The Feasibility of Practical Training in Minimally Invasive Surgery at Medical School-A Prospective Study on the Pelvitrainer.

Background and Objectives: The acquisition of practical skills at medical school is an important part of the multidimensional education program of future physicians. However, medical schools throughout the world have been slow in incorporating practical skills in their curriculum. Therefore, the aims of the present prospective study were (a) to demonstrate the feasibility of such surgical training, (b) to objectify its benefit in medical education, and (c) to investigate the impact of such training on subsequent career choices. Material and Methods: We introduced a two-day laparoscopy course on the pelvitrainer as part of the curriculum of the gynecological internship of fifth year medical students from 2019 to 2020. The results of the students' training were matched to those of surgeons who completed the same curriculum in a professional postgraduate laparoscopy course from 2017 to 2020 in a comparative study design. Additionally, we performed a questionnaire-based evaluation of the impact of the course on medical education and subsequent career choices directly before and after completing the course. Results: A total of 261 medical students and 206 physicians completed the training program. At baseline, the students performed significantly more poorly than physicians in a median of three of four exercises (p < 0.001). However, this evened out in the final runs, during which students performed more poorly than physicians only in one exercise and even better than physicians in one. The general integration of surgical training in medical school curricula was rated very low (12.4% on the VAS, IQR 3-16%) despite the high demand for such training. In the survey, the course was deemed very beneficial for medical education (median VAS 80.7%, IQR 73-98%), but did not appear to influence the students' subsequent career preferences. Conclusions: The acquisition of practical surgical skills during medical school is significantly under-represented in many medical faculties. The benefits of such training, as demonstrated in our study, would improve the education of future physicians.

Trends and Perioperative Outcomes across Elective Benign Hysterectomy Procedures from the ACS-NSQIP 2007-2017.

STUDY OBJECTIVE: In this study, we describe trends of all 3 routes of hysterectomy, patient demographics, and perioperative morbidity among women undergoing surgery for benign indications between 2007 and 2017. We also sought to compare the rates of extended length of stay (ELOS) and readmission rates among the laparoscopic, abdominal, and transvaginal routes. STUDY DESIGN: A retrospective cohort study. STUDY SETTING: National database study. PATIENTS: The American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent an elective hysterectomy for benign indication between 2007 and 2017. INTERVENTIONS: Patients were identified using Current Procedural Terminology codes and excluded if their indication for surgery included cancer and pelvic organ prolapse diagnoses based on International Classification of Diseases codes. The collected variables of interest included age, body mass index, American Society of Anesthesiologists classification, uterine weight of >250 grams, and operative time. Our outcomes of interest included ELOS and readmission within 30 days. ELOS was defined as a hospital admission of 2 days or more after laparoscopic and transvaginal hysterectomy and greater than 3 days for an abdominal hysterectomy. Summary statistics were used to evaluate shifts in patient characteristics and postoperative outcomes by hysterectomy route and year of surgery. Multivariable logistic regression analysis, stratified by year, comparing laparoscopic with transvaginal and abdominal hysterectomies was performed. MEASUREMENTS AND MAIN RESULTS: There were 224 357 patients who met the inclusion and exclusion criteria. Of those, 132 567 (59.1%) underwent a laparoscopic hysterectomy, 30 105 (13.4%) a vaginal hysterectomy, and 61 685 (27.5%) an abdominal hysterectomy. The rate of laparoscopic hysterectomy increased by >200% between 2007 and 2017, whereas the rates of transvaginal and abdominal hysterectomies steadily decreased (-58% and -42%, respectively) The mean age, median obesity, and American Society of Anesthesiologists classification increased among women undergoing hysterectomy across all routes with the sharpest increase within the laparoscopic hysterectomy group (% increase in mean age [2.1%, 1.3%, 0.7%] and mean body mass index [9.1%, 4.3%, 3.7%] for laparoscopic, transvaginal, and abdominal routes, respectively). In 2017, the odds of ELOS were 29% lower for those who received laparoscopic than those who received abdominal hysterectomy (p <.001). Comparing the rates of readmission between the laparoscopic and abdominal hysterectomy groups shows that the odds of readmission are significantly lower for patients who receive a laparoscopic hysterectomy across all 11 years (p <.001). CONCLUSION: The rates of laparoscopic hysterectomy have been steadily increasing over the past 11 years. This large retrospective study confirms the lowest rates of readmission and ELOS within the laparoscopic hysterectomy group despite the rising medical complexity of the patients.

Endometrioma and assisted reproductive technology: a review.

PURPOSE: Endometriomas are a common cause of infertility necessitating assisted reproductive technology (ART). It had been previously thought that surgical removal of the endometriomas prior to ART would improve reproductive outcomes, but recent data suggests that surgical cystectomy might affect the ovarian reserve, decreasing the chances of ART success. The aim of this article is to review the literature on the effects of endometrioma surgery on ART outcomes providing an overview of the current evidence and assessing the need for further studies. METHODS: A literature search was performed using PubMed and MEDLINE databases to identify studies that discuss endometriomas and assisted reproductive technology before versus after surgery. RESULTS: In women with an endometrioma requiring ART, growing evidence suggests that surgery might result in damage to the ovarian reserve and further decrease chances of fertility. However, pregnancy rates, implantation rates, fertilization rates, and live birth rates seemed to be consistently similar across both groups. CONCLUSION: The current evidence is inconclusive on whether endometriomas should be surgically removed prior to ART. Further large randomized controlled trials are needed for a definite answer, and until then, management should be individualized.

Adenomyosis and infertility.

PURPOSE: Adenomyosis is a poorly understood entity with no unified treatment protocol. It has been thought to only affect the quality of life of older women, but growing evidence is highlighting the increased frequency of adenomyosis in younger patients and its possible effects on fertility outcomes. This can have a great impact on how clinicians screen, diagnose, and treat this condition. The aim of this review is to explore the relationship between adenomyosis and infertility. METHODS: A literature search of the keywords "adenomyosis", "infertility", "pregnancy" and "fertility" was conducted using the PubMed and Medline search engines. The articles selected were observational, systematic reviews, meta-analyses, and randomized controlled trials. The search was limited to English, abstracts were screened, and articles were selected. RESULTS: The literature reports lower clinical pregnancy rates, lower live birth rates, higher miscarriage rates, and higher odds of adverse obstetric outcomes in patients with adenomyosis. Treatment seems to be associated with higher pregnancy rates and live births rates. CONCLUSION: An association between adenomyosis and infertility seems to exist, and treatment could lead to improved fertility outcomes.

Robot-Assisted Surgery for Endometriosis Current and Future Perspectives.

Successful resection of all visible lesions may effectively treat endometriosis-related infertility and pelvic pain. Minimally invasive surgery provides significant advantages, with lower rates of surgical complications such as surgical trauma, infection, postoperative pain, and hospital stay. Robotic surgery is shown to have similar perioperative outcomes to conventional laparoscopy; however, complex stage III and IV endometriosis, especially cases requiring significant resection such as deep infiltrating endometriosis, widespread peritoneal implants, and urologic and intestinal involvement, may benefit most from a robotic approach. There are certain aspects of endometriosis surgery where utilization of robotic technology might provide an additional benefit. These include (1) heterogeneity of lesions, and thus difficulty in identification; (2) difficulty in accurately predicting surgical complexity; and (3) prolonged operative time for complex cases. The objective of this review is to describe the current and future perspectives of robotic surgery as it pertains to endometriosis.

Relationships between pelvic nerves and levator ani muscle for posterior sacrocolpopexy: an anatomic study.

BACKGROUND: The placement of posterior mesh during pelvic organ prolapse laparoscopic surgery has been incriminated as responsible for postoperative adverse outcomes such as digestive symptoms, chronic pelvic pain, and sexual dysfunction. These complications may be related to neural injuries that occur during the fixation of the posterior mesh on the levator ani muscle. OBJECTIVES: The aim of our study was to describe the course of the autonomic nerves of the pararectal space and their anatomical relationship with the posterior mesh fixation zone on the levator ani muscle. STUDY DESIGN: Twenty hemi-pelvis specimens from 10 fresh female cadavers were dissected. We measured the distance between the posterior mesh fixation zone on the levator ani, and the nearest point of adjacent structures: the hypogastric nerve, inferior hypogastric plexus, uterosacral ligament, uterine artery, and ureter. Measurements were repeated starting from the inferior hypogastric plexus. RESULTS: Nerve fibers of the inferior hypogastric plexus spread out systematically above the superior aspect of the levator ani muscle. Median distance from the posterior mesh fixation zone and the inferior hypogastric plexus was around 2.8 (range 2.1-3.5) cm. CONCLUSIONS: The inferior hypogastric plexus lies above the superior aspect of the levator ani muscle. A short distance between the posterior mesh fixation zone on the levator ani muscle and inferior hypogastric plexus could explain in part postoperative digestive symptoms. These observations support the development of nerve-sparing procedures for posterior mesh placement in the context of pelvic organ prolapse repair and suggest that postoperative complications could be improved by changing the fixation zone.

Lymphadenectomy in endometrial cancer - achieving more with less?

The lymph node status of patients with endometrial cancer is known to be a crucial determinant for the prognosis of the disease. It also provides the indication for further adjuvant treatment. The staging of endometrial cancer by surgery has been a controversial issue for more than 30 years. The significant complication rate after lymphadenectomy and the development of minimally invasive surgery have led to the use of sentinel lymph node (SLN) mapping. In the present review, we present the development of surgical staging procedures in patients with endometrial cancer and summarize the recently expanding body of published literature on the subject. SLN mapping is a safe and accurate technique, especially when indocyanine green is used as a tracer. SLN mapping appears to reduce complication rates as well as costs without affecting the oncologic outcome. Large prospective studies are needed to establish the effects of SLN mapping on the outcome of disease, especially in high-risk patients with endometrial cancer. Furthermore, the need for additional systematic lymphadenectomy prior to adjuvant radio-chemotherapy in patients diagnosed with isolated lymph node metastasis during SLN biopsy must be investigated further. This might pave the way for a new surgical approach in patients with endometrial cancer.

Impact of lifestyle and diet on endometriosis: a fresh look to a busy corner.

Endometriosis is a chronic inflammatory disorder with a prevalence of six to ten percent in women of childbearing age. As long as the aetiology of endometriosis is not fully understood and the disease has no definitive treatment, an examination of the environmental factors or interventions that could modify or cure endometriosis would greatly benefit women suffering from this chronic condition. This literature review utilized the electronic databases PubMed, EMBASE, and MEDLINE until February 2021. Studies indicate that fish oil may have a positive effect on reducing endometriosis-related pain due to the effects of pro-inflammatory prostaglandins derived from omega-3 fatty acids. The same effect was seen with the introduction of antioxidant vitamins C, D, and E. There is clinical viability of a low fermentable oligo-, di-, and mono-saccharides and polyols diet to successfully reduce the symptoms of patients who suffer from both endometriosis and irritable bowel syndrome. Despite the low level of evidence, there are frequent associations between endometriosis and gastrointestinal conditions in addition to the influence of various nutritional factors on the disease. The management of endometriosis requires a holistic approach focused on reducing overall inflammation, increasing detoxification, and attenuating troublesome symptoms. A dietician may provide great benefit in the management of these patients, especially at younger ages and in early stages. High-level evidence and well-designed randomized studies are lacking when it comes to studying the effect of lifestyle and dietary intake on endometriosis. Inarguably, further research with a more extensive focus is needed.

Pelvic Neuroanatomy: An Overview of Commonly Encountered Pelvic Nerves in Gynecologic Surgery.

OBJECTIVE: This video tutorial identifies key anatomic landmarks useful in identifying the path of the most commonly encountered pelvic nerves in benign gynecologic surgery. DESIGN: This is a narrated overview of commonly encountered pelvic nerves during benign gynecology, their origin, sensory, and motor function, as well as sequelae related to injury. SETTING: The unintended injury of pelvic neural connections can be a complication of any pelvic surgery, however, surgery for malignancy or endometriosis may increase the likelihood of encountering these nerves. The majority of focus surrounding surgical nerve injury, however, relates to patient positioning [1]. Injury to the pelvic nerves can lead to lifelong sexual, bladder, and defecatory dysfunction [2]. INTERVENTIONS: We review the Genitofemoral, Lateral Femoral Cutaneous, Ilioinguinal, Obturator, Superior and Inferior Hypogastric nerves, Pelvic Splanchnic nerves, and the Sacral nerves. Surgical illustrations are used (Fig. 1) alongside real-time narrated video to help viewers recognize the normal course of commonly encountered pelvic nerves at the time of gynecologic surgery (Figs2-3). CONCLUSION: The surgical management of complex pelvic disease can unfortunately carry significant patient morbidity [3]. The neural pathways traveling through the pelvis via the hypogastric nerves are responsible for proprioception, vaginal lubrication, and proper functioning or the urethral and anal sphincters [4]. Sparing these nerves during pelvic surgery, and especially when anatomic planes are distorted by pelvic disease, requires surgical expertise and an immense understanding of pelvic neuroanatomy [4,5]. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications. This video tutorial also highlights the origin of these nerves, their anatomic location, procedures in which these nerves may be encountered, and what sequelae occur from their unintended injury.

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes. DATA SOURCES: We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications"). METHODS OF STUDY SELECTION: Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations. TABULATION, INTEGRATION, AND RESULTS: Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I2 = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I2 = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I2 = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I2 = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I2 = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I2 = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I2 = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I2 = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I2 = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I2 = 71%). CONCLUSION: Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.

Pudendal Neurolysis: 6-Step Laparoscopic Approach.

OBJECTIVE: To demonstrate the safety and feasibility of the laparoscopic approach to perform pudendal neurolysis in a case of pudendal nerve entrapment syndrome [1-3]. DESIGN: A video tutorial that highlights the laparoscopic steps to performing pudendal neurolysis, with a focus on the main anatomic landmarks [4,5]. SETTING: A tertiary care regional hospital. INTERVENTIONS: This video shows a 6-step approach to laparoscopic pudendal neurolysis for the treatment of pudendal nerve entrapment between the sacrospinous and sacrotuberous ligaments [2,6-8]. Step 1: Identification of the umbilical artery. Step 2: Dissection and development of the lateral paravesical space until the pelvic floor. Step 3: Identification of the arcus tendineus of the endopelvic fascia. Step 4: Identification of the ischial spine and the sacrospinous ligament covered by the coccygeus muscle. Step 5: Coagulation and section of the coccygeus muscle and the sacrospinous ligament. Step 6: Medialization of the pudendal nerve until its entrance into the Alcock canal. CONCLUSION: This video demonstrates the safety, feasibility, and reproducibility of laparoscopic pudendal neurolysis in 6 steps. A minimally invasive approach is adequate to treat the pudendal compression until the Alcock canal [2].

A Clinically Applicable Prediction Model for the Risk of Transfusion in Women Undergoing Myomectomy.

STUDY OBJECTIVE: We sought to identify the variables independently associated with intra/postoperative blood transfusion at the time of myomectomy. We further hoped to develop an accurate prediction model using preoperative variables to categorize an individual's risk of blood transfusion during myomectomy. DESIGN: Case-control study. SETTING: Not applicable to this study, which used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. PATIENTS: Women who underwent an open/abdominal or laparoscopic (robotic or conventional) myomectomy between 2014 and 2017 at participating ACS-NSQIP sites. INTERVENTION: The primary dependent variable was occurrence of intra/postoperative bleeding requiring blood transfusion. Patient demographics, clinical characteristics, preoperative comorbidities, intraoperative variables, and additional 30-day postoperative outcomes were compared at the bivariable level. For the prediction-model development, only variables that can be reasonably known before surgery were included. Variables associated with intra/postoperative bleeding were entered into 2 separate multivariable logistic regression models. Validation of our prediction model was performed internally using 250 bootstrapped iterations of 50% subsamples drawn from the overall population of myomectomy cases from the ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS: We identified 6387 myomectomies performed during the defined study period. The most common race in our population was black/African American (45.7%), and most of the patients (57.5%) received an open/abdominal route of myomectomy. A total of 623 patients who underwent myomectomy (9.8%) experienced intraoperative/postoperative bleeding with a need for blood transfusion. At the bivariable level, we identified several variables independently associated with the need for blood transfusion at the time of myomectomy. In using only those variables that can be reasonably known before surgery to develop our prediction model, additional multivariable logistic regression elucidated black race, need for preoperative blood transfusion, planned abdominal/open route of surgery, and preoperative hematocrit value as independently associated with blood transfusion. CONCLUSION: We identified a number of perioperative variables associated with intraoperative or postoperative bleeding requiring blood transfusion at the time of myomectomy. We subsequently created a model that accurately predicts individual bleeding risk from myomectomy, using variables that are reasonably apparent preoperatively. Making this prediction model clinically available to gynecologic surgeons will serve to improve the care of women undergoing myomectomy.

A narrative review of platelet-rich plasma (PRP) in reproductive medicine.

PURPOSE: Platelet-rich plasma (PRP) has become a novel treatment in various aspects of medicine including orthopedics, cardiothoracic surgery, plastic surgery, dermatology, dentistry, and diabetic wound healing. PRP is now starting to become an area of interest in reproductive medicine more specifically focusing on infertility. Poor ovarian reserve, menopause, premature ovarian failure, and thin endometrium have been the main areas of research. The aim of this article is to review the existing literature on the effects of autologous PRP in reproductive medicine providing a summation of the current studies and assessing the need for additional research. METHODS: A literature search is performed using PubMed, MEDLINE, and CINAHL Plus to identify studies focusing on the use of PRP therapy in reproductive medicine. Articles were divided into 3 categories: PRP in thin lining, PRP in poor ovarian reserve, and PRP in recurrent implantation failure. RESULTS: In women with thin endometrium, the literature shows an increase in endometrial thickness and increase in chemical and clinical pregnancy rates following autologous PRP therapy. In women with poor ovarian reserve, autologous intraovarian PRP therapy increased anti-Mullerian hormone (AMH) levels and decreased follicle-stimulating hormone (FSH), with a trend toward increasing clinical and live birth rates. This trend was also noted in women with recurrent implantation failure. CONCLUSIONS: Limited literature shows promise in increasing endometrial thickness, increasing AMH, and decreasing FSH levels, as well as increasing chemical and clinical pregnancy rates. The lack of standardization of PRP preparation along with the lack of large randomized controlled trials needs to be addressed in future studies. Until definitive large RCTs are available, PRP use should be considered experimental.

Intraoperative tranexamic acid to decrease blood loss during myomectomy: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Myomectomy is associated with a significant risk of hemorrhage. Tranexamic acid is a synthetic lysine derivative with antifibrinolytic activity used in other surgical disciplines to reduce blood loss during surgery. However, its utility in gynecologic surgery is not well understood. OBJECTIVE: This study aimed to determine the effect of early administration of intravenous tranexamic acid on perioperative bleeding and blood transfusion requirements in women undergoing myomectomy. STUDY DESIGN: This study was a double-blinded, randomized, placebo-controlled trial conducted in an academic teaching hospital. Women with symptomatic fibroids thought to be at risk for large intraoperative blood loss who met the following criteria were included in the study: (1) at least 1 fibroid ≥10 cm, (2) any intramural or broad ligament fibroid ≥6 cm, and/or (3) at least 5 total fibroids based on preoperative imaging. Patients were randomized to receive a single intravenous bolus injection of tranexamic acid 15 mg/kg (intervention group) versus an intravenous bolus injection of saline of equivalent volume (placebo group) 20 minutes before the initial surgical incision. Perioperative bleeding was defined by measuring intraoperative estimated blood loss, change between pre- and postoperative hemoglobin, and frequency of blood transfusions. Estimated blood loss was calculated by combining the blood volume collected within the suction canister and the weight of used sponges. The 2 groups were compared for age; body mass index; perioperative hemoglobin and hematocrit; perioperative blood loss; duration of surgery; blood transfusion requirements; and the number, total weight, and volume of myomas removed. RESULTS: A total of 60 patients (30 per arm) were enrolled into the study between March 1, 2015, and January 29, 2018. Age, body mass index, baseline hemoglobin and/or hematocrit, number and total weight of myomas removed, and size of myomas did not differ between arms. Of 60 patients, 32 (53%) had laparoscopic myomectomy, 24 (40%) had robotic myomectomy, and 4 (7%) had laparotomy. Median estimated blood loss was 200 mL for the tranexamic acid group and 240 mL for the placebo group (P=.88). There was no difference in median duration of surgery (165 vs 164 minutes; P=.64) or change in perioperative hemoglobin (1.00 vs 1.1 g/dL; P=.64). Patients in the tranexamic acid group did not require blood transfusions; however, 4 patients (13.3%) in the placebo group (P=.11) required blood transfusions. CONCLUSION: Intravenous administration of tranexamic acid in patients undergoing laparoscopic or robotic myomectomies was not associated with decreased blood loss.

Spironolactone use does not increase the risk of female breast cancer recurrence: A retrospective analysis.

BACKGROUND: Spironolactone is used off-label for androgenic alopecia because of its ability to arrest hair loss progression and long-term safety profile. However, little is known about the safety of spironolactone in breast cancer (BC) survivors. Because spironolactone has estrogenic effects, there is a theoretical risk for BC recurrence. Given that spironolactone is an important tool in the treatment of alopecia, we investigated whether spironolactone increased risk for BC recurrence. OBJECTIVE: To determine whether spironolactone is associated with increased BC recurrence. METHODS: A retrospective analysis was conducted using the Humana Insurance database. Patients with a history of BC were identified using International Classification of Diseases codes, stratified by spironolactone prescription, and also matched 1:1 using propensity score analysis. Patient characteristics and cancer recurrence rates between both cohorts were compared and analyzed. RESULTS: BC recurrence developed in 123 patients (16.5%) who were prescribed spironolactone compared with 3649 patients (12.8%) who developed BC recurrence without spironolactone prescribed (P = .004). After propensity matching, adjusted Cox regression analysis showed no association between spironolactone and increased BC recurrence (adjusted hazard ratio, 0.966; 95% confidence interval, 0.807-1.156; P = .953). LIMITATIONS: Retrospective study. CONCLUSION: Spironolactone was not independently associated with increased BC recurrence and may be considered for the treatment of alopecia in BC survivors.

Comparing benign laparoscopic and abdominal hysterectomy outcomes by time.

BACKGROUND: While laparoscopic hysterectomy has benefits compared to abdominal hysterectomy, the operative times are longer. Longer operative times have been associated with negative outcomes. This study's purpose was to elucidate if there is an operative time at which 30-day outcomes for laparoscopic hysterectomy become inferior to a more expeditiously completed abdominal hysterectomy. METHODS: This was a retrospective cohort study (Canadian Task Force classification II-2) using the American College of Surgeons National Surgical Quality Improvement Program database to identify women undergoing hysterectomy for benign indications from 2010 to 2016 by current procedural terminology code. Hysterectomy cases were stratified by approach and 60-min intervals. 30-day post-operative outcomes were analyzed by operative time and approach. RESULTS: 109,821 hysterectomies were included in our analysis, of which 66,560 (61%) were laparoscopic, and 43,261 (39%) were abdominal. In a multivariable logistic regression analysis comparing outcomes by surgical approach and operative time, there was no time combination in which patients who had a abdominal hysterectomy had significantly lower odds of the composite complications variable. This was true even in laparoscopic hysterectomies greater than 240 min compared to abdominal hysterectomies completed between 20 and 60 min. When compared to laparoscopic hysterectomies greater than 240 min, abdominal hysterectomies between 20 and 60 min had lower odds of sepsis and abdominal hysterectomies less than 180 min had lower odds of urinary tract infection. CONCLUSION: Given that benefits persist even in prolonged cases, a laparoscopic approach should be offered to most patients undergoing benign hysterectomy. Surgical efficiency should be prioritized for any surgical approach.

Correction to: Comparing benign laparoscopic and abdominal hysterectomy outcomes by time.

The original article was updated to correct the author listing: the last five author names were reversed.

The effect of anemia severity on postoperative morbidity among patients undergoing laparoscopic hysterectomy for benign indications.

INTRODUCTION: One-third of non-pregnant women worldwide are anemic.1 Anemia is a known independent risk factor for postoperative morbidity.2 Given that the vast majority of hysterectomies are not performed in the emergency setting, we designed this study to evaluate the effect of preoperative anemia on postoperative morbidity following laparoscopic hysterectomy performed for benign indications. Our main goal is to encourage surgeons to use anemia-corrective measures before surgery when feasible. MATERIAL AND METHODS: Retrospective cohort study of 98 813 patients who underwent a laparoscopic hysterectomy between 2005 and 2016 for benign indications identified through the American College of Surgeons National Surgical Quality Improvement Program. Anemia was examined as a function of hematocrit and was analyzed as an ordinal variable stratified by anemia severity as mild, moderate or severe. Associations between preoperative anemia and patient demographics, preoperative comorbidities and postoperative outcomes were evaluated using univariate analyses. Multivariable logistic regression models were used to identify independent associations between hematocrit level and postoperative outcomes after adjusting for confounding covariates. At the multivariable logistic regression level, anemia severity was analyzed using hematocrit as a continuous variable to assess the independent association between each 5% decrease in hematocrit level and several postoperative morbidities. RESULTS: Of the 98 813 patients who met our inclusion and exclusion criteria, 19.5% were anemic. A lower preoperative hematocrit was associated with higher body mass index, younger age, Black or African American race, longer operative times, and multiple other medical comorbidities. After appropriate regression modeling, anemia was identified as an independent risk factor for extended length of stay, readmission and composite morbidity after surgery. CONCLUSIONS: Preoperative anemia is common among patients undergoing laparoscopic hysterectomy. Preoperative anemia increases patients' risk for multiple postoperative comorbidities. Given that most hysterectomies are performed in the elective setting, gynecologic surgeons should consider the use of anemia-corrective measures to minimize postoperative morbidity.

Predictors of Overnight Admission After Laparoscopic Myomectomy in a High-Volume Minimally Invasive Gynecologic Surgery Setting.

STUDY OBJECTIVE: Our primary goal was to uncover preoperative and intraoperative risk factors that prevented same-day discharge (SDD) after myomectomy in a setting where SDD was the standard of care. Uncovered predictors would serve to enhance patient counseling and medical optimization before surgery. DESIGN: Single-center retrospective cohort study. SETTING: Urban university hospital center, by fellowship-trained minimally invasive gynecologic surgeons. PATIENTS: A total of 315 consecutive patients undergoing minimally invasive myomectomy between March 2012 and May 2018. INTERVENTION: Minimally invasive myomectomy. MEASUREMENTS AND MAIN RESULTS: Preoperative and intraoperative characteristics were collected for analysis as predictors of SDD vs overnight admission. Comparisons of demographic, clinical, imaging, and operative characteristics were made using appropriate statistical methods for normally distributed, skewed, and categorical variables. Length of stay was analyzed as a categorical variable, SDD vs overnight admission. A logistic regression model was used to evaluate SDD vs any overnight stay. Out of the 315 patients undergoing laparoscopic myomectomy, 208 (66.03%) were discharged on the same day, and 107 (33.96%) were admitted for at least 1 day after surgery. The patients were more likely to be admitted overnight if they were of Asian ethnicity (p = .01), or if they had a lower preoperative Hct (36.15 vs 37.57; p < .003). An increase in any myoma characteristic metric was associated with overnight stay after surgery; these included mean myoma weight (512.0 g vs 310.1 g; p < .001), estimated size of the largest myoma on imaging (9.01 cm vs 7.77 cm; p < .001), and number of myomas removed (6.59 vs 5.57; p = .021). Other statistically significant differences between the overnight admission and SDD groups were mean estimated blood loss (599.4 mL vs 221.9 mL; p < .001), operative time (224.4 minutes vs 140.9 minutes; p < .001), and surgery end time (15:02 hours vs 12:43 hours; p < .001). Intraoperative complications associated with overnight admission were estimated blood loss >1 L (p < .001) and any intraoperative transfusion (p < .001). The adjusted logistic regression model identified an increase in operative time (by 60 minutes) and later surgery end time (by 60 minutes) as predictors of an overnight stay, whereas an 5% increase in preoperative hematocrit was associated with a 34% decrease in odds for an overnight stay. CONCLUSION: Perioperative factors, such as preoperative hematocrit, and myoma characteristics, as well as intraoperative factors, such as prolonged operative time and surgery end-time, are independent predictors of overnight hospital admission after minimally invasive myomectomy. Our present data can be used to provide better patient counseling before surgery.

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: Surgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis. DATA SOURCES: We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction. METHODS OF STUDY SELECTION: Study Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted. TABULATION, INTEGRATION AND RESULTS: Out of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18-0.63; I2 = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09-0.51; I2 = 0%; p  <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32-1.69; I2 = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14-0.66; I2 = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4-1.31; I2 = 63%; p = .28). CONCLUSION: Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.