Gynae Flashcards
Define robotic assisted laparoscopy
Defined as the use of a fixed or mobile automatically controlled, multipurpose manipulator in >3 axes, to assist surgical procedures
The patient and surgeon may be separated during the procedure by a master-slave telerobotic system, which allows the surgeon to perform the operation in a remote location
RANZCOG position on robotic assisted laparoscopy
Current place for benign gynae procedures is yet to be established. Evidence that it takes as long or longer to perform with significantly more cost.
Gynaecologists should not perform RALS until they have reached the equivalent RANZCOG level skill level in conventional laparoscopy and can provide evidence of the on-site or off-site robotic surgery training necessary to complete the relevant procedure
Rate of complications at gynae laparoscopy
3-8/1000
50% of injuries at gynae laparoscopy occur at time of entry
Tests for correct Veress entry
Saline test - Withdraw to see if any fluid, pus, blood, faeces are aspirated, Instill saline to ensure no blockage, Withdraw syringe and watch if saline flows easily
Initial insufflation pressure should be relatively low (<5-8mmHg) and gas should be flowing freely - Highest sensitivity and specificity for correct placement
If incorrect placement after 3 attempts with veress, consider
Assistance from senior colleague
Alternate site for placement
Alternate entry
Cease the procedure completely
Informed consent for gynae exams and procedures
Adequate explanation Interpreter offered if required Patient has change to ask questions Support person Can decline exam Verbal consent obtained
Privacy for gynae exams and procedures
Privacy for derobing
Suitable cover for exam, e.g. gown
Always wear gloves
Don’t allow pt to remain undressed for any longer than is needed
Cease exam if consent uncertain or withdrawn
If no support person, professional suitably qualified and of acceptable gender to the patient could take on that role
If concern about patients understanding or level of consent, delay exam until f/u
Presence of an observer for gynae exams and procedures
Term observer being used instead of chaperone. Observe the consult or part of it on the doctor’s behalf.
Verbal consent for observer should be obtained from the patient and documented.
Observer must be suitably qualified, of a gender approved by the patient, respect the privacy and dignity of the patient,
When there is not agreement on the presence of a third person
Patient has the right to decline a third person being present. A doctor may decline to examine a patient on their own.
Doctor or patient may withdraw from consult until mutually acceptable third person available, or patient may be referred to another doctor
Nurses health study findings related to oophorectomy at hysterectomy
Median f/u 24y
Bilateral oophorectomy at time of hysterectomy for benign disease a/w:
- Decreased risk of breast and ovarian cancer
- Increased risk of all-cause mortality, and fatal and non-fatal CHD
At no age was oophorectomy a/w increased survival
Oophorectomy not associated with decreased survival in women >55y at the time of hysterectomy + oophorectomy
Potential risks of oophorectomy at time of hysterectomy for benign disease
Increased: mortality due to coronary heart disease, morbidity and mortality due to osteoporosis related fracture, risk of cognitive dysfunction, incl dementia, depressive and anxiety symptoms
In premenopausal women: more severe and prolonged vasomotor symptoms than those seen following natural menopause, reduction in libido and sexual dysfunction
Removal of tubes at hysterectomy?
- Growing evidence that high-grade serous tumours of ovary and peritoneal surface epithelium may originate in the fallopian tubes
- Removal does not appear to increase surgical complications or impact ovarian function
- No population based data to quantify the risk-benefit profile
Incidence of leiomyosarcoma
0.02-0.3% depending on study population
Risk factors for leiomyosarcoma
Age (mean age of diagnosis: 60) Menopausal status African American ethnic background Current or prior tamoxifen exposure Hx of pelvic irradiation Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome Survivors of childhood retinoblastoma
Clinical features suggestive of leiomyosarcoma
Rapidly expanding mass
PMB or variants of AUB (if premenopausal)
Ascites
Lymphadenopathy
Evidence of secondary spread
May be an elevation in LDH related to increased cell turnover
Imaging features suggestive of leiomyosarcoma
Large size or large interval growth Tissue signal heterogeneity Central necrosis Ill-defined margins Ascites Metastases
Define morcellation
Defined as the division of a large specimen into smaller fragments to permit removal from the peritoneal cavity
Types of mocellation
Manual - use a scalpel
- Bivalving, coring
Electromechanically - devices designed for this purpose
- Advanced surgical technique
- Use of devices restricted to practitioners at AGES-RANZCOG level 5 and above
Risks of morcellation
Patient injury - tissue or vessels may be inadvertently injured
Dissemination - fragments of tissue may disseminate throughout the peritoneal cavity. Especially with electromechanical morcellators as create a larger volume of small fragments
Pathology - the size of fragments and loss of anatomical relationships may complicate the diagnosis by the pathologist
Precautions when using a morcellator
- No suspicion of malignancy on preoperative or intraoperative assessment
- Maintain the tip of the instrument in view at all times
- Maintain control of the specimen at all times
- Feed the specimen into the morcellator in a controlled manner
- Minimise spillage of specimen fragments wherever possible
- Post-morcellation retrieval of all macroscopic fragments
To minimise risk of dissemination with morcellation
- Case selection
- Pre-op assessment, specifically to assess the risk of malignancy
- Consent should involve mechanism of tissue extraction
- Intra-op assessment - if suspicious pathology, adapt plan
UAE procedure
Involves the placement of an angiographic catheter into the uterine arteries via the common femoral artery, followed by injection of embolic particles until the flow becomes sluggish in both uterine arteries. Aims to reduce uterine blood flow at the arteriolar levels –> ischaemic injury to the fibroids –> necrosis and shrinkage.
Surrounding normal myometrium allowed to recover under supply of vaginal and ovarian collateral circulations
UAE - Absolute contraindications
Asymptomatic fibroids
Pregnancy
PID (recurrent or current)
Suspected or known uterine malignancy
UAE - relative contraindications
Desire to conceive - High quality data lacking
Postmenopausal status
Fibroid location - Submucosal or subserosal with narrow stalk - sterile peritonitis or intrauterine infection.
Number / size of fibroids
UAE outcomes
Reduced pressure / bulk-related symptoms in ~60%
Reduced AUB (heavy) in 7-90%
Reduced pain in ~80%
The 2 largest RCTs (REST, EMMY) revealed reintervention rates of 28.4-35% at 5-10y compared to 2-10.7% for surgical groups
UAE - risks
Risk of minor complication 30-45%
Risk of major complications - 5%
Procedural: Groin haematoma, Arterial thrombosis, Pseudo-aneurysm
Early: ‘Embolisation syndrome’ (pain, nausea, malaise, fever), Vaginal discharge, pelvic infection (incl pyomyoma), expulsion of necrotic submucosal fibroid
Late: Ovarian insufficiency, Failure of response, re-intervention, VTE (0.286%)
Cochrane 2014 - UAE vs. surgery (myomectomy, hysterectomy) for symptomatic fibroids
Increased: - Minor complications - Number of unplanned reviews and re-admissions after discharge - Surgical reintervention rate Decreased: - Length of hospitalisation - Procedure duration - Resumption of ADL
No significant difference in: Intra procedural complications, Short or long term major complications, Patient satisfaction at 2 and 5y, long-term ovarian failure rates
EMMY trial
Dutch, randomised trial
Hysterectomy rate in the UAE group - 35% by 10y. 5% performed immediately after failed bilateral UAE, Further 19% resorted to hysterectomy by the end of 2y due to inadequate response
65% of women avoided hysterectomy by undertaking UAE
High rate of re-intervention may negate any initial cost-benefit provided by UAE
Concerning outcomes of UAE that could affect reproductive potential
- Non-targeted embolisation –> ovarian embolisation and impaired ovarian reserve
- Decrease in endometrial volume due to an inadequate blood supply
- An otherwise healthy myometrium adversely affected by embolisation –> contraction disturbance and implantation failure
Fertility rates after UAE
1 small RCT comparing UAE to myomectomy
- Pregnancy rates were significantly higher, with lower miscarriage rates in myomectomy group
- Obstetric and perinatal outcomes in ongoing pregnancies were similar between the groups
1 prospective cohort study - ‘fertility-sparing’ protocol with limited embolisation of both uterine arteries
- Monthly fecundability was 0.1%
- No control group with surgical treatment
- Authors commented that UAE did not improve fertility potential and may have worsened it
Pregnancy outcomes with UAE
No difference in PTB, IUGR, malpresentation
Significantly higher rates of CS, PPH and miscarriage
RANZCOG recommendation re. UAE in those wishing future fertility
Due to the lack of good quality evidence, caution should be employed to avoid routine use of UAE in young patients with fibroid disease wishing to conceive
Effect of fibroids on fertility
poorly understood and most appropriate management remains controversial
Fibroid position appears key
Imaging to assess fibroid position in infertility
Optimal imaging techniques:
- MRI
- Sonohysterography
- Hysteroscopy - however may under-represent submucosal lesions because of raised intrauterine pressure
HSG and TVS are insufficiently sensitive or specific
Impact of subserosal fibroids on fertility
do not appear to have a significant effect on fertility outcome
Impact of intramural fibroids on fertility
may be associated with reduced fertility and increased miscarriage rate
- There is insufficient evidence to determine whether myomectomy for IM fibroids improves fertility outcomes
Impact of submucosal fibroids on fertility
associated with reduced fertility and an increased miscarriage rate
- Hysteroscopic myomectomy is likely to improve fertility outcomes, but only poor quality studies therefore further research is required
Indications for myomectomy in infertile women
Those undergoing ART who have demonstrated SM fibroid(s)
Those with symptomatic fibroids (e.g. HMB, pressure symptoms) - trial evidence does not show clear fertility benefit, but presence of symptoms may justify the intervention
Couples with multiple failed ART cycles and the female has IM fibroids
Medical management of fibroids and infertility
Medical management not recommended as delays efforts to conceive
- Short term use of GnRH analogue can be useful for pre-op correction of anaemia or short-term reduction in fibroid volume
PCOS prevalence in Australia
6-7% of the population
Conservative estimate - recent data suggests higher, particularly in Aboriginal population
