Purpose: This study aimed to report the uptake of hysterectomy and/or bilateral salpingo-oophorectomy (BSO) to prevent gynaecological cancers (risk-reducing surgery [RRS]) in carriers of pathogenic... Show morePurpose: This study aimed to report the uptake of hysterectomy and/or bilateral salpingo-oophorectomy (BSO) to prevent gynaecological cancers (risk-reducing surgery [RRS]) in carriers of pathogenic MMR (path_MMR) variants.Methods: The Prospective Lynch Syndrome Database (PLSD) was used to investigate RRS by a cross-sectional study in 2292 female path_MMR carriers aged 30-69 years.Results: Overall, 144, 79, and 517 carriers underwent risk-reducing hysterectomy, BSO, or both combined, respectively. Two-thirds of procedures before 50 years of age were combined hysterectomy and BSO, and 81% of all procedures included BSO. Risk-reducing hysterectomy was performed before age 50 years in 28%, 25%, 15%, and 9%, and BSO in 26%, 25%, 14% and 13% of path_MLH1, path_MSH2, path_MSH6, and path_PMS2 carriers, respectively. Before 50 years of age, 107 of 188 (57%) BSO and 126 of 204 (62%) hysterectomies were performed in women without any prior cancer, and only 5% (20/392) were performed simultaneously with colorectal cancer (CRC) surgery.Conclusion: Uptake of RRS before 50 years of age was low, and RRS was rarely undertaken in association with surgical treatment of CRC. Uptake of RRS aligned poorly with gene-and age-associated risk estimates for endometrial or ovarian cancer that were published recently from PLSD and did not correspond well with current clinical guidelines. The reasons should be clarified. Decision-making on opting for or against RRS and its timing should be better aligned with predicted risk and mortality for endometrial and ovarian cancer in Lynch syn-drome to improve outcomes. (C) 2021 The Author(s). Published by Elsevier Ltd. Show less
Meeuwsen, F.C.; Luyn, F. van; Blikkendaal, M.D.; Jansen, F.W.; Dobbelsteen, J.J. van den 2019
BackgroundSurgical Process Modelling (SPM) offers the possibility to automatically gain insight in the surgical workflow, with the potential to improve OR logistics and surgical care. Most studies... Show moreBackgroundSurgical Process Modelling (SPM) offers the possibility to automatically gain insight in the surgical workflow, with the potential to improve OR logistics and surgical care. Most studies have focussed on phase recognition modelling of the laparoscopic cholecystectomy, because of its standard and frequent execution. To demonstrate the broad applicability of SPM, more diverse and complex procedures need to be studied. The aim of this study is to investigate the accuracy in which we can recognise and extract surgical phases in laparoscopic hysterectomies (LHs) with inherent variability in procedure time. To show the applicability of the approach, the model was used to automatically predict surgical end-times.MethodsA dataset of 40 video-recorded LHs was manually annotated for instrument use and divided into ten surgical phases. The use of instruments provided the feature input for building a Random Forest surgical phase recognition model that was trained to automatically recognise surgical phases. Tenfold cross-validation was performed to optimise the model for predicting the surgical end-time throughout the procedure.ResultsAverage surgery time is 12827min. Large variability within specific phases is seen. Overall, the Random Forest model reaches an accuracy of 77% recognising the current phase in the procedure. Six of the phases are predicted accurately over 80% of their duration. When predicting the surgical end-time, on average an error of 16 +/- 13min is reached throughout the procedure.Conclusionsp id=ParThis study demonstrates an intra-operative approach to recognise surgical phases in 40 laparoscopic hysterectomy cases based on instrument usage data. The model is capable of automatic detection of surgical phases for generation of a solid prediction of the surgical end-time. Show less
Haak, L. van den; Kroon, C.D. de; Warmerdam, M.I.; Siebers, A.G.; Rhemrev, J.P.; Nieboer, T.E.; Jansen, F.W. 2019
In this thesis, quantitative and qualitative evidence was gathered in an attempt to improve and extend the current sexual health care of gynaecological cancer survivors. Although surgery has a... Show moreIn this thesis, quantitative and qualitative evidence was gathered in an attempt to improve and extend the current sexual health care of gynaecological cancer survivors. Although surgery has a major impact on sexual functioning, vaginal changes and symptoms have been shown to be more profound after intensive radiotherapy. Therefore, the studies in this thesis were especially focused on gynaecological cancer survivors who received radiotherapy, and mainly concerned cervical cancer patients; a relatively young patient population often treated with intensive external-beam radiation therapy (EBRT) in combination concurrent chemotherapy, and intrauterine and vaginal brachytherapy (BT), although the results are equally relevant to other gynaecological cancer patients treated with EBRT with or without BT. In order to assess what type of patient education and/or support would be needed to minimise the impact of gynaecological cancer treatment on sexual functioning, and to improve the survivors’ sexual recovery we followed several approaches: assessment of survivors’ experience with sexual distress after treatment, and unmet needs for psychosexual counselling and support; it was explored how survivors and professionals could best deal with treatment-induced vaginal changes; and, partly based on the previous findings, a sexual rehabilitation intervention was developed and evaluated in a pilot study. Show less
Haak, L. van den; Alleblas, C.; Nieboer, T.E.; Rhemrev, J.P.; Jansen, F.W. 2015
Although hospitals increasingly opt for the laparoscopic over the conventional approach and the decline in diagnostic procedures is well compensated by an increase in numbers of all types of... Show moreAlthough hospitals increasingly opt for the laparoscopic over the conventional approach and the decline in diagnostic procedures is well compensated by an increase in numbers of all types of therapeutic procedures, the implementation of laparoscopic hysterectomy in the Netherlands seems to be hampered and scattered (chapter 2). The majority of hospitals that apply laparoscopic hysterectomy perform only a minority of the total volume of procedures, whereas the minority of hospitals performs a high annual caseload of procedures. From our studies, preference and referral tendencies seem to be suboptimal, despite knowledge indication and advantages of this minimally invasive technique (chapter 4). Gynecologists employed in a hospital that did not perform laparoscopic hysterectomies were much less likely to refer candidates for this procedure, despite basic knowledge about the indication and limitations of the approach. Furthermore, patient related factors, such as body mass index and uterus weight, might play a role in this tendency. The level of experience (expressed in number of laparoscopic hysterectomies performed) did not significantly influence the laparoscopist__s opinion on body mass index, uterus weight and previous abdominal surgery as restrictive characteristics for the laparoscopic approach. Both, performers as well as referring colleagues regarded a high body mass index, big uterus weight and previous abdominal surgery as restricting parameters for the laparoscopic approach. This is worrisome, as we know that the majority of these __challenging__ patients have an uneventful procedure (85%) and especially since there is evidence that the obese patient is better served by a laparoscopic approach than by conventional abdominal surgery. Furthermore, it was shown that with growing popularity of this procedure (half of laparoscopic hysterectomy performing gynecologists had less than five years experience), a steady state of implementation of this advanced laparoscopic surgical procedure has yet not been reached. The Laparoscopic Assisted Vaginal Hysterectomy (LAVH), a variant of laparoscopic hysterectomy, showed to be generally performed by inexperienced surgeons in low volume hospitals, while adverse events and blood loss were increased compared to Total Laparoscopic Hysterectomy (chapter 3 and chapter 5). In our prospective study in 79 surgeons (the LapTop! study), we observed that the success of surgical outcomes was significantly influenced by uterus weight, body mass index, ASA classification and previous abdominal surgeries, next to the type of laparoscopic hysterectomy (chapter 5). Surgical experience also predicted the successful outcome of laparoscopic hysterectomy with respect to blood loss and adverse events. However, also an experience independent surgical skills factor was identified, representing a crucial determinant in measuring quality of surgery. This skills factor was also present in the probability of conversion to laparotomy in the same cohort (chapter 6). The majority of conversions were performed because of strategic considerations, while uncontrollable bleeding was the main adverse event leading to a reactive conversion. A high body mass index and increased uterus weight predicted conversion probability, while experience did not.vaginal and abdominal hysterectomy (chapter 7). Therefore, minimally invasive surgery is not necessarily minimally painful. However, patients in the minimally invasive group reported a steeper decline in pain scores postoperatively. Acquiring and maintaining skills in laparoscopic hysterectomy by mentorship showed to be effective, safe and durable, as indication, operative time and adverse event rates were comparable to those of the mentor in his own hospital during and after completing the mentorship program (chapter 8). Assessment of skills in advanced laparoscopic surgery is increasingly demanded. Prediction of surgical skills based on __in vitro__ box trainers outcomes was not conclusive as surgeons with suboptimal average clinical outcomes could not be indicated by means of a box trainer task (chapter 9). However, __real time__ risk-adjusted clinical monitoring of performance by means of cumulative sum (CUSUM) analysis appeared to be a valuable tool in order to signal derailing performance in a timely fashion (chapter 10). This is paramount, as in laparoscopic hysterectomy no definitive accomplishment of the proficiency curve is foreseen and applying relevant predictors of quality of surgery should guard patient safety. Show less
This thesis describes the results of the LEMMoN study, a nationwide prospective cohort study into severe maternal morbidity in the Netherlands in which all hospitals in the Netherlands participated... Show moreThis thesis describes the results of the LEMMoN study, a nationwide prospective cohort study into severe maternal morbidity in the Netherlands in which all hospitals in the Netherlands participated. The main objectives of the study were to assess incidence, case fatality rate, risk factors and substandard care in severe maternal morbidity in the Netherlands. Cases of severe maternal morbidity were collected during a two-year period. All pregnant women in the Netherlands in the same period acted as reference cohort (n=371,021). Special attention was paid to the ethnic background. Substandard care was assessed in selected cases during audit meetings. Severe maternal morbidity was reported in 2552 cases, overall incidence being 7.1 per 1000 deliveries. Incidences of ICU admission, uterine rupture, eclampsia and major obstetric haemorrhage were 0.24%, 0.06%, 0.06% and 0.45% per 1000, respectively. Non-Western immigrant women had a 1.3 fold increased risk of severe maternal morbidity as compared with Western women. Jehovah__s witnesses had a 3.1-fold increased risk. Overall case fatality rate was 1 in 53. Substandard care was found in 80% of assessed cases during clinical audit. Since substandard care was found in the majority of assessed cases, reduction of severe maternal morbidity seems a mandatory challenge. Show less
In the recent past, the established method for investigating women with abnormal uterine bleeding was dilatation and curettage. When hysteroscopic examination of the uterus proved to be more... Show moreIn the recent past, the established method for investigating women with abnormal uterine bleeding was dilatation and curettage. When hysteroscopic examination of the uterus proved to be more accurate, diagnostic hysteroscopy with or without endometrial sampling was suggested as the method of choice. The small diameter scopes with working- channels combined with the vaginoscopic approach have caused a shift from the inpatient setting to an ambulatory one without anaesthesia. Likewise, the introduction of several new surgical techniques has improved handling of instruments, patient safety and therapeutic options. This thesis deals with the implementation of hysteroscopic surgery in The Netherlands, the diagnostic accuracy of hysteroscopy, the patient preference with regard to the method of examining the uterine cavity, and the effectiveness of several hysteroscopic applications in the treatment of abnormal uterine bleeding. Show less
