Safety and Efficiency Outcomes of Ambulatory Gynaecologic Procedures in Canadian Surgical Centres Adopting a Common Model.

OBJECTIVE: The present study aims to compare the safety and efficiency outcomes of ambulatory gynaecologic procedures performed under conscious sedation and/or local anaesthetic at 2 Canadian institutions. METHODS: A retrospective cohort study was completed over 1-year on patients presenting to the ambulatory care centres at 2 Canadian institutions that shared a common care model. Outcomes of interest were lead time (registration to discharge), procedural time, and intraoperative complications. Surgical data was derived from a retrospective chart review and outcomes were compared using the independent t test and one-way analysis of variance. RESULTS: A total of 1495 and 1098 patients presented to the 2 sites. The average age of patients was 35.5 ± 12.3 years and 41.7 ± 10.2 years. The most commonly performed procedures were dilatation and curettages at the first centre and operative hysteroscopies at the second centre. Average lead times were similar: 170.3 ± 35.8 minutes and 171.6 ± 45.4 minutes (P = 0.45). There was a significant difference in mean procedural time being 9.8 ± 5.5 minutes and 17.0 ± 10.0 minutes (P < 0.001). The rate of minor intraoperative complications was 3.8% and 6.6% (P = 0.002); whereas the rate of major complications was 2.7% and 3.3% (P = 0.43). CONCLUSION: In Canada, the majority of gynaecologic procedures are performed under general anesthesia. By comparing outcomes at 2 separate Canadian centres, we demonstrated the reproducibility of a common ambulatory model for minor gynaecologic procedures, supporting the implementation of similar care models across Canada.

An Arterial Vaginal Bleed Resulting from Short-Term Pessary Use: A Case Report.

BACKGROUND: Pessaries are commonly used for the management of pelvic organ prolapse. Complications are rare, with major complications usually related to long-term use and neglect. Complications related to short-term pessary use, as well as complications requiring surgical intervention, are even less common. CASE: We present the case of a 58-year-old postmenopausal woman who presented with acute, arterial vaginal bleeding requiring surgical intervention 3 weeks after being fitted for a pessary for management of pelvic organ prolapse. CONCLUSION: Severe, short-term complications are rare, but can occur with pessary management of pelvic organ prolapse. To our knowledge, this is the first case to describe an acute arterial hemorrhage requiring surgical intervention following short-term placement of a vaginal pessary.

Safety and Efficiency in a Canadian Outpatient Gynaecological Surgical Centre.

OBJECTIVE: This study sought to describe safety and efficiency outcomes for patients undergoing procedures at the Women's Health Centre, an outpatient gynaecological surgical centre in Saskatoon, SK. METHODS: A retrospective chart review of surgical outpatient health records was conducted for the period of July 2014 to June 2015. Data were abstracted using a standardized data form for patient admissions during the study period. Primary outcomes of interest included procedure time, lead time (registration to discharge), complication rates, readmission rates, and reoperation rates. Descriptive statistics were calculated using Microsoft Excel and were summarized using frequencies and percentages. The Kruskal-Wallis test was performed for lead time and procedural time by using IBM SPSS Statistics 24 software (IBM, Armonk, NY). RESULTS: During the study period, 1720 patients were seen by 21 providers. The mean number of patients seen per month was 144. The main services provided include hysteroscopic sterilization, non-resectoscopic endometrial ablation, loop electrosurgical excision procedure, hysteroscopy, and therapeutic abortion. Pain management was administered by local anaesthetic and/or conscious sedation. The mean procedure time was 10 ± 6 minutes, whereas the lead time was 171 ± 43 minutes. Immediate complications occurred in 3.9% of patients, the most common being vaginal bleeding (1.3%). The long-term complication rate was 5.1%, with the most common complication being reoperation in the main operating room, at 2.9%. CONCLUSION: Currently, many gynaecological procedures in Canada occur in a formal operating theatre setting. Our study demonstrates the safety and efficiency of an alternate setting where gynaecological procedures are performed on an outpatient basis by using local anaesthetic and conscious sedation.

No. 250-Recurrent Urinary Tract Infection.

OBJECTIVE: To provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women. OPTIONS: Continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives. EVIDENCE: A search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. VALUES: This update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). OPTIONS: Recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patient's characteristics.

Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair.

OBJECTIVE: To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS. OPTIONS: Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies. OUTCOMES: The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth. EVIDENCE: Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the 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 in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.

Objectif : Analyser les données probantes traitant des lésions obstétricales du sphincter anal (LOSA) en ce qui concerne leur diagnostic, les techniques visant leur réparation et les résultats de l'intervention. Formuler des recommandations permettant d'éclairer les conseils offerts aux patientes ayant connu des LOSA en ce qui a trait à la voie d'accouchement à privilégier dans le cadre des grossesses subséquentes. Options : Les fournisseurs de soins obstétricaux qui comptent des patientes ayant connu des LOSA disposent de l'option de réparer le sphincter anal en faisant appel à la méthode de suture « bout à bout ¼ (end-to-end) ou à la méthode « en paletot ¼ (overlapping). Ils pourraient également être appelés à conseiller des femmes ayant déjà connu des LOSA en ce qui a trait à la voie d'accouchement à privilégier pour les grossesses subséquentes. Issues : Le critère d'évaluation était la continence anale à la suite d'une réparation primaire de LOSA et à la suite d'un accouchement subséquent. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, EMBASE et The Cochrane Library en mai 2011 au moyen d'un vocabulaire contrôlé (p. ex. anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) et de mots clés (p. ex. obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs. Aucune restriction n'a été imposée en matière de date ou de langue. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en septembre 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : Parmi les avantages de la mise en œuvre de la présente directive clinique, on trouve : l'amélioration du diagnostic des LOSA, l'obtention d'issues fonctionnelles optimales à la suite de la réparation et l'offre de conseils reposant sur des données probantes aux femmes en ce qui concerne leurs futures grossesses. Déclarations sommaires 1. Les lésions obstétricales du sphincter anal mènent à des comorbidités considérables, dont l'incontinence anale, les fistules rectovaginales et la douleur. (II-2) 2. Les lésions obstétricales du sphincter anal sont plus souvent associées aux accouchements par forceps qu'aux accouchements par ventouse obstétricale. (II-2) 3. Réparation des lésions obstétricales du sphincter anal : a. L'utilisation de polyglactin 2-0 ou de polydioxanone 3-0 donne lieu, après six semaines, à des taux semblables de morbidité liée aux sutures. (I) b. La réparation du sphincter anal interne est recommandée puisque les femmes chez lesquelles la présence d'une anomalie affectant ce sphincter est révélée au cours de l'échographie postpartum sont plus susceptibles de connaître une incontinence anale. (III) c. La réparation du sphincter anal externe devrait englober la gaine fasciale. Le recours à la technique de suture « en paletot ¼ (chevauchement) nécessite souvent une mobilisation et une dissection de plus grande envergure des extrémités du sphincter; l'utilisation de cette technique n'est possible qu'en présence de déchirures sphinctériennes de degré 3b ou plus. (III) d. La présence persistante d'une anomalie du sphincter anal externe longtemps après l'accouchement pourrait accroître le risque de voir apparaître une aggravation des symptômes à la suite des accouchements vaginaux subséquents. (II-2) 4. Les lésions obstétricales du sphincter anal sont associées à une hausse du risque de rétention urinaire postpartum. (II-2) 5. À la suite de la réparation réussie d'une lésion obstétricale du sphincter anal, la plupart des femmes peuvent connaître un accouchement vaginal en toute sûreté dans le cadre d'une grossesse subséquente. (III) 6. Services de counseling offerts aux femmes au sujet de leurs accouchements subséquents : a. Le risque de récurrence d'une lésion obstétricale du sphincter anal dans le cadre d'un accouchement subséquent est de 4-8 %. (II-2) b. On a calculé que, pour prévenir un cas d'incontinence anale chez des femmes ayant déjà subi une lésion obstétricale du sphincter anal, la tenue de 2,3 césariennes planifiées s'avérerait nécessaire, le tout s'accompagnant alors d'une hausse des risques maternels. (II-2) Recommandations 1. Toutes les femmes devraient faire l'objet d'un examen rigoureux visant la détection de déchirures périnéales ou vaginales; celles qui présentent une déchirure dont la profondeur est plus que superficielle devraient, avant la mise en œuvre d'une réparation, faire l'objet d'un examen rectal systématique cherchant à établir la présence de lésions obstétricales du sphincter anal. (II-2B) 2. Le système de classification de l'Organisation mondiale de la santé devrait être utilisé pour classer les lésions obstétricales du sphincter anal. Ce système permet l'établissement d'une distinction entre le degré de déchirure du sphincter externe (3a < 50 % ou 3b ≥ 50 %) et la présence d'anomalies du sphincter interne (3c). La présence d'une lésion en boutonnière (button-hole injury) constitue un incident distinct et devrait être classée en conséquence. (III-B) 3. Chez les femmes qui connaissent un accouchement vaginal spontané, le taux de lésions obstétricales du sphincter anal est amoindri lorsque le fournisseur de soins obstétricaux ralentit la tête fœtale au moment du dégagement. (II-2A) 4. Épisiotomie : a. Dans le cadre d'un accouchement vaginal spontané ou instrumental, le fournisseur de soins obstétricaux devrait, pour assurer la prévention des lésions obstétricales du sphincter anal, respecter une politique prévoyant une utilisation « restreinte ¼ de l'épisiotomie (c.-à-d. seulement lorsque cela s'avère indiqué), plutôt qu'une utilisation « libre ¼ de cette intervention (c.-à-d. de façon systématique). (I-A) b. Lorsque la tenue d'une épisiotomie est jugée indiquée, l'octroi d'une préférence envers la tenue d'une incision médiolatérale (plutôt qu'envers la tenue d'une incision médiane) devrait être envisagé. (II-2B) L'angle d'incision optimal semble être d'au moins 45 degrés (idéalement, aux alentours de 60 degrés). (II-2B) 5. La réparation peut être différée (pendant 8-12h) sans effets nuisibles. La mise en œuvre d'un délai pourrait s'avérer nécessaire jusqu'à ce que les services d'un fournisseur de soins disposant de l'expérience nécessaire pour procéder à la réparation puissent être retenus. (I-A) 6. L'administration prophylactique d'une dose intraveineuse unique d'antibiotiques (céphalosporine de 2e génération, p. ex. céfotétan ou céfoxitine) devrait être mise en œuvre pour assurer la baisse des taux de complications de lésion périnéale à la suite de la réparation des lésions obstétricales du sphincter anal. (I-A) 7. Des laxatifs (p. ex. lactulose) devraient être prescrits à la suite de la réparation primaire d'une lésion obstétricale du sphincter anal puisqu'ils sont associés à des premières selles moins douloureuses et survenant plus rapidement, et à l'obtention plus rapide du congé de l'hôpital. L'utilisation d'agents constipants et d'agents de gonflement n'est pas recommandée. (I-A) 8. Les anti-inflammatoires non stéroïdiens et l'acétaminophène sont les analgésiques de première intention. Les opioïdes ne devraient être utilisés qu'avec précaution. La constipation devrait être évitée au moyen d'un laxatif ou d'un émollient fécal. (1-A) 9. À la suite de la constatation d'une lésion obstétricale du sphincter anal, les fournisseurs de soins devraient divulguer à leurs patientes le degré de la lésion subie et prendre les dispositions nécessaires à la mise en œuvre d'un suivi. Il est nécessaire de procéder à la documentation détaillée de la lésion et de sa réparation. (III-L) 10. Les femmes qui connaissent une incontinence anale après avoir subi une lésion obstétricale du sphincter anal devraient être orientées vers des services de physiothérapie du plancher pelvien. (I-A).

Recurrent urinary tract infection.

OBJECTIVE: to provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women. OPTIONS: continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives. EVIDENCE: a search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. VALUES: this update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). OPTIONS: recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patient's characteristics.

Ethical issues associated with the introduction of new surgical devices, or just because we can, doesn't mean we should.

Surgical devices are often marketed before there is good evidence of their safety and effectiveness. Our paper discusses the ethical issues associated with the early marketing and use of new surgical devices from the perspectives of the six groups most concerned. Health Canada, which is responsible for licensing new surgical devices, should amend their requirements to include rigorous clinical trials that provide data on effectiveness and safety for each new product before it is marketed. Industry should comply with all Health Canada requirements to obtain licenses for new products. Until Health Canada requires effectiveness and safety data, industry should cooperate with physicians in appropriate studies before releasing new products and should make balanced presentations of all the available evidence. Surgeons should, before using a new surgical device, assess the evidence on its effectiveness and safety and ensure they are properly trained and competent in using the device. Surgeons should provide their patients with an evaluation of the available evidence and inform them about possible complications and the surgeon's level of experience with the new device. Patients, who should be given an honest evaluation of the available evidence, possible complications, and the surgeon's experience, should be encouraged to evaluate the evidence and information to their own satisfaction to ensure that fully informed consent is given. Health institutions, responsible for regulating practice within their walls, should review new devices for safety, effectiveness, and economic impacts, before allowing their use. They should also limit the use of new surgical devices to surgeons trained and competent in the new technology. Professional societies should provide guidance on the early adoption of new surgical devices and technologies. We urge all those involved in the development, licensing, and use of new surgical devices to aim for higher ethical standards to protect the health and safety of patients requiring surgery. The lowest acceptable ethical standard would require device manufacturers to provide surgeons with accurate and timely information on the efficacy and safety of their products, allowing surgeons and patients to evaluate the evidence (and the significance of information not yet available) before surgery.

RETIRED: Choice of surgery for stress incontinence.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

RETIRED: Tension-free vaginal tape (TVT) procedure.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

The evaluation of stress incontinence prior to primary surgery.

OBJECTIVE: To provide clinical guidelines for the evaluation of women with stress urinary incontinence prior to primary anti-incontinence surgery. OPTIONS: The modalities of evaluation range from basic pelvic examination through to the use of adjuncts including ultrasound and urodynamic testing. OUTCOMES: These guidelines provide a comprehensive approach to the preoperative evaluation of urinary incontinence to ensure that excessive evaluation is avoided without sacrificing diagnostic accuracy. EVIDENCE: Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Comprehensive evaluation of women considering surgery to treat urinary incontinence is essential to rule out causes of incontinence that may not be amenable to surgical treatment. Simplifying the evaluation minimizes the discomfort and embarrassment potentially experienced by women. RECOMMENDATIONS: 1. Thorough evaluation of each woman is essential to determine the underlying etiology of the urinary incontinence and to guide management. (II-3B) 2. Preoperative pelvic examination should be performed to identify pelvic masses that may provoke lower urinary tract symptoms (e.g., a large fibroid uterus impinging on the bladder), concomitant pelvic organ prolapse, and to rule out latent stress incontinence. All of these findings may necessitate a modification of the surgical approach. (III-C) 3. Hypermobility of the urethra should be confirmed preoperatively, as women with fixed, well-supported bladder necks are less likely to experience a cure following standard anti-incontinence procedures. (II-2B) 4. Stress incontinence should be objectively demonstrated prior to anti-incontinence surgery. (III-B) 5. The volume of postvoid residual urine should be measured prior to anti-incontinence surgery. Elevated postvoid residual volumes are uncommon and should signal the need for further evaluation of the voiding mechanism. (III-C) 6. Urinary tract infection should be identified and treated prior to initiating further investigation or therapeutic intervention for urinary incontinence. (II-2B) 7. In women presenting with pure stress incontinence that can be objectively demonstrated during examination, preoperative urodynamic testing is not necessary (II-3B). For women with other lower urinary tract symptoms and/or mixed urinary incontinence, the clinician s judgment must guide the use of preoperative urodynamic testing (II-3B). VALIDATION: These guidelines have been approved by the Urogynaecology Committee and the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.