Bradford Fenton - Academia.edu (original) (raw)

Papers by Bradford Fenton

Research paper thumbnail of Receiver Operating Characteristic Curves of Symptom Scores in the Diagnosis of Interstitial Cystitis/Painful Bladder Syndrome

Journal of Minimally Invasive Gynecology, Sep 1, 2008

Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several sym... more Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several symptom scoring measures exist. However, the receiver operating characteristic (ROC) curves for these scores have not been described, even though such analysis could identify an optimal noninvasive test and suggest diagnostic test thresholds. The objective of this study was to develop ROC curves for IC symptom scores based on the standard of pain relief after cystoscopy with hydrodistention (HD). This is a retrospective analysis of IC symptom index (ICSI) and visual analog scale (VAS) bladder pain (VASb) scores recorded at initial patient visit. Patients underwent a diagnostic algorithm leading to selected HD. The ROC curves were calculated based on the presence of diagnostic criteria for IC found at HD (Canadian Task Force classification III). A multidisciplinary chronic pelvic pain referral center. A total of 277 women with chronic pelvic pain were evaluated. The mean duration of pain was 54 months; mean pelvic pain VAS score was 7.5. Those proved to have IC had a VASb score of 7 and an ICSI score of 11. Initial symptom score tabulation followed by a symptom-based diagnostic algorithm consisting of alkalinized lidocaine instillation with HD offered to responders. The ROC curve for the VASb was shifted to the upper left compared with the ICSI, which was closer to the diagonal. Area under the curve was significantly greater for VASb (0.860) than ICSI (0.773) (p=.045). The maximum diagnostic accuracy for the ICSI was at a value of 14 or more (0.88) and for the VASb at a value of 7 or more (0.94). The most accurate symptom score for detecting IC based on this analysis was the VASb with a threshold of 7. Although the ICSI may have use, in this setting it is not as useful as the VAS for identifying patients who eventually prove to have IC.

Research paper thumbnail of Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more

Jsls-journal of The Society of Laparoendoscopic Surgeons, Oct 1, 2008

Objective: To determine the acceptability and outcome of laparoscopic assisted vaginal hysterecto... more Objective: To determine the acceptability and outcome of laparoscopic assisted vaginal hysterectomy at the Aga Khan Hospital, Nairobi. Design: A retrospective case analysis. Subjects: Two hundrend and twenty nine cases of laparoscopic assisted hysterectomy were undertaken at various hospitals in the presence of the principal author from May 2000 to December 2003. Of these 149 (65.06%) were performed at the Aga Khan Hospital, Nairobi. These cases have been reviewed, analysed and presented. Exclusions: All cases performed at the various other hospitals were excluded, along with those cases of laparoscopic assisted vaginal hysterectomy which are now being performed by other consultants obstetricians and gynaecologists, on their own and who have now learnt the technique Results: Over the last three years, 149 cases of laparoscopic assisted vaginal hysterectomy were undertaken at the Aga Khan Hospital, Nairobi. Annual case load increased from three cases in 2000, to 71 cases by December, 2003. Fifty one percent of the patients were between 46 to 50 years of age, while 93.9% were para 2 + 0 and above. Menorrhagia was the presenting complaint in 55.7%. The operative procedure was performed in 91 to 120 minutes in 58.3% of the cases. Hospital stays were two nights in 95.3%. The complications encountered were bladder injury (3.4%), bowel injury (1.3%), port site herniation (0.67%) and a delayed recognition of bladder injury (0.67%). Conclusion: In Kenya, laparoscopic surgery is gradually being accepted by gynaecologists and general surgeons. The conversion from total abdominal hysterectomy to laparoscopic assisted vaginal hysterectomy for benign uterine pathology is now becoming more popular amongst gynaecologists and patients. With time laparoscopic assistance during hysterectomy will become the norm.

Research paper thumbnail of Robotic radical hysterectomy

American Journal of Obstetrics and Gynecology, Jun 1, 2008

Advanced laparoscopic procedures are increasing being used in gynecologic surgery. The da Vinci r... more Advanced laparoscopic procedures are increasing being used in gynecologic surgery. The da Vinci robotic system (Intuitive Surgical Corporation, Sunnyvale, CA) can further augment laparoscopic surgery. We describe our initial experience using the da Vinci robotic system to perform radical hysterectomy. STUDY DESIGN: Twenty consecutive patients with primary stage IB-IIA cervical carcinoma underwent class 3 radical hysterectomy with the use of the da Vinci robotic system. Median age was 44 years, median weight was 69.9 kg, 65% of patients had medical comorbidity, and 40% had prior abdominal surgery. RESULTS: All 20 patients successfully underwent robotic radical hysterectomy. Median operative time was 6.5 hours (3.5-8.5 hours) and median blood loss was 300 mL. All patients were discharged on the first day after surgery. At median follow-up of 2 years (0.6-3 years), 90% of patients are alive and disease free. CONCLUSION: We report the first series of robotic radical hysterectomy for early stage cervical cancer. All cases were successfully performed robotically with minimal complications and all patients were discharged on postoperative day 1.

Research paper thumbnail of Proton magnetic resonance spectroscopy can detect a lecithin signal from human fetal lung in utero: A potentially noninvasive technique for fetal lung maturity testing

Obstetrics & Gynecology, Apr 1, 1999

Research paper thumbnail of Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more

Journal of the Society of Laparoendoscopic Surgeons

Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterect... more Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing > or =1000 grams. Fifteen patients underwent attempted LAVH for uteri >1000g. Median age was 45 years old (range, 31 to 57), and median weight was 170 pounds (range, 130 to 236); 64% had medical comorbidities, and 43% had prior pelvic surgery. Five ports (5 mm) were used to allow maximum uterine manipulation. Uterine vessels were doubly coagulated. Fourteen of 15 cases (93%) were successfully completed laparoscopically. Median uterine weight was 1090 grams (range, 1000 to 1650). Median operative time was 3.5 hours (range, 2 to 4.6), and median blood loss was 400 mL (range, 100 to 1200). All patients were discharged on postoperative day one, and no patients developed a postoperative complication. We believe that LAVH is a safe and ef...

Research paper thumbnail of Quantification of Abdominal Wall Pain Using Pain Pressure Threshold Algometry in Patients With Chronic Pelvic Pain

The Clinical Journal of Pain, 2009

Chronic pelvic pain (CPP) is a syndrome involving 1 or more pain generating organs in the pelvis,... more Chronic pelvic pain (CPP) is a syndrome involving 1 or more pain generating organs in the pelvis, which includes pain from the lower anterior abdominal wall. This entity has been termed myofascial pain syndrome (MFPS), but its characteristics, definition, and quantification have not been well described. In this study, pain pressure threshold (PPT) testing of the lower anterior abdominal wall in CPP patients was performed to determine the range and distribution of values at each site, and the clinical utility of using PPT in a definition of MFPS. Fifty-six patients evaluated in a CPP specialty clinic underwent PPT algometry of 14 sites on the lower anterior abdominal wall. These values were described and evaluated before and after treatment. PPT values were also evaluated in patients found to be drug seeking. Twenty percent of the PPT tests reached the threshold of 3 kgf/cm2. The abnormal tests usually formed a normal distribution. PPT testing had a weak but appropriate correlation with other pain symptom measures. After trigger point injection there was a 75% improvement in PPT, and response to medical therapy resulted in a 60% improvement. A composite measure was able to distinguish drug-seeking patients with statistical accuracy. PPT testing can be used to evaluate MFPS in CPP patients. One suggested definition would exclude patients with low scores in the upper abdomen while including patients with low scores in the lower abdomen.

Research paper thumbnail of A preliminary study of transcranial direct current stimulation for the treatment of refractory chronic pelvic pain

Research paper thumbnail of Cost-effectiveness analysis of the treatment of large leiomyomas: laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy

American Journal of Obstetrics and Gynecology, 2007

The purpose of this study was to perform a cost-effectiveness analysis comparing the treatment of... more The purpose of this study was to perform a cost-effectiveness analysis comparing the treatment of large leiomyomas by laparoscopic assisted vaginal hysterectomy (LAVH) versus abdominal hysterectomy (AH). STUDY DESIGN: Twenty consecutive LAVH were compared to 20 consecutive AH for leiomyoma Ն 250 g. Hospital costs were obtained through Healthcare cost accounting system. The 6 principles of costeffectiveness analysis were used. RESULTS: The groups were similar in respect to age, weight, race, medical comorbidities, blood loss, and operative time. Median uterine weight (513 g) was Ϸ 20% Ͼ for LAVH. Length of stay and pain was significantly less for LAVH. Total hospital cost for AH was Ϸ 12% less expensive ($4394 vs $5023, P ϭ .18). CONCLUSION: Because of multiple benefits of LAVH versus AH and no significant difference in cost, we believe LAVH is an acceptable treatment for large leiomyoma.

Research paper thumbnail of Laparoscopic application of hyaluronate/carboxymethylcellulose slurry

American Journal of Obstetrics and Gynecology, 2008

Research paper thumbnail of Receiver Operating Characteristic Curves of Symptom Scores in the Diagnosis of Interstitial Cystitis/Painful Bladder Syndrome

Journal of Minimally Invasive Gynecology, 2008

Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several sym... more Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several symptom scoring measures exist. However, the receiver operating characteristic (ROC) curves for these scores have not been described, even though such analysis could identify an optimal noninvasive test and suggest diagnostic test thresholds. The objective of this study was to develop ROC curves for IC symptom scores based on the standard of pain relief after cystoscopy with hydrodistention (HD). This is a retrospective analysis of IC symptom index (ICSI) and visual analog scale (VAS) bladder pain (VASb) scores recorded at initial patient visit. Patients underwent a diagnostic algorithm leading to selected HD. The ROC curves were calculated based on the presence of diagnostic criteria for IC found at HD (Canadian Task Force classification III). A multidisciplinary chronic pelvic pain referral center. A total of 277 women with chronic pelvic pain were evaluated. The mean duration of pain was 54 months; mean pelvic pain VAS score was 7.5. Those proved to have IC had a VASb score of 7 and an ICSI score of 11. Initial symptom score tabulation followed by a symptom-based diagnostic algorithm consisting of alkalinized lidocaine instillation with HD offered to responders. The ROC curve for the VASb was shifted to the upper left compared with the ICSI, which was closer to the diagonal. Area under the curve was significantly greater for VASb (0.860) than ICSI (0.773) (p=.045). The maximum diagnostic accuracy for the ICSI was at a value of 14 or more (0.88) and for the VASb at a value of 7 or more (0.94). The most accurate symptom score for detecting IC based on this analysis was the VASb with a threshold of 7. Although the ICSI may have use, in this setting it is not as useful as the VAS for identifying patients who eventually prove to have IC.

Research paper thumbnail of SCIENTIFIC PAPER Laparoscopic-Assisted Vaginal Hysterectomy for Uteri Weighing 1000 Grams or More

Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vag... more Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing �1000

Research paper thumbnail of A Laparoscopic Simulator Tool for Objective Measurement of Residents' Laparoscopic Ability

JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2007

Objective: We sought to develop an objective measurement of residents' laparoscopic ability b... more Objective: We sought to develop an objective measurement of residents' laparoscopic ability by using a laparoscopic simulator assessment tool. Methods: An inexpensive laparoscopic simulator was developed. Three laparoscopic assessment procedures were created: 1) bead/pom-pom drop, 2) checkerboard drill, and 3) bead manipulation. Two minimally invasive surgeons and 8 PGY 3/4 and 15 PGY 1 residents were timed performing the 3 procedures. Ten of the PGY 1 residents were retested at the end of their PGY 1 year. Results: The minimally invasive surgeons completed the laparoscopic drills in approximately half the time of the PGY 3/4 (P=0.02), and PGY 3/4 were 60% faster than PGY 1 (P=0.01). PGY 1 completed the drills in half the time at the end of the PGY 1 year (P=0.005). As an objective measurement of residents' laparoscopic surgery competency, by the completion of the academic year, all PGY 1 residents must be able to complete the drills as fast as or faster than the original PG...

Research paper thumbnail of Laparoscopic-Assisted Vaginal Hysterectomy for Uteri Weighing 1000 Grams or More

Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vag... more Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing ≥1000 grams. Methods: Fifteen patients underwent attempted LAVH for uteri >1000g. Median age was 45 years old (range, 31 to 57), and median weight was 170 pounds (range, 130 to 236); 64% had medical comorbidities, and 43% had prior pelvic surgery. Five ports (5 mm) were used to allow maximum uterine manipulation. Uterine vessels were doubly coagulated. Results: Fourteen of 15 cases (93%) were successfully completed laparoscopically. Median uterine weight was 1090 grams (range, 1000 to 1650). Median operative time was 3.5 hours (range, 2 to 4.6), and median blood loss was 400 mL (range, 100 to 1200). All patients were discharged on postoperative day one, and no patients developed a postoperative complication. Conclusion: W...

Research paper thumbnail of Incidental Kidney Stone Diagnosed During Laparoscopy-Assisted Vaginal Hysterectomy

CRSLS: MIS Case Reports from SLS

Introduction: Hysterectomies are the second most common major surgical procedure among women in t... more Introduction: Hysterectomies are the second most common major surgical procedure among women in their reproductive years. Ureteral injury is a known complication of this surgery. Intraoperative cystoscopy is not yet used routinely to evaluate the ureteral function before concluding a benign hysterectomy. Case Description: A 40-year-old woman had a laparoscopy-assisted vaginal hysterectomy with intraoperative cystoscopy that noted unilateral absence of ureteral dye spill. Urology was consulted and diagnosed an incidental, complete, obstructing kidney stone in the ureter, which was removed and stented during an exploratory laparotomy. Conclusion: Although the chance of ureteral obstruction secondary to a kidney stone is small, either during or after gynecologic surgery, this case suggests that it should remain on the list of differential diagnoses.

Research paper thumbnail of Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more

Jsls Journal of the Society of Laparoendoscopic Surgeons Society of Laparoendoscopic Surgeons, 2008

Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vag... more Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing > or =1000 grams. Methods: Fifteen patients underwent attempted LAVH for uteri >1000g. Median age was 45 years old (range, 31 to 57), and median weight was 170 pounds (range, 130 to 236); 64% had medical comorbidities, and 43% had prior pelvic surgery. Five ports (5 mm) were used to allow maximum uterine manipulation. Uterine vessels were doubly coagulated. Results: Fourteen of 15 cases (93%) were successfully completed laparoscopically. Median uterine weight was 1090 grams (range, 1000 to 1650). Median operative time was 3.5 hours (range, 2 to 4.6), and median blood loss was 400 mL (range, 100 to 1200). All patients were discharged on postoperative day one, and no patients developed a postoperative complication. Conclusion: We believe that LAVH is a safe and effective approach for uteri larger than 1000 g. It is our opinion that 3 surgical techniques are required; maximum Trendelenburg position, adequate number of ports, and double coagulations of the uterine vessels.

Research paper thumbnail of Measuring quality of life in chronic pelvic pain syndrome

Expert Review of Obstetrics Gynecology, 2010

... levator ani syndrome • myofascial pain syndrome • pain scale • pelvic floor tension myalgia •... more ... levator ani syndrome • myofascial pain syndrome • pain scale • pelvic floor tension myalgia •sexual functioning ... 5]. Patients with a secondary agenda for supporting a narcotic addiction make the ... of identifying patients at risk for malignancy or other acute medical or surgical ...

Research paper thumbnail of Limbic associated pelvic pain: A hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain

Medical Hypotheses, Feb 1, 2007

Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly... more Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly encountered in patients with chronic pelvic pain, including the presence of multiple pain diagnoses, the frequency of previous abuse, the minimal or discordant pathologic changes of the involved organs, the paradoxical effectiveness of many treatments, and the recurrent nature of the condition. These conditions include endometriosis, interstitial cystitis, irritable bowel syndrome, levator ani syndrome, pelvic floor tension myalgia, vulvar vestibulitis, and vulvodynia. The hypothesis is based on recent improvements in the understanding of pain processing pathways in the central nervous system, and in particular the role of limbic structures, especially the anterior cingulate cortex, hippocampus and amygdala, in chronic and affective pain perception. Limbic associated pelvic pain is hypothesized to occur in patients with chronic pelvic pain out of proportion to any demonstrable pathology (hyperalgesia), and with more than one demonstrable pain generator (allodynia), and who are susceptible to development of the syndrome. This most likely occurs as a result of childhood sexual abuse but may include other painful pelvic events or stressors, which lead to limbic dysfunction. This limbic dysfunction is manifest both as an increased sensitivity to pain afferents from pelvic organs, and as an abnormal efferent innervation of pelvic musculature, both visceral and somatic. The pelvic musculature undergoes tonic contraction as a result of limbic efferent stimulation, which produces the minimal changes found on pathological examination, and generates a further sensation of pain. The pain afferents from these pelvic organs then follow the medial pain pathway back to the sensitized, hypervigilant limbic system. Chronic stimulation of the limbic system by pelvic pain afferents again produces an efferent contraction of the pelvic muscles, thus perpetuating the cycle. This cycle is susceptible to disruption through blocking afferent signals from pelvic organs, either through anesthesia or muscle manipulation. Disruption of limbic perception with psychiatric medication similarly produces relief. Without a full disruption of both the central hypervigilance and pelvic organ dysfunction, pain recurs. To prevent recurrence, clinicians will need to include some form of therapy, either medical or cognitive, targeted at the underlying limbic hypervigilance. Further research into novel, limbic targeted therapies can hopefully be stimulated by explicitly stating the role of the limbic system in chronic pain. This hypothesis provides a framework for clinicians to rationally approach some of the most challenging patients in medicine, and can potentially improve outcomes by including management of limbic dysfunction in their treatment.

Research paper thumbnail of A Retrospective Analysis to Compare the Effects of Intravenous Acetaminophen Administered Intraoperatively

Journal of Gynecologic Surgery, 2015

Research paper thumbnail of MR spectroscopy in the human fetus - Respond

Research paper thumbnail of Classifying Patients with Chronic Pelvic Pain into Levels of Biopsychosocial Dysfunction Using Latent Class Modeling of Patient Reported Outcome Measures

Pain Research and Treatment, 2015

Chronic pelvic pain affects multiple aspects of a patient’s physical, social, and emotional funct... more Chronic pelvic pain affects multiple aspects of a patient’s physical, social, and emotional functioning. Latent class analysis (LCA) of Patient Reported Outcome Measures Information System (PROMIS) domains has the potential to improve clinical insight into these patients’ pain. Based on the 11 PROMIS domains applied ton=613patients referred for evaluation in a chronic pelvic pain specialty center, exploratory factor analysis (EFA) was used to identify unidimensional superdomains. Latent profile analysis (LPA) was performed to identify the number of homogeneous classes present and to further define the pain classification system. The EFA combined the 11 PROMIS domains into four unidimensional superdomains of biopsychosocial dysfunction: Pain, Negative Affect, Fatigue, and Social Function. Based on multiple fit criteria, a latent class model revealed four distinct classes of CPP: No dysfunction (3.2%); Low Dysfunction (17.8%); Moderate Dysfunction (53.2%); and High Dysfunction (25.8%)...

Research paper thumbnail of Receiver Operating Characteristic Curves of Symptom Scores in the Diagnosis of Interstitial Cystitis/Painful Bladder Syndrome

Journal of Minimally Invasive Gynecology, Sep 1, 2008

Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several sym... more Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several symptom scoring measures exist. However, the receiver operating characteristic (ROC) curves for these scores have not been described, even though such analysis could identify an optimal noninvasive test and suggest diagnostic test thresholds. The objective of this study was to develop ROC curves for IC symptom scores based on the standard of pain relief after cystoscopy with hydrodistention (HD). This is a retrospective analysis of IC symptom index (ICSI) and visual analog scale (VAS) bladder pain (VASb) scores recorded at initial patient visit. Patients underwent a diagnostic algorithm leading to selected HD. The ROC curves were calculated based on the presence of diagnostic criteria for IC found at HD (Canadian Task Force classification III). A multidisciplinary chronic pelvic pain referral center. A total of 277 women with chronic pelvic pain were evaluated. The mean duration of pain was 54 months; mean pelvic pain VAS score was 7.5. Those proved to have IC had a VASb score of 7 and an ICSI score of 11. Initial symptom score tabulation followed by a symptom-based diagnostic algorithm consisting of alkalinized lidocaine instillation with HD offered to responders. The ROC curve for the VASb was shifted to the upper left compared with the ICSI, which was closer to the diagonal. Area under the curve was significantly greater for VASb (0.860) than ICSI (0.773) (p=.045). The maximum diagnostic accuracy for the ICSI was at a value of 14 or more (0.88) and for the VASb at a value of 7 or more (0.94). The most accurate symptom score for detecting IC based on this analysis was the VASb with a threshold of 7. Although the ICSI may have use, in this setting it is not as useful as the VAS for identifying patients who eventually prove to have IC.

Research paper thumbnail of Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more

Jsls-journal of The Society of Laparoendoscopic Surgeons, Oct 1, 2008

Objective: To determine the acceptability and outcome of laparoscopic assisted vaginal hysterecto... more Objective: To determine the acceptability and outcome of laparoscopic assisted vaginal hysterectomy at the Aga Khan Hospital, Nairobi. Design: A retrospective case analysis. Subjects: Two hundrend and twenty nine cases of laparoscopic assisted hysterectomy were undertaken at various hospitals in the presence of the principal author from May 2000 to December 2003. Of these 149 (65.06%) were performed at the Aga Khan Hospital, Nairobi. These cases have been reviewed, analysed and presented. Exclusions: All cases performed at the various other hospitals were excluded, along with those cases of laparoscopic assisted vaginal hysterectomy which are now being performed by other consultants obstetricians and gynaecologists, on their own and who have now learnt the technique Results: Over the last three years, 149 cases of laparoscopic assisted vaginal hysterectomy were undertaken at the Aga Khan Hospital, Nairobi. Annual case load increased from three cases in 2000, to 71 cases by December, 2003. Fifty one percent of the patients were between 46 to 50 years of age, while 93.9% were para 2 + 0 and above. Menorrhagia was the presenting complaint in 55.7%. The operative procedure was performed in 91 to 120 minutes in 58.3% of the cases. Hospital stays were two nights in 95.3%. The complications encountered were bladder injury (3.4%), bowel injury (1.3%), port site herniation (0.67%) and a delayed recognition of bladder injury (0.67%). Conclusion: In Kenya, laparoscopic surgery is gradually being accepted by gynaecologists and general surgeons. The conversion from total abdominal hysterectomy to laparoscopic assisted vaginal hysterectomy for benign uterine pathology is now becoming more popular amongst gynaecologists and patients. With time laparoscopic assistance during hysterectomy will become the norm.

Research paper thumbnail of Robotic radical hysterectomy

American Journal of Obstetrics and Gynecology, Jun 1, 2008

Advanced laparoscopic procedures are increasing being used in gynecologic surgery. The da Vinci r... more Advanced laparoscopic procedures are increasing being used in gynecologic surgery. The da Vinci robotic system (Intuitive Surgical Corporation, Sunnyvale, CA) can further augment laparoscopic surgery. We describe our initial experience using the da Vinci robotic system to perform radical hysterectomy. STUDY DESIGN: Twenty consecutive patients with primary stage IB-IIA cervical carcinoma underwent class 3 radical hysterectomy with the use of the da Vinci robotic system. Median age was 44 years, median weight was 69.9 kg, 65% of patients had medical comorbidity, and 40% had prior abdominal surgery. RESULTS: All 20 patients successfully underwent robotic radical hysterectomy. Median operative time was 6.5 hours (3.5-8.5 hours) and median blood loss was 300 mL. All patients were discharged on the first day after surgery. At median follow-up of 2 years (0.6-3 years), 90% of patients are alive and disease free. CONCLUSION: We report the first series of robotic radical hysterectomy for early stage cervical cancer. All cases were successfully performed robotically with minimal complications and all patients were discharged on postoperative day 1.

Research paper thumbnail of Proton magnetic resonance spectroscopy can detect a lecithin signal from human fetal lung in utero: A potentially noninvasive technique for fetal lung maturity testing

Obstetrics & Gynecology, Apr 1, 1999

Research paper thumbnail of Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more

Journal of the Society of Laparoendoscopic Surgeons

Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterect... more Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing > or =1000 grams. Fifteen patients underwent attempted LAVH for uteri >1000g. Median age was 45 years old (range, 31 to 57), and median weight was 170 pounds (range, 130 to 236); 64% had medical comorbidities, and 43% had prior pelvic surgery. Five ports (5 mm) were used to allow maximum uterine manipulation. Uterine vessels were doubly coagulated. Fourteen of 15 cases (93%) were successfully completed laparoscopically. Median uterine weight was 1090 grams (range, 1000 to 1650). Median operative time was 3.5 hours (range, 2 to 4.6), and median blood loss was 400 mL (range, 100 to 1200). All patients were discharged on postoperative day one, and no patients developed a postoperative complication. We believe that LAVH is a safe and ef...

Research paper thumbnail of Quantification of Abdominal Wall Pain Using Pain Pressure Threshold Algometry in Patients With Chronic Pelvic Pain

The Clinical Journal of Pain, 2009

Chronic pelvic pain (CPP) is a syndrome involving 1 or more pain generating organs in the pelvis,... more Chronic pelvic pain (CPP) is a syndrome involving 1 or more pain generating organs in the pelvis, which includes pain from the lower anterior abdominal wall. This entity has been termed myofascial pain syndrome (MFPS), but its characteristics, definition, and quantification have not been well described. In this study, pain pressure threshold (PPT) testing of the lower anterior abdominal wall in CPP patients was performed to determine the range and distribution of values at each site, and the clinical utility of using PPT in a definition of MFPS. Fifty-six patients evaluated in a CPP specialty clinic underwent PPT algometry of 14 sites on the lower anterior abdominal wall. These values were described and evaluated before and after treatment. PPT values were also evaluated in patients found to be drug seeking. Twenty percent of the PPT tests reached the threshold of 3 kgf/cm2. The abnormal tests usually formed a normal distribution. PPT testing had a weak but appropriate correlation with other pain symptom measures. After trigger point injection there was a 75% improvement in PPT, and response to medical therapy resulted in a 60% improvement. A composite measure was able to distinguish drug-seeking patients with statistical accuracy. PPT testing can be used to evaluate MFPS in CPP patients. One suggested definition would exclude patients with low scores in the upper abdomen while including patients with low scores in the lower abdomen.

Research paper thumbnail of A preliminary study of transcranial direct current stimulation for the treatment of refractory chronic pelvic pain

Research paper thumbnail of Cost-effectiveness analysis of the treatment of large leiomyomas: laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy

American Journal of Obstetrics and Gynecology, 2007

The purpose of this study was to perform a cost-effectiveness analysis comparing the treatment of... more The purpose of this study was to perform a cost-effectiveness analysis comparing the treatment of large leiomyomas by laparoscopic assisted vaginal hysterectomy (LAVH) versus abdominal hysterectomy (AH). STUDY DESIGN: Twenty consecutive LAVH were compared to 20 consecutive AH for leiomyoma Ն 250 g. Hospital costs were obtained through Healthcare cost accounting system. The 6 principles of costeffectiveness analysis were used. RESULTS: The groups were similar in respect to age, weight, race, medical comorbidities, blood loss, and operative time. Median uterine weight (513 g) was Ϸ 20% Ͼ for LAVH. Length of stay and pain was significantly less for LAVH. Total hospital cost for AH was Ϸ 12% less expensive ($4394 vs $5023, P ϭ .18). CONCLUSION: Because of multiple benefits of LAVH versus AH and no significant difference in cost, we believe LAVH is an acceptable treatment for large leiomyoma.

Research paper thumbnail of Laparoscopic application of hyaluronate/carboxymethylcellulose slurry

American Journal of Obstetrics and Gynecology, 2008

Research paper thumbnail of Receiver Operating Characteristic Curves of Symptom Scores in the Diagnosis of Interstitial Cystitis/Painful Bladder Syndrome

Journal of Minimally Invasive Gynecology, 2008

Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several sym... more Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several symptom scoring measures exist. However, the receiver operating characteristic (ROC) curves for these scores have not been described, even though such analysis could identify an optimal noninvasive test and suggest diagnostic test thresholds. The objective of this study was to develop ROC curves for IC symptom scores based on the standard of pain relief after cystoscopy with hydrodistention (HD). This is a retrospective analysis of IC symptom index (ICSI) and visual analog scale (VAS) bladder pain (VASb) scores recorded at initial patient visit. Patients underwent a diagnostic algorithm leading to selected HD. The ROC curves were calculated based on the presence of diagnostic criteria for IC found at HD (Canadian Task Force classification III). A multidisciplinary chronic pelvic pain referral center. A total of 277 women with chronic pelvic pain were evaluated. The mean duration of pain was 54 months; mean pelvic pain VAS score was 7.5. Those proved to have IC had a VASb score of 7 and an ICSI score of 11. Initial symptom score tabulation followed by a symptom-based diagnostic algorithm consisting of alkalinized lidocaine instillation with HD offered to responders. The ROC curve for the VASb was shifted to the upper left compared with the ICSI, which was closer to the diagonal. Area under the curve was significantly greater for VASb (0.860) than ICSI (0.773) (p=.045). The maximum diagnostic accuracy for the ICSI was at a value of 14 or more (0.88) and for the VASb at a value of 7 or more (0.94). The most accurate symptom score for detecting IC based on this analysis was the VASb with a threshold of 7. Although the ICSI may have use, in this setting it is not as useful as the VAS for identifying patients who eventually prove to have IC.

Research paper thumbnail of SCIENTIFIC PAPER Laparoscopic-Assisted Vaginal Hysterectomy for Uteri Weighing 1000 Grams or More

Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vag... more Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing �1000

Research paper thumbnail of A Laparoscopic Simulator Tool for Objective Measurement of Residents' Laparoscopic Ability

JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2007

Objective: We sought to develop an objective measurement of residents' laparoscopic ability b... more Objective: We sought to develop an objective measurement of residents' laparoscopic ability by using a laparoscopic simulator assessment tool. Methods: An inexpensive laparoscopic simulator was developed. Three laparoscopic assessment procedures were created: 1) bead/pom-pom drop, 2) checkerboard drill, and 3) bead manipulation. Two minimally invasive surgeons and 8 PGY 3/4 and 15 PGY 1 residents were timed performing the 3 procedures. Ten of the PGY 1 residents were retested at the end of their PGY 1 year. Results: The minimally invasive surgeons completed the laparoscopic drills in approximately half the time of the PGY 3/4 (P=0.02), and PGY 3/4 were 60% faster than PGY 1 (P=0.01). PGY 1 completed the drills in half the time at the end of the PGY 1 year (P=0.005). As an objective measurement of residents' laparoscopic surgery competency, by the completion of the academic year, all PGY 1 residents must be able to complete the drills as fast as or faster than the original PG...

Research paper thumbnail of Laparoscopic-Assisted Vaginal Hysterectomy for Uteri Weighing 1000 Grams or More

Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vag... more Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing ≥1000 grams. Methods: Fifteen patients underwent attempted LAVH for uteri >1000g. Median age was 45 years old (range, 31 to 57), and median weight was 170 pounds (range, 130 to 236); 64% had medical comorbidities, and 43% had prior pelvic surgery. Five ports (5 mm) were used to allow maximum uterine manipulation. Uterine vessels were doubly coagulated. Results: Fourteen of 15 cases (93%) were successfully completed laparoscopically. Median uterine weight was 1090 grams (range, 1000 to 1650). Median operative time was 3.5 hours (range, 2 to 4.6), and median blood loss was 400 mL (range, 100 to 1200). All patients were discharged on postoperative day one, and no patients developed a postoperative complication. Conclusion: W...

Research paper thumbnail of Incidental Kidney Stone Diagnosed During Laparoscopy-Assisted Vaginal Hysterectomy

CRSLS: MIS Case Reports from SLS

Introduction: Hysterectomies are the second most common major surgical procedure among women in t... more Introduction: Hysterectomies are the second most common major surgical procedure among women in their reproductive years. Ureteral injury is a known complication of this surgery. Intraoperative cystoscopy is not yet used routinely to evaluate the ureteral function before concluding a benign hysterectomy. Case Description: A 40-year-old woman had a laparoscopy-assisted vaginal hysterectomy with intraoperative cystoscopy that noted unilateral absence of ureteral dye spill. Urology was consulted and diagnosed an incidental, complete, obstructing kidney stone in the ureter, which was removed and stented during an exploratory laparotomy. Conclusion: Although the chance of ureteral obstruction secondary to a kidney stone is small, either during or after gynecologic surgery, this case suggests that it should remain on the list of differential diagnoses.

Research paper thumbnail of Laparoscopic-assisted vaginal hysterectomy for uteri weighing 1000 grams or more

Jsls Journal of the Society of Laparoendoscopic Surgeons Society of Laparoendoscopic Surgeons, 2008

Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vag... more Introduction: Prospective randomized trials have proven the benefits of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with abdominal hysterectomy. The purpose of this study was to evaluate the safety and efficacy of LAVH performed for uteri weighing > or =1000 grams. Methods: Fifteen patients underwent attempted LAVH for uteri >1000g. Median age was 45 years old (range, 31 to 57), and median weight was 170 pounds (range, 130 to 236); 64% had medical comorbidities, and 43% had prior pelvic surgery. Five ports (5 mm) were used to allow maximum uterine manipulation. Uterine vessels were doubly coagulated. Results: Fourteen of 15 cases (93%) were successfully completed laparoscopically. Median uterine weight was 1090 grams (range, 1000 to 1650). Median operative time was 3.5 hours (range, 2 to 4.6), and median blood loss was 400 mL (range, 100 to 1200). All patients were discharged on postoperative day one, and no patients developed a postoperative complication. Conclusion: We believe that LAVH is a safe and effective approach for uteri larger than 1000 g. It is our opinion that 3 surgical techniques are required; maximum Trendelenburg position, adequate number of ports, and double coagulations of the uterine vessels.

Research paper thumbnail of Measuring quality of life in chronic pelvic pain syndrome

Expert Review of Obstetrics Gynecology, 2010

... levator ani syndrome • myofascial pain syndrome • pain scale • pelvic floor tension myalgia •... more ... levator ani syndrome • myofascial pain syndrome • pain scale • pelvic floor tension myalgia •sexual functioning ... 5]. Patients with a secondary agenda for supporting a narcotic addiction make the ... of identifying patients at risk for malignancy or other acute medical or surgical ...

Research paper thumbnail of Limbic associated pelvic pain: A hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain

Medical Hypotheses, Feb 1, 2007

Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly... more Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly encountered in patients with chronic pelvic pain, including the presence of multiple pain diagnoses, the frequency of previous abuse, the minimal or discordant pathologic changes of the involved organs, the paradoxical effectiveness of many treatments, and the recurrent nature of the condition. These conditions include endometriosis, interstitial cystitis, irritable bowel syndrome, levator ani syndrome, pelvic floor tension myalgia, vulvar vestibulitis, and vulvodynia. The hypothesis is based on recent improvements in the understanding of pain processing pathways in the central nervous system, and in particular the role of limbic structures, especially the anterior cingulate cortex, hippocampus and amygdala, in chronic and affective pain perception. Limbic associated pelvic pain is hypothesized to occur in patients with chronic pelvic pain out of proportion to any demonstrable pathology (hyperalgesia), and with more than one demonstrable pain generator (allodynia), and who are susceptible to development of the syndrome. This most likely occurs as a result of childhood sexual abuse but may include other painful pelvic events or stressors, which lead to limbic dysfunction. This limbic dysfunction is manifest both as an increased sensitivity to pain afferents from pelvic organs, and as an abnormal efferent innervation of pelvic musculature, both visceral and somatic. The pelvic musculature undergoes tonic contraction as a result of limbic efferent stimulation, which produces the minimal changes found on pathological examination, and generates a further sensation of pain. The pain afferents from these pelvic organs then follow the medial pain pathway back to the sensitized, hypervigilant limbic system. Chronic stimulation of the limbic system by pelvic pain afferents again produces an efferent contraction of the pelvic muscles, thus perpetuating the cycle. This cycle is susceptible to disruption through blocking afferent signals from pelvic organs, either through anesthesia or muscle manipulation. Disruption of limbic perception with psychiatric medication similarly produces relief. Without a full disruption of both the central hypervigilance and pelvic organ dysfunction, pain recurs. To prevent recurrence, clinicians will need to include some form of therapy, either medical or cognitive, targeted at the underlying limbic hypervigilance. Further research into novel, limbic targeted therapies can hopefully be stimulated by explicitly stating the role of the limbic system in chronic pain. This hypothesis provides a framework for clinicians to rationally approach some of the most challenging patients in medicine, and can potentially improve outcomes by including management of limbic dysfunction in their treatment.

Research paper thumbnail of A Retrospective Analysis to Compare the Effects of Intravenous Acetaminophen Administered Intraoperatively

Journal of Gynecologic Surgery, 2015

Research paper thumbnail of MR spectroscopy in the human fetus - Respond

Research paper thumbnail of Classifying Patients with Chronic Pelvic Pain into Levels of Biopsychosocial Dysfunction Using Latent Class Modeling of Patient Reported Outcome Measures

Pain Research and Treatment, 2015

Chronic pelvic pain affects multiple aspects of a patient’s physical, social, and emotional funct... more Chronic pelvic pain affects multiple aspects of a patient’s physical, social, and emotional functioning. Latent class analysis (LCA) of Patient Reported Outcome Measures Information System (PROMIS) domains has the potential to improve clinical insight into these patients’ pain. Based on the 11 PROMIS domains applied ton=613patients referred for evaluation in a chronic pelvic pain specialty center, exploratory factor analysis (EFA) was used to identify unidimensional superdomains. Latent profile analysis (LPA) was performed to identify the number of homogeneous classes present and to further define the pain classification system. The EFA combined the 11 PROMIS domains into four unidimensional superdomains of biopsychosocial dysfunction: Pain, Negative Affect, Fatigue, and Social Function. Based on multiple fit criteria, a latent class model revealed four distinct classes of CPP: No dysfunction (3.2%); Low Dysfunction (17.8%); Moderate Dysfunction (53.2%); and High Dysfunction (25.8%)...