Fertility preservation in patients undergoing gonadotoxic treatments: a Canadian Fertility and Andrology Society clinical practice guideline.

The management of young patients with cancer presents several unique challenges. In general, these patients are ill prepared for the diagnosis and the impact on their fertility. With the improved survival for all tumour types and stages, the need for adequate fertility counselling and a multidisciplinary approach in the reproductive care of these patients is paramount. Recent advances in cryopreservation techniques allow for the banking of spermatozoa, oocytes, embryos and ovarian tissue without compromising survival. This Canadian Fertility and Andrology Society (CFAS) guideline outlines the current understanding of social and medical issues associated with oncofertility, and the medical and surgical technologies available to optimize future fertility.

Residents as supervisors: How senior residents make ad hoc entrustment decisions.

BACKGROUND: As residency programmes transition to competency-based medical education, there has been substantial inquiry into understanding how ad hoc entrustment decisions are made by attending supervisors in the clinical context. However, although attendings are ultimately responsible for the decisions and actions of resident trainees, senior residents are often the ones directly supervising junior residents enrolled in competency-based training programmes. This clinical dynamic has been largely overlooked in the ad hoc entrustment literature. The purpose of this study was to explore the considerations senior residents entertain when making ad hoc entrustment decisions for their junior resident colleagues. METHODS: In semi-structured interviews, 11 senior resident supervisors (third, fourth and fifth year) in obstetrics and gynaecology described how they entrust junior residents with clinical activities in the moment. Following constructivist grounded theory methodology, data were iteratively collected and coded with constant comparison until theoretical sufficiency was determined. RESULTS: Senior residents described many similar considerations as attendings regarding ad hoc entrustment of junior residents, including patient safety, desire to optimise the learning environment, junior resident qualities (such as discernment and communication skills), learner handover from colleagues, and situational factors. Uniquely, senior residents discussed how their role as a middle manager and their desire to protect the junior resident (from burnout, becoming a second victim and from attendings) impacts their decisions. CONCLUSIONS: Although senior residents make ad hoc entrustment decisions with some similar considerations to attendings, they also seem to think about additional factors. It may be that these different considerations need to be accommodated in documentation of ad hoc entrustment decisions if these documents are to be used for high-stakes summative entrustment decisions made by competency committees.

Pregnancy and Placenta Increta in a Noncommunicating Uterine Horn.

BACKGROUND: We present a rare case of pregnancy and invasive placentation in a unruptured, noncommunicating rudimentary uterine horn at 20 weeks' gestation. CASE: The patient was followed with ultrasound throughout early pregnancy and initial imaging for dating purposes showed a pregnancy within a communicating right horn of the uterus. At the 18-week anatomy ultrasound, the pregnancy was discovered to be within the noncommunicating, rudimentary left horn of the uterus. This was confirmed using pelvic magnetic resonance imaging. The patient opted for surgical management and subsequently underwent laparotomy and removal of the noncommunicating uterine horn and pregnancy. Placental tissue was adherent to the level of the serosa during surgery and pathologic diagnosis was significant for a placenta increta. SUMMARY AND CONCLUSION: The patient recovered well from surgery and subsequently went on to have a successful term pregnancy delivered via cesarean section for breech in the right horn 15 months later.

Who Should be Following the Trans-Female Patient Pre and Post Vaginoplasty? An Argument for the Pediatric Gynaecologist.

Increasing numbers of transgender patients are opting for gender-affirming care. Since pediatric and adolescent gynaecology (PAG) providers perform the majority of vaginoplasty procedures for developmental anomalies of the female reproductive tract (such as vaginal agenesis), this commentary supports the position that PAG providers should be involved in the pre- and postoperative care of trans women.

Difficulties in Transition of Care from Pediatric to Adult Gynecology Providers: Should We Maintain Care into Adulthood?

There is evidence that transfer of care for older adolescent patients to adult care is associated with a deterioration in health, especially in those with chronic conditions. Because several specific conditions in pediatric and adolescent gynecology continue into adulthood, it is important that patients have a seamless healthcare transition. In this commentary, it is argued that instead of arranging transfer, long-term retention of patients by the same physician or physician team may be the more caring, patient-centered approach.

Resident Perspectives on Competency-By-Design Curriculum.

OBJECTIVE: The Royal College of Physicians and Surgeons of Canada is implementing a competency-by-design (CBD) curriculum for residency training across Canada. Although praise and criticism have been published regarding competency-based residency training, little has been published from the resident perspective. The University of Calgary obstetrics and gynaecology residents were surveyed to gather information on their viewpoints and allow their expectations and concerns to be incorporated into the design and implementation process for the curriculum. METHODS: An anonymous survey was administered to residents from the University of Calgary obstetrics and gynaecology program. The survey contained a mixture of Likert-scale responses, multiple-choice questions, and free-text response questions. Summary statistics were used to analyze the Likert-scale and multiple-choice responses, and thematic analysis was performed on free-text responses (Canadian Task Force Classification Level III). RESULTS: The survey respondents identified several anticipated benefits and challenges regarding the CBD curriculum. Overall, resident respondents seemed optimistic about the curriculum redesign; however, many residents identified concerns, including potential impacts on work relationships, challenges with operating room and call scheduling given the less rigid structure of CBD, and the amount of time and effort that evaluation will require. CONCLUSION: Residents offer a valuable perspective on CBD curriculum redesign and implementation. Gathering their input and including it in the curriculum redesign and implementation process will only strengthen the new curriculum and resident buy-in.

No. 313-Menstrual Suppression in Special Circumstances.

OBJECTIVE: To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health. OPTIONS: This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression. OUTCOMES: Clinicians will be better informed about the options and indications for menstrual suppression in patients with cognitive and/or physical disabilities and patients undergoing chemotherapy, radiation, or other treatments for cancer. EVIDENCE: Published literature was retrieved through searches of Medline, EMBASE, OVID, and the Cochrane Library using appropriate controlled vocabulary and key words (heavy menstrual bleeding, menstrual suppression, chemotherapy/radiation, cognitive disability, physical disability, learning disability). Results were restricted to systematic reviews, randomized controlled trials, observation studies, and pilot studies. There were no language or date restrictions. Searches were updated on a regular basis and new material was incorporated into the guideline until September 2013. Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: There is a need for specific guidelines on menstrual suppression in at-risk populations for health care providers.

Fertility Preservation Toolkit: A Clinician Resource to Assist Clinical Discussion and Decision Making in Pediatric and Adolescent Oncology.

PURPOSE: Fertility preservation (FP) discussions in children with cancer presents unique challenges due to ethical considerations, lack of models-of-care, and the triadic nature of discussions. This study evaluated a fertility toolkit for clinicians involved in FP discussions with pediatric, adolescent, and young adult patients and parents. MATERIALS AND METHODS: A survey-based, longitudinal study of clinicians at The Royal Children's Hospital Melbourne involved in FP discussions undertaken at 3 time-points: 2014, alongside an education session for baseline assessment of oncofertility practices (survey 1); after each toolkit use to evaluate case-specific implementation (survey 2); 2016, to evaluate impact on clinical practice (survey 3). RESULTS: Fifty-nine clinicians completed survey 1. Over 66% reported baseline dissatisfaction with the existing FP system; 56.7% were not confident in providing up-to-date information. Only 34.5% "often" or "always" provided verbal information; 14.0% "often" or "always" provided written information. Survey 2 was completed after 11 consultations. All clinicians were satisfied with the discussions and outcomes using the toolkit. Thirty-nine clinicians completed survey 3. Over 70% felt confident providing up-to-date FP knowledge, 67.7% "often" or "always" provided verbal information, and 35.4% "often" or "always" provided written information. CONCLUSIONS: Clinicians desire improvement in FP practice. The toolkit provided significant perceived and actual benefits.

Outcomes of renal transplant from donors with polycystic kidney disease.

INTRODUCTION: Kidneys from donors affected by autosomal-dominant polycystic kidney disease (ADPKD) are, in general, considered unsuitable for transplantation. However, some authors report cases of patients who received kidneys from a deceased ADPKD donor showing encouraging outcomes. Our aim is to provide our experience of a patient with end stage renal failure who received a deceased donor kidney from a 29-year-old who themselves had been diagnosed with ADPKD but well maintained renal function, and to provide a comprehensive review of all the published literature. METHODS: In addition to our case, a literature search (PubMed database, Embase, Cochrane Library) of articles published between 1980 and 2017 was performed. RESULTS: Sixteen cases were identified. Median donor age was 24 (range12-55) years old. Median recipient age was 46 (range 19-72) years old. Fifteen cases had a single kidney transplant and one case had a dual kidney transplant. 13/16 (81%) had immediate function, 2 patients (12.5%) had delayed graft function and one patient (6.25%) had primary non-function. Median graft follow up was 36 months (range 6-180). Median serum creatinine at last follow up was 124 µmol/L (range75-442). Thirteen patients (81%) were still alive with a working renal transplant at last follow up. CONCLUSION: The published literature is encouraging and supports the use of polycystic kidneys from younger deceased donors. Therefore, we believe that if kidneys from ADPKD donors are offered, they should have a full assessment and be considered acceptable for renal donation to recipients who may have a life expectancy of 10 years or less and who are fully informed and have the capacity to consent to receiving a polycystic kidney.

Audit of referrals for concern regarding labial appearance at the Royal Children's Hospital: 2000-2012.

AIM: To audit the clinical features and outcomes for all patients referred to our centre with concerns regarding labial appearance. METHODS: Young females referred to a paediatric/adolescent gynaecology tertiary centre between 2000 and 2012 with concerns regarding their labial appearance were retrospectively identified. Adolescents presenting with anomalies were excluded. Retrospective chart review was undertaken to identify reasons for referral, patient characteristics, outcome of referral and concurrent health problems. RESULTS: In total, 46 females presenting with concerns about labial appearance were identified. Five were excluded. Median age of the study population was 14.5 years (range 5-21 years). Only four (9.8%) underwent surgery after a minimum of five consultations each, with mental health review in three of four cases prior to surgery. None of the 41 patients had documented abnormal labia; however, 6 patients had asymmetry, and 3 had a labial width of >5 cm. Of mothers, 24% (n = 10) raised the initial concern regarding labial appearance to a physician, of whom, 50% of patients had a comorbid condition. In total, 70.7% initially reported interference with daily activities, and 87.8% were reassured following discussion. CONCLUSIONS: With appropriate education and counselling, the majority of girls with concerns regarding labial appearance can be managed without surgery. Overall, our data support current international policy that female cosmetic genital surgery not be performed in mature minors unless there are specific indications. More research about characteristics of patients referred with labial concerns, definition of labial size and long-term satisfaction of conservative versus surgical methods is necessary to determine the best approach.

Literature Review of Periclitoral Cysts in the Prepubertal Population.

STUDY OBJECTIVE: Clitoral cysts in the pediatric population are rare conditions that require careful evaluation. In this review of the literature we discuss the evaluation of clitoral abnormalities in the pediatric population, the development of clitoral cysts, and how to differentiate benign from malignant tumors. In addition, a summary of relevant cases of clitoral tumors in the literature are discussed. DESIGN: Literature review. DATA SOURCE: A MedLine and advanced PubMed search was conducted of all English language articles published using the search terms "clitoris" and "cyst" until February 2015. Reference tracing was completed for all articles for completeness. MAIN OUTCOME: Literature review of clitoral cysts in the prepubertal population. RESULTS: In total, we found 15 cases of benign, spontaneously forming clitoral cysts reported. Eleven of those cases document symptom onset before puberty. Reports of other benign clitoral lesions in the pediatric population include 1 angiokeratoma, 1 hemangiopericytoma, 1 granular cell tumor, 6 hemangiomas, and approximately 30 neurofibromas. Clitoral malignancies in the pediatric population are even more rare with only 3 cases of clitoral schwannomas, 2 rhabdomyosarcomas, 1 lymphoma, and 1 endodermal sinus tumor documented in the literature. CONCLUSION: Clitoral cysts must be considered as a possible cause of clitoral enlargement in the prepubertal population. Clitoral tumors are distinguished clinically from hormonal abnormalities and intersex disorders by their hormonal profile, and the presence of an underlying mass. Ultrasound and magnetic resonance imaging might be useful imaging modalities to further characterize the clitoral enlargement. When confirmed as the most likely diagnosis, surgical resection is the mainstay of treatment for clitoral cysts.

Literature Review of Benign Müllerian Papilloma Contrasted With Vaginal Rhabdomyosarcoma.

STUDY OBJECTIVES: Benign müllerian papillomas of the genital tract are rare and, hence, can be mistaken for vaginal rhabdomyosarcoma on initial clinical review. This review of the literature will consolidate the previous cases of müllerian papilloma reported and looks for clues to differentiate the 2 entities. DESIGN AND SETTING: We provide a case report and literature review, with patients from a pediatric adolescent gynecology clinic in a tertiary center. METHODS: We conducted a search of English-language publications from 1951 (the first case report) until January 2014 by using the search words "Müllerian papilloma" and "prepubertal bleeding." References from previous published reports were also obtained for completeness. MAIN OUTCOME: Literature review of benign müllerian papilloma. RESULTS: Since 1951, 56 cases of müllerian papilloma were reported, including 4 cases at our institution. Comorbid conditions were found in 31.5% of cases (with 3 cases associated with mesenchymal tumors). The average length of time from onset of symptoms (primarily vaginal bleeding) to diagnosis was 6.7 months (range, 1 day to 3 years), with only 1 case diagnosed incidentally. Median age of presentation was 5 years (range, 1 day to 52 years). Most cases were localized and resected with ease. Histology reveals complex papillary lesions without cytologic atypia. CONCLUSION: Benign müllerian papilloma is distinguished from the more significant diagnosis of vaginal rhabdomyosarcoma by initial length of vaginal bleeding at presentation, lack of vaginal wall extension, ease of resection, and histopathology. This is compared with vaginal rhabdomyosarcoma which commonly exhibits both localized and distant spread.