Faculty Bibliography

Objective: With the increasing age of the population, more elderly patients undergo gynecologic surgery. While multiple studies demonstrate the advantages of minimally invasive surgery (MIS), including reduced morbidity and hospital stay, there is a paucity of data in the elderly population, especially in patients older than 80 years. We sought to evaluate outcomes among elderly patients undergoing MIS by a gynecologic oncologist. Method: We reviewed the medical records of patients 65 years of age and older who underwent MIS (robotic, laparoscopic, or vaginal surgery) by a gynecologic oncologist at a single institution between 2009 and 2016. We compared outcomes among "younger-elderly" (65-79) and "older-elderly" (80 and older) patients. Results: A total of 298 patients underwent MIS by a gynecologic oncologist (younger-elderly, 268; older-elderly, 29). The median age was 69 years (range 65-79) in the younger-elderly and 83 years (range 80-93) in the older-elderly. The older-elderly had more medical comorbidity conditions (median Charlson index 7 vs 5, P b 0.001). There was no significant difference between the 2 groups with respect to surgical approach, underlying malignancy, conversion to laparotomy and hospital stay (Table 1). Two hundred and nineteen (81%) younger-elderly patients and 22 (76%) older-elderly patients had ambulatory surgery, defined as an admission of less than 24 hours (P = 0.31). Surgical complications were rare (8/298, 3%), and there was no difference between the younger-and olderelderly patients in rates of complications or 30-and 90-day readmissions. Conclusion: We found MIS with early discharge to be a safe approach in elderly patients undergoing surgery by gynecologic oncologists. While patients older than 80 years were poorer surgical candidates, there were no differences in surgical outcomes or hospital stay when compared to the younger-elderly group. Elderly age should not prohibit consideration of MIS with early hospital discharge

Objective: Enhanced recovery pathways (ERP) challenge traditional perioperative care by minimizing the stress response associated with surgery. ERP in gynecologic surgery has been shown to decrease postoperative opioid consumption and reduce the length of stay (LOS). In contrast, surgery in elderly patients is associated with an increase risk of postoperative complications, longer hospital stays, and higher readmission rates. We sought to compare perioperative outcomes in elderly (age 70 years and older) and nonelderly patients on an ERP. Method: From January 2016 to August 2016, patients undergoing laparotomies for gynecologic surgery at a single institution were enrolled in an enhanced recovery pathway. Demographics and outcomes were collected via prospective chart review. Primary outcomes included pain scores, nausea score, LOS, complication rates, and readmission rates. Comparisons were performed using ?2 tests and Fisher's exact tests for categorical data, and student's t test for continuous variables, with P b 0.05 for significance (SPSS Version 23). Results: Sixty-three patients were enrolled in the study, including 11 patients N70 years old. The median age was 64 years, with an average age of 48.5 years for the nonelderly and 76 years for the elderly. There were no statistically significant differences in inpatient complications, pain and nausea scores, rates of patient-controlled analgesia, operative times, renal function, 30-day complications, or readmission rates (Table 1). However, elderly patients were more likely to undergo laparotomy for malignancy in comparison to nonelderly (9 of 11 [82%] versus 19 of 52 [37%], P = 0.016). Elderly patients had a longer LOS compared to nonelderly patients (2.64 vs 1.92 days, P = 0.029). Conclusion: Elderly patients, though more likely to have a cancer diagnosis, had the same complication and readmission rates as nonelderly patients on an enhanced recovery pathway. Despite the parity in perioperative outcomes, elderly patients had a longer LOS. This may reflect a reluctance of patients and surgeons to discharge these patients, despite meeting appropriate milestones

Objective: Minimally invasive surgery is the preferred surgical method to treat women with endometrial cancer, with advantages including faster recovery, fewer postoperative complications (POC), and shorter hospital stays. Prior studies have shown same-day discharge (SDD) after laparoscopic hysterectomy (LH) to be safe, but the majority of patients are routinely admitted overnight. The objective of this study is to evaluate the rates and timing of 30-day POC in patients undergoing LH for endometrial cancer, and the association between POC and hospital admission status. Method: Patients who underwent hysterectomy for endometrial cancer from 2010 to 2014 were identified from the American College of Surgeons National Surgical Quality Improvement Program database by ICD-9 and CPT codes. Comparative analyses were performed and stratified by POC to evaluate for hospital lengths of stay. Results: We identified 13,745 patients who underwent hysterectomy for endometrial cancer: 4,457 had open hysterectomies (OH), 9,020 had LH, and 268 had vaginal hysterectomies (VH). POC rates were significantly lower in the LH and VH groups compared to OH: 16.9% of OH had POC compared to 5.3% of LH and 7.5 % of VH (P b 0.0001). There were 9,020 patients who underwent LH, and of these, 8,291 were admitted and 729 underwent SDD. Out of the 9,020 LH patients, 633 patients had at least 1 POC (7.0%), and of these, 221 (34.9%) had more than 1 POC. There were a total of 978 POC captured, as listed in Table 1. A median of 10 days elapsed from the surgery date to the development of any POC (range 0-30 days). Only 45 patients had a POC on either postoperative day 0 or 1 (0.5% of all patients after LH, 7.1% of patients with POC). Of the 633 patients who had a POC, 593 patients (93.7%) were admitted after surgery and 40 patients (6.3%) underwent SDD. SDD patients were younger, had lower BMI, and fewer medical comorbidity conditions than admitted patients, but there was no significant difference in POC rates between the admitted and SDD patients (P = 0.1). Conclusion: The most common POC was hospital readmission followed by urinary tract and surgical site infection. The majority of POC occur after postoperative day 1, and there is no association between SDD and POC rates. Patients may be safely discharged home the same day after LH without an increased risk of POC

Objective: With the growing use of robotic surgery, there is an increased occurrence of port-site hernias requiring operative intervention. Currently there is limited literature, and prior studies have failed to find surgical or patient-related risk factors. We sought to identify patient and surgical risk factors, evaluate clinical presentation, and report management of this postoperative complication at a high-volume multispecialty robotic surgical center. Method: All robotic surgeries performed at a single institution from September 1, 2010, to September 1, 2015, were included. Univariate analysis was used to compare patient demographics and medical conditions for those who did and did not develop port-site hernias. Results: A total of 4,858 robotic surgeries were completed during the study period. A total of 37 (0.7%) port-site hernias requiring operative intervention were identified following urologic (23/1,888, 1.2%), gynecologic (13/2,661, 0.5%), and general surgery (1/309, 0.3%) procedures. Hernias occurred at the umbilical (n = 23) and 8-mm lateral port sites (n = 14). Only umbilical ports were closed under direct visualization. Median time from surgery to hernia diagnosis was 201 days (range 2-975). Presentation included bulge symptoms (n = 29) and nausea/vomiting (n = 6). The herniated contents included bowel/omentum (n =19), fat (n =14), or empty sac (n = 4). All cases were managed surgically, 21 with laparoscopy and 16 with laparotomy, with presentation within 30 days necessitating urgent surgery (n = 6). A total of 7/37 patients had complications from reoperation (bowel resection, n = 3; abscess formation, n=2; blood transfusion, n = 1). There was no difference between patients who did and did not develop a port-site hernia with regards to age, gender, BMI, smoking status, hypertension, diabetes, rheumatologic disease, HIV, prior hernia, or cancer diagnosis. (See Table 1.) Conclusion: Port-site hernias necessitating operative intervention following robotic surgery are rare, occurring in 0.7% of patients in our cohort. We found no patient or surgical variable to be predictive of this complication. Hernias occurred at both the umbilical and lateral ports. Despite needing a second surgery, all patients recovered and did not suffer significant long-term morbidity

Objective: Approximately 30% of ovarian cancer is attributable to germline mutations, and genetic assessment is recommended for all women with ovarian cancer. However, only 15-30% are currently being offered genetic evaluation. We sought to determine whether a patient-centered, facilitated genetics referral pathway, whereby all newly diagnosed ovarian cancer patients are contacted by a genetics navigator to schedule genetic assessment as part of routine care, could increase rates of genetic counseling and uptake of testing. Method: Patients with epithelial ovarian cancer were referred for genetic assessment by their gynecologic oncologist within 6 weeks of diagnosis and consented for participation in our institutional review board-approved facilitated genetics pathway. Enrolled patients were contacted by a genetics navigator to schedule a genetic counselor appointment within 6 weeks. Patients who did not schedule or missed sessions were recontacted by the navigator. The genetic counselors offered pre-and post-test counseling and multigene panel testing. Primary outcome was feasibility of this pathway as defined by presentation for genetic assessment or declining genetic evaluation. Results: From October 2015 to July 2016, 50 patients were enrolled. Thirty-six patients (72%) underwent genetic assessment and, of these patients, 34 (94%) had genetic testing. Three patients (6%) are currently scheduled for appointments. Eleven patients (22%) did not undergo genetic assessment for the following reasons: not interested (4), not feeling well (2), missed appointment (2), nervous about testing (1), unable to see genetics counselors within 6 weeks (1), and death (1). Median time from diagnosis to genetics appointment was 13 days (range 0-53). Among the 32 patients for whom results are available, 7 (22%) had pathogenic mutations (BRCA1, 4; BRCA2, 3). Conclusion: The genetic testing pathway we present, characterized by facilitated referral to genetic counselors at time of ovarian cancer diagnosis, is both effective and efficient, resulting in genetic assessment of 72% of patients with newly diagnosed ovarian cancer, testing in 94% of these patients, and discovery of pathogenic mutations in 22% of those tested. Because germline mutations have both prognostic and therapeutic implications, the time of diagnosis may present an idealwindow to offer genetic testing

Uterine sarcomas are rare malignant uterine neoplasms that are responsible for a large majority of uterine cancer-associated deaths. The subtypes include leiomyosarcomas, endometrial stromal tumors, and adenosarcomas. Standard treatment includes complete surgical resection. Adjuvant treatment with chemotherapy, hormonal therapy, or radiation may be considered in patients with high-risk disease. However, because the ability of adjuvant treatment to improve overall survival in patients with uterine sarcomas is unclear, there is no standard recommendation regarding adjuvant therapy. The risk in forgoing chemotherapy is that uterine sarcomas have a tendency to develop distant recurrences. Many cytotoxic agents have been investigated in clinical trials in an attempt to identify an effective treatment that can improve the course of this disease. Adjuvant radiation appears to improve local control but has no significant impact on survival. In this review we discuss preoperative diagnosis and the role of pathology, and we summarize the current literature regarding the management of uterine sarcomas.

OBJECTIVES: To evaluate the efficacy and safety of irinotecan and bevacizumab in recurrent ovarian cancer. The primary objective was to estimate the progression free survival (PFS) rate at 6months. Secondary objectives included estimation of overall survival (OS), objective response rate (ORR), duration of response, and an evaluation of toxicity. METHODS: Recurrent ovarian cancer patients with no limit on prior treatments were eligible. Irinotecan 250mg/m2 (amended to 175mg/m2 after toxicity assessment in first 6 patients) and bevacizumab 15mg/kg were administered every 3weeks until progression or toxicity. Response was assessed by RECIST or CA-125 criteria every 2cycles. RESULTS: Twenty nine patients enrolled (10 were platinum-sensitive and 19 were platinum-resistant). The median number of prior regimens was 5 (range 1-12); 13 patients had prior bevacizumab and 11 prior topotecan. The PFS rate at 6months was 55.2% (95% CI: 40%-77%). The median number of study cycles given was 7 (range 1-34). Median PFS was 6.8months (95% CI: 5.1-12.1months); median OS was 15.4months (95% CI: 11.9-20.4months). In this study, no complete response (CR) was observed. The objective response rate (ORR; PR or CR) for all patients entered was 27.6% (95% CI: 12.7%-47.2%) and the clinical benefit rate (CR+PR+SD) was 72.4% (95% CI: 52.8%-87.3%); twelve patients experienced duration of response longer than 6months. In the 24 patients with measurable disease, a partial response (PR) was documented in 8 (30%) patients; 13 patients maintained stable disease (SD) at first assessment. The most common grade 3/4 toxicity was diarrhea. No treatment-related deaths were observed. CONCLUSIONS: Irinotecan and bevacizumab has activity in heavily pre-treated patients with recurrent ovarian cancer, including those with prior bevacizumab and topoisomerase inhibitor use.

OBJECTIVE: To determine factors influencing discharge patterns after laparoscopic hysterectomy for endometrial cancer and to evaluate the safety of same-day discharge during the 30-day postoperative period. METHODS: Using the American College of Surgeons' National Surgical Quality Improvement Project's database, patients who underwent hysterectomy for endometrial cancer from 2010 to 2014 were identified and categorized by their hospital length of stay. Statistical analyses were performed to assess the relationship between hospital stay and demographics, medical comorbidities, intraoperative surgical factors and postoperative outcomes. RESULTS: A total of 9020 patients had laparoscopic hysterectomies for endometrial cancer and of these, 729 patients (8.1%) were successfully discharged on the day of surgery. These patients were younger and had lower body mass indexes and fewer medical comorbidities than patients who were admitted after their procedure. The same-day discharge group underwent surgical procedures of less complexity than the hospital admission group based on shorter operative times and fewer relative value units (RVUs). There was a lower rate of surgical site infections in the same-day discharge group, and no difference in rates of other postoperative complications including hospital readmissions and reoperations. CONCLUSIONS: Rates of laparoscopic hysterectomy for endometrial cancer are gradually increasing but the rates of same-day discharge have increased at a much slower rate. Same-day discharge has been successful despite differences in preoperative demographics, medical comorbidities and intraoperative surgical complexity. Overall postoperative complication rates were equivalent despite length of hospital stay, demonstrating the safety and feasibility of same-day discharge after laparoscopic hysterectomy for endometrial cancer.

Objectives: Minimally invasive surgery is the preferred surgical method to treat women with endometrial cancer. Several single-institution reports have described the feasibility and safety of outpatient laparoscopic hysterectomies (LH) for both benign and malignant indications. The objective of this study is to identify patient and surgical factors associated with outpatient laparoscopic hysterectomies (OLH) and to compare outcomes between OLH and inpatient laparoscopic hysterectomies (ILH) in women with endometrial cancer.Methods: Data were obtained from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. All patients who underwent hysterectomies for endometrial cancer from 2007 to 2013 were identified by ICD-9 and CPT codes. These patients were then filtered for LH. Comparative analyses were performed and stratified by admission status to evaluate demographics, preoperative and intraoperative variables, and surgical outcomes. Statistical tests were performed with R Studio version 0.99.442.Results: LH rates have been steadily increasing. (See Table 1.) Between 2010 and 2013, 5,851 patients underwent LH for endometrial cancer; of these, 3,428 (58.6%) were ILH and 2,423 (41.4%) were OLH. OLH rates increased each year from 30.0% in 2010 to 50.0% in 2013. OLH patients were on average 61.81 years old compared with 63.03 years for ILH patients (P <.001). Medical comorbidities were not different between the 2 groups. Total operating time and anesthesia time were both significantly shorter in the OLH group: average times were 161.3 and 187.0 minutes (P <.001) and 245.2 versus 256.3 minutes (P =.002), respectively. More lymph node dissections were performed in the ILH group than the OLH group: 2,074 (60.5%) versus 1,390 (57.4%, P =.016). There were more radical hysterectomies in the ILH group (n = 803; 23.4%) compared with the OLH group (n = 315; 13.1%) (P <.001). OLHs were assigned fewer relative value units than ILHs (mean 28.5 vs 30.6, respectively, P <.001). Postoperative complications were not different between the groups.Conclusions: Younger age, fewer RVUs, shorter operating and anesthesia times were associated with successful OLH in patients with endometrial cancer. Lymph node dissection and radical surgery were associated with an increased rate of ILH. There were no differences in postoperative complications between OLH and ILH. (table present)