Guideline No. 437: Diagnosis and Management of Adenomyosis.

OBJECTIVE: To describe the current evidence-based diagnosis and management of adenomyosis. TARGET POPULATION: All patients with a uterus of reproductive age. OPTIONS: Diagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy). OUTCOMES: Outcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes). BENEFITS, HARMS, AND COSTS: This guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options. EVIDENCE: Databases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows. TWEETABLE ABSTRACT: Adenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available. SUMMARY STATEMENTS: RECOMMENDATIONS.

Internal iliac artery ligation-a contemporary simplified approach.

Bilateral ligation of the anterior division of the internal iliac arteries can be a lifesaving intervention for severe pelvic hemorrhage. The procedure results in decreased pelvic perfusion and promotes coagulation. The classical method of internal iliac artery ligation involved extensive retroperitoneal dissection with complete circumferential isolation of the vessel to allow the passage of a suture around the artery. This can be surgically challenging and fraught with risks of inadvertent injury to the surrounding iliac veins. We propose a contemporary technique that requires limited dissection of the anterior division of the internal iliac artery. A few millimeters of space is created on either side of the artery by spreading right-angle forceps parallel to the vessel. The artery is occluded by 2 large vascular clips. Because circumferential vessel dissection is not necessary with this technique, there is limited disruption of the delicate underlying internal iliac vein. In addition, this approach may decrease the risk of inadvertent injury to the adjacent external iliac vein. By showcasing the ease of our approach to internal iliac artery ligation, we hope to empower surgeons with an alternative approach to this lifesaving procedure.

No. 377-Hysterectomy for Benign Gynaecologic Indications.

OBJECTIVE: To assist physicians performing gynaecologic surgery in decision making surrounding hysterectomy for benign indications. INTENDED USERS: Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers. TARGET POPULATION: Adult women (18 years and older) who will undergo hysterectomy for benign gynaecologic indications. OPTIONS: The approach to hysterectomy and utility of concurrent surgical procedures are reviewed in this guideline. EVIDENCE: For this guideline relevant studies were searched in the PubMed, Medline, and Cochrane Library databases. The following MeSH search terms and their variations for the last 5 years (2012-2017) were used: vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy, and total vaginal hysterectomy. VALIDATION METHODS: The content and recommendations were drafted and agreed upon by the principal authors and members of the Gynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2). The Summary of Findings is available upon request. BENEFITS, HARMS, AND COSTS: Hysterectomy is common, yet surgical practice still varies widely among gynaecologic physicians. This guideline outlines preoperative and perioperative considerations to improve the quality of care for women undergoing benign gynaecologic surgery. GUIDELINE UPDATE: This Society of Obstetricians and Gynaecologists of Canada clinical practice guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. SPONSORS: This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: RECOMMENDATIONS.

Saline Hysteroscopy for Removal of Retained Intrauterine Contraceptive Devices in Early Pregnancy.

OBJECTIVE: Pregnancies complicated by a retained intrauterine device (IUD) are at increased risk for adverse outcomes such as miscarriage and preterm labour. There is limited evidence to guide the management of retained IUDs in pregnancy when the strings are not visible at the external cervical os. We describe a method for IUD retrieval in such cases. METHODS: Twenty-six patients underwent saline hysteroscopy with or without concurrent ultrasound guidance for retrieval of a retained IUD in early pregnancy between 2002 and 2015. We retrospectively evaluated procedural and pregnancy-related outcomes in this case series. RESULTS: The average gestational age at the time of the procedure was 11+0 weeks. Successful IUD retrieval occurred in 22 of 26 cases (84.6%). There were 23 live births, including 20 full term and three preterm deliveries. The average gestational age at delivery was 38+4 weeks. There was one miscarriage and one elective termination of pregnancy following the procedure. There were no complications directly related to the procedure. CONCLUSION: Saline hysteroscopy is a safe and effective method for retrieval of a retained IUD in early pregnancy. It appears that concurrent ultrasound guidance can facilitate IUD localization, but more cases are needed to confirm this. Pregnancy outcomes after IUD retrieval were favourable, with a low rate of miscarriage and preterm labour.

Uterine artery occlusion at myomectomy.

OBJECTIVE: To demonstrate three approaches to uterine artery occlusion at time of myomectomy as a blood-sparing intraoperative technique. DESIGN: A step-by-step explanation of the procedure with surgical video footage. SETTING: Academic medical center. PATIENT(S): Patients undergoing laparoscopic myomectomy, for whom a uterine artery occlusion was performed before any uterine incision. INTERVENTION(S): A step-wise approach is applied before beginning the myomectomy portion of the procedure, which includes the following: [1] selecting the appropriate approach to uterine artery occlusion (lateral vs. posterior vs. anterior) on the basis of individual anatomy; [2] identification of relevant anatomy and important landmarks for the procedure; [3] isolating the uterine artery and identifying the ureter; [4] occluding the uterine artery. MAIN OUTCOME MEASURE(S): Successful identification of the ureter and uterine artery, and occlusion of the latter by surgical clipping. RESULT(S): In all cases, the uterine artery was clearly identified, as was the ureter, and surgical clips were placed, resulting in successful uterine artery occlusion. CONCLUSION(S): Uterine artery occlusion can be performed by three different approaches, as have been demonstrated in this video. A systematic review and meta-analysis of the literature supports the efficacy of this procedure in terms of limiting blood loss, blood transfusion, and fibroid recurrence, albeit at slightly longer operative times.