Transvaginally Adjustable Apical Suspension and Compartment-Specific Tensioning in Vaginal Natural-Orifice Transluminal Endoscopic Surgery Sacrocolpopexy: Cadaveric and Live Patient Experience.

Objective: This article provides a systematic approach to performing a vaginal natural-orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy (SCP) to create an anatomically aligned vaginal axis, an intraoperatively adjustable apical suspension, and variable compartment tensioning. Methods: The technique presented for vNOTES SCP focuses on: (1) retroperitoneal tunneling; (2) direct sacrum access below the S-1 level, using uterosacral-ligament guidance; (3) transvaginal tensioning of the mesh to ensure both adequate vaginal length and cuff elevation using the DZOH apical-suspension technique; (4) circumvention of intrapelvic laparoscopic suturing; and (5) near-total peritoneal coverage of the mesh arms. Results: This detailed description of a successful novel technique to perform vNOTES SCP was based on cadaveric experience as well as in live patients that is reproducible on living patients. Conclusions: This apical suspension technique for vNOTES SCP may be a viable, reproducible, safe, and efficient transvaginal alternative to the commonly practiced minimally invasive approaches that involve abdominal-port placements. (J GYNECOL SURG 40:116).

Oxidative stress contributes to hypermethylation of Histone H3 lysine 9 in placental trophoblasts from preeclamptic pregnancies.

Background and objective: Aberrant epigenetic regulation and increased oxidative stress in the placenta play a significant role in placental pathophysiology and fetal programming in preeclampsia, a hypertensive disorder in human pregnancy. The purpose of the study is to investigate if hypermethylation of histone H3K9 occurs in placental trophoblasts from preeclampsia. Methods: Trophoblasts were isolated and cultured from 14 placentas, 7 from normotensive pregnant women and 7 from preeclamptic pregnancies. Methylated H3K9 expression and antioxidant superoxide dismutase expression were determined by Western blot. We also examined consequences of oxidative stress and the downstream effects of histone methyltransferase inhibition on H3K9 expression associated with antioxidant CuZn-SOD and Mn-SOD expression in placental trophoblasts. Results: We found that expression of mono-, di-, and tri-methylation of histone H3 lysine 9 (H3K9me1, H3K9me2 and H3K9me3) was significantly increased, p<0.01, which correlated with downregulation of antioxidant superoxide dismutase CuZn-SOD and Mn-SOD expression, in trophoblasts from preeclamptic placentas compared to those from uncomplicated control placentas. We further demonstrated hypoxia could promote histone H3K9 methylation in placental trophoblasts, and hypoxia-induced upregulation of H3K9me1, H3K9me2 and H3K9me3 expression was reversible when hypoxic condition was removed. In addition, we also uncovered that inhibition of methyltransferase not only prevented hypoxia-induced upregulation of H3K9me1, H3K9me2 and H3K9me3 expression, but also abolished hypoxia-induced downregulation of CuZn-SOD and Mn-SOD expression in placental trophoblasts. Conclusions: These findings are noteworthy and provide further evidence that increased oxidative stress in the intrauterine environment is likely a mechanism to induce aberrant histone modification in placental trophoblasts in preeclampsia. Moreover, CuZn-SOD and Mn-SOD expression/activity are possibly H3K9 methylation-dependent in placental trophoblasts, which further suggest that oxidative stress and aberrant histone modification have significant impact on placental trophoblasts/fetal programming in preeclampsia.

Early Exposure to Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) Medicine: Assessing Confidence and Comfort in Preclinical Medical Students.

BACKGROUND: Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) individuals face unique health challenges when compared to the general population. Physicians can play an integral role in either addressing these health inequities or further perpetuate discrimination. Despite the growing LGBTQ+ population in the United States and exposure during clinical care, many medical schools still lack an effective, standardized LGBTQ+ healthcare curriculum. Research has shown that when medical students receive exposure to LGBTQ+ healthcare topics, it results in superior quality of care. Considering the unique challenges LGBTQ+ individuals face, coupled with the perception medical students have of the current LGBTQ+ curriculum, and the positive impact LGBTQ+ education may have on patient care, there is a need for an effective and standardized LGBTQ+ curriculum in medical school education. OBJECTIVES: The aim of this study was to assess the effectiveness of a two-hour interactive LGBTQ+ workshop at increasing confidence and comfortability in LGBTQ+ topics and healthcare education for preclinical medical students. METHODS: Twenty-five first- and second-year medical students participated in an optional two-hour interactive LGBTQ+ workshop. The first hour consisted of a lecture overviewing LGBTQ+ clinical medicine from a physician specializing in LGBTQ+ topics and care. The second hour was made up of four 15-minute stations. Students were split up evenly and rotated through these four stations consisting of: (1) a one-on-one standardized patient simulation, (2) discussion-based case scenarios, (3) an interactive seminar on transgender healthcare, and (4) a debriefing station. All facilitators and standardized patients were members of the LGBTQ+ community. Consenting participants were provided with a pre- and post-survey consisting of basic demographic questions, and 16 LGBTQ+ healthcare specific statements that they answered using a 7-point Likert scale. RESULTS: Fifteen of the 25 (60%) preclinical medical students completed all components of both the pre- and post-survey. 53.3% of the respondents were heterosexual, while 40% identified as being a part of the LGBTQ+ community. Survey results demonstrated a significant increase compared to the pre-workshop baseline in preclinical student comfort and confidence in 12 out of the 16 LGBTQ+ healthcare specific statements after completion of the workshop. CONCLUSIONS: Our study suggests that focused education, such as through workshops, on LGBTQ+ topics can significantly increase preclinical student comfort and confidence when encountering LGBTQ+ clinical scenarios. In the future, we hope this workshop is implemented within our core medical school curriculum as a mandatory course to reach a wider audience. This workshop offers an efficient and effective model for other medical schools to implement to educate their medical students on LGBTQ+ healthcare topics.

Older Patient Receptivity to the Integration of Patient Portals and Telehealth in Urogynecology: Promoters and Deterrents.

IMPORTANCE: Limited studies focus on the integration of online portals, including telehealth services, in urogynecology while identifying promoters and deterrents of utilization, especially for the older population. OBJECTIVE: This study aimed to identify facilitators, concerns, technical or personal issues encountered, and the desired features of the online patient portals among older urogynecology patients. STUDY DESIGN: This is a secondary analysis of a cross-sectional study of older patients (≥65 years). The survey was devised using 2 focus groups with questions addressing older patient practicality and comfort with virtual visits for menopause and urogynecology-specific conditions. RESULTS: A total of 205 patients completed the study. Promoters of use included health care professional encouragement, enrollment on site with concurrent education, and clarification of relevance of the virtual care to one's care. Patients who were uncomfortable with portal use reported anxiety and technical issues as deterrents for using such technology. More than half of the patients were comfortable having online visits for preoperative (51.7%), postoperative (66.3%), and medical management (73.7%). Up to 60.5% of the patients believed that virtual visits were equally stressful as in-person visits, whereas 24.4% believed that the logistics of in-person visits were the cause of stress. CONCLUSIONS: To improve access to care, augment the utilization of online patient portals, and combat ageism, enhancing the older urogynecologic patient's portal experience is vital. Investment in this population's needs includes education of patients, active enrollment, and engagement by health care systems, and addressing technical concerns.

Addition of Transversus Abdominis Plane Block to Conventional Pain Regimens in Robotic Sacrocolpopexy Procedures-A Pilot Randomized Controlled Trial (SACROTAP).

IMPORTANCE: There have been no randomized trials assessing the benefits of integration of transversus abdominis plane (TAP) blocks in sacrocolpopexy procedure postoperative pain management. OBJECTIVE: The aim of this study was to assess the variation in pain perception upon adding TAP blocks to conventional oral pain medications in patients undergoing sacrocolpopexy. The primary outcome was the reduction in pain reported using the numeric rating scale (NRS) among patient groups. The secondary outcome was the change in narcotic analgesic use postoperatively. STUDY DESIGN: This was a prospective double-blind, pilot randomized controlled trial of women undergoing robotic sacrocolpopexy, with and without supracervical hysterectomy, with 20 patients enrolled in each arm. Randomization included receiving a TAP block in addition to the conventional analgesic regimen. RESULTS: A total of 48 women were approached to participate in the study; 40 women provided consent (20 per study arm) and completed the 7-day follow-up. Patients receiving a TAP block had lower NRS pain scores at 4 hours postoperatively (4.95 ± 0.76 vs 5.50 ± 0.61, P = 0.02), 7 days postoperatively (2.20 ± 1.11 vs 3.15 ± 1.04, P = 0.008), and lower cumulative NRS pain scores at 48 hours postoperatively (14.90 ± 2.2 vs 16.60 ± 2.04, P = 0.02) and 7 days postoperatively (17.10 ± 2.63 vs 19.75 ± 2.65, P = 0.003) than patients not receiving a block. Patients in the intervention group also had lower cumulative morphine milliequivalents at 7 days postoperatively (17.25 ± 10.7 vs 29.25 ± 14.53, P = 0.005). CONCLUSION: Use of TAP blocks in robotic sacrocolpopexy cases, with or without concurrent hysterectomy, may reduce postoperative pain and narcotic medication needs.

Patient Receptivity to Integration of Telehealth in Pelvic Floor Physical Therapy Regimens.

IMPORTANCE: Limited research has focused on patient perceptions and barriers to integration of virtual care in the pelvic health arena. OBJECTIVES: The purpose of this study was to determine the willingness of patients to consider telehealth as a means to seek pelvic floor physical therapy (PFPT) care and the promoters and deterrents for deployment in this treatment modality. METHODS: This is a cross-sectional study of patients (≥18 years of age) at a multidisciplinary pelvic health service in an academic medical center in Northwest Ohio. The data collection occurred over 6 months in the latter half of 2021 using a novel 21-question survey based on focus group perceived patient requests, needs, and concerns that were aligned and cross-referenced with published literature. RESULTS: The survey was completed by 210 patients, with up to 40% (n = 83) being new PFPT patients. Of those interested in telehealth being a component of their PFPT therapeutic regimen (n = 142 [68%]), interest was driven by convenience (78%). Privacy (n = 52 [76%]) was the main barrier impeding interest in this modality. Up to 80% (n = 169) preferred to establish care through in-person visits before initiating PFPT regimens remotely, with 44% (n = 93) suggesting that incorporation of telehealth would positively affect their adherence with care regimens. CONCLUSION: Offering patients in-person visits or hybrid alternatives may be optimal for improving adherence to therapeutic regimens especially when considering access to care.

Published Support for Wellness, Diversity, Equity, and Inclusion Among Internal Medicine Residency Program Websites.

INTRODUCTION: The objective of this study was to review internal medicine residency program websites in the United States based on their published support for wellness, diversity, equity, and inclusion concepts. Inclusion of wellness, diversity, equity, and inclusion on program websites can serve as critical student benchmarks, and it may be paramount to optimize residency program websites accordingly. METHODS: This is a cross-sectional study of the websites of 597 internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education between March 25 and April 25, 2022. The websites were assessed based on 22 characteristics consisting of wellness verbiage, gender and underrepresented in medicine evaluation of faculty and residents, and diversity, equity, and inclusion-related semantics. Website photos were used to assess ethnic/sex representation. These attributes were devised by two sequentially set up focus groups consisting of 49 racially, ethnically, and gender-diverse medical students. RESULTS: A total of 579 internal medicine programs were reviewed. Only 239 (41%) had a dedicated page for resident wellness activities and efforts, while 134 (19%) had no mention of the concept throughout their web pages. Similarly, only 136 (23%) had a dedicated wellness officer, whether faculty or resident, who was focused on departmental interests. Gender diversity could be determined in 445 (77%) and 459 (79%) websites for faculty and residents, respectively. Underrepresented in medicine faculty and residents was noted in 293 (51%) and 393 (68%) of websites, respectively. A diversity, equity, and inclusion section was present in 172 (30%) of programs, with 93 (16%) having an assigned faculty or resident. Chairpersons or program directors stressed diversity, equity, and inclusion in up to 456 (79%) of the websites, with 181 (31%) having program mission statements or goals that include diversity, equity, and inclusion verbiage. CONCLUSION: A deficit of various essential wellness, diversity, equity, and inclusion attributes persists across internal medicine residency websites. Residency programs would benefit from optimizing their websites to attract more diverse applicants.

Ageism in healthcare technology: the older patients' aspirations for improved online accessibility.

Objective: To identify concerns, barriers and facilitators impacting the use of patient portals by older patients as well as desired features in future updates. Materials and Methods: This is a cross-sectional study consisting of 2 focus group discussions culminating in an anonymous survey administered to women who were 65 years and older receiving urogynecologic care in Northwest Ohio. Results: Of the 205 women surveyed (91% response rate), providers and healthcare systems play the primary 2 roles (73% and 69%, respectively) in facilitating patients' use of patient portal systems and telehealth applications. Barriers to use revolved around technical difficulties (50%), privacy concerns (45%), and cost of technology (24%). The most important features desired were the ability to modify the text size within the application (47%) and an intuitive, simple interface (46%). Additional assistance for navigating technical challenges was suggested, specifically set-up of accounts (36%), saving and sharing information with caregivers (35%), and sign-in and navigation of portals (32%). Conclusion: The paucity of age-aligned medical access software and products may lead to worsening of digital exclusion and disparities in healthcare. Portal application developers and healthcare systems must advance efforts that consider the needs of those who may be older when designing patient portals.

The Effect of Video Education on Skin-to-Skin Contact at the Time of Delivery: A Randomized Controlled Trial.

Objective The objective of this study was to measure the impact of video education at the time of admission for delivery on intent and participation in skin-to-skin contact (SSC) immediately after birth. Methods This study was a randomized controlled trial of educational intervention in women ( N = 240) of 18 years or older admitted in anticipation of normal spontaneous term delivery. Alternate patients were randomized into video ( N = 120) and no video ( N = 120) groups. Both groups received a survey about SSC. The video group watched an educational DVD and completed a postsurvey about SSC. Results During the preintervention survey, 89.2% of those in the video group compared with 83.3% of those in the no video group indicated that they planned to use SSC ( p = 0.396). After the video, 98.3% planned to do SSC after delivery ( p < 0.001). However, only 59.8% started SSC within 5 minutes of delivery in the video group and only 49.4% started SSC within 5 minutes of delivery in the no video group ( p = 0.17). Conclusion Video education alters the intention and trends toward participation in SSC within 5 minutes of delivery. Despite the plans for SSC, however, there was no significant difference in rates between the two groups. These findings support that obstacles, other than prenatal education, may affect early SSC. Key Points Significant obstacles impact skin-to-skin rate.Video education alters skin-to-skin intent.Video education can improve skin-to-skin rate.Education can happen at the time of delivery.Video education can impact mothers and infants.

Bupivacaine Use After Posterior Colporrhaphy to Reduce Postoperative Pain: A Multicenter, Double-Blinded, Placebo-Controlled, Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to determine if injection of bupivacaine into levator muscles after posterior colporrhaphy reduces postoperative pain. METHODS: This study was a multicenter, double-blinded, placebo-controlled, randomized clinical trial of 130 participants, comparing bilateral infiltration of puborectalis and iliococcygeus muscles with 0.5% bupivacaine without epinephrine or normal saline after vaginal prolapse repair that included a posterior colporrhaphy. Primary outcome was the 24-hour cumulative Visual Analog Scale (VAS) pain score (measured as a sum of VAS pain scores at postoperative hours 0, 4, 8, 16, and 24) across intervention allocations. Secondary outcomes include the individual VAS pain scores per postoperative times 0, 4, 8, 16, and 24 hours and at 1 and 2 weeks, morphine equivalent use, postoperative void trial success, and time to first bowel movement. RESULTS: Sixty-eight participants received bupivacaine, and 62 participants received normal saline. No significant differences were identified in the 24-hour postoperative cumulative VAS pain scores for the bupivacaine and normal saline arms, 19 and 18 (P = 0.71); individual pain scores per each postoperative assessment time; opiate use (24-hour use was 42 vs 48, P = 0.39; 48-hour use was 75 vs 37, P = 0.09); length of hospital stay (26 hours vs 22 hours, P = 0.069); hours to passing void trial (10 hours vs 12 hours, P = 0.17); or hours to first postoperative bowel movement (18 hours vs 12 hours, P = 0.78). CONCLUSIONS: Use of bupivacaine for muscle block after posterior colporrhaphy does not reduce postoperative pain, opiate use, and time to first bowel movement, or increase void trial success.

Do medical student mental stress and burnout vary with virtual versus in-person residency interviews.

AIM: This study aimed to identify medical student stressors and mitigation methodologies based on interview modality. MATERIALS & METHODS: A survey was administered to obstetrics and gynecology applicants in in-person (IP) and virtual (VR) National Resident Matching Program cycles. This included demographics, the Mayo Clinic Medical Students Well-Being Index and stressor questions. RESULTS: A total of 137 of 151 surveys were completed (91% response rate). Subjective stress was significant in 76% of IP and 57% of VR applicants (p = 0.07). The objective Mayo Clinic Medical Students Well-Being Index values were higher in the IP (2.47 ± 1.75) compared with the VR group (2.00 ± 1.55; p = 0.10), suggesting lower stress with VR interviews. More IP (53%) compared with VR applicants (44%) were deemed 'at risk' (p < 0.01). CONCLUSION: VR interviews may mitigate select stressors during interviews.

Insight into resident burnout, mental wellness, and coping mechanisms early in the COVID-19 pandemic.

BACKGROUND: Acute augmentation of stress and disruption of training, such as during the COVID-19 pandemic, may impact resident wellbeing. OBJECTIVES: We investigated how residents in various specialties in the United States were impacted by COVID-19 on mental wellbeing and resilience levels, and the methodology for coping with the stress incurred. METHODS: In April 2020, the authors electronically surveyed 200 residency programs of all specialties nationally. The survey utilized two validated questionnaires to assess wellbeing and resilience, while investigating demographics and coping mechanisms. The authors used student t-test and ANOVA to quantitatively analyze the data. RESULTS: The sample consisted of 1115 respondents (with an 18% response rate). Male gender & Age >39 years were associated with more favorable average well-being indices (both p<0.01). Regarding resources, institutional support (IS) appeared favorable for resident well-being (IS 2.74, SD1.96 vs NoIS 3.71, SD2.29, p<0.01) & resilience (IS 3.72, SD0.70 vs NoIS 3.53, SD0.73, p = 0.05). The effects of mindfulness practices (MP) were not statistically significant for improvement of wellness (MP 2.87, SD 1.99 vs No MP 2.76, SD 2.15, p = 0.85) or resilience (MP 3.71, SD 0.70 vs No MP 3.72, SD 0.68, p = 0.87). CONCLUSIONS: Findings highlight the critical importance of resident mental status in cases of augmented stress situations. Institutional support may contribute to promotion of resident wellbeing.

Endometriosis-associated colorectal carcinosarcoma: A case report and review of the literature.

•Endometriosis associated intestinal tumors are rare, with 5 cases documented.•Endometriosis associated intestinal tumors might present like colorectal carcinoma.•Endometriosis associated intestinal Carcinoma is associated with poor prognosis.

Uterine Fibroid in a 16-Year-Old Adolescent Managed with a Fertility-Sparing Approach: A Case Report and Review of the Literature.

BACKGROUND: Uterine fibroids are the most common benign tumor of the uterus in adult women. However, it is exceedingly rare in adolescents. CASE: A 16-year-old girl presented with severe anemia and abnormal uterine bleeding. MRI of the pelvis demonstrated a 9-cm mass within the uterus concerning for leiomyoma or leiomyosarcoma. A fertility preserving myomectomy led to the final diagnosis of a benign uterine fibroid. SUMMARY AND CONCLUSION: Despite the rare incidence of leiomyomas in adolescents, it is imperative that it is included in the differential diagnosis when young women present with abnormal uterine bleeding. A less common diagnosis to consider is leiomyosarcoma; however, this is histologically diagnosed. Thus, a fertility-preserving myomectomy permits for a diagnostic opportunity to rule out a potential malignancy.

Multi-institutional Validation of a Vaginal Hysterectomy Simulation Model for Resident Training.

STUDY OBJECTIVE: The purpose of the research was to both develop a vaginal hysterectomy model with surgically pertinent anatomic landmarks and assess its validity for simulation training. DESIGN: A low-cost, reproducible vaginal hysterectomy model with relevant anatomic landmarks for key surgical steps. SETTING: Nine academic and community-based obstetrics and gynecology residency programs. PARTICIPANTS: One hundred sixty-nine obstetrics and gynecology residents. INTERVENTIONS: A vaginal hysterectomy model with surgically pertinent anatomic landmarks was developed and tested for construct validity. MEASUREMENTS AND MAIN RESULTS: Of the 184 available residents, 169 (91%) participated in this study and performed a vaginal hysterectomy procedure on the described model. The validated objective 7-item global rating scale (GRS) and the 13-item task-specific checklist (TSC) were used as tools to assess performance. The median TSC and GRS scores correlated with year of training, prior experience, and trainee confidence. In addition, the TSC scores also correlated with the GRS scores (p <.001) with regard to performance and resident year of training. Receiver Operator Curves for identification of the residents meeting national residency accreditation minimum numbers for vaginal hysterectomy using the GRS and TSC scores had an area under the curve of 0.89 and 0.83, respectively. CONCLUSION: This reduced-cost vaginal hysterectomy model offers high construct validity and pertinence for simulation.

Management of a Splenic Artery Aneurysm in the Third Trimester of Pregnancy.

BACKGROUND: Splenic artery aneurysm (SAA) is a rare but potentially fatal complication associated with high maternal and fetal mortality when occurring during pregnancy. CASE: A 29-year-old G4P3003 at 34 4/7 weeks of gestation was admitted with left upper quadrant pain and newly diagnosed SAA in the hilum. She was scheduled for embolization of the SAA but the night before went into labor. A multidisciplinary team discussion was held, and the patient underwent successful primary low transverse c-section via Pfannenstiel skin incision followed by laparoscopic splenectomy under general anesthesia. She delivered a male newborn with birth weight of 2855 and Apgar score of 8/5. Summary and Conclusion. Early diagnosis and management of SAA are key for improved maternal and fetal outcomes. Our case demonstrates that through a multidisciplinary approach and anticipation of the possible clinical scenarios, good outcomes can be achieved.

Translating Sexual Dysfunction: Does Language Impact Clinical Discussion of Painful Sex?

OBJECTIVES: Dyspareunia and sexual dysfunction are estimated to affect up to 22% and 43% of women, respectively. There is concern that these statistics do not depict the true prevalence and that these conditions are frequently undiagnosed and untreated. By 2060, Latinos will make up 30% of the total population in the United States. Because our patient population becomes more diverse, we need to ensure that our healthcare practices accommodate the changes. METHODS: We surveyed a convenience sample of 107 English and 71 Spanish-speaking women, aged 18 to 45 years, at university-affiliated clinics to identify the prevalence of dyspareunia and sexual dysfunction within our community. In addition, we wanted to identify the rate that clinicians discuss painful sex with patients to identify whether language impacted communication. The surveys collected data on subjective reporting of pain with sex and objective identification of sexual dysfunction with the Female Sexual Function Index. Additional questions identified if subjects discussed pain with their clinician. These questions were analyzed between languages across all domains. RESULTS: A greater prevalence of both dyspareunia and sexual dysfunction was measured in our study population compared with previous reports (37.79% and 54.71%, respectively). Spanish-speaking women had significantly lower self-reported dyspareunia (28.99%) but scored significantly lower on the Female Sexual Function Index, qualifying for sexual dysfunction (63.24%). Spanish speakers discussed painful sex significantly less compared with the English cohort, but the overall discussion rate was only 17.26%. CONCLUSIONS: These pilot data demonstrate a need for further research on language as a barrier to communication about sexual function in clinic.

Corrigendum to "Symptomatic Clitoral Neuroma within an Epidermal Inclusion Cyst at the Site of Prior Female Genital Cutting".

[This corrects the article DOI: 10.1155/2019/5347873.].

Maternal morbidity associated with skin incision type at cesarean delivery in obese patients: a systematic review.

AIM: To describe the relationship between cesarean skin incision type and postoperative wound complications (WCs) in obese pregnant patients. MATERIALS & METHODS: MEDLINE (PubMed and OVID), Embase, Scopus, Web of Science Core Collection, Cochrane Library and ClinicalTrials.gov databases were used for publication search. Selection criteria consisted of articles studying pregnant patients with BMI ≥30 kg/m2 undergoing cesarean delivery and assessing the effect of skin incision type on postoperative maternal outcomes. RESULTS: Ten publications met criteria for a systematic review of a total of 2946 patients. The transverse skin incision was associated with a lower rate of WC compared with the vertical skin incision. The pooled risk ratio for WCs was 0.47 (95% CI: 0.37-0.58; p < 0.00001). CONCLUSION: Transverse skin incision may be preferable to vertical skin incision at cesarean delivery in pregnant patients with obesity as it may be associated with a lower rate of WCs.PROSPERO registration ID: CRD42020151106.

Gartner's duct cysts: a review of surgical management and a new technique using fluorescein dye.

INTRODUCTION AND HYPOTHESIS: Gartner's duct cysts (GDC) are benign lesions that may become symptomatic, leading to surgical intervention. There is no standard surgical technique for management of GDC. This article provides a comprehensive review of surgical the management of GDC. We also present a new technique using fluorescein dye to help delineate GDC walls and facilitate complete cyst excision. METHODS: We conducted a PubMed search for English-language articles without a defined time range. The search combined subject headings, title, abstract, and text words relating to Gartner duct cysts. Articles describing surgical management of GDC were included. Exclusion criteria included inadequate diagnosis of GDC, infected cysts, nonsurgical management, or article unavailable for interlibrary loan. A novel approach using intra-cyst fluorescein dye injection is described. RESULTS: Two hundred sixty-seven articles were identified via PubMed, and 34 articles were included in the review based on eligibility criteria. Concomitant genitourinary malformations occurred in 19 of the 92 surgically managed patients. Surgical techniques included cyst excision (50 patients), tetracycline injection following aspiration (15), marsupialization (14), unroofing/partial excision (9), and puncture/evacuation (4). Recurrences occurred in 4, 1, 0, 0, and 1 patient, respectively. One patient underwent uncomplicated fluorescein dye-assisted cyst excision with no recurrence 30 months post-procedure. CONCLUSIONS: The low incidence of GDCs necessitating surgical intervention has resulted in a lack of standard surgical technique, especially in patients with concurrent genitourinary malformations. Utilizing fluorescein dye provides a surgical method that can help confirm the absence of urologic involvement as well as facilitate precise excision of GDC.