Gynaecological care of women with chronic pelvic pain: Patient perspectives and care preferences.

OBJECTIVE: To explore the experiences and care preferences of women with chronic pelvic pain, with or without a history of sexual trauma, seeking gynaecological care. DESIGN: Qualitative study. SETTING: Ambulatory endometriosis centre. POPULATION OR SAMPLE: Women aged 18-55 years with chronic pelvic pain. METHODS: Baseline demographics and sexual trauma history were obtained, and participants were assigned to focus groups according to a positive (four groups, 13 participants) or negative (two groups, nine participants) screen for a history of sexual trauma. The focus groups were led by a clinical psychologist and a gynaecological surgeon and consisted of semi-structured interviews. The interviews were audio-recorded and transcribed, and the transcripts were coded in NVivo 12. MAIN OUTCOME MEASURES: Content analysis was used to derive themes according to the participants' own words. RESULTS: Participants with chronic pelvic pain, with or without a history of sexual trauma, experienced delay in diagnosis and repetitive dismissals by clinicians. Participants' experiences of dismissals included: clinicians not listening, insufficient allocation of time to appointments and perceived redundant medical testing (i.e. sexually transmitted infection testing, urine cultures, ultrasounds). Participants identified clinician interactions as pivotal in coping with both pelvic pain and sexual abuse. Participants also provided feedback regarding trauma-informed practices and care delivery specific to patients with chronic pelvic pain. CONCLUSION: Patients with chronic pelvic pain, with or without a history of sexual trauma, report negative experiences when interacting with the healthcare system. They have clear needs and preferences regarding gynaecological care and provide feasible suggestions for improving care delivery.

Appendectomy in the surgical management of women with endometriosis and pelvic pain.

OBJECTIVE: To evaluate the role of appendectomy in surgical excision of endometriosis and to assess complications associated with appendectomy. METHODS: Retrospective study of women undergoing appendectomy for pelvic pain and/or endometriosis during a primary gynecologic procedure. RESULTS: Record review was performed for 609 women who underwent appendectomy between 2013 and 2019 for pelvic pain (6.9%, 42/609), stage I-II endometriosis (63.7%, 388/609), or stage III-IV endometriosis (29.4%, 179/609). Appendiceal endometriosis (AppE) was present in 14.9% (91/609); 2.4% without endometriosis (1/42, reference group), 7.0% with stage I-II endometriosis (27/388, odds ratio [OR] 3.06, 95% confidence interval [CI] 0.41-23.11, P = 0.278), and 35.2% with stage III-IV endometriosis (63/179, OR 22.24, 95% CI 2.99-165.40, P = 0.002). AppE was significantly associated with endometriosis present in other locations (OR 5.27, 95% CI 2.66-10.43, P < 0.001). The predicted probability of identifying AppE ranged from 6% with 0 positive endometriosis sites to 56% when 4 or more sites were identified. There were no complications related to the performance of an appendectomy. CONCLUSION: Women with chronic pelvic pain and/or endometriosis have an increased risk of AppE. Modern appendectomy at the time of gynecologic surgery is safe, with no associated complications in this study. Our findings support the consideration of appendectomy as part of the comprehensive surgical management of endometriosis.

Appendiceal Endometriosis: Is Diagnosis Dependent on Pathology Evaluation? A Prospective Cohort Study.

STUDY OBJECTIVE: To evaluate the diagnosis of appendiceal endometriosis (AppE) in coincidental appendectomy specimens using standard versus modified histopathologic analysis. DESIGN: Prospective analysis of 300 consecutive patients undergoing coincidental appendectomy at the time of a primary gynecologic procedure. SETTING: Academic tertiary referral hospital in the northeastern United States. PATIENTS: Women aged 22 to 52 years undergoing gynecologic surgery for the management of endometriosis or chronic pelvic pain between 2013 and 2015. INTERVENTIONS: Each appendix specimen underwent standard pathologic analysis with 4 sections performed. Modified pathologic analysis, consisting of standard analysis plus serial sectioning and complete evaluation of the appendix and mesoappendix, was then performed. The first pathologist reviewed all the slides to render a diagnosis. The slides of the subjects with abnormal pathology were rereviewed. On rereview, the diagnosis was confirmed, and the data on which protocol, standard or modified, achieved the diagnosis was rendered. The pathologist performing the second review was blinded to whether the slides from the standard or modified histopathology protocol achieved the original diagnosis. This allowed each specimen to serve as its own control. MEASUREMENTS AND MAIN RESULTS: The primary outcome is the detection of AppE. The standard analysis identified endometriosis in 7.7% (n = 23) of appendiceal specimens, whereas the modified analysis identified endometriosis in 10.0% (n = 30; odds ratio 1.3; confidence interval, 1.1-1.7; p = .01). When all pathology findings were combined, the standard analysis identified abnormal pathology in 9.3% (n = 28) of the specimens, whereas the modified analysis identified abnormal pathology in 12.3% (n = 37; odds ratio 1.4; confidence interval, 1.1-1.7; p <.01). Other abnormal appendiceal pathology identified in this study included polyps, neuroendocrine tumors, and acute appendicitis. The average number of slides required for the standard analysis was 1.4 compared with 4.9 slides for the modified analysis. At this institution, the average increase in the cost of slide production for the modified protocol was $12.07. CONCLUSION: Modified pathologic analysis resulted in a significantly higher rate of diagnosis of endometriosis and abnormal pathology in coincidental appendectomy performed during a primary gynecologic procedure for endometriosis and/or chronic pelvic pain. The use of a standard pathologic protocol likely contributes to underdiagnosis of AppE. The implementation of a modified histopathologic protocol should be considered for improving diagnosis rates of appendiceal pathology in coincidental appendectomy specimens.

Surgical Excision Versus Ablation for Superficial Endometriosis-Associated Pain: A Randomized Controlled Trial.

STUDY OBJECTIVE: To compare surgical excision and ablation of endometriosis for treatment of chronic pelvic pain. DESIGN: Randomized clinical trial with 12-month follow-up (Canadian Task Force classification I). SETTING: Single academic tertiary care hospital. PATIENTS: Women with minimal to mild endometriosis undergoing laparoscopy. INTERVENTIONS: Excision or ablation of superficial endometriosis at the time of robot-assisted laparoscopy. MEASUREMENTS AND MAIN RESULTS: Primary outcome was visual analog scale (VAS) scoring at baseline and 6 and 12 months for menstrual pain, nonmenstrual pain, dyspareunia, and dyschezia. Secondary outcomes included survey results at baseline and 6 and 12 months from the Short Form Health Survey, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and the International Pelvic Pain Assessment. From December 2013 to October 2014, 73 patients were randomized intraoperatively to excision (n = 37) or ablation (n = 36) of endometriosis. Patients were followed at 6 and 12 months to evaluate the above outcomes. After ablation of endometriosis, dyspareunia (VAS scores) improved at 6 months (mean change [MC], -14.07; 95% confidence interval [CI], -25.93 to -2.21; p = .02), but improvement was not maintained at 12 months. Dysmenorrhea improved at 6 months (MC, -26.99; 95% CI, -41.48 to -12.50; p < .001) and 12 months (MC, -24.15; 95% CI, 39.62 to -8.68; p = .003) with ablation. No significant changes were seen in VAS scores after excision at 6 or 12 months. When comparing ablation and excision, the only significant difference was a change in dyspareunia at 6 months (MC, -22.96; 95% CI, -39.06 to -6.86; p = .01). CONCLUSION: Treatment with ablation improved dysmenorrhea at 6 and 12 months and improved dyspareunia at 6 months as compared with preoperative data. However, only dyspareunia demonstrated a significant difference between ablation and excision. Excision and ablation showed similar effectiveness for the treatment of pain associated with superficial endometriosis, with ablation showing more significant individual changes. Careful patient counseling regarding expectations of surgical intervention is vital in the management of endometriosis.

Ovarian Artery Embolization as a Treatment for Persistent Ovarian Remnant Syndrome.

Ovarian remnant syndrome (ORS) is a rare condition in which ovarian tissue persists at the site of prior oophorectomy and often causes debilitating pelvic pain. Gold standard of treatment is surgical resection. We report a case of persistent ORS in a 44-year-old female who was successfully treated with ovarian artery embolization after failure of standard medical and gynecologic therapies. The ovarian tissue remnant was reduced by 75% in volume, and the patient was near symptom-free four months after the procedure.

Randomized controlled trial comparing operative times between standard and robot-assisted laparoscopic hysterectomy.

OBJECTIVE: To compare the operative time between robot-assisted laparoscopic hysterectomies and standard laparoscopic hysterectomies. METHODS: A prospective, randomized controlled trial enrolled women aged 18-80 years attending Penn State Hershey Medical Center between April 23 and October 20, 2014 to undergo hysterectomy. Participants were randomized using a random number generator to undergo either robot-assisted or standard laparoscopic hysterectomy. The primary outcome was the total operative time (surgeon incision to surgeon stop, including robot docking time, if applicable). Intention-to-treat analyses were performed and the operative time was compared between the two treatments for non-inferiority, defined as a difference in operative time of no longer than 15 minutes. RESULTS: There were 72 patients randomized to each treatment arm. The mean operative time was 73.9 minutes (median 67.0 minutes; interquartile range 59.0-83.0 minutes) in the robot-assisted hysterectomy group and 74.9 minutes (median 65.5 minutes; interquartile range 57.0-90.5 minutes) in the standard laparoscopic hysterectomy group. The upper bound of the 95% confidence interval of the difference in operative time was 6.6 minutes, below the 15-minute measure of non-inferiority. CONCLUSION: When performed by a surgeon experienced in both techniques, the operative time for robot-assisted laparoscopic hysterectomy was non-inferior to that achieved with standard laparoscopic hysterectomy. CLINICALTRIALS.GOV: NCT02118974.

Bowel perforation after placement of tubal occlusion contraceptive.

BACKGROUND: The tubal occlusion contraceptive provides a hysteroscopic technique for female sterilization. Efficacy of the tubal occlusion contraceptive relies on proper placement within the proximal aspect of the fallopian tubes. As long-term data become available, rates of complications are better defined. CASE: This is a case of a patient who underwent placement of a tubal occlusion contraceptive. As a result of persistent pain and nausea, imaging was performed and malposition of the tubal occlusion contraceptive was identified. During laparoscopy, bowel perforation at the terminal ileum was diagnosed. Laparoscopic ileocecectomy was performed. CONCLUSION: There should be a low threshold for evaluation of complications after tubal occlusion contraceptive placement. Although rare, bowel perforation after placement of the tubal occlusion contraceptive can occur. Laparoscopic management should be considered.

Minimally invasive hysterectomy at a university teaching hospital.

BACKGROUND AND OBJECTIVES: To evaluate the feasibility of a minimally invasive approach for hysterectomy for benign disease at a university teaching hospital. METHODS: Five hundred thirty-seven consecutive patients underwent hysterectomy for benign disease at Penn State Milton S. Hershey Medical Center in 2010. No cases were excluded. Minimally invasive approaches included total vaginal hysterectomy, laparoscopy-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and laparoscopic supracervical hysterectomy. All surgeries were completed with the resident as the primary surgeon or first assistant. RESULTS: The median age was 45 years, the median body mass index was 30 kg/m2, the median estimated uterine size was 11 cm, and 22% of patients had a prior cesarean section. Of the 537 hysterectomies, 526 (98%) were started with a minimally invasive approach and 517 (96%) were completed in that fashion; thus only 9 conversions (2%) were required. Of the cases in which a minimally invasive approach was used, 16% were vaginal and 84% were laparoscopic. The median operative time was 86 minutes, the median blood loss was 95 mL, the median hospital stay was 1 day, and the median uterine weight was 199 g. For the minimally invasive hysterectomies, there was a 5% major complication rate. CONCLUSION: Our residency training institution completed 96% of 537 hysterectomies using a minimally invasive approach while maintaining an acceptable operative time, amount of blood loss, hospital stay, and complication rate. Thus our study supports that a minimally invasive approach for hysterectomy for benign disease at an academic resident teaching facility is feasible.

Long-term patient satisfaction with thermal balloon ablation for abnormal uterine bleeding.

BACKGROUND AND OBJECTIVE: Thermal balloon ablation is a minimally invasive surgical technique that can be used to treat abnormal uterine bleeding/heavy menstrual bleeding (AUB/HMB). Most published studies to date provide information on short-term patient satisfaction and outcomes. The purpose of this study was to determine long-term patient satisfaction after thermal balloon endometrial ablation 7 to 10 years postoperatively in a population previously surveyed at the Penn State Milton S. Hershey Medical Center at 1 to 5 years postoperatively. METHODS: Two-hundred fourteen patients were identified who underwent thermal balloon ablation at our institution between January 1, 2001 and December 31, 2004. These patients were mailed a 2-page survey asking for information on demographics, patient satisfaction, postoperative bleeding patterns, and the need for subsequent surgery. Satisfaction rates, amenorrhea rates, and the rates of women who required hysterectomy were calculated as percentages. RESULTS: Ninety-seven patients returned completed surveys. The survey response rate was 62%, excluding 57 surveys that were returned as undeliverable. The follow-up interval was 93 to 129 months. Eighty-seven percent of respondents were satisfied with the results of their procedure compared with 88% in the original study. Subsequent hysterectomy was required in 21.6% of women after 7 to 10 years compared with 9% after the 1- to 5-year follow-up period. Of the 76 women who did not undergo hysterectomy, 58% reported amenorrhea and 35.5% reported minimal to light bleeding. CONCLUSION: This study demonstrates a consistently high patient satisfaction rate with thermal balloon ablation at our institution at 7 to 11 years postoperatively compared with 1 to 5 years postoperatively. The hysterectomy rate, however, was 2.4 times greater in the long-term follow-up period.

Oxidized regenerated cellulose resembling vaginal cuff abscess.

INTRODUCTION: Application of oxidized regenerated cellulose is commonly performed in laparoscopy to achieve hemostasis during surgery. The appearance of an abscess resembles oxidized regenerated cellulose, causing imaging studies to be difficult to interpret. CASE DESCRIPTION: We describe the cases of 3 patients who underwent oxidized regenerated cellulose placement during laparoscopic gynecologic surgery. They subsequently presented with signs and symptoms resembling an abscess. Computed tomographic imaging can be challenging to interpret in such cases; radiologic findings can be used to differentiate between the characteristics of oxidized regenerated cellulose and those of abscess formation on the vaginal cuff. DISCUSSION: Oxidized regenerated cellulose has an appearance that often mimics postsurgical abscess formation. There are distinct characteristics that distinguish both findings. It is essential that patients' records accurately describe the presence and location of regenerated oxidized cellulose when placed intraoperatively, and this information must be relayed to the interpreting radiologist to facilitate medical diagnosis and guide clinical management.

Infiltration of bupivacaine local anesthetic to trocar insertion sites after laparoscopy: a randomized, double-blind, stratified, and controlled trial.

STUDY OBJECTIVE: To determine if injection of local anesthetic into trocar insertion sites after laparoscopy improves postoperative pain. DESIGN: A prospective, 2-arm, randomized, double-blind, stratified, and controlled trial (Canadian Task Force classification I). SETTING: A university-based teaching hospital. PATIENTS: This study was performed on women who had a laparoscopic gynecologic procedure for benign indications from March 2013 to June 2013. One hundred thirty-five subjects were stratified by chronic pelvic pain or no chronic pelvic pain. Chronic pelvic pain was defined as pelvic pain occurring for 6 months or more in duration. Randomization was performed for this trial, with 68 receiving a bupivacaine block and 67 receiving no bupivacaine block. Of the 71 patients with chronic pelvic pain, 35 patients were in group 1 (i.e., bupivacaine block) and 36 patients were in group 2 (i.e., no bupivacaine block). INTERVENTIONS: After the laparoscopic surgery was completed, the trocar incision sites were closed. For subjects randomized to receive a local anesthesia block, bupivacaine (0.25%) was injected. Incisions 8 mm or greater were injected with 10 mL 0.25% bupivacaine. Incisions 5 mm or less were infiltrated with 5 mL. Injecting the local anesthetic through all preperitoneal layers provided a full-thickness local injection. Group 2 did not receive a local injection. MEASUREMENTS AND MAIN RESULTS: At the preoperative suite, the nurses gauged the patient's pain using the Numeric Rating Scale. This score was used as the baseline pain level with which the postoperative pain scores were compared. The primary objective was to measure changes in pain scores, from preoperative to postoperative time frames of 2 to 4 hours, 6 to 8 hours, 18 to 24 hours, and 3 to 7 days postoperatively. These score changes were measured as the main objective. Secondary objectives include estimated blood loss, operating time, length of hospital stay, and histopathologic diagnosis. The hospital personnel caring for the patient during the preoperative and postoperative course were given standard pain evaluation protocols. All study pain evaluators and patients were blinded to treatment assignments throughout the pain assessment process. There were no statistically significant differences in patient characteristics between the 2 treatment groups. No significant difference was found in secondary outcomes including estimated blood loss, length of hospital stay, and histopathologic diagnosis. In general, Numeric Rating Scale pain scores were lower (i.e., less pain) in the "bupivacaine block" group compared with the "no bupivacaine" block group at the following postsurgery time assessments: 2 to 4 hours, 6 to 8 hours, 18 to 24 hours, and 3 to 7 days after surgery. However, the effect was not large enough (<1 point) to show a statistical difference between the treatment groups at any of these postsurgery assessments. CONCLUSION: The postoperative injection of bupivacaine in trocar port sites did not significantly improve pain scores after laparoscopic gynecologic surgery.

The head butler with design modification: a useful mountable shelf for the operating table in robotic surgery.

The 'head butler' or 'iron maiden', as it is sometimes referred to, is a mountable shelf that is attached to the main operating room table using stirrup clamps or brackets. It provides an elevated flat surface, which protects the patient's face and chest from inadvertent trauma of robotic arms, instruments and camera while also serving as a platform for placement of instrumentation that minimizes handoffs to improve workflow. Its canted design also prevents slippage of instruments off the operating field during steep Trendelenburg positioning. This operating room equipment was designed to improve efficiency in an operating room set-up while ensuring safety during patient positioning when performing robotic procedures. A modification of the original Head Butler(®) (Tri-Medical Corporation, Portland, OR, USA) is presented here which improves upon the design by avoiding brachial plexus nerve injury to the patient due to pressure from the uprights pressing on the patient's shoulders during use.

Effects of electrosurgery and vaginal closure technique on postoperative vaginal cuff dehiscence.

BACKGROUND AND OBJECTIVES: The aim of our study is to evaluate the role of electrosurgery and vaginal closure technique in the development of postoperative vaginal cuff dehiscence. METHODS: From prospective surgical databases, we identified 463 patients who underwent total laparoscopic hysterectomy (TLH) for benign disease and 147 patients who underwent laparoscopic-assisted vaginal hysterectomy (LAVH) for cancer. All TLHs and LAVHs were performed entirely by use of electrosurgery, including colpotomy. Colpotomy in the TLH group was performed with Harmonic Ace Curved Shears (Ethicon Endo-Surgery, Cincinnati, OH, USA), and in the LAVH group, it was performed with a monopolar electrosurgical pencil. The main surgical difference was vaginal cuff closure--laparoscopically in the TLH group and vaginally in the LAVH group. RESULTS: Although patients in the LAVH group were at increased risk for poor healing (significantly older, higher body mass index, more medical comorbidities, higher blood loss, and longer operative time), there were no vaginal cuff dehiscences in the LAVH group compared with 17 vaginal cuff dehiscences (4%) in the TLH group (P = .02). CONCLUSION: It does not appear that the increased vaginal cuff dehiscence rate associated with TLH is due to electrosurgery; rather, it is due to the vaginal closure technique.

Endometrial dye instillation: a novel approach to histopathologic evaluation of morcellated hysterectomy specimens.

The purpose of this prospective pilot case study was to determine whether instillation of trypan blue dye into the uterine cavity before laparoscopic hysterectomy and morcellation aids in gross identification of endometrium. The most common commercially available trypan blue stain, VisionBlue was used in this study. Instillation was performed at the beginning of the procedure using an embryo transfer catheter. A sterile solution of trypan blue, 0.5 mL, was instilled transcervically into the uterine cavities in 12 patients before laparoscopic hysterectomy with uterine morcellation. The morcellated specimens were sent for routine gross pathologic and histologic examination. It was concluded that intrauterine instillation of trypan blue stained the endometrium, thus aiding the pathologist in identification of the endometrium in morcellated uterine specimens.

Characteristics of patients undergoing hysterectomy for failed endometrial ablation.

BACKGROUND AND OBJECTIVES: Endometrial ablation is a minimally invasive procedure for menorrhagia. High success rates are documented with >90% of patients experiencing satisfaction. However, adequate relief after endometrial ablation is not obtained in a cohort of patients. The purpose of this study is to identify the characteristics of patients for whom endometrial ablation fails due to persistent symptoms, causing them to choose hysterectomy for definitive treatment. METHODS: We conducted a retrospective chart review of patients who underwent hysterectomy for persistent menorrhagia, pain, or both, who previously had endometrial ablation. We reviewed medical records including pathology reports from hysterectomy. We compared demographics to a group previously studied at our institution that were identified as satisfied 5 years after ablation. RESULTS: The number of patients in our study group was 51 (n = 51). Median age of patients was 39 (range 29-50) years. Average body mass index was 31 (range 19-47) kg/m(2). Average parity was 1.9. Sixty-nine percent underwent tubal ligation. The majority were nonsmokers (75%). Ninety-six percent were Caucasian. Compared with the previously studied satisfied group, the only statistically significant difference was age. Of 51 patients, 11 (22%) noted pelvic pain as their chief concern. Menorrhagia was the chief concern in 22 (43%). Eighteen patients (35%) complained of both. The most common diagnosis was endometriosis, which was identified in 35 patients (68%). Leiomyomata were present in 33 patients (64%). Adenomyosis was identified in 22 patients (43%). CONCLUSIONS: Patients who present for hysterectomy after endometrial ablation have a high rate of endometriosis, adenomyosis, and leiomyomata, with endometriosis being the most common finding.

Robotic-assisted laparoscopic trachelectomy: a case series and review of surgical technique.

We present a retrospective case series of patients who underwent robotic-assisted laparoscopic trachelectomies from August 1, 2011 to August 30, 2012, with a description of the surgical technique for successful cervical removal. The patients, at the Department of Obstetrics and Gynecology, Division of Urogynecology and Minimally Invasive Surgery at Penn State Milton S. Hershey Medical Center, were identified using ICD-9 coding for robotic-assisted trachelectomy. Of the 180 patients who had robotic-assisted gynecologic surgery during the study period, eight underwent robotic-assisted laparoscopic trachelectomy. The patients' average age was 40.4 years, average parity was 1.5, and mean body mass index was 28. The time interval from initial surgery of supracervical hysterectomy to robotic-assisted trachelectomy was 4 years. Pre-operative cervical cytology was negative in all patients. The average length of stay was one overnight admission. The primary indication for prior supracervical hysterectomy was dense pelvic adhesions, and the main indications for robotic-assisted trachelectomy were pelvic pain due to endometriosis and cyclic vaginal bleeding. Surgical outcomes included minimal blood loss (<50 ml) and mean operative time of 1.15 h (74.88 min), without any immediate intra-operative or post-operative complications reported. Histopathology reports on all cervical specimens were normal. Adnexectomy is the most common concomitant procedure performed with trachelectomy. Robotic-assisted laparoscopic trachelectomy is a viable option for patients requesting a minimally invasive approach to cervical stump removal.