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Uterine manipulator in total laparoscopic hysterectomy: safety and usefulness

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Abstract

The aim of this review is to evaluate the effectiveness and safety of uterine manipulators in facilitating total laparoscopic hysterectomy (TLH). A literature search in MEDLINE, EMBASE, Cochrane Library, UpToDate, SpringerLink, ClinicalKey and Elsevier ScienceDirect databases was performed, and articles describing TLH with or without the use of uterine manipulators were retrieved. Complications related to the use of uterine manipulators are numerous, and although uterine manipulator seems to facilitate TLH, the procedure without a uterine manipulator seems to have a comparable safety and effectiveness, although evidence based on a direct comparison of the two approaches is limited without available controlled trials. Uterine manipulator may provide support in cases of large uteri, severe endometriosis, recto vaginal adhesions and regional anesthesia, while its use may increase complications in cases of vaginal stenosis and nulliparity. Therefore, to perform TLH, the surgeon should individualize for each case if uterine manipulator is needed and which manipulator best suits the surgical procedure requirements and case characteristics. Further studies comparing the two approaches are mandatory.

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References

  1. Janda M, Armfield NR, Kerr G et al (2018) Surgical approach to hysterectomy and barriers to using minimally invasive methods. Aust N Z J Obstet Gynaecol 58:690–695. https://doi.org/10.1111/ajo.12824

    Article  PubMed  Google Scholar 

  2. Macciò A, Madeddu C, Kotsonis P et al (2018) Feasibility and safety of total laparoscopic hysterectomy for huge uteri without the use of uterine manipulator: description of emblematic cases. Gynecol Surg 15:6. https://doi.org/10.1186/s10397-018-1037-5

    Article  PubMed  PubMed Central  Google Scholar 

  3. Aarts JWM, Nieboer TE, Johnson N et al (2015) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.cd003677.pub5

    Article  PubMed  PubMed Central  Google Scholar 

  4. Vitale SG, Capriglione S, Zito G et al (2019) Management of endometrial, ovarian and cervical cancer in the elderly: current approach to a challenging condition. Arch Gynecol Obstet 299:299–315. https://doi.org/10.1007/s00404-018-5006-z

    Article  PubMed  Google Scholar 

  5. van den Haak L, Alleblas C, Nieboer TE et al (2015) Efficacy and safety of uterine manipulators in laparoscopic surgery: a review. Arch Gynecol Obstet 292:1003–1011. https://doi.org/10.1007/s00404-015-3727-9

    Article  PubMed  Google Scholar 

  6. Kavallaris A, Chalvatzas N, Kelling K et al (2011) Total laparoscopic hysterectomy without uterine manipulator: description of a new technique and its outcome. Arch Gynecol Obstet 283:1053–1057. https://doi.org/10.1007/s00404-010-1494-1

    Article  PubMed  Google Scholar 

  7. Macciò A, Chiappe G, Kotsonis P et al (2016) Surgical outcome and complications of total laparoscopic hysterectomy for very large myomatous uteri in relation to uterine weight: a prospective study in a continuous series of 461 procedures. Arch Gynecol Obstet 294:525–531. https://doi.org/10.1007/s00404-016-4075-0

    Article  PubMed  Google Scholar 

  8. Ng CCM, Chern BSM, Siow AYM (2007) Retrospective study of the success rates and complications associated with total laparoscopic hysterectomy. J Obstet Gynaecol Res 33:512–518. https://doi.org/10.1111/j.1447-0756.2007.00577.x

    Article  PubMed  Google Scholar 

  9. Boztosun A, Atılgan R, Pala Ş, Olgan Ş (2018) A new method used in laparoscopic hysterectomy for uterine manipulation: uterine rein technique. J Obstet Gynaecol 38:864–868. https://doi.org/10.1080/01443615.2018.1441273

    Article  PubMed  Google Scholar 

  10. Shinohara S, Sakamoto I, Numata M et al (2017) Risk of spilling cancer cells during total laparoscopic hysterectomy in low-risk endometrial cancer. Gynecol Minim Invasive Ther 6:113–115. https://doi.org/10.1016/j.gmit.2016.10.002

    Article  PubMed  Google Scholar 

  11. Mangeshikar P, Mangeshikar AP (2018) Uterine Manipulators for Total Laparoscopic Hysterectomy. In: Alkatout I, Mettler L (eds) Hysterectomy. Springer International Publishing, Cham, pp 359–367

    Chapter  Google Scholar 

  12. Tinelli R, Cicinelli E, Tinelli A et al (2016) Laparoscopic treatment of early-stage endometrial cancer with and without uterine manipulator: our experience and review of literature. Surg Oncol 25:98–103. https://doi.org/10.1016/j.suronc.2016.03.005

    Article  PubMed  Google Scholar 

  13. Uccella S, Bonzini M, Malzoni M et al (2017) The effect of a uterine manipulator on the recurrence and mortality of endometrial cancer: a multi-centric study by the Italian Society of Gynecological Endoscopy. Am J Obstet Gynecol 216:592.e1–592.e11. https://doi.org/10.1016/j.ajog.2017.01.027

    Article  Google Scholar 

  14. Marcos-Sanmartín J, López Fernández JA, Sánchez-Payá J et al (2016) Does the type of surgical approach and the use of uterine manipulators influence the disease-free survival and recurrence rates in early-stage endometrial cancer? Int J Gynecol Cancer 26:1722–1726. https://doi.org/10.1097/IGC.0000000000000808

    Article  PubMed  PubMed Central  Google Scholar 

  15. Wattiez A, Soriano D, Cohen SB et al (2002) The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc 9:339–345

    Article  CAS  Google Scholar 

  16. Croft K, Mattingly PJ, Bosse P, Naumann RW (2017) Physician education on controllable costs significantly reduces cost of laparoscopic hysterectomy. J Minim Invasive Gynecol 24:62–66. https://doi.org/10.1016/j.jmig.2016.10.003

    Article  PubMed  Google Scholar 

  17. Cook JR, O’Shea RT, Seman EI (2004) Laparovaginal hysterectomy: a decade of evolution. Aust N Z J Obstet Gynaecol 44:111–116. https://doi.org/10.1111/j.1479-828X.2004.00170.x

    Article  PubMed  Google Scholar 

  18. Chapron C, Dubuisson JB, Ansquer Y, Fernandez B (1998) Total hysterectomy for benign pathologies. Laparoscopic surgery does not seem to increase the risk of complications. J Gynecol Obstet Biol Reprod 27:55–61

    CAS  Google Scholar 

  19. Garry R, Fountain J, Mason S et al (2004) The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 328:129. https://doi.org/10.1136/bmj.37984.623889.F6

    Article  PubMed  PubMed Central  Google Scholar 

  20. Macciò A, Kotsonis P, Lavra F et al (2017) Laparoscopic removal of a very large uterus weighting 5320 g is feasible and safe: a case report. BMC Surg 17:50. https://doi.org/10.1186/s12893-017-0248-4

    Article  PubMed  PubMed Central  Google Scholar 

  21. Siedhoff MT, Louie M, Misal M, Moulder JK (2019) Total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for a 6095-g myomatous uterus in a patient of the Jehovah’s witness faith. J Minim Invasive Gynecol 26:25–28. https://doi.org/10.1016/j.jmig.2018.02.018

    Article  PubMed  Google Scholar 

  22. Domingo S, Perales-Puchalt A, Vila-Vives JM et al (2012) Vaginal relapse after laparoscopic hysterectomy in early endometrial carcinoma: does the intrauterine manipulator affect the results? Gynecol Surg 9:461–463. https://doi.org/10.1007/s10397-012-0727-7

    Article  Google Scholar 

  23. Akdemir A, Cirpan T (2014) Iatrogenic uterine perforation and bowel penetration using a Hohlmanipulator: a case report. Int J Surg Case Rep 5:271–273. https://doi.org/10.1016/j.ijscr.2013.10.005

    Article  PubMed  PubMed Central  Google Scholar 

  24. Seki T, Hamada Y, Ichikawa T et al (2017) Uterine artery pseudoaneurysm caused by a uterine manipulator. Gynecol Minim Invasive Ther 6:25–27. https://doi.org/10.1016/j.gmit.2016.04.002

    Article  PubMed  Google Scholar 

  25. Wu H-H, Yeh G-P, Hsieh T-C (2005) Iatrogenic uterine rupture caused by overinflation of RUMI manipulator balloon. J Minim Invasive Gynecol 12:174–176. https://doi.org/10.1016/j.jmig.2005.01.012

    Article  PubMed  Google Scholar 

  26. Gomes-da-Silveira GG, de Oliveira AR, Dibi RP, Beitune PE (2012) The role of uterine manipulator in laparoscopic hysterectomy without general anesthesia. J Minim Invasive Gynecol 19:S150. https://doi.org/10.1016/j.jmig.2012.08.411

    Article  Google Scholar 

  27. Mettler L, Nikam YA (2006) A comparative survey of various uterine manipulators used in operative laparoscopy. Gynecol Surg 3:239–243. https://doi.org/10.1007/s10397-006-0215-z

    Article  Google Scholar 

  28. Uccella S, Cromi A, Serati M et al (2014) Laparoscopic hysterectomy in case of uteri weighing ≥ 1 kilogram: a series of 71 cases and review of the literature. J Minim Invasive Gynecol 21:460–465. https://doi.org/10.1016/j.jmig.2013.08.706

    Article  PubMed  Google Scholar 

  29. Hald K, Viktil E, Lieng M (2015) Effect of uterine manipulation on the relation of the ureter and the uterine vessels. J Minimal Invasive Gynecol 22:S81. https://doi.org/10.1016/j.jmig.2015.08.217

    Article  CAS  Google Scholar 

  30. Terzi H, Biler A, Demirtas O et al (2016) Total laparoscopic hysterectomy: analysis of the surgical learning curve in benign conditions. Int J Surg 35:51–57. https://doi.org/10.1016/j.ijsu.2016.09.010

    Article  PubMed  Google Scholar 

  31. Asai S, Ishimoto H, Okuno S et al (2014) Rectal injury associated with insertion of a vaginal delineator tube during total laparoscopic hysterectomy: a case report and review of the literature. Gynecol Minimal Invasive Therapy 3:54–56. https://doi.org/10.1016/j.gmit.2014.02.003

    Article  Google Scholar 

  32. Mavrova R, Radosa JC, Wagenpfeil G et al (2016) Learning curves for laparoscopic hysterectomy after implementation of minimally invasive surgery. Int J Gynaecol Obstet 134:225–230. https://doi.org/10.1016/j.ijgo.2016.01.017

    Article  PubMed  Google Scholar 

  33. Mebes I, Diedrich K, Banz-Jansen C (2012) Total laparoscopic hysterectomy without uterine manipulator at big uterus weight (> 280 g). Arch Gynecol Obstet 286:131–134. https://doi.org/10.1007/s00404-012-2249-y

    Article  PubMed  Google Scholar 

  34. Srinivasan S, Singhal P, Misra S et al (2016) Techniques to perform robot-assisted total laparoscopic hysterectomy without a uterine manipulator in a case of severe cervical stenosis. J Minimal Invasive Gynecol 23:S127. https://doi.org/10.1016/j.jmig.2016.08.348

    Article  Google Scholar 

  35. Vitale SG, Rossetti D, Tropea A et al (2017) Fertility sparing surgery for stage IA type I and G2 endometrial cancer in reproductive-aged patients: evidence-based approach and future perspectives. Updates Surg 69:29–34. https://doi.org/10.1007/s13304-017-0419-y

    Article  PubMed  Google Scholar 

  36. Denschlag D, Reed NS, Rodolakis A (2012) Fertility-sparing approaches in gynecologic cancers: a review of ESGO task force activities. Curr Oncol Rep 14:535–538. https://doi.org/10.1007/s11912-012-0261-9

    Article  PubMed  Google Scholar 

  37. Vitale SG, La Rosa VL, Rapisarda AMC, Laganà AS (2017) The importance of fertility preservation counseling in patients with gynecologic cancer. J Reprod Infertil 18:261–263

    PubMed  PubMed Central  Google Scholar 

  38. Lim S, Kim HS, Lee KB et al (2008) Does the use of a uterine manipulator with an intrauterine balloon in total laparoscopic hysterectomy facilitate tumor cell spillage into the peritoneal cavity in patients with endometrial cancer? Int J Gynecol Cancer 18:1145–1149. https://doi.org/10.1111/j.1525-1438.2007.01165.x

    Article  CAS  PubMed  Google Scholar 

  39. Eltabbakh GH, Mount SL (2006) Laparoscopic surgery does not increase the positive peritoneal cytology among women with endometrial carcinoma. Gynecol Oncol 100:361–364. https://doi.org/10.1016/j.ygyno.2005.08.040

    Article  PubMed  Google Scholar 

  40. Machida H, Hom MS, Adams CL et al (2018) Intrauterine manipulator use during minimally invasive hysterectomy and risk of lymphovascular space invasion in endometrial cancer. Int J Gynecol Cancer 28:208–219. https://doi.org/10.1097/IGC.0000000000001181

    Article  PubMed  PubMed Central  Google Scholar 

  41. Rossetti D, Vitale SG, Tropea A et al (2017) New procedures for the identification of sentinel lymph node: shaping the horizon of future management in early stage uterine cervical cancer. Updates Surg 69:383–388. https://doi.org/10.1007/s13304-017-0456-6

    Article  PubMed  Google Scholar 

  42. Bodurtha Smith AJ, Fader AN, Tanner EJ (2017) Sentinel lymph node assessment in endometrial cancer: a systematic review and meta-analysis. Am J Obstet Gynecol 216:459–476.e10. https://doi.org/10.1016/j.ajog.2016.11.1033

    Article  PubMed  Google Scholar 

  43. Cignini P, Vitale SG, Laganà AS et al (2017) Preoperative work-up for definition of lymph node risk involvement in early stage endometrial cancer: 5-year follow-up. Updates Surg 69:75–82. https://doi.org/10.1007/s13304-017-0418-z

    Article  PubMed  Google Scholar 

  44. Winter ML, Leu S-Y, Lagrew DC, Bustillo G (2015) Cost comparison of robotic-assisted laparoscopic hysterectomy versus standard laparoscopic hysterectomy. J Robot Surg 9:269–275. https://doi.org/10.1007/s11701-015-0526-z

    Article  PubMed  PubMed Central  Google Scholar 

  45. Schaer GN, Sarlos D, Khan Z (2019) A multipurpose uterine/vaginal manipulator for laparoscopic urogynecologic procedures. Int Urogynecol J. https://doi.org/10.1007/s00192-019-03940-x

    Article  PubMed  Google Scholar 

  46. Vitale SG, Laganà AS, Noventa M et al (2018) Transvaginal bilateral sacrospinous fixation after second recurrence of vaginal vault prolapse: efficacy and impact on quality of life and sexuality. Biomed Res Int 2018:5727165. https://doi.org/10.1155/2018/5727165

    Article  PubMed  PubMed Central  Google Scholar 

  47. Coolen A-LWM, Bui BN, Dietz V et al (2017) The treatment of post-hysterectomy vaginal vault prolapse: a systematic review and meta-analysis. Int Urogynecol J 28:1767–1783. https://doi.org/10.1007/s00192-017-3493-2

    Article  PubMed  PubMed Central  Google Scholar 

  48. Cianci S, Gueli Alletti S, Rumolo V et al (2019) Total laparoscopic hysterectomy for enlarged uteri: factors associated with the rate of conversion to open surgery. J Obstet Gynaecol. https://doi.org/10.1080/01443615.2019.1575342

    Article  PubMed  Google Scholar 

  49. Laganà AS, Vergara D, Favilli A et al (2017) Epigenetic and genetic landscape of uterine leiomyomas: a current view over a common gynecological disease. Arch Gynecol Obstet 296:855–867. https://doi.org/10.1007/s00404-017-4515-5

    Article  CAS  PubMed  Google Scholar 

  50. Meurs EAIM, Brito LG, Ajao MO et al (2017) Comparison of morcellation techniques at the time of laparoscopic hysterectomy and myomectomy. J Minim Invasive Gynecol 24:843–849. https://doi.org/10.1016/j.jmig.2017.04.023

    Article  PubMed  Google Scholar 

  51. Tinelli A, Farghaly SA (2018) Morcellation of occulted sarcomas during laparoscopic myomectomy and hysterectomy for patients with large fibroid uterus. Minerva Ginecol 70:84–88. https://doi.org/10.23736/s0026-4784.17.04149-1

    Article  PubMed  Google Scholar 

  52. Kyriazoglou A, Liontos M, Ziogas DC et al (2018) Management of uterine sarcomas and prognostic indicators: real world data from a single-institution. BMC Cancer 18:1247. https://doi.org/10.1186/s12885-018-5156-1

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Vitale SG, Laganà AS, Capriglione S et al (2017) Target therapies for uterine carcinosarcomas: current evidence and future perspectives. Int J Mol Sci. https://doi.org/10.3390/ijms18051100

    Article  PubMed  PubMed Central  Google Scholar 

  54. Cavaco-Gomes J, Martinho M, Gilabert-Aguilar J, Gilabert-Estélles J (2017) Laparoscopic management of ureteral endometriosis: a systematic review. Eur J Obstet Gynecol Reprod Biol 210:94–101. https://doi.org/10.1016/j.ejogrb.2016.12.011

    Article  CAS  PubMed  Google Scholar 

  55. Butticè S, Laganà AS, Mucciardi G et al (2016) Different patterns of pelvic ureteral endometriosis. What is the best treatment? Results of a retrospective analysis. Arch Ital Urol Androl 88:266–269. https://doi.org/10.4081/aiua.2016.4.266

    Article  PubMed  Google Scholar 

  56. Freire MJ, Dinis PJ, Medeiros R et al (2017) Deep infiltrating endometriosis-urinary tract involvement and predictive factors for major surgery. Urology 108:65–70. https://doi.org/10.1016/j.urology.2017.06.039

    Article  PubMed  Google Scholar 

  57. Afors K, Murtada R, Centini G et al (2014) Employing laparoscopic surgery for endometriosis. Womens Health (Lond) 10:431–443. https://doi.org/10.2217/whe.14.28

    Article  CAS  Google Scholar 

  58. Laganà AS, Vitale SG, Trovato MA et al (2016) Full-thickness excision versus shaving by laparoscopy for intestinal deep infiltrating endometriosis: rationale and potential treatment options. Biomed Res Int 2016:3617179. https://doi.org/10.1155/2016/3617179

    Article  PubMed  PubMed Central  Google Scholar 

  59. Donnez O, Roman H (2017) Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril 108:931–942. https://doi.org/10.1016/j.fertnstert.2017.09.006

    Article  PubMed  Google Scholar 

  60. Raffaelli R, Garzon S, Baggio S et al (2018) Mesenteric vascular and nerve sparing surgery in laparoscopic segmental intestinal resection for deep infiltrating endometriosis. Eur J Obstet Gynecol Reprod Biol 231:214–219. https://doi.org/10.1016/j.ejogrb.2018.10.057

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Saint Joseph University, Beirut, Lebanon

    Yara Abdel Khalek & Zaki Sleiman

  2. Department of Obstetrics and Gynecology, Lebanese American University, Zahar Street, Beirut, Lebanon

    Roger Bitar & Zaki Sleiman

  3. Christoforou Clinic, Larnaca, Cyprus

    Costas Christoforou

  4. Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy

    Simone Garzon

  5. Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT(Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), University of Pittsburgh Medical Center Italy, Palermo, Italy

    Alessandro Tropea

  6. Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy

    Antonio Biondi

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  1. Yara Abdel Khalek
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  2. Roger Bitar
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Correspondence to Zaki Sleiman.

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Abdel Khalek, Y., Bitar, R., Christoforou, C. et al. Uterine manipulator in total laparoscopic hysterectomy: safety and usefulness. Updates Surg 72, 1247–1254 (2020). https://doi.org/10.1007/s13304-019-00681-w

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