Faculty Bibliography

BACKGROUND:Conversion rates during minimally invasive surgery are generally examined in the limited scope of a particular procedure. However, for a hospital or payor, the cumulative impact of conversions during commonly performed procedures could have a much larger negative effect than what is appreciated by individual surgeons. The aim of this study is to assess open conversion rates during minimally invasive surgery (MIS) across common procedures using laparoscopic/thoracoscopic (LAP/VATS) and robotic-assisted (RAS) approaches. STUDY DESIGN/METHODS:Retrospective cohort study using the Premier Database on patients who underwent common operations (hysterectomy, lobectomy, right colectomy, benign sigmoidectomy, low anterior resection, inguinal and ventral hernia repair, and partial nephrectomy) between January 2013 and September 2015. ICD-9 and CPT codes were used to define procedures, modality, and conversion. Propensity scores were calculated using patient, hospital, and surgeon characteristics. Propensity-score matched analysis was used to compare conversions between LAP/VATS and RAS for each procedure. RESULTS:A total of 278,520 patients had MIS approaches of the ten operations. Conversion occurred in 5% of patients and was associated with a 1.77 day incremental increase in length of stay and $3441 incremental increase in cost. RAS was associated with a 58.5% lower rate of conversion to open surgery compared to LAP/VATS. CONCLUSION/CONCLUSIONS:At a health system or payer level, conversion to open is detrimental not just for the patient and surgeon but also puts a significant strain on hospital resources. Use of RAS was associated with less than half of the conversion rate observed for LAP/VATS.

The role of the radiologist in the diagnosis and management of patients with endometriosis is increasing. Improvement in MRI imaging techniques has improved detection rate of subtle manifestations of endometriosis by radiologists. Therefore, the role of imaging in the diagnosis and follow-up after treatment is also likely to increase. Knowledge of new medical management pathways used in treating patients with endometriosis-related pain is important. The knowledge of various medication regimens will allow radiologists to continue to evaluate baseline disease, and to potentially assess for imaging response/stability to these medications. This article will review the current medical therapies in use in the management of endometriosis-related pain and describe potential imaging-related findings expected with these therapies.

BACKGROUND:and diffusion-weighted imaging (DWI) can be utilized as a screening exam. PURPOSE/OBJECTIVE:To review the accuracy and feasibility of an interdisciplinary prospective contrast-enhanced MRI pelvis with DWI screening system for LMS prior to fibroid resection. STUDY TYPE/METHODS:Retrospective cohort study. POPULATION/METHODS:In all, 1960 adult female patients aged 18-87 undergoing screening MRI pelvis prior to uterine fibroid resection. FIELD STRENGTH/SEQUENCE/UNASSIGNED:-weighted imaging, DWI, and contrast-enhanced images were acquired at 1.5 T and 3.0 T. ASSESSMENT/RESULTS:signal intensity, irregular margins, hemorrhage, and necrosis. A preliminary cost-effectiveness analysis was performed, comparing the costs of treatment of uterine fibroids with vs. without a collaborative screening protocol using MRI. STATISTICAL TESTS/UNASSIGNED:Sensitivity, specificity, positive predictive value, and negative predictive value were obtained from the prospective evaluations. Student's t-tests were used to compare demographics and apparent diffusion coefficient values between LMS and false-positive results. RESULTS:We prospectively identified LMS patients with 100% sensitivity and 97% specificity. Preliminary cost analysis demonstrated that the MR screening protocol increased life expectancy by 0.04 years at a cost of $12,937 per life-year gained. DATA CONCLUSION/UNASSIGNED:MRI is an effective and potentially economic screening test, especially with standardized reporting and coordination with clinicians. LEVEL OF EVIDENCE/METHODS:3 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019.

Objective: To investigate the effects of decreasing insufflation pressure during robotic-assisted gynecologic surgery on intraoperative and postoperative parameters. The primary outcomes were patient-reported postoperative pain scores and length of stay in the post-anesthesia care unit (PACU). Secondary outcomes included intraoperative respiratory parameters, duration of surgery, total anesthesia time, and postoperative pain medication use. Design: Retrospective cohort study. Settings: Single academic urban hospital. Patients: Female patients undergoing robot-assisted surgery for benign gynecologic conditions performed by a single surgeon from 2014 to 2018. Interventions: Exposure to surgery performed at four different insufflation pressures: 15 mmHg (n = 99), 12 mmHg (n = 100), 10 mmHg (n = 99), and 8 mmHg (n = 300). Measurements/Results: 598 patients were identified. P values for continuous variables were determined using analysis of variance. Two-sided chi² test was used for categorical variables. When comparing the four groups, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs 3.8, p = < 0.0001), anesthesia time (p = .007), and length of stay in the PACU (449 vs 467 vs 351 vs 317 minutes, p = < 0.0001). There was no difference in duration of surgery (p = .31) or estimated blood loss (p = .09). Throughout the surgery, lower operating pressure was correlated with significantly lower peak inspiratory pressures (p < .0001) and tidal volumes (p < .0001), but a higher end tidal CO2 (p < .0001). Conclusions: Robot-assisted gynecologic surgery is associated with improved intraoperative and postoperative clinical outcomes with each decrease in insufflation pressure. Significant improvements include faster postoperative recovery times, decreased immediate postoperative pain, and improved intraoperative respiratory parameters without increasing duration of surgery or blood loss. [Figure presented] [Figure presented] [Figure presented]

OBJECTIVE: To review the first 100 cases of robotic-assisted hysterectomy performed by an individual surgeon. METHODS: A retrospective cohort study of the first 100 consecutive patients who underwent robotic-assisted hysterectomy by a newly trained minimally invasive gynecologic surgeon was conducted. Demographic factors and short-term surgical outcome variables were abstracted from medical records. We examined univariate associations and performed multivariable modeling with linear regression, and modeled the learning curve for total operative time using power-law function. RESULTS: Mean age was 46 years; mean body mass index was 27.8 kg/m(2). Median operative time was 120 minutes; median estimated blood loss was 100mL. On multivariable analysis, case number (beta -0.296; P<0.005) and uterine weight (beta 0.330; P<0.005) independently predicted operative time, while uterine weight (beta 0.387; P<0.005) independently predicted estimated blood loss. The point at which the slope of the case number-operative time curve crosses -1.0 is at case 28 when uncontrolled and at case 24 when controlled for other factors. CONCLUSION: There was a significantly decreased operative time for robotic-assisted hysterectomies performed later in the surgeon's learning curve. Surgical proficiency, as measured by operative time, seemed to be attained after 20-30 cases.

OBJECTIVE: To compare short-term morbidity and quality of life after laparoscopic hysterectomy (LH) and laparoscopic myomectomy (LM) for the treatment of symptomatic uterine leiomyomas. METHOD: We performed a prospective, observational study of women who were eligible for both surgical procedures. After informed consent was obtained, each participant was asked to complete the SF-12v2 Health Survey before surgery and to repeat it seven days and 28 days after surgery. Data on short-term morbidities, such as operative time, blood loss, length of hospital stay, and surgical complications, were collected by an obstetrician-gynaecologist. Women who underwent LH were compared by non-parametric statistical analyses with those who underwent LM. RESULTS: Sixty-one women were recruited between January 1 and December 31, 2008, including 40 who underwent LM and 21 LH. Women who underwent LH were older, had higher parity, and were less likely to have infertility than those who chose LM. Median LH operative time of 223 minutes (IQR 214 to 241) was slightly longer than for LM (188 minutes, IQR 154 to 239; P = 0.02). However, we found no difference between the two groups in terms of SF-12v2 fluctuation, blood loss, hospital stay, and short-term complications. CONCLUSION: Laparoscopic myomectomy is a viable alternative to laparoscopic hysterectomy for women with symptomatic leiomyomas who want conservative surgery. The procedures have similar morbidity and impact on quality of life.

BACKGROUND: Cystic fibrosis (CF) is one of the most common genetic disorders that can often lead to chronic pulmonary disease. Patients with respiratory failure due to CF may achieve a good quality of life after lung transplant, and many will desire to have children. CASE: A 26-year-old, nulliparous female with CF and double lung transplant presented for fertility treatment. She was successfully treated with controlled ovarian hyperstimulation and gestational surrogacy. CONCLUSION: Controlled ovarian hyperstimulation and gestational surrogacy is a safe option for patients with lung transplant to have a genetic child.

OBJECTIVE: To investigate the coexistence of endometriosis in women presenting with symptomatic leiomyomas. DESIGN: Retrospective study. SETTING: Tertiary university medical center. PATIENT(S): We reviewed the medical records of 131 patients who underwent laparoscopic myomectomy or hysterectomy. All patients were consented for possible concomitant diagnosis and treatment of endometriosis. INTERVENTION(S): All patients underwent laparoscopic myomectomy or hysterectomy. MAIN OUTCOME MEASURE(S): The main outcome measure of the study was the presence or absence of endometriosis. RESULT(S): Of the 131 patients, 113 were diagnosed with endometriosis and fibroids, while 18 were diagnosed with fibroids alone. Patients with fibroids were on average 4.0 years older than those with endometriosis and fibroids (41 vs. 45). Patients with both diagnoses were also more likely to present with pelvic pain and nulliparity than those with fibroids alone. CONCLUSION(S): An overwhelming majority of patients with symptomatic fibroids were also diagnosed with endometriosis. Overlooking the concomitant diagnosis of endometriosis in these women may lead to suboptimal treatment of the patients. Further studies are needed to evaluate the impact of surgical treatments on symptom resolution.

OBJECTIVE: To evaluate controlled ovarian hyperstimulation (COH) in women with cancer compared with healthy women. DESIGN: A retrospective cohort study. SETTING: Academic assisted reproductive technology (ART) program. PATIENT(S): Fifty women undergoing oocyte retrieval before cancer treatment and 50 age-matched controls. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number of oocytes and matured oocytes retrieved, number of fertilized oocytes, days of stimulation, dose of gonadotropins. RESULT(S): There were no significant differences in the number of oocytes retrieved (13 vs. 11.5), the number of matured oocytes retrieved (9.7 vs. 9.6), and the number of oocytes fertilized (7.4 vs. 6.8). However, the patients with cancer had a longer duration of stimulation (10.5 vs. 9.0 days) and higher total dose of gonadotropins (4,174 IU vs. 3,416 IU). CONCLUSION(S): In our study, reasonable ovarian response was achieved by women with cancer with increased doses of gonadotropins and a longer duration of stimulation.