Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies.

STUDY OBJECTIVE: The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. DESIGN: A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. SETTING: Canada. PATIENTS: All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different. CONCLUSION: The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.

Laparoscopic Single-port Subtotal Hysterectomy: Technique and Advantages.

Single-port laparoscopy aims to extend the benefits of minimally invasive surgery by reducing surgical trauma and enhancing patient recovery. Current evidence suggests that single-port hysterectomy is feasible, safe, and equally effective as compared with conventional laparoscopic hysterectomy, although global uptake of this approach has been geographically limited. To our knowledge, this is the first report of a single-port subtotal hysterectomy described in Canada. This online video discusses the technique and perioperative outcomes of a laparoscopic subtotal hysterectomy performed on a 47-year-old woman with severe dysmenorrhea refractory to medical management. In this case, the cervix was conserved in accordance with the patient's preference. The set-up for single-port entry consisted of widely available materials, and total equipment cost for the procedure was $230. The duration of the procedure was 2 hours. The patient was discharged the same day as surgery without the need for postoperative narcotics, and she endorsed a high level of satisfaction with wound cosmesis 6 weeks after surgery. Although the results of this single case cannot be generalized, they are consistent with prior studies underlining the feasibility and effectiveness of a single-port approach for laparoscopic hysterectomy.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes.

STUDY OBJECTIVE: Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications. DESIGN: Retrospective, multicenter, cohort study (Canadian Task Force classification II-2). SETTING: Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites. PATIENTS: Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012. INTERVENTION: ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS: Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality. CONCLUSION: Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Uterine artery embolization for uterine arteriovenous malformation in five women desiring fertility: pregnancy outcomes.

Uterine arteriovenous malformations (AVM) are rare and can be classified as either congenital or acquired. Acquired AVMs may result from trauma, uterine instrumentation, infection or gestational trophoblastic disease. The majority of acquired AVMs are encountered in women of reproductive age with a history of at least one pregnancy. Traditional therapies of AVMs include medical management of symptomatic bleeding, blood transfusions, uterine artery embolization (UAE) or hysterectomy. In this retrospective case series, we report our experience with AVM and UAE in five symptomatic women of reproductive age who wished to preserve fertility. Patients were 18-32 years old, and had 1-3 previous pregnancies prior to initial presentation. All patients were followed until their deliveries. All five patients delivered live births. Three of the five patients required two embolization procedures and one of these women required a subsequent hysterectomy. Two deliveries were at term and had normal weight babies and normal placenta. One woman had cerclage placed and developed chorioamnionitis at 34 weeks but had a normal placenta. Two pregnancies were induced <37 weeks for pre-eclampsia/b intrauterine growth restriction ± abnormal umbilical artery dopplers. The low birthweight were both <2000 g. Both placentas showed accelerated maturity and infarcts. All estimated blood losses were recorded as <500 cc. In conclusion, UAE may not be as effective at managing AVM as previously thought and should be questioned as an initial therapy in symptomatic women of reproductive age desiring fertility preservation.

Combined transurethral and laparoscopic partial cystectomy and robotically assisted bladder repair for the treatment of bladder endocervicosis: case report and review of the literature.

BACKGROUND: Endocervicosis, endosalpingiosis, endometriosis, and adenomyosis represent choristomas of Mullerian origin and are referred to as mullerianosis. These conditions frequently coexist, and they may present with pelvic pain, mass lesions, and/or infertility. Clinically, they are indistinguishable from one another, and histologically their epithelium is that of the endocervix, endosalpinx, or endometrium. Endocervicosis can be found in the urinary tract, frequently presenting as a bladder lesion or bladder dysfunction. CASE: We report here a case of bladder endocervicosis in a woman with extensive endometriosis and a bladder tumour who presented with chronic pelvic pain and infertility. Pelvic endometriosis was excised and vaporized with the CO2 laser, and the bladder lesion was excised in a combined transurethral and laparoscopic approach using the CO2 laser and robotic monopolar electrosurgical scissors. The cystotomy was then repaired using the robot, and the patient had an uneventful recovery with good clinical outcomes including spontaneous conception. CONCLUSION: Endocervicosis of the urinary bladder is a rare Mullerian choristoma. Symptomatic lesions can be removed surgically by various surgical techniques, and a collaborative team-based approach is in the patient's best interest.

Contexte : L'endocervicose, l'endosalpingiose, l'endométriose et l'adénomyose constituent des choristomes d'origine müllérienne et sont connues sous le nom de mullérianose. Ces pathologies coexistent fréquemment et peuvent donner lieu à de la douleur pelvienne, à des lésions de masse et/ou à une infertilité. Sur le plan clinique, elles ne peuvent être distinguées l'une de l'autre et, sur le plan histologique, leur épithélium est celui de l'endocol, de l'endosalpinx ou de l'endomètre. La présence d'une endocervicose peut être constatée dans les voies urinaires et prend fréquemment la forme d'une lésion ou d'une dysfonction vésicale. Cas : Nous signalons ici un cas d'endocervicose vésicale chez une femme qui présentait une endométriose étendue et une tumeur vésicale, et qui connaissait des douleurs pelviennes chroniques et une infertilité. L'endométriose pelvienne a été excisée et vaporisée au moyen d'un laser CO2, et la lésion vésicale a été excisée au moyen d'une approche combinée transurétrale et laparoscopique faisant appel au laser CO2 et à des ciseaux électrochirurgicaux monopolaires robotisés. La cystotomie a par la suite été réparée au moyen du robot et la patiente a connu une récupération sans incidents s'accompagnant de bonnes issues cliniques (y compris une conception spontanée). Conclusion : L'endocervicose de la vessie constitue un rare choristome d'origine müllérienne. Les lésions symptomatiques peuvent être retirées au moyen de chirurgies faisant appel à diverses techniques; le recours à une approche d'équipe concertée constitue la mesure qui est la plus favorable pour la patiente.

Electrosurgical generators and monopolar and bipolar electrosurgery.

Electrosurgery is the most commonly used and misunderstood technology by all surgical and medical disciplines. A lack of basic knowledge or ignorance of principles of electrosurgery and equipment among obstetricians and gynecologists is reported. As a result, thermal injuries during laparoscopic electrosurgery occur, which frequently lead to significant morbidity and mortality and medicolegal actions. Surveys indicate that up to 90% of general surgeons and gynecologists use monopolar radiofrequency (RF) during laparoscopy, 18% have experienced visceral burns, and 13% admitted 1 or more ongoing cases of litigations associated with such burns. This article describes the basics of electrosurgery beginning with the generation of electrons and their physical characteristics and governing laws before their arrival in the operating room where they are fed to an electrosurgical unit (ESU) to boost their frequency with step-up transformers from 60 Hz to >500 000 Hz. This RF creates heat, resulting in dissection, desiccation, coagulation, and fulguration of tissues without neuromuscular stimulation, pain, or burn to the patient. The ESU delivers power (wattage = volts × amps) in monopolar or bipolar (1 vs 2 high-density electrodes) configuration. Because of RF, monopolar electrosurgery compared with other energy sources is associated with unique characteristics, inherent risks, and complications caused by the requirement of a return/dispersive electrode, inadvertent direct and/or capacitive coupling, or insulation failure of instruments. These dangers become particularly important with the popular and frequent use of monopolar electrodes (hook, needle, and scissors) during cholecystectomy; robot-assisted surgeries; and the re-emergence of single-port laparoscopy, which requires close proximity and crossing of multiple intraabdominal instruments outside the surgeon's field of view. Presently, we identify all these potential risks and complications associated with the use of electrosurgery and provide suggestions and solutions to mitigate/minimize these risks based on good clinical practice and sound biophysical principles.

Postpartum Magnesium Sulfate Overdose: A Multidisciplinary and Interprofessional Simulation Scenario.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (OB/GYN) and anesthesiology. Consultation with a nurse educator maintained the quality and relevance of objectives for nursing participants. The curriculum was prepared to train OB/GYN and anesthesiology residents and labor and delivery nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets in a four-year cycle to allow OB/GYN and anesthesiology residents exposure to all scenarios during a five-year residency, beginning in their second year. Prospective evaluative data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for "Was an effective use of my educational time" and "Will influence/enhance my future practice." In this scenario, participants must evaluate and treat a postpartum preeclamptic woman who is being treated with magnesium sulfate for the purpose of seizure prophylaxis. The patient experiences magnesium sulfate toxicity and subsequent respiratory arrest. Any mannequin that can display vital signs can be used for this scenario. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

Reconceptualizing Benchmarks for Residency Training.

Postgraduate medical education (PGME) is currently transitioning to a competency-based framework. This model clarifies the desired outcome of residency training - competence. However, since the popularization of Ericsson's work on the effect of time and deliberate practice on performance level, his findings have been applied in some areas of residency training. Though this may be grounded in a noble effort to maximize patient well-being, it imposes unrealistic expectations on trainees. This work aims to demonstrate the fundamental flaws of this application and therefore the lack of validity in using Ericsson's work to develop training benchmarks at the postgraduate level as well as expose potential harms in doing so.

Autonomic Dysreflexia in the Peripartum Patient: A Multidisciplinary and Interprofessional Simulation Scenario.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (ob/gyn) and anesthesiology. Consultation with a nurse educator maintained quality and relevance of objectives for nursing participants. The curriculum was prepared to train ob/gyn and anesthesiology residents and nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets on a four-year cycle to allow ob/gyn and anesthesiology residents exposure to all scenarios during a five-year residency beginning in their second year. Prospective evaluation data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for "Was an effective use of my educational time" and "Will influence/enhance my future practice". In this scenario, participants must recognize and manage a parturient with spinal cord injury in active labour who develops autonomic dysreflexia. The fetal heart tracing becomes abnormal and the team must respond with urgent delivery. This scenario requires a mannequin for a pelvic exam and a pregnant abdomen. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

Umbilical Cord Prolapse in a Labouring Patient: A Multidisciplinary and Interprofessional Simulation Scenario.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (OB/GYN) and anesthesiology. Consultation from a nurse educator maintained quality and relevance of objectives for nursing participants. The curriculum was prepared to train OB/GYN and anesthesiology residents and nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations, and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets on a four-year cycle to allow OB/GYN and anesthesiology residents exposure to all scenarios during a five-year residency beginning in their second year. Prospective evaluative data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 with comments, such as "Was an effective use of my educational time" and "Will influence/enhance my future practice". In this scenario, participants must recognize and manage fetal distress resulting from umbilical cord prolapse in a labouring patient and respond with urgent operative delivery. This scenario requires adult and fetal mannequins with presenting umbilical cord for pelvic examination as well as equipment for fetal monitoring, general anesthetic, and emergency cesarean section. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

Bisphenol A disrupts gene expression in human placental trophoblast cells.

This study examined the effect of bisphenol A (BPA) on human placental gene expression using primary trophoblast cells as an in vitro model system. Trophoblast cells were isolated from human placentas at term, cultured and then exposed to environmentally relevant concentrations of BPA (0.1-2 µg/ml) for up to 24h, after which levels of 11ß-HSD2 mRNA, protein and activity were determined by standard radiometric conversion assay, western blotting, and qRT-PCR, respectively. The mRNA levels of several other prominent placental hormones/factors were also assessed by qRT-PCR. BPA dramatically increased levels of 11ß-HSD2 activity, protein and mRNA in a time- and concentration-dependent manner (> 4-fold). BPA also augmented aromatase, glucose transporter-1, CRH, and hCG mRNA levels while reducing the level of leptin mRNA. These findings demonstrate that BPA severely disrupts human placental gene expression in vitro, which suggests that exposure to BPA may contribute to altered placental function and consequent pregnancy complications.