Operative Time and Accrual of Postoperative Complications in Minimally Invasive Versus Open Myomectomy.

STUDY OBJECTIVE: To compare the prevalence and accrual of 30-day postoperative complications by operative time for open myomectomy (OM) and minimally invasive myomectomy (MIM). DESIGN: Retrospective cohort study SETTING: Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2021. PATIENTS: Female patients aged ≥18 years undergoing OM or MIM. INTERVENTIONS: Patients were categorized into OM and MIM cohorts. Covariates associated with operative time and composite complications were identified using general linear model and chi-square or Fisher's exact test as appropriate. Adjusted spline regression was performed as a test of linearity between operative time and composite complications. Adjusted risk ratios of 30-day postoperative individual, minor, major, and composite complications by 60-minute operative time increments were estimated using Poisson regression with robust error variance. MEASUREMENTS AND MAIN RESULTS: Of 27 728 patients, 11 071 underwent MIM and 16 657 underwent OM. Mean operative times (SD) were 164.6 (82.0) for MIM and 129.2 (67.0) for OM. Raw composite complication rates were 5.5% for MIM and 15.8% for OM. Adjusted spline regression demonstrated linearity between operative time and relative risk of composite postoperative complications for both MIM and OM. MIM had higher adjusted relative risk (aRR, 95% CI) compared to OM of blood transfusion (1.55, 1.45-1.64 versus 1.29, 1.25-1.34), overall minor complications (1.13, 1.03-1.23 versus 1.01, 0.92-1.10), and overall major complications (1.43, 1.35-1.51 versus 1.27, 1.12-1.32). Operative time had greater impact on risk of composite complications for MIM than OM, reaching aRR 2.0 at 296 minutes versus 461 minutes for OM. CONCLUSION: OM has a higher overall rate of composite, minor, and major complications compared to MIM. While operative time is independently and linearly associated with postoperative complications with myomectomy regardless of approach, optimizing surgical efficiency for MIM may be more critical than for OM.

Classification and treatment of vaginal strictures at the donor-recipient anastomosis after uterus transplant.

OBJECTIVE: To describe the incidence and management of vaginal stricture after uterus transplantation (UTx) in the US, to propose a grading system to classify stricture severity, and to identify risk factors for stricture formation. DESIGN: Prospective cohort study. SETTING: University Hospital. PATIENTS: Recipients undergoing UTx from 2016-2023 at Baylor University Medical Center in Dallas, Cleveland Clinic, the University of Pennsylvania, and the University of Alabama at Birmingham were monitored postoperatively with regular pelvic examinations. Stricture was defined as vaginal narrowing of <3 cm in patients with graft survival of at least 7 days. INTERVENTION: Demographic and surgery characteristics. MAIN OUTCOME MEASURES: Stricture development and severity (grade 1 for diameter 2-<3 cm, grade 2 for 1-<2 cm, or grade 3 for <1 cm). RESULTS: Of the 45 UTx from 2016-2023 (16 deceased donors and 29 living donors), 3 were excluded from the analysis because of graft loss within 7 days. Of the 42 remaining recipients, 39 (92.9%) had Mayer-Rokitansky-Küster-Hauser syndrome and 3 (7.1%) had a prior hysterectomy. Twenty-eight (66.7%) UTx recipients developed postoperative vaginal strictures with a median time to stricture of 33 days (interquartile range 19-53 days). Most strictures were of moderate severity, with 4 (14.3%) strictures categorized as grade 1, 19 (67.9%) as grade 2, and 5 (17.9%) as grade 3. History of Mayer-Rokitansky-Küster-Hauser syndrome and preoperative recipient vaginal length were significant risk factors for stricture, after adjustment for donor and recipient age and body mass index, anastomosis technique, total ischemia time, center, and year. Patients with longer preoperative vaginal length had a lower risk of stricture (hazard ratio 0.45, 0.29-0.70). The severity grading of the stricture was associated with the effectiveness of a nonoperative treatment approach (grade 1 vs. grade 3). No patients with grade 3 strictures improved with self-dilation alone; all required surgical repair and/or dilation under anesthesia. Conversely, for grade 1 or 2 strictures, self-dilation alone was successful in 47.8% (11/23), and no grade 1 strictures required surgical repair. CONCLUSIONS: Vaginal stricture is a common postoperative complication after UTx, affecting >65% of recipients. Short preoperative vaginal length and history of müllerian agenesis in the recipient are significant risk factors. Vaginal self-dilation was effective for some mild to moderate strictures, although dilation under anesthesia or surgical repair was required in most cases. CLINICAL TRIAL REGISTRATION NUMBERS: Dallas UtErus Transplant Study (DUETS) at Baylor University Medical Center (NCT02656550), Uterine transplantation for the treatment of uterine factor infertility at the Cleveland Clinic (NCT02573415), The University of Pennsylvania Uterus Transplant for Uterine Factor Infertility Trial (UNTIL) (NCT03307356).

Impact of coronavirus disease 2019 vaccination on live birth rates after in vitro fertilization.

OBJECTIVE: To investigate coronavirus disease 2019 (COVID-19) vaccination on the live birth rates in patients who underwent in vitro fertilization. DESIGN: Retrospective cohort study. SETTING: Academic fertility practice. PATIENT(S): Patients who underwent fresh or frozen embryo transfer cycles at an academic center between January 1, 2020, and December 31, 2021. INTERVENTION(S): Coronavirus disease 2019 vaccination, defined as completing a 2-dose regimen (Pfizer or Moderna) or 1-dose regimen (Johnson & Johnson/Janssen) before cycle initiation. MAIN OUTCOME MEASURE(S): The primary outcome was the live birth rate per embryo transfer. The secondary outcomes included positive human chorionic gonadotropin (hCG) and clinical pregnancy rates per embryo transfer. The outcomes from cycles among vaccinated and unvaccinated patients were compared. Descriptive statistics were used to analyze demographic and cycle characteristics using the Student t test and Wilcoxon rank sum, Pearson chi-square, and Fisher exact tests as appropriate for univariate analysis. Generalized estimating equation models were used to examine the strength of the relationship between vaccination status and pregnancy outcomes. RESULT(S): Among 709 unvaccinated and 648 vaccinated fresh cycles, no statistically significant differences were observed between the number of oocytes retrieved, oocyte maturity, fertilization, and blastocyst utilization rates. In the adjusted multivariate analysis, no statistically significant differences were noted between fresh cycles among vaccinated patients compared with those among unvaccinated patients with the rates of positive hCG (adjusted odds ratio [aOR], 1.37; 95% confidence interval [CI], 0.84-2.25), clinical pregnancy (aOR, 1.22; 95% CI, 0.73-2.03), or live birth (aOR, 1.37; 95% CI, 0.79-2.25) per embryo transfer. Among 264 unvaccinated and 423 vaccinated frozen embryo transfer (FET) cycles, vaccinated patients had higher odds of positive hCG (aOR, 1.54; 95% CI, 1.08-2.20), clinical pregnancy (aOR, 1.80; 95% CI, 1.27-2.56), and live birth (aOR, 2.31; 95% CI, 1.60-3.32) per embryo transfer than unvaccinated patients. CONCLUSION(S): Patients who were COVID-19 vaccinated before FET had higher rates of biochemical pregnancy, clinical pregnancy, and live birth. Vaccination was not associated with the pregnancy or live birth rates after fresh cycles. This study contributes to evidence supporting COVID-19 vaccination for patients attempting pregnancy.

Use of a shaving technique for surgical management of partial ureteral obstruction due to endometriosis.

OBJECTIVE: To illustrate the surgical management of advanced endometriosis causing extrinsic ureteral compression. DESIGN: Video description of the case, demonstration of the surgical technique, reevaluation at 14-year follow-up, and review of urogenital endometriosis. Patient provided consent for the video recording and publication. This surgical report with no identifying patient data was exempt from Institutional Review Board approval. SETTING: Tertiary referral center. PATIENT(S): A 42-year-old nulligravida with a known history of endometriosis presented with persistent pelvic pain and no other specific symptoms. She had previously undergone a diagnostic laparoscopy demonstrating advanced endometriosis involving multiple organs, including the urinary tract. She was referred to us for further surgical management. Preoperative intravenous pyelogram showed partial obstruction and constriction of a long portion of the midpelvic and distal left ureter with proximal hydroureter, consistent with extrinsic ureteral compression. INTERVENTION(S): The patient underwent operative video laparoscopy using a multipuncture technique, with enterolysis, extensive left ureterolysis, shaving of periureteral constrictive fibrosis and endometriosis, cystoscopy, and placement of left ureteral stent. MAIN OUTCOME MEASURE(S): There was extensive endometriosis and fibrotic adhesions involving the left pelvic sidewall. Proximal hydroureter was noted to the pelvic inlet secondary to severe periureteral fibrosis from the pelvic brim to the bladder meatus, with significant narrowing of the pelvic ureter. The endometriosis was resected using hydrodissection and shaving with a carbon dioxide laser. Histopathologic evaluation of the resection specimens confirmed endometriosis. RESULT(S): An intravenous pyelogram performed 4 weeks postoperatively revealed ureteral patency and resolving hydroureter, and her ureteral stent was removed. Annual renal ultrasounds for the subsequent 2 years were normal. Fourteen years later, she remained asymptomatic on no suppressive treatment. A follow-up intravenous pyelogram was performed and showed a normal urinary tract with bilateral ureteral patency and no recurrent strictures or hydroureter. CONCLUSION(S): In selected cases, conservative shaving of periureteral fibrotic endometriosis avoids ureteral resection and has acceptable outcomes.

Is younger better? Donor age less than 25 does not predict more favorable outcomes after in vitro fertilization.

OBJECTIVE: To determine whether younger oocyte donor age is associated with better outcomes after in vitro fertilization (IVF) compared with older oocyte donor age. DESIGN: A retrospective cohort study. SETTING: Large academically affiliated infertility treatment center. PATIENTS: We included all women ≥ 18 years who started their first fresh cycle using donor oocytes at our center from January 2002 through October 2017; only the first oocyte recipient cycle was analyzed. INTERVENTION: Log-binomial regression was used to compare the incidence of clinical pregnancy and live birth among the following donor age groups: < 25 years, 25 to < 30 years, and 30 to <35 years. MAIN OUTCOME MEASURE: Incidence of clinical pregnancy and live birth among donor age groups. RESULTS: We included 774 donor cycles; 269 (34.8%) used donors < 25 years, 399 (51.6%) used donors 25 to < 30 years, and 106 (13.7%) used donors 30 to < 35 years. Median donor age was 26 years (range 18-34.5), and median recipient age and partner age were both 42 years. Per cycle start, after adjusting for recipient age, cycles using donors < 25 years were not associated with a higher incidence of clinical pregnancy (RR 0.90; 95% CI 0.77-1.06) or live birth (RR 0.87; 95% CI 0.72-1.04) compared with donors age 25-< 30 years. CONCLUSIONS: Donor age < 25 was not associated with better outcomes after IVF. Under the age of 30, the prioritization of <25 year old donors may not be recommended given the lack of evidence for superior pregnancy or live birth outcomes.

Influence of race and ethnicity on in vitro fertilization outcomes: systematic review.

OBJECTIVE: We conducted a systematic review to evaluate the influence of race and ethnicity on clinical pregnancy and live birth outcomes after in vitro fertilization (IVF). STUDY: We searched PubMed, EMBASE, Web of Science, CINAHL, POPLINE, and Cochrane Central, and hand-searched relevant articles published through July 22, 2015. STUDY APPRAISAL AND SYNTHESIS METHODS: Two reviewers independently evaluated abstracts to identify studies that compared clinical pregnancy rates and live birth rates for ≥2 racial and/or ethnic groups after nondonor IVF cycles. RESULTS: Twenty-four studies were included. All 5 US registry-based studies showed that black, Hispanic, and Asian women had lower clinical pregnancy rates and/or live birth rates after IVF, compared with white women. Similarly, most clinic-specific studies reported significant disparities in these primary outcomes, potentially attributable to differences in infertility diagnosis, spontaneous abortion, and obesity. Studies varied with respect to definitions of race/ethnicity, inclusion of first cycles vs multiple cycles for individual women, and collected covariates. Most studies were limited by sample size, inadequate adjustment for confounding, selection bias, and extensive missing data. CONCLUSIONS: Although current evidence points to race and ethnicity, especially black race, as strong predictors of poorer outcomes after IVF, the utility of results is constrained by the limitations described.

Pro-apoptotic TP53 homolog TAp63 is repressed via epigenetic silencing and B-cell receptor signalling in chronic lymphocytic leukaemia.

Chronic lymphocytic leukaemia (CLL) is an accumulative disorder marked by deficient apoptosis. The TP53 homolog TAp63 promotes apoptosis and chemosensitivity in solid tumours and its deregulation may contribute to CLL cell survival. We found that TAp63α was the most prevalent TP63 isoform in CLL. Compared to healthy B cells, TAp63 mRNA was repressed in 55·7% of CLL samples. TP63 promoter methylation was high in CLL and inversely correlated with TP63 protein expression in B-cell lymphoma cell lines. siRNA-mediated knockdown of TP63 resulted in partial protection from spontaneous apoptosis accompanied by reductions in PMAIP1 (NOXA), BBC3 (PUMA), and BAX mRNA in CLL cells and increased proliferation of Raji lymphoma cells. TAp63 mRNA levels were higher in CLL with unmutated IGHV. B-cell receptor (BCR) engagement led to repression of TP63 mRNA expression in malignant B cells, while pharmacological inhibition of BCR signalling prevented TP63 downregulation. MIR21, known to target TAp63, correlated inversely with TAp63 expression in CLL, and BCR-mediated downregulation of TP63 was accompanied by MIR21 upregulation in most CLL samples. Our data illustrate the pro-apoptotic function of TP63, provide insights into the mechanisms of BCR-targeting agents, and establish a rationale for designing novel approaches to induce TP63 in CLL and B-cell lymphoma.

Causes of dissatisfaction after laparoscopic fundoplication: the impact of new symptoms, recurrent symptoms, and the patient experience.

BACKGROUND: Although laparoscopic fundoplication effectively alleviates gastroesophageal reflux disease (GERD) in the great majority of patients, some patients remain dissatisfied after the operation. This study was undertaken to report the outcomes of these patients and to determine the causes of dissatisfaction after laparoscopic fundoplication. METHODS: All patients undergoing laparoscopic fundoplication in the authors' series from 1992 to 2010 were evaluated for frequency and severity of symptoms before and after laparoscopic fundoplication, and their experiences were graded from "very satisfying" to "very unsatisfying." Objective outcomes were determined by endoscopy, barium swallow, and pH monitoring. Primary complaints were derived from postoperative surveys. Median data are reported. RESULTS: Of the 1,063 patients undergoing laparoscopic fundoplication, 101 patients reported dissatisfaction after the procedure. The follow-up period was 33 months. The dissatisfied patients (n = 101) were more likely than the satisfied patients to have postoperative complications (9 vs 4 %; p < 0.05) and to have undergone a prior fundoplication (22 vs 11 %; p < 0.05). For the dissatisfied patients, heartburn decreased in frequency and severity after fundoplication (p < 0.05) but remained notable. Also for the dissatisfied patients, new symptoms (gas bloat/dysphagia) were the most prominent postoperative complaint (59 %), followed by symptom recurrence (23 %), symptom persistence (4 %), and the overall experience (14 %). Primary complaints of new symptoms were most common within the first year of follow-up assessment and less frequent thereafter. Primary complaints of recurrent symptoms generally occurred more than 1 year after fundoplication. CONCLUSIONS: Dissatisfaction is uncommon after laparoscopic fundoplication. New symptoms, such as dysphagia and gas/bloating, are primary causes of dissatisfaction despite general reflux alleviation among these patients. New symptoms occur sooner after fundoplication than recurrent symptoms and may become less common with time.