Spotlight On: Urogynecology/Vaginal Surgery

This month we cast a spotlight on articles, SurgeryU videos, and Journal of Minimally Invasive Gynecology (JMIG) article recommendations from the AAGL Urogynecology/Vaginal Surgery Special Interest Group (SIG) led by Chair Soorena Fatehchehr, MD, MSc, FACOG.

Access to SurgeryU and JMIG are two of the many benefits included in AAGL membership. The SurgeryU library features high-definition surgical videos by experts from around the world. JMIG presents cutting-edge, peer-reviewed research, clinical opinions, and case report articles by the brightest minds in gynecologic surgery.

SurgeryU video recommendations by our SIGs are available for public access for a limited time. The links to JMIG article recommendations are accessible by AAGL members only. For full access to SurgeryU, JMIG, CME programming, and member-only discounts on meetings, join AAGL today! 

SurgeryU Video Recommendation #1:

Laparoscopic Repair of Colo-Ovarian Fistula (Golden Laparoscope Winner 2021)
by Drs. Eung-Mi Lee, Christine E. Foley, and Ted TM Lee

This is a rare case of Colo-ovarian fistula and demonstrates successful laparoscopic excision and repair.

Click Image to View Video

SurgeryU Video Recommendation #2:

Urethral Diverticulum Excision and Placement of Autologous Fascia Lata Sling
by Drs. Danilo A. Acosta, Aakriti R. Carrubba, Paul Pettit, and Anita Chen

This video shows the repair of urethral diverticulum with concomitant autologous fascial graft placement for management of stress urinary incontinence.

Click Image to View Video

JMIG Article Recommendation #1:

Hysterectomy Trends and Risk of Vaginal Cuff Dehiscence: An Update by Mode of Surgery
by Melanie Polin, MD, Ryan Boone, MD, Francesca Lim, MS, Arnold P. Advincula, MD, Benjamin May, BS, Chin Hur, MD, MPH, and Hye-Chun Hur, MD, MPH

This article is an updated review of 4100 hysterectomies assessing rates of vaginal cuff dehiscence by mode of surgery from 2010 to 2021 as rates of RA-TLH, TLH and LAVH increased significantly. There were 15 vaginal cuff dehiscence (VCD overall rate 0.37%). This article showed that Cuff dehiscence after laparoscopic hysterectomies decreased from previously reported. Overall, VCD was highest after RA-TLH (0.66%), followed by TLH (0.32%) and TAH (0.27%), with no VCDs after laparoscopic-assisted vaginal hysterectomy or total vaginal hysterectomy. Compared with TAH, the relative risk for VCD after RA-TLH was 2.44 (95% confidence interval 0.66−9.00) and after TLH was 1.18 (95% confidence interval 0.24−5.83), which were not statistically significant. The mean time to dehiscence was 39 days (range 8−145 days). The most common trigger event was coitus (41%).

Journal of Minimally Invasive Gynecology, Volume 30, Issue 7, p562-568, July 2023, DOI: https://doi.org/10.1016/j.jmig.2023.03.005.

JMIG Article Recommendation #2:

Effectiveness of Laparoscopic Pectopexy for Pelvic Organ Prolapse Compared with Laparoscopic Sacrocolpopexy
by Yingying Yang, MD, Zhen Li, MD, PhD, Keyi Si, MD, PhD, Qingqiang Dai, MD, Yingying Qiao, MD, Dazhuang Li, MD, Li Zhang, MD, Fan Wu, MD, Jia He, MD, PhD, and Guizhu Wu, MD, PhD

Pectopexy is an alternative surgical treatment for pelvic organ prolapse. This prospective cohort study was comparing anatomic outcome, recurrence rate and Quality of Life questionnaires at enrollment and up to one year postoperative between Laparoscopic Pectopexy for Pelvic Organ Prolapse Compared with Laparoscopic Sacrocolpopexy, which is a gold standard surgical treatment for pelvic organ prolapse. Their average operating time for Pectopexy was shorter by 13.5 minutes, maybe due to lower robotic cases in that group as compared to Sacrocolpopexy. There were no differences in blood loss, length of hospital stay, and postoperative 7-day complications. There was similar anatomic success with similar improvement in POP Quantification scores in both groups. The Pectopexy group had a higher rate of urinary symptoms recurrence in one year, however had more improvement in The Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life scores at postoperative months 3, 6, and 12, as compared to Sacrocolpopexy group.

Journal of Minimally Invasive Gynecology, Volume 30, Issue 6, June 2023, DOI: https://doi.org/10.1016/j.jmig.2023.06.011.

Minimally Invasive Robotic Hysterectomy and Vaginal Extraction of 2370 grams (5.3 Ibs) Fibroid Uterus in a Class III Obese and Anemic Patient
by Drs. Soorena Fatehchehr, Cheyenne McKee, Amira Shaikh, and Maggie Jiang

Leiomyomas are benign tumors of the uterus.¹ Hysterectomy is a surgical option for patients who have completed childbearing and desire definitive treatment. Minimally invasive approaches are associated with decreased morbidity.^2,3 Patients should be counselled on possibility of morcellation of presumed leiomyomas and its risks, benefits, and alternatives in making a shared decision for the surgical approach.³

Minimally invasive robotic hysterectomy for significantly enlarged and deformed fibroid uterus in patients with major risk factors (i.e., morbid obesity and anemia) is feasible and safe with excellent perioperative outcomes. Combined robotic and manual morcellation via the vaginal route can also be successfully performed for enlarged fibroid uterus with benign characteristics. Despite increasing operative times, minimally invasive robotic surgical approach and vaginal extraction should be offered to all patients in appropriate settings.

Case

This is a case of a 39-year-old African American female with class III obesity who presented with symptomatic anemia secondary to menorrhagia. Pre-operative endometrial biopsy pathology was benign. MRI displayed a significantly enlarged and retroflexed uterus measuring 29.3cm by 11.5cm by 12.2cm with multiple necrotic fibroids, the largest measured 16.7 x 10.6cm without malignant characteristics (Figure 1-4).

Figure 1                                             Figure 2

Figure 3                                            Figure 4

After extensive counseling including risk of parasitic fibroid and leiomyosarcoma, patient elected to undergo robotic assisted laparoscopic hysterectomy. Uterine manipulation was not feasible to place due to distorted uterine cavity. Five French opened-ended stents were placed bilaterally via cystoscopy and indocyanine green (ICG) was injected for ureteral identification. Laparoscopic entry was performed through abdominal left upper quadrant and intra-operative evaluation revealed an enlarged and deformed extra pelvis fibrotic uterus, occupying into the upper abdomen with adhesions.

We started by dissecting away the omentum that was attached to the apical fibroid, and then we freed adhesions between the left tube and sigmoid. The uterus was then injected with four units of vasopressin to minimize the bleeding. Two units of packed red blood cells were ordered for transfusion in the beginning of surgery due to patient’s anemia. Robot was then docked and a 30-degree camera was used. Two accessory ports and an 8 mm air seal were placed.

Starting from right side round ligament was coagulated and transected via the bipolar. We then opened the anterior leaf of the broad ligament and skeletonized the right uterine vessels. Bladder flap was then created. A similar step was performed on the left side. Tenaculum was then used to mobilize the uterus. Using vessel sealing device bilateral uterine vessels were coagulated and transected. Once this was accomplished monopolar scissors were used to circumferentially amputate the uterus and cervix.

The specimens were extracted via the vaginal route with a combination of manual and robotic morcellation in a specimen bag. The vaginal cuff was closed by incorporating both uterosacral ligaments. The specimen weighed 2370 grams and the pathology revealed leiomyoma without evidence of hyperplasia or malignancy. Total blood loss during the operation was 100 mL. Post-operatively the patient was discharged home on day 2 and was followed for 6 months without any major complications.

References:

1. Munro MG, Critchley HO, Fraser IS; FIGO Menstrual Disorders Working Group. The FIGO classification of causes of abnormal uterine bleeding in the reproductive years. Fertil Steril. 2011 Jun;95(7):2204-8, 2208.e1-3. doi: 10.1016/j.fertnstert.2011.03.079. Epub 2011 Apr 15. PMID: 21496802.
2. American College of Obstetricians and Gynecologists. Choosing the route of hysterectomy for benign disease. Committee Opinion No. 701. Obstet Gynecol 2017:129;e155-9.
3. American College of Obstetricians and Gynecologists. Uterine morcellation for presumed leiomyomas. Committee Opinion No. 822. Obstet Gynecol 2021:137; e63-74.

About the Authors:

Soorena Fatehchehr, MD. MSc, FACOG
Cheyenne McKee, BSc
Amira Shaikh, DO
Maggie Jiang, DO

Dr. Fatehchehr is Chair of the AAGL Urogynecology/Vaginal Surgery SIG, Female Pelvic Medicine & Reconstructive Surgery (Urogynecology), Advanced Minimally Invasive & Robotic Surgery, Assistant Clinical Professor, Department of Obstetrics and Gynecology, and Associate Clinical Faculty, Kern Medical at the University of California Los Angeles (UCLA) in Los Angeles, California.

Ms. McKee is a 4th year medical student at Ross University School of Medicine in Barbados.

Dr. Shaikh is an AAGL Urogynecology/Vaginal Surgery SIG Member and a Resident Physician in Obstetrics and Gynecology at Loma Linda University in Loma Linda, CA.

Dr. Jiang is an AAGL Urogynecology/Vaginal Surgery SIG Member, Chief Resident Physician in Obstetrics and Gynecology at Kern Medical Center, University of California (UCLA), in Los Angeles, California. 

Urinary Tract Endometriosis
by Drs. Soorena Fatehcher, Maggie Jiang, and Susan Nasab

Study Objective: To summarize the epidemiology, diagnostic modalities, and treatment methods of urinary tract endometriosis (UE).

Design: Retrospective literature review of 141 select articles from January 1976 to March 2023

Patients or Participants: UE articles from Medline, PubMed, Ovid, Embase, MEDLINE, Cochrane Review

Measurements and Main Results: UE is prevalent in 0.3-12% of all endometriosis cases and 19-53% of deep infiltrating endometriosis. Prevalence of endometriosis increases to 28-75% in women with interstitial cystitis.

Bladder endometriosis is the most common (80-85%) and has specific symptoms, most frequently dysuria and hematuria but should be considered in any patient with irritative urological symptoms. Ultrasound (US) and magnetic resonance imaging (MRI) reported sensitivities of 50-89% and 67-100%, and specificities of 98-100% and 83-100%. Other imaging modalities include computed tomography urogram (CTU) and cystoscopy, with reported sensitivities of 46% and 58% and specificities of 98% and 97%. Combined MRI with cystoscopy will maximize preoperative detection.

Ureteral endometriosis is the second most common (9-23%) with non-specific symptoms. It is up to 50% asymptomatic and can get complicated with advanced hydronephrosis with up to 30% developing acute renal failure. US and MRI have sensitivities of 50-97% and 33-87% and specificities of 95-100% and 98-100%. CTU has a less diagnostic value, with sensitivity and specificity of 36-57% and 76-89% for left ureter, and 18-60% and 70-88% for right ureter.

Renal (<1-2%) and urethral (<1-2%) endometriosis are less prevalent with less available data. Limited case reports describe imaging findings of renal endometriosis, often misinterpreted as renal tumors, and urethral endometriosis, which has been misdiagnosed as urethral diverticulum. Endoscopic visualization with excisional confirmation remains the diagnostic gold standard. Medical management consisting of hormonal treatment post excision surgical procedures is based on disease location and associated complications.

Minimally invasive surgical management with excision of UE leads to more definitive treatment with low complication rates. Laparoscopic, and recently robotic excision are the gold standard. When comparing different surgical approaches, laparotomy surgeries for bladder or ureteral endometriosis excision were associated with a higher odds ratio (OR) for recurrence (1.16 OR) compared to conventional laparoscopy (1.105 OR) or robotic assisted laparoscopy (1 OR).

In terms of surgical complication rates (Calvien-Dindo grade I-IV), robotic-assisted laparoscopy is reported to have a superior outcome when compared to conventional laparoscopy or laparotomy. Post-surgical pregnancy rate has been reported to be as high as 88.9% after surgical excision of UE via robotic-assisted laparoscopy.

In Conclusion: Diagnosis of UE is very challenging and due to its broad clinical presentation; it could be misdiagnosed or late diagnosed. UE requires high index of suspicion in order to make an accurate and early detection. Most suitable diagnostic modalities to detect UE are MRI, US, and cystoscopy. Proper initial surveillance measures maximize the preparation for more effective minimally invasive treatment plans in a multi-disciplinary setting, and lead to definitive treatment with excellent outcomes. Accurate, close follow-up evaluation will minimize the recurrence and progression of UE.

About the Authors:

Soorena Fatehcher, MD, MSc, FACOG
Maggie Jiang DO
Susan Nasab, MD, FACOG

Dr. Fatehchehr is Chair of the AAGL Urogynecology/Vaginal Surgery SIG, Female Pelvic Medicine & Reconstructive Surgery (Urogynecology), Advanced Minimally Invasive & Robotic Surgery, Assistant Clinical Professor, Department of Obstetrics and Gynecology, and Associate Clinical Faculty, Kern Medical at the University of California Los Angeles (UCLA) in Los Angeles, California.

Dr. Jiang is an AAGL Urogynecology/Vaginal Surgery SIG Member, Chief Resident Physician in Obstetrics and Gynecology at Kern Medical Center, University of California (UCLA), in Los Angeles, California. 

Dr. Nasab is Chief Fellow Physician in the Division of Reproductive Endocrinology and Infertility at Johns Hopkins University in Baltimore, Maryland. 

Artificial Intelligence in the Surgical Field: Pioneering a New Era of Precision and Safety
by Soorena Fatehchehr, MD and Victoria Pintar, BSc

The use of artificial intelligence (AI) technology in the medical field has exciting potential and many possible applications, especially in the field of surgery. As a surgeon, I have witnessed firsthand the remarkable changes brought about by new technologies in surgical practices. AI-powered technologies used in surgery offer unprecedented advantages in precision, safety, and patient outcomes. In this article, we will explore some of the potential benefits of AI in surgery and how it may advance the field into the future.

Improved Pre-operative Planning:

The ability of AI to analyze and synthesize vast amounts of patient data to provide surgeons with comprehensive patient profiles is a key domain for AI use in surgery. By analyzing medical imaging, patient histories, and laboratory results, AI could provide recommendations for each patient based on their personalized risks and benefits during pre-operative planning, reducing the risk of unexpected complications.[1] The use of AI technology in this way would reduce complications for individual patients and the cost burden on healthcare systems as a whole. The American College of Surgeons emphasizes that AI-driven pre-operative planning could reduce surgical time and decrease the length of stay in hospitals, streamlining the overall surgical process.1 By harnessing the predictive capacities of AI, surgeons can recognize potential risks and customize surgical approaches to meet the needs of individual patients.

Enhanced Surgical Navigation:

AI-powered navigation systems have the potential to revolutionize the surgical landscape. They can act as virtual assistants by analyzing data from pre-operative and intra-operative imaging and patient-specific anatomy to formulate dynamic surgical maps, allowing more precise completion of complex procedures.[2] This dynamic mapping provides information in real time to improve surgical accuracy and reduce the risk of errors. For example, an AI model may be used during colonoscopies to provide real-time differentiation between neoplastic and non-neoplastic polyps, preventing unnecessary polypectomies.[3] Artificially intelligent robots have been used to assist plastic surgeons in incredibly intricate procedures such as anastomosing microscopic blood vessels and surgically restoring hand function after amputation.[4] The increased precision of AI-powered navigation will improve surgical outcomes and ultimately result in faster recovery and decreased morbidity and mortality.

Predictive Analytics for Surgical Outcomes:

In addition to analyzing individual patients’ data, AI can be used to analyze patterns in historical surgical data and subsequent postoperative outcomes. This data can then be used to develop predictive models using a specific patient’s characteristics and risk factors.3 As many medical domains shift toward personalized healthcare, AI can assist surgeons in embracing this paradigm. Individual treatment plans and post-operative care can be determined for each patient using AI predictive models, as well as early identification of any potential complications. This approach can result in improved outcomes and patient satisfaction.3 In a study by Bektaş et al.[5], an AI model accurately predicted weight loss and post-operative complications for patients after bariatric surgery with up to 98% accuracy. Incorporating AI-driven predictive analysis of both individual and historical surgical trends into surgical planning has the potential to highly individualize surgical care, improving success rates and overall patient satisfaction.

Augmented Reality and Virtual Reality in Surgical Training:

The integration of AI into the medical field has brought with it the incorporation of augmented reality (AR) and virtual reality (VR) in surgical training. These immersive technologies allow all levels of learners to practice surgical techniques in a risk-free environment, increasing their skills, confidence, and performance. The AI in Surgery Journal highlights the merits of AI-driven AR and VR training in surgical education, stating that it can reduce the learning curve for surgeons and provides opportunities for continued professional development.[6] In addition, AR and VR provide surgeons with nearly limitless opportunities to learn new skills and enhance their current skills. AI-simulated surgical scenarios allow surgeons to refine their techniques, leading to improved performance and safer surgeries.

Intelligent Surgical Robots:

The landscape of robotic-assisted surgery has been transformed by AI-powered surgical robots. These robotic systems allow unparalleled control and dexterity beyond human capabilities, leading to safer surgeries and decreased healthcare spending.3 The American College of Surgeons underscores the ability of AI-powered robots to predict the subsequent 15-30 seconds of surgery based on reviewing hundreds of hours of surgical videos. Eventually, they may be able to make recommendations or identify potential mistakes before they happen.1 In the near future, intelligent robots should have the capability to be remotely controlled, allowing surgeons to operate in remote or inaccessible areas, including space. In 2024, NASA plans to send a surgical robot called MIRA to the International Space Station to conduct surgical simulations in zero gravity.[7] AI-driven surgical robots increase the capabilities of surgeons and allow expanded access to surgical care across the world and beyond.

Conclusion:

The integration of AI technology into many aspects of surgery is undoubtedly revolutionizing the surgical landscape. From improved preoperative planning and surgical navigation to predictive analytics, AI offers unparalleled advantages in precision, safety, and patient outcomes. The use of augmented reality technologies in surgical training and the advent of intelligent surgical robots further highlights the revolutionary potential of AI in surgery. As AI technologies continue to change and improve, it is imperative that surgeons and healthcare systems recognize the potential of these systems and incorporate them into surgical practices and training. By leveraging the powerful potential of AI, medical systems can provide better and safer surgical care to patients around the world and soon, even in space.

References

[1] The American College of Surgeons. (2023, June). AI Is Poised to Revolutionize Surgery. Bulletin of the American College of Surgeons, Volume 108, Issue 6.

[2] MobiHealthNews. (n.d.). The Power of AI in Surgery. Retrieved from https://www.mobihealthnews.com/news/contributed-power-ai-surgery

[3] Mitsala, A., Tsalikidis, C., Pitiakoudis, M., Simopoulos, C., & Tsaroucha, A. (2021). Artificial intelligence in Colorectal cancer Screening, Diagnosis and treatment. A new era. Current Oncology, 28(3), 1581–1607.

[4] Moellhoff N, Giunta RE. Künstliche Intelligenz in der Plastischen Chirurgie : Aktuelle Entwicklungen und Perspektiven [Artificial intelligence in plastic surgery : Current developments and perspectives]. Chirurg. 2020 Mar;91(3):211-215. German. doi: 10.1007/s00104-019-01052-2. PMID: 31650203.

[5] Bektaş, M., Reiber, B. M. M., Pereira, J. C., Burchell, G. L., & Van Der Peet, D. L. (2022). Artificial intelligence in Bariatric Surgery: Current status and future perspectives. Obesity Surgery, 32(8), 2772–2783. https://doi.org/10.1007/s11695-022-06146-1

[6]AI in Surgery Journal. (n.d.). Retrieved from https://aisjournal.net

[7] Demaitre, E. (2022, August 10). Virtual Incision’s MIRA surgical robot to show skills on International Space Station. Robotics 24/7. https://www.robotics247.com/article/virtual_incisions_mira_surgical_robot_to_show_skills_on_international_space_station

About the Authors:

   
Soorena Fatehchehr, MD, MSc, FACOG
Victoria Pintar, BSc

Dr. Fatehchehr is Chair of the AAGL Urogynecology/Vaginal Surgery SIG, Female Pelvic Medicine & Reconstructive Surgery (Urogynecology), Advanced Minimally Invasive & Robotic Surgery, Assistant Clinical Professor, Department of Obstetrics and Gynecology, and Associate Clinical Faculty, Kern Medical at the University of California Los Angeles (UCLA) in Los Angeles, California.

Ms. Pintar is a 4^th year medical student at Ross University School of Medicine in Barbados.