Assessment of Uterine Fibroid Knowledge and Educational Interests Among Health Care Professionals.

BACKGROUND: Uterine fibroid diagnosis and management can be delayed by a lack of access to care. To combat this barrier, this study aimed to determine gaps in knowledge and investigate areas of education interest. METHODS: Obstetrics-gynecology, family medicine, and internal medicine resident and attending physicians received an electronic survey via RedCap. Descriptive statistics were performed in Mintab and Excel. RESULTS: Seventy of the 316 physicians (22%) who received the survey completed it. Most participants answered questions regarding diagnosis timing, instruments for validated reported outcomes, and risk factors incorrectly. Seventy-six percent of respondents desired more education about treatment options and guidelines. DISCUSSION: This study provides insight regarding current knowledge of uterine fibroids and areas of educational interest among different physicians.

Tubulovillous Adenoma Identified on Transvaginal Ultrasound: A Case Report.

Tubulovillous adenomas are colonic polyps with a relatively high potential for malignancy that are typically identified on colonoscopy. We present a case of colonic tubulovillous adenoma first discovered on gynecologic transvaginal ultrasound. The patient was a 42-year-old gravida 2 para 2 female with symptoms suggestive of endometriosis, including left lower quadrant pain, heavy menstrual bleeding, urinary urgency, and dyschezia. The patient underwent transvaginal ultrasound following the International Deep Endometriosis Analysis protocol that identified an intermediate echogenicity, vascular solid mass of the rectosigmoid lumen. Consequent colonoscopy and polypectomy revealed tubulovillous tissue negative for high-grade dysplasia or malignancy. This case report highlights the importance of gynecologists developing an acute awareness of colonic pathologies that might be encountered while performing endometriosis ultrasounds with direct assessment of the rectum.

A Low-fidelity Model for Office-based Hysteroscopy with a Vaginoscopic Approach.

STUDY OBJECTIVE: Hysteroscopy is an established method for the diagnosis and treatment of intrauterine pathology. A vaginoscopic approach for office-based hysteroscopy confers less pain; however, trainees report lack of confidence with this procedure. We sought to create a low-fidelity simulation model for office-based hysteroscopy with a vaginoscopic approach and to evaluate the validity and reliability of this model. DESIGN: Prospective cohort study. SETTING: A single academic medical center. PARTICIPANTS: Eligible participants included obstetrics and gynecology residents and attendings who regularly perform hysteroscopy. INTERVENTIONS: The vaginoscopy model was created with an inanimate female pelvis simulator with an exam glove placed within the vagina. Following 2 instructional videos, participants performed a hysteroscopy simulation with a vaginoscopic approach. The primary outcome was total score on a modified Global Rating Scale and Objective Structured Assessment of Technical Skills. The Objective Structured Assessment of Technical Skills outlines a series of steps that must be performed and was created with assistance from experts in hysteroscopy for providing content-oriented evidence of validity. Time to complete each task and total time were tracked. Participants completed a postprocedure survey assessing the model and experience. MEASUREMENTS AND MAIN RESULTS: A total of 30 physicians participated, with 20 residents (9 junior and 11 senior) and 10 attendings. Attending physicians completed the simulation faster than junior residents (197.2 ± 30.9 vs 289.8 ± 107.4 seconds, p = .022). On the Global Rating Scale, both attending physicians and senior residents scored significantly higher than junior residents (26.1 ± 2.4 vs 22.5 ± 3.7, p = .01). Postsurvey data demonstrated that 93.3% of all participants were satisfied with simulation, 96.6% found it useful, 80% found it realistic, and 93% indicated that they may use this technique in the future. CONCLUSION: This study shows our low-fidelity model to be effective and useful and to improve confidence for vaginoscopic approach to hysteroscopy. Further studies are needed to assess ability to predict or improve clinical and surgical skills.

Deaths and Severe Adverse Events after the use of Mifepristone as an Abortifacient from September 2000 to February 2019.

OBJECTIVES: Primary: Analyze the Adverse Events (AEs) reported to the Food and Drug Administration (FDA) after use of mifepristone as an abortifacient. Secondary: Analyze maternal intent after ongoing pregnancy and investigate hemorrhage after mifepristone alone. METHODS: Adverse Event Reports (AERs) for mifepristone used as an abortifacient, submitted to the FDA from September 2000 to February 2019, were analyzed using the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAEv3). RESULTS: The FDA provided 6158 pages of AERs. Duplicates, non-US, or AERs previously published (Gary, 2006) were excluded. Of the remaining, there were 3197 unique, US-only AERs of which there were 537 (16.80%) with insufficient information to determine clinical severity, leaving 2660 (83.20%) Codable US AERs. (Figure 1). Of these, 20 were Deaths, 529 were Life-threatening, 1957 were Severe, 151 were Moderate, and 3 were Mild.The deaths included: 9 (45.00%) sepsis, 4 (20.00%) drug toxicity/overdose, 1 (5.00%) ruptured ectopic pregnancy, 1 (5.00%) hemorrhage, 3 (15.00%) possible homicides, 1 (5.00%) suicide, 1 (5.00%) unknown. (Table 1).Retained products of conception and hemorrhage caused most morbidity. There were 75 ectopic pregnancies, including 26 ruptured ectopics (includes one death).There were 2243 surgeries including 2146 (95.68%) D&Cs of which only 853 (39.75%) were performed by abortion providers.Of 452 patients with ongoing pregnancies, 102 (22.57%) chose to keep their baby, 148 (32.74%) had terminations, 1 (0.22%) miscarried, and 201 (44.47%) had unknown outcomes.Hemorrhage occurred more often in those who took mifepristone and misoprostol (51.44%) than in those who took mifepristone alone (22.41%). CONCLUSIONS: Significant morbidity and mortality have occurred following the use of mifepristone as an abortifacient. A pre-abortion ultrasound should be required to rule out ectopic pregnancy and confirm gestational age. The FDA AER system is inadequate and significantly underestimates the adverse events from mifepristone.A mandatory registry of ongoing pregnancies is essential considering the number of ongoing pregnancies especially considering the known teratogenicity of misoprostol.The decision to prevent the FDA from enforcing REMS during the COVID-19 pandemic needs to be reversed and REMS must be strengthened.

An Analysis of Obstetrics-Gynecology Residency Interview Methods in a Single Institution.

OBJECTIVE: Interviews for residency are important for resident selection, yet how to best perform the interviews remains uncertain. Multiple approaches have been described with a variety of results. Our purpose of this study was to evaluate our Obstetrics-Gynecology residency program's interview structure to determine which interview components have association with performance evaluations completed by physicians and nurses during the residents' years of training at our program. DESIGN: Using only data from our matched residents, existing interview scores from our standard interview process were compared to performance evaluation scores completed by faculty and nursing throughout the training years. Our standard interview process consisted of 4 interviews with individual faculty, 1 structured behavioral-based interview by a blinded faculty member, and 1 interview with a pair of current residents. SETTING: A single, multisite, Obstetrics-Gynecology residency program. PARTICIPANTS: Interviewees of the Obstetrics-Gynecology residency program that ultimately matched with our program. RESULTS: Interview scores from 44 residents were compared to their performance evaluation scores. Positive associations were seen between performance evaluation scores and both resident teams' interviews and unstructured faculty interviews, with the resident teams' score showing a stronger degree of association. The behavioral-based interview total score did not have association with the performance evaluation scores, nor did any of the individual questions. CONCLUSIONS: Resident teams' interview scores of applicants show the strongest association with eventual performance evaluations completed by faculty and nursing during residency. This demonstrates that current residents should have a role in the resident selection process during interviews. This does not provide data to abandon behavior-based interview techniques, but rather encourage each program to carefully apply their use during the resident selection process.

Laser Angiography to Assess the Vaginal Cuff During Robotic Hysterectomy.

BACKGROUND AND OBJECTIVES: Vaginal cuff dehiscence may be a vascular-mediated event, and reports show a higher incidence after robot-assisted total laparoscopic hysterectomy (RATLH), when compared with other surgical routes. This study was conducted to determine the feasibility of using laser angiography to assess vaginal cuff perfusion during RATLH. METHODS: This was a pilot feasibility trial incorporating 20 women who underwent RATLH for benign disease. Colpotomy was made with ultrasonic or monopolar instruments, whereas barbed or nonbarbed suture was used for cuff closure. Time of instrument activation during colpotomy was recorded. Images were captured of vaginal cuff perfusion before and after cuff closure. Reviewers evaluated these images and determined areas of adequate cuff perfusion. RESULTS: Indocyanine green (ICG) was visible at the vaginal cuff in all participants. Optimal dosage was determined to be 7.5 mg of ICG per intravenous dose. Mean time to appearance for ICG was 18.4 ± 7.3 s (mean ± SD) before closure and 19.0 ± 8.7 s after closure. No significant difference (P = .19) was noted in judged perfusion in open cuffs after colpotomy with a monopolar (48.9 ± 26.0%; mean ± SD) or ultrasonic (40.2 ± 14.1%) device. No difference was seen after cuff closure (P = .36) when a monopolar (70.9 ± 21.1%) or ultrasonic (70.5 ± 20.5%) device was used. The use of barbed (74.1 ± 20.1%) or nonbarbed (66.4 ± 20.9%) sutures did not significantly affect estimated closed cuff perfusion (P = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs (R2 = 0.3175). CONCLUSION: Laser angiography during RATLH allows visualization of vascular perfusion of the vaginal cuff. The technology remains limited by the lack of quantifiable fluorescence and knowledge of clinically significant levels of fluorescence.

Anatomy of the Internal Iliac Vein: Implications for Uterine Transplant.

STUDY OBJECTIVE: Uterine transplantation has proven feasible since the first live birth reported in 2014. To enable attachment of the uterus in the recipient, long vascular pedicles of the uterine and internal iliac vessels were obtained during donor hysterectomy, which required a prolonged laparotomy to the living donors. To assist further attempts at uterine transplantation, our video serves to review literature reports of internal iliac vein anatomy and demonstrate a laparoscopic dissection of cadaver pelvic vascular anatomy. DESIGN: Observational (Canadian Task Force Classification III). SETTING: Academic anatomic laboratory. Institutional Review Board ruled that approval was not required for this study. INTERVENTION: Literature review and laparoscopic dissection of cadaveric pelvic vasculature, focusing on the internal iliac vein. MEASUREMENTS AND MAIN RESULTS: Although the internal iliac artery tends to have minimal anatomic variation, its counterpart, the internal iliac vein, shows much variation in published studies [1,2]. Relative to the internal iliac artery, the vein can lie medially or laterally. Normal anatomy is defined as some by meeting 2 criteria: bilateral common iliac vein formed by ipsilateral external and internal iliac vein at a low position and bilateral common iliac vein joining to form a right-sided inferior vena cava [2]. Reports show 79.1% of people have normal internal iliac vein anatomy by these criteria [2]. The cadaver dissection revealed internal iliac vein anatomy meeting criteria for normal anatomy. CONCLUSION: Understanding the complexity and variations of internal iliac vein anatomy can assist future trials of uterine transplantation.

Sterility of Selected Operative Sites During Total Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To describe the type and quantity of bacteria found intraoperatively on the abdomen, vagina, surgical gloves, instrument tips, and uterus at distinct time points during total laparoscopic hysterectomy (TLH). DESIGN: Observational study (Canadian Task Force classification III). SETTING: Academic affiliated hospital. PATIENTS: Thirty-one women undergoing TLH for benign indications in 2016. INTERVENTIONS: After antibiotic prophylaxis and chlorhexidine preparation, swabs were collected from the vaginal fornices and abdomen. During subsequent TLH, additional swabs were collected from the following sites: surgeon's gloves after placement of the uterine manipulator, tips of instruments used to close the vaginal cuff, uterine fundus after extraction, and surgeon's gloves after removal of the uterus. A calibrated loop was used to inoculate each specimen onto 5% blood and chocolate agars for growth of aerobes and onto Brucella blood, phenylethyl alcohol, kanamycin vancomycin, and Bacteroides bile esculin agars for growth of anaerobes. Manual colony counts were tabulated for all positive cultures and reported in colony-forming units per milliliter (CFU/mL). MEASUREMENTS AND MAIN RESULTS: Anaerobic growth was not seen on the instrument tips, in the vagina, or on the abdomen of any patient. Aerobic bacterial growth was not seen in the vagina of any patient. On the surgeon's gloves after uterine manipulator placement, no patients demonstrated sufficient bacterial growth to potentially cause surgical site infection (≥5000 CFU/mL). On the surgeon's gloves following uterine extraction, 1 patient demonstrated sufficient growth to potentially cause infection. None of the patients developed surgical site infections postoperatively. CONCLUSION: Cultures from multiple operative sites yielded bacterial growth, but the bacterial concentrations did not exceed the threshold for infection in 98.9% of cultures. Given absent growth from vaginal cultures and rare growth from abdominal cultures, chlorhexidine gluconate 4% is considered an appropriate surgical preparation for use in laparoscopic hysterectomy.

Uterine viability in the baboon after ligation of uterine vasculature: a pilot study to assess alternative perfusion and venous return for uterine transplantation.

OBJECTIVE: To assess, in two separate groups of baboons, uterine viability after ligation of the uterine veins and uterine viability after ligation of both the uterine arteries and veins, respectively. DESIGN: Prospective, observational study. SETTING: Baboon breeding colony. ANIMAL(S): Six naïve female Papio hamadryas baboons with indicators of normal reproductive function. INTERVENTION(S): Three baboons underwent surgical interruption of the uterine veins bilaterally, and three baboons underwent surgical interruption of the uterine arteries and the uterine veins bilaterally. All baboons also underwent colpotomy, cervico-vaginal reanastomosis, and intraoperative near-infrared fluorescence imaging after vessel ligation. In the postoperative period, transabdominal sonography, vaginoscopy, and endocervical biopsy were performed on all animals. MAIN OUTCOME MEASURE(S): Postoperative uterine and ovarian viability. RESULT(S): Near-infrared imaging confirmed intraoperative perfusion of the uterus and cervico-vaginal anastomosis in all cases. In all subjects, sonography revealed normal uteri, and vaginoscopy revealed well-healed anastomoses. Endocervical biopsies (five of six) demonstrated pathologically normal endocervical tissue without evidence of necrosis. Cyclical sex skin turgescence and menstruation were unanimously observed. CONCLUSION(S): Disruption of bilateral uterine vessels does not affect uterine or ovarian viability in the baboon. Bilateral uterine artery and vein ligation furthers development of a minimally invasive approach to donor hysterectomy.

Laser Angiography with Indocyanine Green to Assess Vaginal Cuff Perfusion during Total Laparoscopic Hysterectomy: A Pilot Study.

STUDY OBJECTIVE: To determine feasibility of using laser angiography with indocyanine green (ICG) to assess vaginal cuff vascular perfusion during total laparoscopic hysterectomy (TLH). DESIGN: Pilot feasibility trial (Canadian Task Force classification II-2). SETTING: Academic-affiliated hospital. PATIENTS: Twenty women undergoing TLH for benign disease. INTERVENTIONS: Participants underwent 1:1 randomization of energy method used for colpotomy (ultrasonic vs monopolar) and vaginal cuff closure suture (barbed vs nonbarbed). After intravenous administration of ICG, laser angiography was used to capture images of the vaginal cuff before and after closure. Three reviewers analyzed fluorescent images of vaginal cuffs to determine percent of cuff perimeter with adequate perfusion when open and length of vaginal cuff adequately perfused when closed. MEASUREMENTS AND MAIN RESULTS: ICG fluorescence was visible at the vaginal cuff in all participants. Mean time to appearance of ICG in the pelvis after administration was 19.8 ± 6.8 seconds (mean ± SD) preclosure, and 26.0 ± 22.2 seconds postclosure. With ultrasonic energy 67.5% ± 17.4% of open cuff perimeter and 74.4% ± 20.5% of closed cuff length were adequately perfused, whereas with monopolar energy use 59.1% ± 17.4% of the open cuff perimeter and 66.3% ± 15.4% of closed cuff length were adequately perfused. Cuffs closed with barbed suture showed adequate perfusion along 71.5% ± 15.1% of the length, whereas those closed with nonbarbed suture showed 68.9% ± 20.9% adequate perfusion. When normalized to cervical cup circumference, ultrasonic energy required 1.0 ± .2 s/mm, whereas monopolar energy required .8 ± .3 s/mm (p = .162). Linear regression showed no association of normalized time of energy activation to percentage of perimeter of open cuff (R2 = .007) or length of closed cuff (R2 = .005) with adequate perfusion. No complications related to intravenous ICG administration occurred. CONCLUSION: Laser angiography with ICG allows evaluation of vascular perfusion at the vaginal cuff during TLH. This technique may facilitate future prospective studies examining causes for vaginal cuff dehiscence, a complication with potential for severe morbidity.