found a removal rate for Paragard and Mirena of 25% after 1 year. In the study by Aoun et al, approximately 20% discontinued IUD use after 1 year. Rasheed mentions 20% removal of TCu380A (Paragard) after less than 1 month.5 We do not believe that counseling is likely to help young women whose IUDs are giving them problems because they are too large for the uterine cavity. Financial Disclosure: The authors did not report any potential conflicts of interest.
Norman D. Goldstuck, MD Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, Western Cape, South Africa Dirk A. Wildemeersch, MD, PhD Ghent, Belgium
REFERENCES 1. Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 2014;123:585–92. 2. Kurz KH. Cavimeter uterine measurements and IUD clinical correlation. In: Zatuchni GI, Goldsmith A, Sciarra JJ, editors. Intrauterine contraception: advances and future prospects. Philadelphia (PA): Harper & Row; 1984. p. 142–62. 3. Benacerraf BR, Shipp TD, Lyons JG, Bromley B. Width of the normal uterine cavity in premenopausal women and effect of parity. Obstet Gynecol 2010; 116:305–10. 4. Garbers S, Haines-Stephan J, Lipton Y, Meserve A, Spieler L, Chiasson MA. Continuation of copper-containing intrauterine devices at 6 months. Contraception 2013; 87:101–6. 5. Rasheed SM, Abdelmonem AM. Complications among adolescents using copper intrauterine contraceptive devices. Int J Gynaecol Obstet 2011;115:269–72. 6. Wildemeersch D, Pett A, Jandi S, Hasskamp T, Rowe P, Vrijens M Precision intrauterine contraception may significantly increase continuation of use: a review of long-term clinical experience with frameless copper-releasing intrauterine contraception devices. Int J Womens Health 2013;5:215–25.
In Reply: We appreciate the opportunity to respond to the comments and concerns raised
VOL. 123, NO. 6, JUNE 2014
by Drs. Goldstuck and Wildemeersch. Data from our study show that, although nulliparous women were significantly more likely to report pain with intrauterine device (IUD) use as compared with parous women (34% compared with 28%, P5.02), their discontinuation rates were similar.1 Expulsion rates were identical in both groups, as was the rate of abnormal bleeding. The overall uterine perforation rate was 0.3%; all three cases occurred in parous women. In regard to uterine dimensions and the effect of age, Benacerraf2 found no appreciable relationship between patient age and the width of the uterine cavity in patients who were never pregnant. However, the width of the cavity enlarged significantly with increasing parity (27.2 mm in nulliparous women, 29.6 mm with one pregnancy, and 31.1 mm with more than one pregnancy). Nevertheless, based on these data, even women with one previous pregnancy had a mean width narrower than the width of the Mirena and Paragard IUDs (less than 32 mm). This study had a small sample size, and the uterine cavities were measured regardless of the menstrual cycle, which may have affected the results. It is indeed a concern that women with narrow uterine cavities might be at increased risk of side effects with IUD use. Further studies are needed to determine whether measurement of the width of the uterine cavity should be performed before IUD insertion. In addition, the new IUD Skyla, with its smaller dimensions, may lessen these side effects, but that remains to be proven. Until more research becomes available, the Mirena and Paragard IUDs should continue to be offered to adolescents and nulliparous women because their benefits outweigh the medical risks and social consequences associated with teenage pregnancies, abortions, and undesired pregnancies. We did not specifically study the effects of counseling on IUD discontinuation rates. However, Garbers et al 3 found that early discontinuation of the copper-containing IUD was lower among women who received method-specific health education before IUD insertion. These data suggest that delivering health education that addresses issues specific to IUD use may reduce early discontinuation. Financial Disclosure: The authors did not report any potential conflicts of interest.
Joelle Aoun, MD Department of Obstetrics and Gynecology, Riverside Health System, Newport News, Virginia Virginia A. Dines, BS Georgetown University School of Medicine, Washington, DC Dale W. Stovall, MD Department of Obstetrics and Gynecology, Riverside Health System, Newport News, Virginia Mihriye Mete, PhD Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Washington, DC Casey B. Nelson, BA Department of Prevention and Community Health, George Washington University School of Public Health and Health Services, Washington, DC Veronica Gomez-Lobo, MD Department of Obstetrics and Gynecology, MedStar Washington Hospital Center and Children’s National Medical Center, Washington, DC
REFERENCES 1. Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 2014;123:1–8. 2. Benacerraf BR, Shipp TD, Lyons JG, Bromley B. Width of the normal uterine cavity in premenopausal women and effect of parity. Obstet Gynecol 2010;116:305–10. 3. Garbers S, Haines-Stephan J, Lipton Y, Meserve A. Continuation of copper- containing intrauterine devices at 6 months. Contraception 2013;87:101–6.
Robotic Compared With Laparoscopic Sacrocolpopexy: A Randomized Controlled Trial To the Editor: In the January 2014 edition of Obstetrics & Gynecology, the debate about the role of robotics in benign gynecology continues, with two editorials,1,2 a randomized
Letters to the Editor
1357
trial on laparoscopic compared with robotic sacrocolpopexy3 and one commentary.4 The randomized trial provides no new insights on the would-be superiority of robotic surgery on outcomes such as comorbidity or effectiveness. What is more, costs of robotic surgery were significantly higher and patient pain scores 1 week after surgery were higher in the robotics group. These findings are consistent with previous studies.5,6 As Dr. Advincula rightly mentions, cost analyses are difficult to perform.2 In our view, however, costs of ergonomic circumstances and physical challenges of (conventional) minimally invasive surgery must also be taken into account. These include both direct costs for the health care provider and indirect costs (ie, from the hospital or societal perspective). First, it is generally known that laparoscopic surgery imposes a high risk of physical complaints and injuries among surgeons.7 Among our directly known colleagues performing minimally invasive surgery, there are cases of cervical and lumbar hernias, frozen shoulders, and finger compression neuropathies. Physical strain rates up to 88% of gynecologists who perform minimally invasive surgery have been described.8 By illustration, in the study by Franasiak et al,8 29% of gynecologists had therapy, such as physical therapy, because of minimally invasive surgery–related physical discomfort or even took time off. Second, to decrease pain, surgeons limited the number of minimally invasive surgery procedures per day or limited the total number of cases. Third, data from large disability insurance companies reveal that surgeons performing minimally invasive surgery have a relative risk of 2–3 of becoming unfit for work during their careers compared with medical doctors not performing minimally invasive surgery (courtesy of MOVIR, Health Insurance Company in The Netherlands). Considering the aforementioned conditions, a complete cost analysis of robotic surgery ideally would include all expenses, both direct and indirect. We realize that, until now, it has been rather unusual to include expenses from the surgeon’s point of view. Nevertheless, to achieve a comprehensive analysis of all benefits and risks regarding robotic surgery in gynecology, ergonomics-related aspects and, in particular, cost items also should be included. Financial Disclosure: The authors did not report any potential conflicts of interest.
1358
Letters to the Editor
Theodoor E. Nieboer, MD, PhD Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands Johanna W.M. Aarts, MD, PhD Department of Obstetrics and Gynecology, Gelderse Vallei Hospital, Ede, The Netherlands
REFERENCES 1. Steege JF, Einarsson JI. Robotics in benign gynecologic surgery: where should we go? Obstet Gynecol 2014; 123:1–2. 2. Advincula AP. Robotics in gynecology: is the glass half empty or half full? Obstet Gynecol 2014;123:3–4. 3. Anger JT, Mueller ER, Tarnay C, Smith B, Stroupe K, Rosenman A, et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014;123:5–12. 4. Desai PH, Lin JF, Slomovitz BM. Milestones to optimal adoption of robotic technology in gynecology. Obstet Gynecol 2014;123:13–20. 5. Paraiso MF, Jelovsek JE, Frick A, Chen CC, Barber MD. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol 2011;118:1005–13. 6. Sarlos D, Kots L, Stevanovic N, von Felten S, Schär G. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol 2012;120:604–11. 7. Park A, Lee G, Seagull FJ, Meenaghan N, Dexter D. Patients benefit while surgeons suffer: an impending epidemic. J Am Coll Surg 2010;210:306–13. 8. Franasiak J, Ko EM, Kidd J, Secord AA, Bell M, Boggess JF, et al. Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery. Gynecol Oncol 2012;126:437–42.
Second Stage of Labor and Epidural Use: A Larger Effect Than Previously Suggested To the Editor: After reading the study reported by Cheng et al,1 I find that some of their results do not support their conclusions. Specifically, the authors address the generalizability of their study, and they seem reassured that their findings are similar to those observed in a multicenter trial by
Zhang et al.2 However, the authors confirm that there was a significant increase in the length of the second stage of labor throughout their three study periods; therefore, they should have used only the data from the 2000 to 2008 study period to compare with the multicenter trial by Zhang, which was conducted from 2002 to 2008. Despite their own findings that labor times have increased significantly, they claim that a 95th percentile of 302 minutes for nulliparous women with epidurals who had normal neonatal outcomes from 1976 to 2008 is similar to the 216 minutes reported by Zhang. The 95th percentile for nulliparous women with epidurals in the 2000– 2008 study period was 432 minutes (7.2 hours), which leaves open the question as to what the 95th percentile for normal outcomes was in the 2000–2008 study period for these women. Furthermore, the analysis of neonatal outcomes fails to address parity. The author’s data reveal that 18% of the nulliparous women suffered neonatal morbidity as compared with only 12.6% of the multiparous women. The data also reveal that 23.1% of the nulliparous women had operative vaginal birth compared with only 8.5% of the multiparous women. It is not clear why the authors report most of their findings divided by parity, yet, with significant differences in neonatal morbidity and births that can cause fetal trauma, they chose to ignore parity when reporting neonatal outcomes. Ignoring parity does not allow for the conclusion that there was no difference in neonatal outcome. With results that are not consistent with a prior multicenter study and with 18% neonatal morbidity and 23.1% operative vaginal births in nulliparous women, it seems that the conclusions reached in this study simply may reflect the labor management at one institution and not be generalizable at all. Financial Disclosure: The author did not report any potential conflicts of interest.
Gustavo San Román, MD Department of Obstetrics and Gynecology, St. Charles Hospital, Port Jefferson, New York
REFERENCES 1. Cheng YW, Shaffer BL, Nicholson JM, Caughey AB. Second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol 2014; 123:527–35.
OBSTETRICS & GYNECOLOGY
Norman D. Goldstuck, MD Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, Western Cape, South Africa Dirk A. Wildemeersch, MD, PhD Ghent, Belgium
REFERENCES 1. Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 2014;123:585–92. 2. Kurz KH. Cavimeter uterine measurements and IUD clinical correlation. In: Zatuchni GI, Goldsmith A, Sciarra JJ, editors. Intrauterine contraception: advances and future prospects. Philadelphia (PA): Harper & Row; 1984. p. 142–62. 3. Benacerraf BR, Shipp TD, Lyons JG, Bromley B. Width of the normal uterine cavity in premenopausal women and effect of parity. Obstet Gynecol 2010; 116:305–10. 4. Garbers S, Haines-Stephan J, Lipton Y, Meserve A, Spieler L, Chiasson MA. Continuation of copper-containing intrauterine devices at 6 months. Contraception 2013; 87:101–6. 5. Rasheed SM, Abdelmonem AM. Complications among adolescents using copper intrauterine contraceptive devices. Int J Gynaecol Obstet 2011;115:269–72. 6. Wildemeersch D, Pett A, Jandi S, Hasskamp T, Rowe P, Vrijens M Precision intrauterine contraception may significantly increase continuation of use: a review of long-term clinical experience with frameless copper-releasing intrauterine contraception devices. Int J Womens Health 2013;5:215–25.
In Reply: We appreciate the opportunity to respond to the comments and concerns raised
VOL. 123, NO. 6, JUNE 2014
by Drs. Goldstuck and Wildemeersch. Data from our study show that, although nulliparous women were significantly more likely to report pain with intrauterine device (IUD) use as compared with parous women (34% compared with 28%, P5.02), their discontinuation rates were similar.1 Expulsion rates were identical in both groups, as was the rate of abnormal bleeding. The overall uterine perforation rate was 0.3%; all three cases occurred in parous women. In regard to uterine dimensions and the effect of age, Benacerraf2 found no appreciable relationship between patient age and the width of the uterine cavity in patients who were never pregnant. However, the width of the cavity enlarged significantly with increasing parity (27.2 mm in nulliparous women, 29.6 mm with one pregnancy, and 31.1 mm with more than one pregnancy). Nevertheless, based on these data, even women with one previous pregnancy had a mean width narrower than the width of the Mirena and Paragard IUDs (less than 32 mm). This study had a small sample size, and the uterine cavities were measured regardless of the menstrual cycle, which may have affected the results. It is indeed a concern that women with narrow uterine cavities might be at increased risk of side effects with IUD use. Further studies are needed to determine whether measurement of the width of the uterine cavity should be performed before IUD insertion. In addition, the new IUD Skyla, with its smaller dimensions, may lessen these side effects, but that remains to be proven. Until more research becomes available, the Mirena and Paragard IUDs should continue to be offered to adolescents and nulliparous women because their benefits outweigh the medical risks and social consequences associated with teenage pregnancies, abortions, and undesired pregnancies. We did not specifically study the effects of counseling on IUD discontinuation rates. However, Garbers et al 3 found that early discontinuation of the copper-containing IUD was lower among women who received method-specific health education before IUD insertion. These data suggest that delivering health education that addresses issues specific to IUD use may reduce early discontinuation. Financial Disclosure: The authors did not report any potential conflicts of interest.
Joelle Aoun, MD Department of Obstetrics and Gynecology, Riverside Health System, Newport News, Virginia Virginia A. Dines, BS Georgetown University School of Medicine, Washington, DC Dale W. Stovall, MD Department of Obstetrics and Gynecology, Riverside Health System, Newport News, Virginia Mihriye Mete, PhD Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Washington, DC Casey B. Nelson, BA Department of Prevention and Community Health, George Washington University School of Public Health and Health Services, Washington, DC Veronica Gomez-Lobo, MD Department of Obstetrics and Gynecology, MedStar Washington Hospital Center and Children’s National Medical Center, Washington, DC
REFERENCES 1. Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 2014;123:1–8. 2. Benacerraf BR, Shipp TD, Lyons JG, Bromley B. Width of the normal uterine cavity in premenopausal women and effect of parity. Obstet Gynecol 2010;116:305–10. 3. Garbers S, Haines-Stephan J, Lipton Y, Meserve A. Continuation of copper- containing intrauterine devices at 6 months. Contraception 2013;87:101–6.
Robotic Compared With Laparoscopic Sacrocolpopexy: A Randomized Controlled Trial To the Editor: In the January 2014 edition of Obstetrics & Gynecology, the debate about the role of robotics in benign gynecology continues, with two editorials,1,2 a randomized
Letters to the Editor
1357
trial on laparoscopic compared with robotic sacrocolpopexy3 and one commentary.4 The randomized trial provides no new insights on the would-be superiority of robotic surgery on outcomes such as comorbidity or effectiveness. What is more, costs of robotic surgery were significantly higher and patient pain scores 1 week after surgery were higher in the robotics group. These findings are consistent with previous studies.5,6 As Dr. Advincula rightly mentions, cost analyses are difficult to perform.2 In our view, however, costs of ergonomic circumstances and physical challenges of (conventional) minimally invasive surgery must also be taken into account. These include both direct costs for the health care provider and indirect costs (ie, from the hospital or societal perspective). First, it is generally known that laparoscopic surgery imposes a high risk of physical complaints and injuries among surgeons.7 Among our directly known colleagues performing minimally invasive surgery, there are cases of cervical and lumbar hernias, frozen shoulders, and finger compression neuropathies. Physical strain rates up to 88% of gynecologists who perform minimally invasive surgery have been described.8 By illustration, in the study by Franasiak et al,8 29% of gynecologists had therapy, such as physical therapy, because of minimally invasive surgery–related physical discomfort or even took time off. Second, to decrease pain, surgeons limited the number of minimally invasive surgery procedures per day or limited the total number of cases. Third, data from large disability insurance companies reveal that surgeons performing minimally invasive surgery have a relative risk of 2–3 of becoming unfit for work during their careers compared with medical doctors not performing minimally invasive surgery (courtesy of MOVIR, Health Insurance Company in The Netherlands). Considering the aforementioned conditions, a complete cost analysis of robotic surgery ideally would include all expenses, both direct and indirect. We realize that, until now, it has been rather unusual to include expenses from the surgeon’s point of view. Nevertheless, to achieve a comprehensive analysis of all benefits and risks regarding robotic surgery in gynecology, ergonomics-related aspects and, in particular, cost items also should be included. Financial Disclosure: The authors did not report any potential conflicts of interest.
1358
Letters to the Editor
Theodoor E. Nieboer, MD, PhD Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands Johanna W.M. Aarts, MD, PhD Department of Obstetrics and Gynecology, Gelderse Vallei Hospital, Ede, The Netherlands
REFERENCES 1. Steege JF, Einarsson JI. Robotics in benign gynecologic surgery: where should we go? Obstet Gynecol 2014; 123:1–2. 2. Advincula AP. Robotics in gynecology: is the glass half empty or half full? Obstet Gynecol 2014;123:3–4. 3. Anger JT, Mueller ER, Tarnay C, Smith B, Stroupe K, Rosenman A, et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014;123:5–12. 4. Desai PH, Lin JF, Slomovitz BM. Milestones to optimal adoption of robotic technology in gynecology. Obstet Gynecol 2014;123:13–20. 5. Paraiso MF, Jelovsek JE, Frick A, Chen CC, Barber MD. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol 2011;118:1005–13. 6. Sarlos D, Kots L, Stevanovic N, von Felten S, Schär G. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol 2012;120:604–11. 7. Park A, Lee G, Seagull FJ, Meenaghan N, Dexter D. Patients benefit while surgeons suffer: an impending epidemic. J Am Coll Surg 2010;210:306–13. 8. Franasiak J, Ko EM, Kidd J, Secord AA, Bell M, Boggess JF, et al. Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery. Gynecol Oncol 2012;126:437–42.
Second Stage of Labor and Epidural Use: A Larger Effect Than Previously Suggested To the Editor: After reading the study reported by Cheng et al,1 I find that some of their results do not support their conclusions. Specifically, the authors address the generalizability of their study, and they seem reassured that their findings are similar to those observed in a multicenter trial by
Zhang et al.2 However, the authors confirm that there was a significant increase in the length of the second stage of labor throughout their three study periods; therefore, they should have used only the data from the 2000 to 2008 study period to compare with the multicenter trial by Zhang, which was conducted from 2002 to 2008. Despite their own findings that labor times have increased significantly, they claim that a 95th percentile of 302 minutes for nulliparous women with epidurals who had normal neonatal outcomes from 1976 to 2008 is similar to the 216 minutes reported by Zhang. The 95th percentile for nulliparous women with epidurals in the 2000– 2008 study period was 432 minutes (7.2 hours), which leaves open the question as to what the 95th percentile for normal outcomes was in the 2000–2008 study period for these women. Furthermore, the analysis of neonatal outcomes fails to address parity. The author’s data reveal that 18% of the nulliparous women suffered neonatal morbidity as compared with only 12.6% of the multiparous women. The data also reveal that 23.1% of the nulliparous women had operative vaginal birth compared with only 8.5% of the multiparous women. It is not clear why the authors report most of their findings divided by parity, yet, with significant differences in neonatal morbidity and births that can cause fetal trauma, they chose to ignore parity when reporting neonatal outcomes. Ignoring parity does not allow for the conclusion that there was no difference in neonatal outcome. With results that are not consistent with a prior multicenter study and with 18% neonatal morbidity and 23.1% operative vaginal births in nulliparous women, it seems that the conclusions reached in this study simply may reflect the labor management at one institution and not be generalizable at all. Financial Disclosure: The author did not report any potential conflicts of interest.
Gustavo San Román, MD Department of Obstetrics and Gynecology, St. Charles Hospital, Port Jefferson, New York
REFERENCES 1. Cheng YW, Shaffer BL, Nicholson JM, Caughey AB. Second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol 2014; 123:527–35.
OBSTETRICS & GYNECOLOGY
