Hysteroscopy needs of indigenous communities in Northern Quebec: a retrospective cohort study.

We aimed to determine the surgical output for patients from Nunavik undergoing transfer to an urban centre for hysteroscopy, and associated costs. We performed a retrospective chart review of all patients from the 14 villages of Nunavik transferred for hysteroscopic surgery from 2016 to 2021. Diagnoses, surgical intervention, and nature of the procedure were all extracted from the patient charts, and costs/length of stay obtained from logisticians and administrators servicing the Nunavik region. Over a 5-year period, 22 patients were transferred from Nunavik for hysteroscopy, of which all were elective save one. The most common diagnosis was endometrial or cervical polyp and the most common procedure was diagnostic hysteroscopy. The average cost for patient transfer and lodging to undergo hysteroscopy in Montreal ranged from $6,000 to $15,000 CDN. On average, 4-5 patient transfers occur annually for hysteroscopy, most commonly for management of endometrial polyps, at a cost of $6,000 to $15,000 CDN, suggesting the need to investigate local capacity building in Nunavik and assess cost-effectiveness.

Medical Management of Ovarian Endometriomas: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effect of medical management on the size of ovarian endometriomas. DATA SOURCE: Online databases were searched from inception to October 2022, including Ovid MEDLINE, Ovid EMBASE, PubMed, EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov , and Web of Science. METHODS OF STUDY SELECTION: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we included all English-language, full-text articles that reported on change in endometrioma size (either diameter or volume) after medical interventions. Studies evaluating surgical interventions or postoperative recurrence were excluded. All screening and data extraction were performed independently by two authors. Risk of bias assessment was performed with either the Cochrane Risk of Bias Tool for randomized controlled trials or a modified Newcastle-Ottawa Scale for observational studies. TABULATION, INTEGRATION, AND RESULTS: After removal of duplicates, 9,332 studies were screened, with 33 full-text articles deemed eligible for inclusion. In the meta-analysis, dienogest showed significant reduction in cyst diameter (reduction 1.32 cm, 95% CI, 0.91-1.73, eight studies, n=418 cysts) and volume (mean difference of log-transformed volume 1.35, 95% CI, 0.87-1.83, seven studies, n=282 cysts). Similarly, significant reductions were seen with the oral contraceptive pill (OCP) (1.06 cm, 95% CI, 0.59-1.53, nine studies, n=455), gonadotropin-releasing hormone (GnRH) agonists (1.17 cm, 95% CI, 0.42-1.92, four studies, n=128 cysts), norethindrone acetate (0.6 cm, 95% CI, 0.27-0.94, two studies, n=88 cysts), and danazol (1.95 cm, 95% CI, 1.18-2.73, two studies, n=34 cysts). Norethindrone acetate with aromatase inhibitor was also effective in reducing endometrioma volume (mean difference of log-transformed volume 1.47, 95% CI, 0.16-2.78, two studies, n=34 cysts). CONCLUSION: Medical management with dienogest, OCPs, GnRH agonists, norethindrone acetate, norethindrone acetate with aromatase inhibitor, or danazol can reduce the size of ovarian endometriomas. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD 42022363319.

Pharmacologic Interventions to Minimize Fluid Absorption at the Time of Hysteroscopy: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess which interventions are effective in reducing fluid absorption at the time of hysteroscopy. DATA SOURCE: Ovid MEDLINE, Ovid EMBASE, PubMed (non-MEDLINE records only), EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov , and Web of Science were searched from inception to February 2022 without restriction on language or geographic origin. METHODS OF STUDY SELECTION: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, all English-language, full-text articles reporting fluid balance, with an intervention and comparator arm, were included. Title and abstract screening and full-text review were completed independently by two authors. Conflicts were resolved through discussion and consensus. Studies' risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies. TABULATION, INTEGRATION, AND RESULTS: The search identified 906 studies, 28 of which were eligible for inclusion, examining the following interventions: gonadotropin-releasing hormone (GnRH) agonist; ulipristal acetate; vasopressin; danazol; oxytocin; and local, general, and regional anesthesia. A significant reduction in mean fluid absorption was seen in patients preoperatively treated with danazol (-175.7 mL, 95% CI -325.4 to -26.0) and a GnRH agonist (-139.68 mL, 95% CI -203.2, -76.2) compared with patients in a control group. Ulipristal acetate and type of anesthesia showed no difference. Data on type of anesthesia and vasopressin use were not amenable to meta-analysis; however, four studies favored vasopressin over control regarding fluid absorption. Mean operative time was reduced after preoperative treatment with ulipristal acetate (-7.1 min, 95% CI -11.31 to -2.9), danazol (-7.5 min, 95% CI -8.7 to -6.3), and a GnRH agonist (-3.3 min, 95% CI -5.6 to -0.98). CONCLUSION: Preoperative treatment with a GnRH agonist and danazol were both found to be effective in reducing fluid absorption and operative time across a range of hysteroscopic procedures. High-quality research aimed at evaluating other interventions, such as combined hormonal contraception, progestin therapy, and vasopressin, are still lacking in the literature. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021233804.

Task shifting cesarean sections in low- and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Safe and timely access to cesarean section (CS) in low- and middle-income countries (LMIC) remains a significant challenge. OBJECTIVES: To compare maternal and perinatal outcomes of CS by non-physician clinicians (NPCs) versus physicians in LMIC. SEARCH STRATEGY AND SELECTION CRITERIA: A systematic search of Ovid MEDLINE, EMBASE, Cochrane Library (including CENTRAL), Web of Science, and LILACS was performed from inception to January 2022. DATA COLLECTION AND ANALYSIS: Data were extracted by two independent reviewers and meta-analysis was performed when possible. MAIN RESULTS: Ten studies from seven African countries were included. There was no significant difference in maternal mortality for CS performed by NPCs versus physicians (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.56-2.14, P = 0.8, I2  = 70%, P < 0.05, eight studies, n = 20 711) or in perinatal mortality (OR 1.18, 95% CI 0.86-1.61, P = 0.3, I2  = 88%, n = 19 716). Despite heterogeneous clinical settings between providers, there was no difference in the rates of wound infection or re-operation, although there was a higher rate of wound complications (such as dehiscence) in the NPC group (OR 1.89, 95% CI 1.21-2.95, P = 0.005, n = 6507). CONCLUSIONS: NPCs have comparable maternal and neonatal outcomes for CS compared with standard providers, albeit with increased odds of wound complication. PROSPERO REGISTRATION: CRD42020217966.

vNOTES Hysterectomy, Adnexectomy, and Uterosacral Ligament Suspension: A Walk-Through Guide.

OBJECTIVE: To provide a stepwise guide to performing vNOTES hysterectomy, adnexectomy, and vault suspension, using 2 access platform methods. DESIGN: Narrated surgical video based on 2 cases of vNOTES for abnormal uterine bleeding and endometrial intraepithelial neoplasia. SETTING: A single tertiary-care academic center. INTERVENTIONS: Step-by-step walk-through is shown to demonstrate the successful completion of a hysterectomy, adnexectomy, and vault suspension. Use of a traditional glove platform and that of an advanced access system, the GelPOINT Access System (Applied Medical), are illustrated. The surgical steps are summarized as follows: (1) colpotomy and abdominal entry, (2) transection of the uterosacral ligaments, (3) placement of an access platform, (4) upper abdominal survey, (5) transection of the uterine and cornual pedicles, (6) identification of the ureters, (7) bilateral salpingo-oophorectomy, (8) uterosacral ligament suspension, (9) cystoscopy, and (10) vaginal vault closure and tying of the suspension sutures. CONCLUSION: This video demonstrates the steps to safely reproduce a vNOTES hysterectomy, adnexectomy, and uterosacral ligament suspension with 2 access techniques. vNOTES offers scar-free surgery, improved access to high pedicles and surgical fields, and a favorable recovery profile, making it an attractive surgical route in appropriate candidates.

Spontaneous Uterine Rupture in a Multigravid Pregnant Woman with Unscarred Uterus on Chronic Steroid Use: A Case Report.

BACKGROUND: Uterine rupture in pregnancy is associated with severe maternal and fetal complications. Although it is a rare event, uterine rupture has been associated with certain risk factors. Glucocorticoids are known to weaken skeletal muscles; however, there have been no studies on the effects of chronic steroid use on the uterine myometrium. CASE: We present the case of a 40-year-old multigravid woman who experienced a posterior uterine wall rupture on an unscarred uterus. She was on chronic glucocorticoids for the treatment of psoriatic arthritis. We hypothesize that the catabolic effects of glucocorticoids on skeletal muscles also weakened the uterine myometrium, leading to a higher risk of uterine rupture. CONCLUSION: Uterine rupture may be associated with chronic use of corticosteroids. Identifying the different risk factors for uterine rupture can lead to more prompt diagnosis and management of uterine rupture, resulting in better maternal and fetal outcomes.

Non-Hodgkin Lymphomas in Mature Cystic Teratomas: A Case Report and Review of the Literature.

BACKGROUND: Mature teratomas, better known as dermoid cysts, are the most common ovarian neoplasms in women in the second and third decade of life. They are invariably benign, and most women are asymptomatic. Ovarian cystectomy is the preferred therapeutic option. CASE: A 24-year-old woman was planned for elective laparoscopic cystectomy for a suspected teratoma; operative findings led to a unilateral oophorectomy. Pathological analysis of the specimen revealed a focus of large cell lymphoma of unknown lineage arising in a mature cystic teratoma. A total body positron emission tomography (PET) scan revealed no other disease, and the patient was managed conservatively with regular follow-up. CONCLUSION: Lymphoma in a teratoma is an excessively rare finding with only five previously reported cases. A review of the literature revealed very different theories as to its pathogenesis and management.

Robotically assisted laparoscopic myomectomy: a Canadian experience.

OBJECTIVE: To compare operative and immediate postoperative outcomes of robotically assisted laparoscopic myomectomy (RALM) and open myomectomy. METHODS: We conducted a retrospective review of 38 cases of RALM performed in women of reproductive age with symptomatic uterine fibroids between October 2008 and February 2011. Twenty-one cases of open myomectomy were used as historical controls. Operative and immediate postoperative outcomes were compared. Data analysis was performed using Student t test, chi-square test, and analysis of covariance where appropriate. RESULTS: The two groups were comparable in age, body mass index, parity, and symptoms. Up to 12 fibroids were resected robotically with a mean diameter of 9.1 ± 2.0 cm and a mean weight of 389 ± 170 g (range 73 to 900 g). RALM was associated with less blood loss (decrease in hemoglobin concentration 25.6 ± 12.0g/L) than open myomectomy (37.7 ± 20.1 g/L) (P = 0.018). Adjusting for baseline levels, postoperative hemoglobin levels were 99 g/L and 88 g/L in the robotic and open groups, respectively (P = 0.005). RALM was associated with shorter hospitalization (1.2 ± 0.5 vs. 2.5 ± 0.6 days, P < 0.001) and longer operating times (189.7 ± 71.5 vs. 92.5 ± 33.0 minutes, P < 0.001). Three patients in the open myomectomy group and one in the robotic group required blood transfusion. One patient in the robotic group developed lumbar plexopathy postoperatively. CONCLUSION: Robotically assisted laparoscopic myomectomy is associated with less blood loss and shorter hospital stay than myomectomy by laparotomy. Accumulating evidence of the risks and benefits of RALM will contribute to enhancing access to this technology on the part of women and their surgeons.