovarian cystectomy (70%), partial vaginal resection (20%), and appendectomy (20%).
The mean operative time was 117 minutes. There were no conversions to open surgery, no transfusions, and no intra- or postoperative complications. The mean length of stay was 3 days. The pathology of all resected lesions was stromal and glandular endometriosis.
After the surgery, 96 pregnancies occurred among the subgroup with infertility (62%). The median time to conception was 8 months. The majority of pregnancies were spontaneous (71), with the rest achieved by in vitro fertilization. There were four miscarriages.
A quality of life survey was conducted at 6 months. By that time, dysmenorrhea, dyspareunia and pain on defecation, intestinal cramping, diarrhea and constipation had disappeared in all women.
Dr. Neme had no financial disclosures.
NATIONAL HARBOR, MD. – Pregnancy occurred in more than half of infertile women who had a segmental laparoscopic bowel resection for endometriosis.
Of 155 women, 96 (62%) conceived after the surgery. Most of these pregnancies (71 of 96; 74%) were spontaneous, Dr. Rosa Maria Neme reported at a meeting sponsored by AAGL.
The prospective study included women treated during 2009-2012 at the University of São Paulo, Brazil, said Dr. Neme, director of the university’s endometriosis center. The patients were a mean of 32 years old.
Most (92%) had bowel symptoms, including pain during defecation, diarrhea and constipation, abdominal bloating, and dyschezia. Endometriosis-related symptoms were present in all, and included dysmenorrhea, nonmenstrual pelvic pain and dyspareunia, tenesmus, cyclic rectal bleeding, lower back pain, and asthenia.
An associated infertility was present in 62% (155), with a mean duration of 18 months. Most patients (78%) had already undergone some form of fertility treatment before surgery and 69% had undergone a previous surgery for pelvic pain.
All of the patients had a torus bowel resection. A number of other procedures also were performed during the surgery, including extensive ureterolysis (80%), ovarian cystectomy (70%), partial vaginal resection (20%), and appendectomy (20%).
The mean operative time was 117 minutes. There were no conversions to open surgery, no transfusions, and no intra- or postoperative complications. The mean length of stay was 3 days. The pathology of all resected lesions was stromal and glandular endometriosis.
After the surgery, 96 pregnancies occurred among the subgroup with infertility (62%). The median time to conception was 8 months. The majority of pregnancies were spontaneous (71), with the rest achieved by in vitro fertilization. There were four miscarriages.
A quality of life survey was conducted at 6 months. By that time, dysmenorrhea, dyspareunia and pain on defecation, intestinal cramping, diarrhea and constipation had disappeared in all women.
Dr. Neme had no financial disclosures.
NATIONAL HARBOR, MD. – Pregnancy occurred in more than half of infertile women who had a segmental laparoscopic bowel resection for endometriosis.
Of 155 women, 96 (62%) conceived after the surgery. Most of these pregnancies (71 of 96; 74%) were spontaneous, Dr. Rosa Maria Neme reported at a meeting sponsored by AAGL.
The prospective study included women treated during 2009-2012 at the University of São Paulo, Brazil, said Dr. Neme, director of the university’s endometriosis center. The patients were a mean of 32 years old.
Most (92%) had bowel symptoms, including pain during defecation, diarrhea and constipation, abdominal bloating, and dyschezia. Endometriosis-related symptoms were present in all, and included dysmenorrhea, nonmenstrual pelvic pain and dyspareunia, tenesmus, cyclic rectal bleeding, lower back pain, and asthenia.
An associated infertility was present in 62% (155), with a mean duration of 18 months. Most patients (78%) had already undergone some form of fertility treatment before surgery and 69% had undergone a previous surgery for pelvic pain.
All of the patients had a torus bowel resection. A number of other procedures also were performed during the surgery, including extensive ureterolysis (80%), ovarian cystectomy (70%), partial vaginal resection (20%), and appendectomy (20%).
The mean operative time was 117 minutes. There were no conversions to open surgery, no transfusions, and no intra- or postoperative complications. The mean length of stay was 3 days. The pathology of all resected lesions was stromal and glandular endometriosis.
After the surgery, 96 pregnancies occurred among the subgroup with infertility (62%). The median time to conception was 8 months. The majority of pregnancies were spontaneous (71), with the rest achieved by in vitro fertilization. There were four miscarriages.
A quality of life survey was conducted at 6 months. By that time, dysmenorrhea, dyspareunia and pain on defecation, intestinal cramping, diarrhea and constipation had disappeared in all women.
Dr. Neme had no financial disclosures.
AT THE AAGL GLOBAL CONGRESS
Major finding: Pregnancy occurred in 62% of women with bowel endometriosis who underwent a bowel resection.
Data source: The prospective study involved 250 women, 155 of whom had infertility.
Disclosures: Dr. Neme had no financial disclosures.
Extraperitoneal lymphadenectomy nets bigger node harvest in endometrial cancer
NATIONAL HARBOR, MD. – Extraperitoneal para-aortic lymphadenectomy can result in more harvested nodes than standard laparoscopic or robot-assisted laparoscopic staging of patients with endometrial cancer, according to Dr. Janelle Pakish.
Harvesting the nodes does take longer this way – about 50 minutes longer than a standard laparoscopic staging and 40 minutes longer than a robotic-assisted one. But a retrospective study of 194 cases found that it secured twice as many para-aortic nodes, with half the conversion rate to open surgery as with laparoscopic staging, Dr. Pakish said at a meeting sponsored by the AAGL.
"It is safe and feasible, and especially effective for obese patients," in whom the technique yielded the largest node retrieval, said Dr. Pakish, a gynecologic oncologist at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
The study included data on patients who underwent extra- or transperitoneal laparoscopic lymphadenectomy for endometrial cancer staging at M.D. Anderson Cancer Center in Houston, from 2007 to 2012. The cohort was divided into three groups: those who had extraperitoneal para-aortic sampling followed by robot-assisted total laparoscopic lymphadenectomy (extraperitoneal group, 34); those who had a transperitoneal para-aortic lymphadenectomy followed by robot-assisted total laparoscopic hysterectomy (transperitoneal robotic group, 52); and those who had transperitoneal laparoscopic lymphadenectomy followed by a total laparoscopic hysterectomy (transperitoneal laparoscopic group, 108).
Significantly more para-aortic nodes were harvested in the extraperitoneal group than in the transperitoneal laparoscopic or the transperitoneal robotic groups (median of 10 vs. 5 and 4.5, respectively). The number of pelvic nodes was not significantly different between the three groups (median of 14, 13, and 13.5, respectively).
The extraperitoneal method was particularly effective in patients with a body mass index of 35 kg/m2 or more, harvesting a median of four more nodes than transperitoneal laparoscopy and seven more than transperitoneal robot-assisted laparoscopy.
The method was more time consuming, however, Dr. Pakish said. The median operative time for extraperitoneal lymphadenectomy was 339 minutes, compared with 286 minutes for the transperitoneal laparoscopy group and 297 for the transperitoneal robotic group.
There were three conversions to transperitoneal laparoscopy and three to laparoscopy in the extraperitoneal group (8.8%). In the transperitoneal laparoscopy group, there were 17 conversions to laparotomy (15.7%). The transperitoneal robotic group had the lowest conversion rate (two patients, 3.8%).
Dr. Pakish said she had no relevant financial disclosures.
NATIONAL HARBOR, MD. – Extraperitoneal para-aortic lymphadenectomy can result in more harvested nodes than standard laparoscopic or robot-assisted laparoscopic staging of patients with endometrial cancer, according to Dr. Janelle Pakish.
Harvesting the nodes does take longer this way – about 50 minutes longer than a standard laparoscopic staging and 40 minutes longer than a robotic-assisted one. But a retrospective study of 194 cases found that it secured twice as many para-aortic nodes, with half the conversion rate to open surgery as with laparoscopic staging, Dr. Pakish said at a meeting sponsored by the AAGL.
"It is safe and feasible, and especially effective for obese patients," in whom the technique yielded the largest node retrieval, said Dr. Pakish, a gynecologic oncologist at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
The study included data on patients who underwent extra- or transperitoneal laparoscopic lymphadenectomy for endometrial cancer staging at M.D. Anderson Cancer Center in Houston, from 2007 to 2012. The cohort was divided into three groups: those who had extraperitoneal para-aortic sampling followed by robot-assisted total laparoscopic lymphadenectomy (extraperitoneal group, 34); those who had a transperitoneal para-aortic lymphadenectomy followed by robot-assisted total laparoscopic hysterectomy (transperitoneal robotic group, 52); and those who had transperitoneal laparoscopic lymphadenectomy followed by a total laparoscopic hysterectomy (transperitoneal laparoscopic group, 108).
Significantly more para-aortic nodes were harvested in the extraperitoneal group than in the transperitoneal laparoscopic or the transperitoneal robotic groups (median of 10 vs. 5 and 4.5, respectively). The number of pelvic nodes was not significantly different between the three groups (median of 14, 13, and 13.5, respectively).
The extraperitoneal method was particularly effective in patients with a body mass index of 35 kg/m2 or more, harvesting a median of four more nodes than transperitoneal laparoscopy and seven more than transperitoneal robot-assisted laparoscopy.
The method was more time consuming, however, Dr. Pakish said. The median operative time for extraperitoneal lymphadenectomy was 339 minutes, compared with 286 minutes for the transperitoneal laparoscopy group and 297 for the transperitoneal robotic group.
There were three conversions to transperitoneal laparoscopy and three to laparoscopy in the extraperitoneal group (8.8%). In the transperitoneal laparoscopy group, there were 17 conversions to laparotomy (15.7%). The transperitoneal robotic group had the lowest conversion rate (two patients, 3.8%).
Dr. Pakish said she had no relevant financial disclosures.
NATIONAL HARBOR, MD. – Extraperitoneal para-aortic lymphadenectomy can result in more harvested nodes than standard laparoscopic or robot-assisted laparoscopic staging of patients with endometrial cancer, according to Dr. Janelle Pakish.
Harvesting the nodes does take longer this way – about 50 minutes longer than a standard laparoscopic staging and 40 minutes longer than a robotic-assisted one. But a retrospective study of 194 cases found that it secured twice as many para-aortic nodes, with half the conversion rate to open surgery as with laparoscopic staging, Dr. Pakish said at a meeting sponsored by the AAGL.
"It is safe and feasible, and especially effective for obese patients," in whom the technique yielded the largest node retrieval, said Dr. Pakish, a gynecologic oncologist at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
The study included data on patients who underwent extra- or transperitoneal laparoscopic lymphadenectomy for endometrial cancer staging at M.D. Anderson Cancer Center in Houston, from 2007 to 2012. The cohort was divided into three groups: those who had extraperitoneal para-aortic sampling followed by robot-assisted total laparoscopic lymphadenectomy (extraperitoneal group, 34); those who had a transperitoneal para-aortic lymphadenectomy followed by robot-assisted total laparoscopic hysterectomy (transperitoneal robotic group, 52); and those who had transperitoneal laparoscopic lymphadenectomy followed by a total laparoscopic hysterectomy (transperitoneal laparoscopic group, 108).
Significantly more para-aortic nodes were harvested in the extraperitoneal group than in the transperitoneal laparoscopic or the transperitoneal robotic groups (median of 10 vs. 5 and 4.5, respectively). The number of pelvic nodes was not significantly different between the three groups (median of 14, 13, and 13.5, respectively).
The extraperitoneal method was particularly effective in patients with a body mass index of 35 kg/m2 or more, harvesting a median of four more nodes than transperitoneal laparoscopy and seven more than transperitoneal robot-assisted laparoscopy.
The method was more time consuming, however, Dr. Pakish said. The median operative time for extraperitoneal lymphadenectomy was 339 minutes, compared with 286 minutes for the transperitoneal laparoscopy group and 297 for the transperitoneal robotic group.
There were three conversions to transperitoneal laparoscopy and three to laparoscopy in the extraperitoneal group (8.8%). In the transperitoneal laparoscopy group, there were 17 conversions to laparotomy (15.7%). The transperitoneal robotic group had the lowest conversion rate (two patients, 3.8%).
Dr. Pakish said she had no relevant financial disclosures.
AT THE AAGL GLOBAL CONGRESS
Major finding: Extraperitoneal laparoscopic lymphadenectomy secured a median of 10 para-aortic lymph nodes during endometrial cancer staging – twice as many as did transperitoneal staging.
Data source: A retrospective study of 194 patients.
Disclosures: Dr. Pakish said she had no relevant financial disclosures.
Race, ethnicity influence chances of minimally invasive hysterectomy
NATIONAL HARBOR, MD. – Race and ethnicity still appear to play a role in determining which patients receive a minimally invasive hysterectomy, and which undergo a traditional abdominal procedure.
Black, Hispanic, and Asian women were up to 50% less likely to have either a laparoscopic or vaginal hysterectomy, compared with whites, Dr. Katharine Esselen reported at the AAGL global congress.
The findings remained statistically significant even after Dr. Esselen and her colleagues controlled for a variety of patient, financial, and hospital characteristics.
"Racial disparities exist in the mode of hysterectomy in endometrial and cervical cancer, and must be further investigated to better understand the contributing factors so that they may be eradicated," said Dr. Esselen, a clinical fellow in gynecologic oncology at Brigham and Women’s Hospital, Boston.
The researchers extracted their data from the 2009 National Inpatient Sample. It included 1,000 hospitals and more than 8 million patient stays – representing 20% of the discharges in the country for that year.
In 2009, there were 64,410 hysterectomies performed for gynecologic malignancy. More than half (54%) were for endometrial cancer, followed by cervical cancer (23%), and ovarian cancer (19%). Other cancers made up the remainder.
The majority of surgeries in all these categories were abdominal: 72% of the endometrial cases, 56% of the cervical cases, and 95% of the ovarian cases. Laparoscopic hysterectomy was the surgical mode in 26% of endometrial cases, 23% of cervical cases, and 4% of ovarian cases. Vaginal hysterectomies were performed for 2% of endometrial cases, 21% of vaginal cases, and just 1% of ovarian cases.
A multivariate regression analysis controlled for demographic factors (age, race/ethnicity, insurance); patient factors (cancer diagnosis, fibroids, endometriosis, prolapse, menstrual disorders, age, severity of comorbidities, obesity); and hospital factors (urban/rural, teaching status, size, and region of country).
After adjustment for all of these factors, black women were 43% less likely to have a minimally invasive hysterectomy for endometrial cancer than were white women – a significant difference. Hispanic and Asian women were also significantly less likely to have minimally invasive surgery (MIS), with odds ratios of 0.61 and 0.63, respectively. Native American women, however, were more than five times as likely to have such a procedure compared with white women (OR, 5.26).
Insurance also played a role, Dr. Esselen said. Those with Medicaid were significantly less likely to have a minimally invasive procedure (OR, 0.64) than were those with private insurance.
The findings were similar for ovarian cancer. Black and Asian women were significantly less likely to have MIS than were whites (OR, 0.41 and 0.44, respectively). There was no significant difference seen for Hispanic women.
Medical comorbidities were significantly related to the chance of MIS as well. MIS was significantly less likely in women with moderate loss of function due to comorbid conditions (endometrial OR, 0.47; cervical OR, 0.62; ovarian OR, 0.38). Those with major to extreme loss of function had an even smaller chance (endometrial OR, 0.23; cervical OR, 0.21; ovarian OR, 0.10). The P values on these were all less than .0001.
Obesity only affected MIS odds in endometrial cancer, significantly increasing the chance of such a procedure (OR, 1.27).
Dr. Esselen said she had no financial disclosures.
NATIONAL HARBOR, MD. – Race and ethnicity still appear to play a role in determining which patients receive a minimally invasive hysterectomy, and which undergo a traditional abdominal procedure.
Black, Hispanic, and Asian women were up to 50% less likely to have either a laparoscopic or vaginal hysterectomy, compared with whites, Dr. Katharine Esselen reported at the AAGL global congress.
The findings remained statistically significant even after Dr. Esselen and her colleagues controlled for a variety of patient, financial, and hospital characteristics.
"Racial disparities exist in the mode of hysterectomy in endometrial and cervical cancer, and must be further investigated to better understand the contributing factors so that they may be eradicated," said Dr. Esselen, a clinical fellow in gynecologic oncology at Brigham and Women’s Hospital, Boston.
The researchers extracted their data from the 2009 National Inpatient Sample. It included 1,000 hospitals and more than 8 million patient stays – representing 20% of the discharges in the country for that year.
In 2009, there were 64,410 hysterectomies performed for gynecologic malignancy. More than half (54%) were for endometrial cancer, followed by cervical cancer (23%), and ovarian cancer (19%). Other cancers made up the remainder.
The majority of surgeries in all these categories were abdominal: 72% of the endometrial cases, 56% of the cervical cases, and 95% of the ovarian cases. Laparoscopic hysterectomy was the surgical mode in 26% of endometrial cases, 23% of cervical cases, and 4% of ovarian cases. Vaginal hysterectomies were performed for 2% of endometrial cases, 21% of vaginal cases, and just 1% of ovarian cases.
A multivariate regression analysis controlled for demographic factors (age, race/ethnicity, insurance); patient factors (cancer diagnosis, fibroids, endometriosis, prolapse, menstrual disorders, age, severity of comorbidities, obesity); and hospital factors (urban/rural, teaching status, size, and region of country).
After adjustment for all of these factors, black women were 43% less likely to have a minimally invasive hysterectomy for endometrial cancer than were white women – a significant difference. Hispanic and Asian women were also significantly less likely to have minimally invasive surgery (MIS), with odds ratios of 0.61 and 0.63, respectively. Native American women, however, were more than five times as likely to have such a procedure compared with white women (OR, 5.26).
Insurance also played a role, Dr. Esselen said. Those with Medicaid were significantly less likely to have a minimally invasive procedure (OR, 0.64) than were those with private insurance.
The findings were similar for ovarian cancer. Black and Asian women were significantly less likely to have MIS than were whites (OR, 0.41 and 0.44, respectively). There was no significant difference seen for Hispanic women.
Medical comorbidities were significantly related to the chance of MIS as well. MIS was significantly less likely in women with moderate loss of function due to comorbid conditions (endometrial OR, 0.47; cervical OR, 0.62; ovarian OR, 0.38). Those with major to extreme loss of function had an even smaller chance (endometrial OR, 0.23; cervical OR, 0.21; ovarian OR, 0.10). The P values on these were all less than .0001.
Obesity only affected MIS odds in endometrial cancer, significantly increasing the chance of such a procedure (OR, 1.27).
Dr. Esselen said she had no financial disclosures.
NATIONAL HARBOR, MD. – Race and ethnicity still appear to play a role in determining which patients receive a minimally invasive hysterectomy, and which undergo a traditional abdominal procedure.
Black, Hispanic, and Asian women were up to 50% less likely to have either a laparoscopic or vaginal hysterectomy, compared with whites, Dr. Katharine Esselen reported at the AAGL global congress.
The findings remained statistically significant even after Dr. Esselen and her colleagues controlled for a variety of patient, financial, and hospital characteristics.
"Racial disparities exist in the mode of hysterectomy in endometrial and cervical cancer, and must be further investigated to better understand the contributing factors so that they may be eradicated," said Dr. Esselen, a clinical fellow in gynecologic oncology at Brigham and Women’s Hospital, Boston.
The researchers extracted their data from the 2009 National Inpatient Sample. It included 1,000 hospitals and more than 8 million patient stays – representing 20% of the discharges in the country for that year.
In 2009, there were 64,410 hysterectomies performed for gynecologic malignancy. More than half (54%) were for endometrial cancer, followed by cervical cancer (23%), and ovarian cancer (19%). Other cancers made up the remainder.
The majority of surgeries in all these categories were abdominal: 72% of the endometrial cases, 56% of the cervical cases, and 95% of the ovarian cases. Laparoscopic hysterectomy was the surgical mode in 26% of endometrial cases, 23% of cervical cases, and 4% of ovarian cases. Vaginal hysterectomies were performed for 2% of endometrial cases, 21% of vaginal cases, and just 1% of ovarian cases.
A multivariate regression analysis controlled for demographic factors (age, race/ethnicity, insurance); patient factors (cancer diagnosis, fibroids, endometriosis, prolapse, menstrual disorders, age, severity of comorbidities, obesity); and hospital factors (urban/rural, teaching status, size, and region of country).
After adjustment for all of these factors, black women were 43% less likely to have a minimally invasive hysterectomy for endometrial cancer than were white women – a significant difference. Hispanic and Asian women were also significantly less likely to have minimally invasive surgery (MIS), with odds ratios of 0.61 and 0.63, respectively. Native American women, however, were more than five times as likely to have such a procedure compared with white women (OR, 5.26).
Insurance also played a role, Dr. Esselen said. Those with Medicaid were significantly less likely to have a minimally invasive procedure (OR, 0.64) than were those with private insurance.
The findings were similar for ovarian cancer. Black and Asian women were significantly less likely to have MIS than were whites (OR, 0.41 and 0.44, respectively). There was no significant difference seen for Hispanic women.
Medical comorbidities were significantly related to the chance of MIS as well. MIS was significantly less likely in women with moderate loss of function due to comorbid conditions (endometrial OR, 0.47; cervical OR, 0.62; ovarian OR, 0.38). Those with major to extreme loss of function had an even smaller chance (endometrial OR, 0.23; cervical OR, 0.21; ovarian OR, 0.10). The P values on these were all less than .0001.
Obesity only affected MIS odds in endometrial cancer, significantly increasing the chance of such a procedure (OR, 1.27).
Dr. Esselen said she had no financial disclosures.
AT THE AAGL GLOBAL CONGRESS
Major finding: Black women were 43% less likely to have a minimally invasive hysterectomy for endometrial cancer than were white women. Hispanic and Asian women were also significantly less likely to have minimally invasive surgery (MIS), with odds ratios of 0.61 and 0.63, respectively.
Data source: The 2009 National Inpatient Sample, with data on more than 64,000 hysterectomies for gynecologic cancers.
Disclosures: Dr. Esselen said she had no financial disclosures.