Ergonomic considerations for unique surgeon populations.

PURPOSE OF REVIEW: Surgeons are rapidly diversifying as a population, introducing new ergonomic challenges. This review describes the challenges that are experienced by special populations of surgeons including small-handed surgeons, pregnant surgeons, and trainees, and evidence-based solutions to overcome them. RECENT FINDINGS: Small-handed and female surgeons report more musculoskeletal complaints compared with their male counterparts. Pregnant surgeons frequently report development or worsening of musculoskeletal disorders such as carpal tunnel syndrome and low back pain. Trainees also report high rates of musculoskeletal complaints with minimal autonomy to alter their environment. Limited objective data exists regarding the ideal instruments currently available for special populations. Several small, randomized studies have proposed exercise regimens targeting the upper extremities and pregnancy-related pain syndromes with improvements in symptoms. Various methods of ergonomic education have been studied in trainees with improvements in operating room posture and performance. SUMMARY: Limited objective data is available to recommend specific surgical instruments for high-risk surgeon populations. Beneficial exercise regimens have been described for musculoskeletal disorders commonly plaguing surgeons but have yet to be studied explicitly in small-handed or pregnant surgeons and trainees.

Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review.

Pelvic venous disorders (PeVD), previously known by various imprecise terms including pelvic congestion syndrome, have historically been underdiagnosed as a cause of chronic pelvic pain (CPP), a significant health problem associated with reduced quality of life. However, progress in the field has helped to provide heightened clarity with respect to definitions relating to PeVD, and evolution in algorithms for PeVD workup and treatment has been accompanied by new insights into the causes of a pelvic venous reservoir and associated symptoms. Ovarian and pelvic vein embolization, as well as endovascular stenting of common iliac vein compression, should be considered as management options for PeVD. Both treatments have been shown to be safe and effective for patients with CPP of venous origin, regardless of age. Current therapeutic protocols for PeVD exhibit significant heterogeneity owing to limited prospective randomized data and evolving understanding of the factors driving successful outcomes; forthcoming clinical trials are anticipated to improve understanding of CPP of venous origin as well as algorithms for PeVD management. This Expert Panel Narrative Review provides a contemporary update relating to PeVD, summarizing the entity's current classification, diagnostic workup, endovascular treatments, management of persistent or recurrent symptoms, and future research directions.

Patient Characteristics Associated with Access to Minimally Invasive Gynecologic Surgery: Changes during the COVID-19 Pandemic.

STUDY OBJECTIVE: To evaluate patient characteristics that affect access to minimally invasive gynecologic surgery (MIGS) subspecialty care and identify changes during the coronavirus disease 2019 pandemic. DESIGN: Retrospective cohort study of patients referred to MIGS from 2014 to 2016 (historic cohort) compared with those referred to MIGS in 2020 (pandemic cohort). Primary outcome was the interval between referral and first appointment. SETTING: Single-institution academic MIGS division. PATIENTS: Historic cohort (n = 1082) and pandemic cohort (n = 770). INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Demographics and socioeconomic variables (race, ethnicity, language, insurance, employment, and socioeconomic factors by census tract) and distance from hospital were compared between historic and pandemic cohorts with respect to referral interval using the chi-square, Fisher exact tests, and logistic regression. After adjusting for referral indication, being unemployed and living in an area with less population density, less education, and higher percentage of poverty were associated with a referral interval >30 days in the historic cohort. In the pandemic cohort, only unemployment persisted as a covariate associated with prolonged referral interval and new associated variables were primary language other than English (odds ratio, 3.20; 95% confidence interval [CI], 1.60-6.40) and "other" race (odds ratio, 2.22; 95% CI, 1.34-3.68). The odds of waiting >30 days increased by 6% with the addition of 1 demographic risk factor (95% CI, 1.01-1.10) and by 17% for 3 risk factors (95% CI, 1.03-1.34) in the historic cohort whereas no significant intersectionality was identified in the pandemic cohort. Average referral intervals were significantly shorter during the pandemic (31 vs 50 days, p <.01). Telemedicine appointments had a significantly shorter referral interval than in-person appointments (27 vs 47 days, p <.01). Of patients using telemedicine, a greater proportion were non-Hispanic, English speaking, employed, privately insured, and lived further from the hospital (p <.05). CONCLUSION: Time from referral to first appointment at a tertiary-care MIGS practice during the coronavirus disease 2019 pandemic was shorter than that before the pandemic, likely owing to the adoption of telemedicine. Differences in socioeconomic and demographic factors suggest that telemedicine improved access to care and decreased access disparities for many populations, but not for non-English-speaking patients.

Effect of length of surgery on the incidence of venous thromboembolism after benign hysterectomy.

BACKGROUND: Venous thromboembolism is a leading cause of morbidity and mortality postoperatively. The current venous thromboembolism risk assessment tools have not been validated in gynecologic patients. Most patients undergoing hysterectomy for benign indications will receive mechanical or pharmacologic prophylaxis based on preoperative risk assessment. However, current guidelines do not incorporate newer data that indicate additional risk of venous thromboembolism with prolonged surgery times or mode of hysterectomy. OBJECTIVE: This study aimed to determine the effect of length of surgery, or operative time, on the risk of venous thromboembolism within 30 days after hysterectomy and determine whether differences in the effect of operative time exist across age, body mass index, and surgical approach. STUDY DESIGN: We performed a secondary analysis of prospectively collected surgical quality improvement data using the American College of Surgeons National Surgical Quality Improvement Program database, which contains demographic and perioperative information and 30-day postoperative outcomes from >500 hospitals, and targeted data files including procedure-specific risk factors and outcomes for a subset of hospitals. We analyzed patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign conditions from 2014 to 2017, identified by the Current Procedural Terminology codes. We excluded patients with cancer, patients whose surgery was not performed by a gynecologist, patients who were not in the targeted files, and patients with missing operative time or with an operative time of <30 minutes. Patients were compared with respect to the incidence of venous thromboembolism and operative time, stratified by age, body mass index, and surgical approach. Multivariable logistic regression was performed; operative time was treated as a continuous, linear variable. RESULTS: A total of 70,606 patients were included. The 30-day venous thromboembolism incidence was 0.4% (n=259). Patients with venous thromboembolism were more likely to be obese, have inpatient procedures, and had, on average, greater uterine weight. Hysterectomy approach was vaginal in 11,641 patients, laparoscopic in 41,557 patients, and abdominal in 17,408 patients. After adjustment, for each 60-minute increase in operative time, there was a 35% increase in the odds of venous thromboembolism (adjusted odds ratio, 1.35; 95% confidence interval, 1.25-1.45). Stratified by surgical approach, the odds of venous thromboembolism per 60-minute increase in operative time was greatest among abdominal hysterectomy (adjusted odds ratio, 1.49; 95% confidence interval, 1.35-1.65) compared with laparoscopic hysterectomy (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.38) and vaginal hysterectomy (adjusted odds ratio, 1.27; 95% confidence interval, 0.97-1.66) (P=.01). Increasing body mass index and increasing age did not modify the impact of operative time on venous thromboembolism incidence (P=.66 and P=.58, respectively). CONCLUSION: Every 60-minute increase in operative time was independently associated with a 35% increased odds of venous thromboembolism within 30 days of hysterectomy, and this risk was cumulative. Minimally invasive hysterectomy had lower odds of venous thromboembolism than abdominal hysterectomy across all time points.

Risk of Urinary Tract Infection Symptoms after Posthysterectomy Cystoscopy with 50% Dextrose as Compared with Saline Cystoscopy with Indigo Carmine.

STUDY OBJECTIVE: Compare odds of postoperative urinary symptoms in women who had cystoscopy after benign laparoscopic hysterectomy with 50% dextrose and with normal saline solution with intravenous indigo carmine. DESIGN: Retrospective cohort study. SETTING: Two tertiary care centers. PATIENTS: All women who underwent benign laparoscopic hysterectomy and intraoperative cystoscopy carried out by a single surgeon. INTERVENTIONS: We compared postoperative urinary symptoms in patients who received 50% dextrose cystoscopy fluid (January 2016-June 2017) with those who received saline cystoscopy with intravenous indigo carmine (November 2013-April 2014). MEASUREMENTS AND MAIN RESULTS: A total of 96 patients had cystoscopy with 50% dextrose and 104 with normal saline with intravenous indigo carmine. Differences in baseline characteristics of the two groups of participants mainly reflected institutional population diversity: age (45.2 vs 41.9, p = .01), body mass index (26.9 vs 33.4, p <.01), race, current smoking status (1% vs 7.8%, p = .04), diabetes (2.1% vs 11.5%, p = .01), history of abdominal surgery (53.1% vs 74%, p <.01), hysterectomy type, receipt of intraoperative antibiotics (92.7% vs 100%, p <.01), recatheterization (10.4% vs 0%, p <.01), and removal of catheter on postoperative day 0 (66.7% vs 12.5%, p <.01). Urinary symptoms were similar for 50% dextrose and saline (12.5% vs 7.7%, p = .19). After adjusting for age, body mass index, race, diabetes, and day of catheter removal, there remained no significant differences in urinary symptoms between the groups (odds ratio 3.19 [95% confidence interval, 0.82-12.35], p = .09). One immediate bladder injury was detected in the saline group and 1 delayed lower urinary tract injury in the 50% dextrose group. CONCLUSION: Overall, most women experienced no urinary symptoms after benign laparoscopic hysterectomy. There were no significant differences in postoperative urinary symptoms or empiric treatment of urinary tract infection after the use of 50% dextrose cystoscopy fluid as compared with normal saline. The previous finding of increased odds of urinary tract infection after dextrose cystoscopy may be due to use in a high-risk population.

The impact of race on hysterectomy for benign indications.

PURPOSE OF REVIEW: To review current literature evaluating racial disparities in benign hysterectomy care in the United States. RECENT FINDINGS: Evidence shows that black women are half as likely to undergo minimally invasive hysterectomy and have an increased risk of surgical complications compared with white women. Patient level differences including fibroids, prior surgical history, medical comorbidities, and obesity have been implied to account for the increased rate of abdominal hysterectomy in black patients; however, inequalities remain even after controlling for clinical differences. Societal factors including insurance status fail to fully account for disparities, though healthcare system factors, such as geographical region and access to a minimally invasive trained surgeon, continue to have a profound impact on the equity of care that patients receive. SUMMARY: Disparities in hysterectomy route and outcomes by race and socioeconomic status exist and have persisted in the literature for over a decade despite a nationwide trend toward minimally invasive hysterectomy and improving surgical outcomes. These disparities are not fully accounted for by patient or health system factors. Successfully addressing these disparities will require a multipronged approach, which may include improved surgical training for residents, fellows, and practicing gynecologists, increasing referrals to high-volume minimally invasive gynecologic surgeons, and provider and patient education.

The Effect of Bariatric Surgery on Perioperative Complications after Hysterectomy.

STUDY OBJECTIVE: To compare intraoperative and 30-day posthysterectomy outcomes between patients who had bariatric surgery before hysterectomy and patients with a body mass index (BMI) >40 kg/m2 without a history of bariatric surgery. DESIGN: A retrospective cohort study. SETTING: A tertiary-care, academic medical center. PATIENTS: Patients with a history of bariatric surgery and patients with BMI >40 kg/m2 and no previous bariatric surgery who underwent any route of hysterectomy between January 1, 2000, and March 1, 2018. INTERVENTIONS: After exclusion of patients with gynecologic malignancy and bariatric surgery reversal, 223 patients with a history of bariatric surgery were matched at a 1:2 ratio by year of hysterectomy to 446 randomly selected patients with a BMI >40 kg/m2 and no bariatric surgery before hysterectomy. Demographics, medical comorbidities, and surgical characteristics were collected by a manual chart review. Chi-square or Fisher's exact tests were used to compare the incidence of intraoperative and 30-day postoperative complications. Polytomous logistic regression was used to estimate the odds of major and minor postoperative complications. Binary logistic regression was used to estimate the odds of any intra- or postoperative complications. MEASUREMENTS AND MAIN RESULTS: The mean BMI in the bariatric surgery group was 35.2 ± 7.9 kg/m2, compared with 46.3 ± 5.6 kg/m2 in the control group (p <.01). Fewer patients in the bariatric surgery group had obesity-related comorbidities than the group with no previous bariatric surgery (p <.01). There were lower odds of any intraoperative complication in the bariatric surgery group than in the group with no bariatric surgery (adjusted odds ratio, 0.32; 95% confidence interval [CI], 0.13-0.77), after adjusting for relevant confounding factors between groups. However, there was no difference in overall postoperative complications between women who had bariatric surgery and those who did not (adjusted odds ratio, 1.25; 95% CI, 0.82-1.91). When analyzed individually, a higher proportion of patients in the bariatric surgery group had postoperative cuff separation or dehiscence (1.4% [3/223], p = .04) and urinary retention (5.8% [13/223], p <.01). Combining all perioperative complications, we found no significant difference in minor complications, defined as Clavien-Dindo Grade 1 or 2 (adjusted odds ratio, 1.04; 95% CI, 0.68-1.60), major complications, defined as Clavien-Dindo Grade 3 or higher (adjusted odds ratio, 1.25; 95% CI, 0.61-2.54), or combined major and minor perioperative complications (adjusted odds ratio, 0.96; 95% CI, 0.63-1.44) between patients with a history of bariatric surgery and morbidly obese patients with no bariatric surgery before hysterectomy, after adjusting for relevant confounding factors between groups. CONCLUSION: Compared with women who had a BMI >40 kg/m2, patients with a history of bariatric surgery before hysterectomy had a lower odds of complications during hysterectomy. However, despite lower BMI and fewer obesity-related medical comorbidities, there was no significant difference in posthysterectomy complications and no significant differences in overall major and minor complications.

Artificial intelligence and augmented reality in gynecology.

PURPOSE OF REVIEW: Artificial intelligence and augmented reality have been progressively incorporated into our daily life. Technological advancements have resulted in the permeation of similar systems into medical practice. RECENT FINDINGS: Both artificial intelligence and augmented reality are being increasingly incorporated into the practice of modern medicine to optimize decision making and ultimately improve patient outcomes. SUMMARY: Artificial intelligence has already been incorporated into many areas of medical practice but has been slow to catch on in clinical gynecology. However, several applications of augmented reality are currently in use in gynecologic surgery. We present an overview of artificial intelligence and augmented reality and current use in medical practice with a focus on gynecology.

Mentoring millennials in surgical education.

PURPOSE OF REVIEW: We seek to define the Millennial generation and identify strengths that can be employed to improve medical and surgical education and career development. We outline how generational traits can be incorporated into adult learning theory, offer suggestions for modernizing traditional teaching and mentorship models, and discuss why Millennials are ideally positioned to succeed in 21st century medicine. RECENT FINDINGS: Millennials (born ∼1981 to 1996) have several consistently identified traits that should be considered when teaching trainees and mentoring junior faculty. Millennials are technologically savvy, accustomed to accessing and assimilating large amounts of information quickly, using the electronic medical record with ease, and learning from a variety of media sources. They learn better with alternatives to traditional lectures, and respond well when given discrete goals, encouragement, and direct feedback early and often. Millennials prefer team-based learning and a flat hierarchy. Millennials are socially responsible, culturally diverse, and strive to promote diversity and work-life integration. SUMMARY: Although the individuals that make up the Millennial generation may not encompass each attribute associated with this cohort, collectively, this generation of physicians is positioned to usher medicine into a new era.

Total Laparoscopic Hysterectomy and Bilateral Salpingo-Oophorectomy for a 6095-g Myomatous Uterus in a Patient of the Jehovah's Witness Faith.

STUDY OBJECTIVE: To demonstrate techniques for addressing the unique challenges for a minimally invasive approach to hysterectomy presented by a massive myomatous uterus. DESIGN: Technical video of an operation demonstrating the methods used to perform hysterectomy in this setting, highlighting such aspects as port placement (Fig. 1), uterine manipulation (Fig. 2), exposure, and vascular control (Figs. 3 and 4) (Canadian Task Force classification III). SETTING: Academic tertiary care hospital. INTERVENTION: A 49-year-old woman elected to proceed with laparoscopic hysterectomy after years of suffering from bleeding and bulk symptoms from a massively enlarged myomatous uterus. A computed tomography scan estimated uterine dimensions of 32 × 27 × 24 cm, for a volume of >7000 mL (Fig. 5). Her surgical history included a ventral herniorrhaphy with mesh, and her body mass index was 43 kg/m2. She was a Jehovah's Witness, and thus blood transfusion was not an acceptable option for her due to a religious prohibition. Intraoperatively, the uterus extended deep into the pararectal and paravesical spaces on the right, from the caudad below the cervix (Fig. 6) to superiorly near the liver edge (Fig. 7). MEASUREMENTS AND MAIN RESULTS: Laparoscopic hysterectomy was successfully completed (Table), and the patient was discharged on the day after surgery. Final pathology revealed a 6095-g uterus with benign leiomyomata. She presented 9 days after surgery with nausea and vomiting, suspicious for an incarcerated hernia at the tissue extraction site. Her symptoms were ultimately determined to be due to either ileus or small bowel obstruction, which likely could have been managed nonoperatively with bowel rest and fluids. She stayed an additional 2 days after readmission and was then discharged, with no further complications. CONCLUSIONS: The size of the uterus was once considered a barrier to the use of laparoscopy for hysterectomy, but experience has shown that the benefits of minimally invasive surgery are particularly relevant for large myomas [1-4], given that a vaginal approach is not feasible and that other risks, such as wound complications and venous thromboembolism, would be greater with the large incision required to perform the procedure by laparotomy. This video uses a particularly challenging case to demonstrate a roadmap for addressing myomas in laparoscopic hysterectomy through exposure and vascular control. Although the presentation focused on the initial steps of the procedure and not on uterine extraction, this patient's readmission highlights potential complications associated with various methods of tissue removal for very large specimens.

Use of Historic Surgical Times to Predict Duration of Hysterectomy: Stratifying by Uterine Weight.

STUDY OBJECTIVE: To describe the accuracy of historic averages for estimating operating room (OR) time for hysterectomy among women with small and large uteri. DESIGN: A retrospective cohort study. SETTING: Data from women who underwent abdominal, vaginal, or laparoscopic hysterectomy between 2015 and 2017 at the University of North Carolina Hospitals were analyzed. Historic and actual OR times were compared using linear regression. Patient characteristics were also evaluated to determine whether they were associated with the accuracy of predicted OR times. PATIENTS: Nine hundred eighty-five adult women (≥18 years old) who underwent surgery for benign indications or for suspected but not biopsy-confirmed malignancy were included. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Historic averages overestimated OR time by a median of 14 minutes (interquartile range [IQR] = -29 to 49 minutes). The OR time in women with small uteri (<250 g) was significantly more likely to be overestimated than women with large uteri (≥250 g) (median time = 21 minutes [IQR = -16 to 52 minutes] and 3 minutes [IQR = -38 to 44 minutes], respectively; p <. 001). In total laparoscopic hysterectomy and laparoscopy-assisted vaginal hysterectomy, women with uteri ≥250 g took significantly longer than hysterectomy for women with uteri <250 g (36 minutes longer [95% confidence interval, 24-50] and 95 minutes longer [95% confidence interval, 12-179], respectively; p < .001 and p = .03). CONCLUSION: Using historic averages overestimates OR time, and it is more pronounced in women with small uteri. However, there is a relatively large range of OR times, even among women with the same size uteri. This study highlights the importance of preoperative planning, and in cases in which endometriosis is expected, manually adding time to estimates is recommended.

Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery.

Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.

Uterine weight and complications after abdominal, laparoscopic, and vaginal hysterectomy.

BACKGROUND: Although uterine size has been a previously cited barrier to minimally invasive hysterectomy, experienced gynecologic surgeons have been able to demonstrate that laparoscopic and vaginal hysterectomy is feasible with increasingly large uteri. By demonstrating that minimally invasive hysterectomy continues to have superior outcomes even with increased uterine weights, opportunity exists to meaningfully decrease morbidity, mortality, and cost associated with abdominal hysterectomy. OBJECTIVE: We sought to determine if there is an association between uterine weight and posthysterectomy complications and if differences in that association exist across vaginal, laparoscopic, and abdominal approaches. STUDY DESIGN: We conducted a cohort study of prospectively collected quality improvement data from the American College of Surgeons National Surgical Quality Improvement Program database, composed of patient information and 30-day postoperative outcomes from >500 hospitals across the United States and targeted data files, which includes additional data on procedure-specific risk factors and outcomes in >100 of those participating hospitals. We analyzed patients undergoing hysterectomy for benign conditions from 2014 through 2015, identified by Current Procedural Terminology code. We excluded patients who had cancer, surgery by a nongynecology specialty, or missing uterine weight. Patients were compared with respect to 30-day postoperative complications and uterine weight, stratified by surgical approach. Bivariable tests and multivariable logistic regression were used for analysis. RESULTS: In all, 27,167 patients were analyzed. After adjusting for potential confounders, including medical and surgical variables, women with 500-g uteri were >30% more likely to have complications compared to women with uteri ≤100 g (adjusted odds ratio, 1.34; 95% confidence interval, 1.17-1.54; P < .0001), women with 750-g uteri were nearly 60% as likely (adjusted odds ratio, 1.58; 95% confidence interval, 1.37-1.82; P < .0001), and women with uteri ≥1000 g were >80% more likely (adjusted odds ratio, 1.85; 95% confidence interval, 1.55-2.21; P < .0001). The incidence of 30-day postsurgical complications was nearly double in the abdominal hysterectomy group (15%) compared to the laparoscopic group (8%). Additionally, for each stratum of uterine weight, abdominal hysterectomy had significantly higher odds of any complication compared to laparoscopic hysterectomy, even after adjusting for potential demographic, medical, and surgical confounders. For uteri <250 g, abdominal hysterectomy had twice the odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.80-2.33), and among women with uteri between 250-500 g, abdominal hysterectomy was associated with an almost 80% increase in odds of any complication (adjusted odds ratio, 1.76; 95% confidence interval, 1.41-2.19). Even among women with uteri >500 g, abdominal hysterectomy was still associated with a >30% increased odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 1.35; 95% confidence interval, 1.07-1.71). CONCLUSION: We found that while uterine weight was an independent risk factor for posthysterectomy complications, abdominal hysterectomy had higher odds of any complication, compared to laparoscopic hysterectomy, even for markedly enlarged uteri. Our study suggests that uterine weight alone is not an appropriate indication for abdominal hysterectomy. We also identified that it is safe to perform larger hysterectomies laparoscopically. Patients may benefit from referral to experienced surgeons who are able to offer laparoscopic hysterectomy even for markedly enlarged uteri.

The case against endometrial ablation for treatment of heavy menstrual bleeding.

PURPOSE OF REVIEW: Endometrial ablation is a common treatment for heavy menstrual bleeding, but serious limitations and long-term complications exist. Our purpose is to summarize the use of endometrial ablation devices, potential short-term and long-term complications, cost effectiveness, and quality of life in relation to alternative treatments. RECENT FINDINGS: There is insufficient evidence to strongly recommend one endometrial ablation device over another. Providers should consider and discuss with their patients, complications including risk of future pregnancy, endometrial cancer, and hysterectomy for continued bleeding or pain. Patient selection is key to reducing postablation pain and failure; patients with a history of tubal ligation and dysmenorrhea should consider alternative treatments. All patients should also be counseled that the levonorgestrel intrauterine device is a cost-effective alternative with higher quality of life and fewer complications. Hysterectomy is definitive treatment with higher quality of life and fewer complications. SUMMARY: Although endometrial ablation can offer adequate symptom control for patients who have failed medical therapy, desire uterine preservation, or who are high-risk surgical candidates, patients should be appropriately selected and counseled regarding the potential for treatment failure and long-term complications.

Cost-effectiveness of treatments for heavy menstrual bleeding.

BACKGROUND: Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown. OBJECTIVE: The objective of the study was to evaluate the relative cost-effectiveness of 4 treatment options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation, nonresectoscopic endometrial ablation, and the levonorgestrel-releasing intrauterine system. STUDY DESIGN: We formulated a decision tree evaluating private payer costs and quality-adjusted life years over a 5 year time horizon for premenopausal women with heavy menstrual bleeding and no suspected malignancy. For each treatment option, we used probabilities derived from literature review to estimate frequencies of minor complications, major complications, and treatment failure resulting in the need for additional treatments. Treatments were compared in terms of total average costs, quality-adjusted life years, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was conducted to understand the range of possible outcomes if model inputs were varied. RESULTS: The levonorgestrel-releasing intrauterine system had superior quality-of-life outcomes to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel-releasing intrauterine system was cost-effective compared with hysterectomy in the majority of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were associated with reduced costs compared with hysterectomy but resulted in a lower average quality of life. According to standard willingness-to-pay thresholds, resectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 44% of scenarios, and nonresectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 53% of scenarios. CONCLUSION: Comparing all trade-offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel-releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel-releasing intrauterine system as a first-course treatment for heavy menstrual bleeding, consideration of cost, procedure-specific complications, and patient preferences can guide the decision between hysterectomy and ablation.

The role of simulation and warm-up in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills. RECENT FINDINGS: Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes. SUMMARY: Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeon's career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.