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To report vaginal cuff dehiscence rates by mode of hysterectomy as the surgical landscape has shifted towards minimally invasive approaches. Retrospective cohort study. Large academic medical center and affiliated community hospital. 4722 patients who underwent hysterectomy for benign and malignant indications between January 2010 and August 2021. Hysterectomy patients and vaginal cuff dehiscences were identified by ICD and CPT codes. There were 663 supracervical hysterectomies and 4059 total hysterectomies identified (1360 robot-assisted total laparoscopic hysterectomies [RA-TLH, 28.8%], 1107 total abdominal hysterectomies [TAH, 23.4%], 938 total laparoscopic hysterectomies [TLH, 19.9%], 498 total vaginal hysterectomies [TVH, 10.5%], and 156 laparoscopic-assisted vaginal hysterectomies [LAVH, 3.3%]). Supracervical hysterectomies were excluded from analysis. Among 4059 total hysterectomies, there were 15 vaginal dehiscences (0.37%). The dehiscence rate was highest after RA-TLH at 0.66% (n=9), followed by TLH at 0.32% (n=3), and TAH at 0.27% (n=3), with no dehiscences after TVH or LAVH; these differences were not statistically significant (p =0.31). Compared to TAH, the relative risk for dehiscence after RA-TLH was 2.44 (95% CI 0.66 – 9.00), and after TLH was 1.18 (95% CI 0.24 – 5.83), which were also not statistically significant. Patient characteristics were reviewed including age, hysterectomy indication, colpotomy type, suture type, medical comorbidities, and presentation. The mean time to dehiscence was 39 days (range 8 – 145). The most common trigger event was coitus (41%). Most dehiscences followed benign hysterectomies (88%). Our study offers the largest representation of robotic hysterectomies to date. Although dehiscence rates were higher after laparoscopic hysterectomy (RA-TLH 0.66%, TLH 0.32%) compared to abdominal hysterectomy (TAH 0.27%), the differences were not significant. Our 0.66% RA-TLH dehiscence rate is much lower than previously reported in large studies (1.6 – 4.1%). While broad conclusions are limited, dehiscences are overall rare (0.37%). More research is needed to evaluate factors responsible for increased risk. [ABSTRACT FROM AUTHOR]

To report the trends in hysterectomy volume and route of surgery at a single tertiary-care institution as the overall surgical landscape has shifted towards minimally invasive surgery. Retrospective cohort study. Large academic medical center and affiliated community hospital. All patients who underwent hysterectomy for benign and malignant indications between January 2010 and August 2021. N/A. During the study period, there were 4722 hysterectomies performed at our institution: 4059 total (86%) and 663 supracervical (14%). Hysterectomy volume rose steadily from 2010 (306 annual cases), peaked in 2016 (483 annual cases), and remained relatively stable through 2021. The laparoscopic approach (conventional laparoscopic, robotic, and laparoscopic-assisted vaginal hysterectomy) was the most common route of hysterectomy overall (59.3%, n= 2799), followed by abdominal (30.2%, n= 1425) and vaginal (10.5%, n= 498) (P <.0001). Among the laparoscopic hysterectomies, there were 1546 robot-assisted laparoscopic hysterectomies (32.7%), 1097 conventional laparoscopic hysterectomies (23.2%), and 156 laparoscopic-assisted vaginal hysterectomies (3.3%). The distribution of route of hysterectomy changed from 2010 (44.8% abdominal, 41.2% laparoscopic, 14.1% vaginal) to 2021 (22.6% abdominal, 66.1% laparoscopic, 11.3% vaginal) (P <.0001). While abdominal hysterectomies constituted the largest proportion of cases in the beginning of our study period, the proportion dropped substantially by the end. Most notably, robot-assisted hysterectomies had the greatest increase from 6.2% of cases in 2010 to 41.1% of cases in 2021, while conventional laparoscopic hysterectomies slightly increased from 21.6% of cases to 24.3%, and vaginal hysterectomies slightly decreased from 14.1% to 11.3%. There has been a large shift towards laparoscopic hysterectomies in the last 10 years, with the most substantial increase in robot-assisted laparoscopy. This trend reflects the increasing popularity of minimally invasive surgery in the gynecology field as a whole. [ABSTRACT FROM AUTHOR]

To demonstrate the use of a transcervical radiofrequency ablation (RFA) device approved for symptomatic uterine fibroids as a possible treatment for adenomyosis. A case report. Community hospital affiliate of a large university hospital. 35-year-old gravida-2 para-0 female with uterine fibroids and infertility, presenting with heavy menstrual bleeding, dysmenorrhea, and recent 1st trimester miscarriage. Pelvic MRI showed a 12 cm uterus with a 2 cm endometrial polyp, 4.5 cm pedunculated fundal fibroid, and diffusely thickened posterior and fundal myometrium consistent with adenomyosis. The patient desired uterine-sparing surgical management and underwent a laparoscopy, hysteroscopy and transcervical RFA. Laparoscopically, extensive posterior adenomyosis, a 4.5 cm pedunculated fibroid, and sub-centimeter exophytic fibroid were noted. Endometriosis and small left ovarian fibromas were incidentally diagnosed. Hysteroscopically, there was a 2 cm endometrial lesion with an otherwise normal endometrial cavity. The patient underwent laparoscopic myomectomy of 2 fibroids (without myometrial incision), excision of left ovarian fibromas, and excision of endometriosis in 2 areas, as well as hysteroscopic resection of the endometrial lesion. Ultrasound-guided transcervical RFA then targeted the thickened posterior myometrium with ablation of two adenomyotic regions (measuring 3.4 × 2.6 cm and 3.8 × 2.6 cm). Outgassing was visualized on intrauterine ultrasound images in these regions similar to ablated uterine fibroids and suggestive of successful adenomyosis ablation. Concomitant laparoscopy confirmed no thermal spread beyond uterine serosa. The patient was discharged home the same day. Final pathology revealed fibroids, endometriosis, ovarian spindle cell tumor, and products of conception. On follow-up evaluation, she had no postoperative complaints and no pain medication requirements beyond the immediate postoperative period. Assessment of long-term symptomatic improvement and fertility outcomes are ongoing. Transcervical radiofrequency ablation is a promising uterine-sparing treatment for patients with adenomyosis. Additional research is warranted to assess long-term symptom improvement and pregnancy outcomes. [ABSTRACT FROM AUTHOR]

The purpose of this article is to provide an updated review of pregnancy outcomes after laparoscopic and transcervical radiofrequency ablation of fibroids. Literature review using PubMed/Medline. N/A. Patients were identified from case reports and case series of pregnancies following trials of radiofrequency ablation (RFA) devices for symptomatic uterine fibroids. The pregnancies identified represented large trials of laparoscopic and transcervical ablation from North America, Asia, Europe, and Latin America. Laparoscopic and transcervical radiofrequency ablation of fibroids. 6 publications met criteria for inclusion, representing 11 clinical trials and 3 reports from real-world settings. 593 patients underwent RFA of fibroids, with 46 total pregnancies identified. The average age of patients was 39 years old and ranged from 27 to 46 years old. The majority of patients had between one and three fibroids ablated, and the size varied from less than 2 centimeters up to 12.5 centimeters. In terms of pregnancy outcomes, among the 46 total pregnancies, there were 4 spontaneous abortions, 7 elective terminations of pregnancy, and 35 term pregnancies with 17 vaginal and 18 cesarean deliveries. The patients who experienced spontaneous abortion were 36 to 38 years old. There was one complication after cesarean delivery presenting as postpartum hemorrhage with resultant expulsion of degenerated myoma with no long-term sequelae. There were no cases of uterine rupture, uterine window, placenta accreta, placental abruption, or fetal growth restriction. The majority of patients who had documented pregnancies after radiofrequency ablation of fibroids had full-term deliveries with no maternal or neonatal complications. Given the inherent obstetric risks with myomectomy (e.g., risk of uterine rupture, intrauterine scarring, possible need for cesarean delivery, etc.), these findings add to the growing consensus that radiofrequency fibroid ablation may offer a safe and effective minimally invasive treatment alternative to women seeking uterine-sparing fibroid treatment to preserve fertility. [ABSTRACT FROM AUTHOR]