Characteristics associated with blood transfusion among women undergoing laparoscopic myomectomy: a National Surgical Quality Improvement Program study.

BACKGROUND: Uterine fibroids are the most common benign tumors that affect females. A laparoscopic myomectomy is the standard surgical treatment for most women who wish to retain their uterus. The most common complication of a myomectomy is excessive bleeding. However, risk factors for hemorrhage during a laparoscopic myomectomy are not well studied and no risk stratification tool specific for identifying the need for a blood transfusion during a laparoscopic myomectomy currently exists in the literature. OBJECTIVE: This study aimed to identify risk factors for intraoperative and postoperative blood transfusion during laparoscopic myomectomies and to develop a risk stratification tool to determine the risk for requiring a blood transfusion. STUDY DESIGN: This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. Women who underwent a laparoscopic (conventional or robotic) myomectomy were included. Women who received 1 or more blood transfusions within 72 hours after the start time of a laparoscopic myomectomy were compared with those who did not require a blood transfusion. A multivariable analysis was performed to identify risk factors independently associated with the risk for transfusion. Two risk stratification tools to determine the need for a blood transfusion were developed based on the multivariable results, namely (1) based on preoperative factors and (2) based on preoperative and intraoperative factors. RESULTS: During the study period, 11,498 women underwent a laparoscopic myomectomy. Of these, 331(2.9%) required a transfusion. In a multivariable regression analysis of the preoperative factors, Black or African American and Asian races, Hispanic ethnicity, bleeding disorders, American Society of Anesthesiologists class III or IV classification, and a preoperative hematocrit value ≤35.0% were independently associated with the risk for transfusion. Identified intraoperative factors included specimen weight >250 g or ≥5 intramural myomas and an operation time of ≥197 minutes. A risk stratification tool was developed in which points are assigned based on the identified risk factors. The mean probability of transfusion can be calculated based on the sum of the points. CONCLUSION: We identified preoperative and intraoperative independent risk factors for a blood transfusion among women who underwent a laparoscopic myomectomy. A risk stratification tool to determine the risk for requiring a blood transfusion was developed based on the identified risk factors. Further studies are needed to validate this tool.

Firearm businesses as partners in suicide prevention: a cross-sectional study of the Gun Shop Project in Colorado, USA.

BACKGROUND: The Gun Shop Project aims to reduce firearm suicide and is widely implemented in the USA, yet little is known about the core firearm business practices and behaviours that might contribute to preventing firearm suicide. METHODS: Owners or managers of all firearm businesses identified as participants in Colorado's Gun Shop Project were invited to respond to a questionnaire. Data collection occurred from March to May 2021. Analyses included unweighted descriptive statistics with CIs and Pearson χ2 tests for categorical associations. RESULTS: 54 firearm businesses participated (response rate: 28%). Under half reported practices that are Gun Shop Project core aspects (range: 14%-45%). 22% of businesses frequently engaged customers on the importance of safe firearm storage in suicide prevention while 26% had denied a firearm sale and 14% had assisted with temporary secure storage in the past year with customers perceived to be in suicidal crisis. However, high proportions reported willingness to engage in these behaviours if a customer was in crisis: 74% were willing to refuse a sale of a firearm or ammunition, 70% were willing to discuss temporary secure storage options and 70% were willing to direct customers to mental health services. CONCLUSIONS: This study suggests that efforts to continue educating and involving firearm businesses may have an impact on the adoption of organisational suicide prevention practices and behaviours. Ongoing efforts are needed to understand core components of Gun Shop Project to inform standardised recommendations for effective firearm business practices that prevent firearm suicide.

Utility of Routine Postoperative Examination for Detecting Vaginal Cuff Dehiscence After Total Laparoscopic Hysterectomy.

STUDY OBJECTIVE: To determine the utility of routine postoperative vaginal cuff examination for detection of vaginal cuff dehiscence (VCD) after total laparoscopic hysterectomy (TLH). DESIGN: Retrospective cohort study. SETTING: Quaternary care academic hospital in the United States. PATIENTS: All patients who underwent TLH with a minimally invasive gynecologic surgeon at our institution from 2016 to 2022. INTERVENTIONS: Laparoscopic hysterectomy with routine vaginal cuff check 6 to 8 weeks postoperatively and laparoscopic hysterectomy without routine vaginal cuff check. MEASUREMENTS AND MAIN RESULTS: We identified 703 patients who underwent TLH, 216 (30.7%) with routine cuff checks and 487 (69.3%) without. Within the no cuff check group, 287 (58.9%) had entirely virtual follow-up. There was no difference in VCD between the routine cuff check (1.28%, n = 2) and no cuff check groups (0.93%, n = 7, p = .73). Median time to VCD was 70.0 days (27.5-114.0). No VCDs were identified in asymptomatic patients on routine examination, and both patients in the cuff check group with VCD had appropriately healing cuffs on routine examination. In the cuff check group, 7 patients (3.2%) had findings of incomplete healing requiring intervention (silver nitrate, extended pelvic rest), all of whom were asymptomatic at the time of examination. Eight patients (3.7%) in the routine cuff check group and 21 (4.3%) in the no examination group required a nonroutine cuff check owing to symptoms. There was no difference in points of contact for postoperative symptoms between the groups (median 0 [0-1.0] for both groups, p = .778). CONCLUSION: Routine postoperative vaginal cuff examination does not seem to affect or negate the risk of future VCD. Virtual follow-up for asymptomatic patients may be appropriate after TLH.

Race, Ethnicity, and Sex Representation Trends Among Minimally Invasive Gynecologic Surgery Fellowship Trainees and Graduates.

STUDY OBJECTIVE: To study the race, ethnicity, and sex representation and annual trends of AAGL FMIGS fellows and graduates. DESIGN: A retrospective cross-sectional study. SETTING: AAMC databases were queried for demographic information between 2011 and 2023. PATIENTS/SUBJECTS: AAGL FMIGS fellows and graduates. INTERVENTIONS: N/A MEASUREMENTS AND MAIN RESULTS: Descriptive statistical analysis and the actual-to-expected (AE) ratio of each race, ethnicity, and sex were performed. AE ratio was calculated by dividing the 13-year average actual percentage of FMIGS trainees and graduates by the expected percentage based demographics of OBGYN residents and the US general population. 477 fellows graduated or were in training between 2011 and 2023; race and ethnicity information was obtained for 347 (72.7%) individuals, and sex information was available for 409 (85.7%). Representation of females ranged from 66.7% in 2017 to 93.3% in 2022. There was a significantly increasing slope for the representation of females (+1.3% per year; 95% CI 0.00-0.03; p = .027). Compared to their distribution among US OBGYN residents, White fellows' representation was lower [AE ratio, 95% CI 0.60 (0.44-0.81)] and of Asian fellows was higher [AE ratio, 95% CI 2.17 (1.47-3.21)]. Female fellows' representation was lower than expected [AE ratio, 95% CI 0.68 (0.48-0.96)] compared to their distribution among US OBGYN residents. Compared to the general US population, White fellows [AE ratio, 95% CI 0.65 (0.48-0.87)] and Hispanic fellows [AE ratio, 95% CI 0.53 (0.34-0.83)] representation was lower. Asian fellows' representation was higher compared to the general US population [AE ratio, 95% CI 5.87 (3.48-9.88)]. CONCLUSION: White and Hispanic fellows' representation was lower than expected, while Asian fellows' representation was higher in AAGL-accredited FMIGS programs. Female representation increased throughout the years, but overall, female fellows' representation was lower than expected compared to their distribution among OBGYN residents. These findings may help develop equitable recruitment strategies for FMIGS programs and reduce health disparities within complex gynecology.

Validation of a Simulation Model for Robotic Myomectomy.

STUDY OBJECTIVE: Several simulation models have been evaluated for gynecologic procedures such as hysterectomy, but there are limited published data for myomectomy. This study aimed to assess the validity of a low-cost robotic myomectomy model for surgical simulation training. DESIGN: Prospective cohort simulation study. SETTING: Surgical simulation laboratory. PARTICIPANTS: Twelve obstetrics and gynecology residents and 4 fellowship-trained minimally invasive gynecologic surgeons were recruited for a 3:1 novice-to-expert ratio. INTERVENTIONS: A robotic myomectomy simulation model was constructed using <$5 worth of materials: a foam cylinder, felt, a stress ball, bandage wrap, and multipurpose sealing wrap. Participants performed a simulation task involving 2 steps: fibroid enucleation and hysterotomy repair. Video-recorded performances were timed and scored by 2 blinded reviewers using the validated Global Evaluative Assessment of Robotic Skills (GEARS) scale (5-25 points) and a modified GEARS scale (5-40 points), which adds 3 novel domains specific to robotic myomectomy. Performance was also scored using predefined task errors. Participants completed a post-task questionnaire assessing the model's realism and utility. MEASUREMENTS AND MAIN RESULTS: Median task completion time was shorter for experts than novices (9.7 vs 24.6 min, p = .001). Experts scored higher than novices on both the GEARS scale (median 23 vs 12, p = .004) and modified GEARS scale (36 vs 20, p = .004). Experts made fewer task errors than novices (median 15.5 vs 37.5, p = .034). For interrater reliability of scoring, the intraclass correlation coefficient was calculated to be 0.91 for the GEARS assessment, 0.93 for the modified GEARS assessment, and 0.60 for task errors. Using the contrasting groups method, the passing mark for the simulation task was set to a minimum modified GEARS score of 28 and a maximum of 28 errors. Most participants agreed that the model was realistic (62.5%) and useful for training (93.8%). CONCLUSION: We have demonstrated evidence supporting the validity of a low-cost robotic myomectomy model. This simulation model and the performance assessments developed in this study provide further educational tools for robotic myomectomy training.

Clinical Trial Racial and Ethnic Disparities in Minimally Invasive Gynecologic Surgery.

STUDY OBJECTIVE: To study racial and ethnic disparities in randomized controlled trials (RCTs) in minimally invasive gynecologic surgery (MIGS). DESIGN: Cross-sectional study. SETTING: Online review of all published MIGS RCTs in high-impact journals from 2012 to 2023. PATIENTS: Journals included all first quartile obstetrics and gynecology journals, as well as The New England Journal of Medicine, The Lancet, The British Medical Journal, and The Journal of the American Medical Association. The National Institutes of Health's PubMed and the ClinicalTrials.gov websites were queried using the following search terms from the American Board of Obstetrics and Gynecology's certifying examination bulletin 2022 to obtain relevant trials: adenomyosis, adnexal surgery, abnormal uterine bleeding, cystectomy, endometriosis, fibroids, gynecology, hysterectomy, hysteroscopy, laparoscopy, leiomyoma, minimally invasive gynecology, myomectomy, ovarian cyst, and robotic surgery. INTERVENTIONS: The US Census Bureau data were used to estimate the expected number of participants. We calculated the enrollment ratio (ER) of actual to expected participants for US trials with available race and ethnicity data. MEASUREMENTS AND MAIN RESULTS: A total of 352 RCTs were identified. Of these, race and/or ethnicity data were available in 65 studies (18.5%). We analyzed the 46 studies that originated in the United States, with a total of 4645 participants. Of these RCTs, only 8 (17.4%) reported ethnicity in addition to race. When comparing published RCT data with expected proportions of participants, White participants were overrepresented (70.8% vs. 59.6%; ER, 1.66; 95% confidence interval [CI], 1.52-1.81), as well as Black or African American participants (15.4% vs. 13.7%; ER, 1.15; 95% CI, 1.03-1.29). Hispanic (6.7% vs. 19.0%; ER, 0.31; 95% CI, 0.27-0.35), Asian (1.7% vs. 6.1%; ER, 0.26; 95% CI, 0.20-0.34), Native Hawaiian or other Pacific Islander (0.1% vs. 0.3%; ER, 0.21; 95% CI, 0.06-0.74), and Indian or Alaska Native participants (0.2% vs. 1.3%; ER, 0.16; 95% CI, 0.08-0.32) were underrepresented. When comparing race/ethnicity proportions in the 20 states where the RCTs were conducted, Black or African American participants were underrepresented. CONCLUSION: In MIGS RCTs conducted in the United States, White and Black or African American participants are overrepresented compared with other races, and ethnicity is characterized in fewer than one-fifth of trials. Efforts should be made to improve racial and ethnic recruitment equity and reporting in future MIGS RCTs.

Improving Data-Driven Decision Making for Primary Prevention: Providing Data Interpretation Resources to Schools and Communities in Colorado.

Communities are increasingly interested in primary prevention efforts to reduce health inequities. However, few communities can access local data on social determinants of health and many do not have the skills or training to interpret data to inform decision making on appropriate strategies that impact social determinants of health. A population-based youth health survey administered to middle and high school students, such as exists in most states in the United States, can assess health behaviors and risk and protective factors. The schools and school districts that participate are provided with reports of results and data interpretation resources that support their understanding of risk and protective factors to inform local decision making and action. Other states can similarly provide local data and resources on risk and protective factors to help communities collaborate on primary prevention efforts that achieve health equity.

Risk factors for major complications following colorectal resections for endometriosis in the USA.

PURPOSE: We aimed to describe the incidence and identify risk factors for the occurrence of short-term major posto-perative complications following colorectal resection for endometriosis. METHODS: A cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012-2020. We included patients with a primary diagnosis of endometriosis who underwent colon or rectal resections for endometriosis. RESULTS: Of 755 women who underwent colorectal resection, 495 (65.6%) had laparoscopic surgery and 260 (34.4%) had open surgery. The major complication rate was 13.5% (n = 102). Women who underwent open surgery had a higher proportion of major complications (n = 53, 20.4% vs. n = 49, 9.9%, p < 0.001). In a multivariable regression analysis, Black race (aOR 95%CI 2.81 (1.60-4.92), p < 0.001), Hispanic ethnicity (aOR 95%CI 3.02 (1.42-6.43), p = 0.004), hypertension (aOR 95%CI 1.89 (1.08-3.30), p = 0.025), laparotomy (aOR 95%CI 1.64 (1.03-3.30), p = 0.025), concomitant enterotomy (aOR 95%CI 3.02 (1.26-7.21), p = 0.013), and hysterectomy (aOR 95%CI 2.59 (1.62-4.15), p < 0.001) were independently associated with major post-operative complications. In a subanalysis of laparoscopies only, Hispanic ethnicity, chronic hypertension, lysis of bowel adhesions, and hysterectomy were independently associated with major complications. In a subanalysis of laparotomies only, Black race and hysterectomy were independently positively associated with the occurrence of major complications. CONCLUSION: This study provides a current population-based estimate of short-term complications after surgery for colorectal endometriosis in the USA. The identified risk factors for complications can assist during preoperative shared decision-making and informed consent process.

Surgical management of endometriosis to optimize fertility.

PURPOSE OF REVIEW: Surgery is an integral element of treatment for infertility caused by endometriosis. This review summarizes the purported mechanisms of infertility in endometriosis, as well as the impacts of surgery for endometriosis on fertility, including pregnancy achieved spontaneously and with assisted reproductive technology (ART). RECENT FINDINGS: Endometriosis' effect on fertility is multifactorial. The sequela of increased inflammation resulting from endometriosis causes alterations in ovarian, tubal, and uterine function. Removing or destroying these lesions reduces inflammation. Surgical treatment of both early-stage endometriosis and deeply infiltrating endometriosis improves spontaneous pregnancy rates and ART pregnancy rates. Conventional or robotic laparoscopy is the preferred surgical approach. SUMMARY: Endometriosis has detrimental effects on fertility, including negative impacts on oocyte, tubal, and endometrial function. Laparoscopic surgery for endometriosis elevates both spontaneous and ART pregnancy rates above those achieved with expectant management alone. The resection or destruction of endometriosis implants reduces inflammation, which likely improves the multifactorial infertility related to endometriosis. This topic is complex and controversial; more research in the form of high-quality randomized control trials is needed.

Racial and Gender Representation Trends Among National Obstetrics and Gynecology Society Leadership.

STUDY OBJECTIVE: The purpose of this study is to review the trends in racial and gender representation among the various national obstetrics and gynecology societies' presidents over the past 15 years. DESIGN: A retrospective cross-sectional study. SETTING: Data obtained from publicly available information on official websites of the professional societies studied. PATIENTS: Presidents of national societies in obstetrics and gynecology. INTERVENTIONS: The study was performed by obtaining publicly available data for past presidents from the official websites of the professional societies studied. Gender and race were inferred based on name and image. Racial classification was selected using the United States Census classification system. Educational background, residency training, and practice type were also collected. Assessment of 15-year trends was completed using linear regression analysis and differences in representation was assessed using analysis of variance and post hoc analysis. MEASUREMENTS AND MAIN RESULTS: Over 15 years, there were 134 presidents elected for the 10 obstetrics and gynecology societies. Of those leaders, 85.2% were white, 8.2% Asian, and 5.2% black; 59% were men and 41% were women. During the study period, there was a significantly increasing slope for representation of women (+2.3% per year; 95% confidence interval, 0.4-4.2; p = .016). The representation of nonwhite presidents (+1.5% per year; 95% confidence interval, 0.2-2.8; p = .028) increased significantly during the same time period. CONCLUSION: Over the last 15 years, less than 50% of obstetrics and gynecology national societies' presidents were women and most were of white race. However, there has been an increasing trend in the ratio of women to men and nonwhite to white representation among presidents of obstetrics and gynecology national societies.

Risk Factors for Major Complications Following Minimally Invasive Surgeries for Endometriosis in the United States.

STUDY OBJECTIVE: To study the rate and risk factors for short-term postoperative complications of patients undergoing minimally invasive surgery (MIS) for endometriosis in the United States. DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. PATIENTS: Patients with endometriosis diagnosis. INTERVENTIONS: Laparoscopic surgery for endometriosis. MEASUREMENTS AND MAIN RESULTS: We compared women with and without 30-day postoperative major complications, defined according to the Clavien-Dindo classification. A total of 28 697 women underwent MIS during the study period, of which 2.6% had major postoperative complications. Organ space surgical site infection and reoperation were the most common complications (47.0% and 39.8%, respectively). In multivariable regression analysis, African American race (adjusted odds ratio [aOR] 95% confidence interval [CI] 1.61 [1.29-2.01], p <.001), hypertension (aOR 95% CI 1.23 [1.01-1.50], p = .036), bleeding disorders (aOR 95% CI 1.96 [1.03-3.74], p = .041), bowel procedures (aOR 95% CI 1.93 [1.37-2.72], p <.001) and hysterectomy (aOR 95% CI 2.09 [1.67-2.63], p <.001) were independently associated with increased risk of major complications. In multivariable regression analysis of laparoscopies without bowel procedures, African American race, bleeding disorders, and hysterectomy were independently associated with increased major complication risk. Among cases with bowel procedures, African American race and colectomy were independently associated with increased major complication risk. In multivariable regression analysis of women who underwent hysterectomy, African American race, bleeding disorders, and lysis of adhesions were independently associated with increased major complications risk. Among women who underwent uterine-sparing surgery, African American race, hypertension, preoperative blood transfusion, and bowel procedures were independently associated with increased major complications risk. CONCLUSION: Among women undergoing MIS for endometriosis, African American race, hypertension, bleeding disorders, and bowel surgery or hysterectomy are risk factors for major complications. African American race is a risk factor for major complications among women undergoing surgeries with and without bowel procedures or hysterectomy.

Selenite Adsorption and Reduction via Iron(II) Impregnated Activated Carbon Produced from the Phosphoric Acid Activation of Construction Waste Wood.

Chemical activation of waste materials, to form activated carbon, (AC) is complicated by the large amounts of chemical activating agents required and wastewater produced. To address these problems, we have developed an optimized process for producing AC, by phosphoric acid activation of construction waste. Waste wood from construction sites was ground and treated with an optimized phosphoric acid digestion and activation that resulted in high surface areas (> 2000 m2/g) and a greater recovery of phosphoric acid. Subsequently the phosphoric acid activated carbon (PAC), was functionalized with iron salts and evaluated for its efficacy on the adsorption of selenite and selenate. Total phosphoric acid recovery was 96.7% for waste wood activated with 25% phosphoric acid at a 1:1 ratio, which is a substantially higher phosphoric acid recovery, than previous literature findings. Post activation impregnation of iron salts resulted in iron(II) species adsorbed to the PAC surface. The iron(II) chloride impregnated AC removed up to 11.41 ± 0.502 mg selenium per g Iron-PAC. Competitive ions such as sulfate and nitrate had little effect on selenium adsorption, however, phosphate concentration did negatively impact the selenium uptake at high phosphate levels. At 250 ppm, approximately 75% of adsorption capacity of both the selenate and the selenite solutions was lost, although selenium was still preferentially adsorbed. Peak adsorption occurred between a pH of 4 and 11, with a complete loss of adsorption at a pH of 13.

Evaluation in Ayres Sensory Integration® (EASI) Tactile Perception Tests: Construct Validity and Internal Reliability.

IMPORTANCE: Assessment of tactile perception is foundational for addressing aspects of occupational performance. OBJECTIVE: To evaluate the construct validity and internal reliability of four new tactile perception tests. DESIGN: Causal comparative groups design. SETTINGS: Homes, schools, and therapy practices across the United States. PARTICIPANTS: Children ages 3 to 12 yr: typically developing (n = 174) and those with sensory integration concerns (n = 153). OUTCOMES AND MEASURES: Rasch analyses to evaluate construct validity; analysis of covariance to evaluate group differences. RESULTS: The Rasch model confirmed evidence of construct validity for each of the four tests. The typically developing group scored significantly higher than the clinical group on all tests (η2p = .040-.105, p < .001). Person reliability indices and strata indicated moderate to strong internal reliability (Rasch person reliability indices = .69-.87; strata = 2.33-3.82). CONCLUSIONS AND RELEVANCE: The Evaluation in Ayres Sensory Integration® (EASI) Tactile Perception Tests are reliable and valid measures for assessing tactile perception in children ages 3 to 12 yr. Findings suggest that these tests are likely to be clinically useful and appropriate for children in this age range and may provide critical information regarding underlying sensory functions necessary for optimal occupational performance. What This Article Adds: This article provides data supporting the reliability and validity of the EASI Tactile Perception Tests in a U.S. SAMPLE: These assessments can be used by therapists trained in their administration to assess tactile functions that may affect participation in activities, tasks, and occupations.

Development and validation of a simulation model for laparoscopic myomectomy.

BACKGROUND: Simulation is an important adjunct to traditional surgical training, allowing for repetitive practice of new skills without compromising patient safety. Although several simulation models have been described and evaluated for gynecologic procedures, there is a lack of such models for laparoscopic myomectomy. OBJECTIVE: This study aimed to design a low-cost, low-fidelity laparoscopic myomectomy simulation model and to assess the model's validity as a training tool. STUDY DESIGN: The model was constructed using a "cup turner" foam cylinder, felt, a 2-inch stress ball, self-adhesive bandage wrap, multipurpose sealing wrap, red marker, and hook-and-loop fastener. Participants were recruited at a quaternary care academic center and at the Society for Gynecologic Surgeons Annual Scientific Meeting. The simulation task involved the following 2 steps: fibroid enucleation and hysterotomy repair. Validity evidence was collected by comparing expert and novice simulation task performances. Video recordings were scored by 2 blinded reviewers using the Global Operative Assessment of Laparoscopic Skills scale (5-20 points) and a modified Global Operative Assessment of Laparoscopic Skills scale (5-35 points), incorporating 3 novel domains specific to laparoscopic myomectomy. The Mann-Whitney U test was used to compare the task completion times and performance scores. Interrater reliability of scoring was assessed using the interclass correlation coefficient. Validity was also assessed with a post-task survey regarding the model's realism, utility, and educational effect. RESULTS: The total cost to construct each model was under $5. A 3:1 ratio was used to recruit 15 novices and 5 experts. The median time to task completion was shorter for experts than for novices (11.8 vs 20.1 minutes; P=.004). The experts scored higher than the novices on both the Global Operative Assessment of Laparoscopic Skills scale (median 19 [range 13-20] vs 10 [6-17.5]; P=.007) and the modified Global Operative Assessment of Laparoscopic Skills scale (31.5 [21.5-33.5] vs 18.5 [13.5-32]; P=.009). The interclass correlation coefficient was 0.95 for the Global Operative Assessment of Laparoscopic Skills scores and 0.96 for the modified Global Operative Assessment of Laparoscopic Skills scores. Most of the participants agreed that the model closely approximated the feel of fibroid enucleation (70% [14/20]) and suturing the uterus (80% [16/20]). All the participants agreed that the model was useful for learning or teaching laparoscopic myomectomy. CONCLUSION: This study demonstrates evidence supporting the validity of a novel, low-cost laparoscopic myomectomy model and a novel assessment scale for laparoscopic myomectomy training. This simulation model provides a targeted training tool that allows learners to focus on the key aspects of laparoscopic myomectomy and may improve readiness for the operating room.

The role of telemedicine in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: Telemedicine has been available for decades but has had minimal use in the USA prior to the COVID-19 pandemic. We aim to educate readers on the benefits of telemedicine and provide insight from our experience to optimize care in this setting. RECENT FINDINGS: The COVID-19 pandemic ushered in a massive increase in use of telemedicine, offering several advantages with comparable clinical outcomes. SUMMARY: This review summarizes the recent vast expansion of telemedicine, describes the benefits specific to minimally invasive gynecologic surgery, and offers practical suggestions for maintaining a successful practice that incorporates both in-person and virtual experiences for patients, anticipating continued use of telemedicine beyond the end of the current public health emergency.

Rates of Complications and Reoperation after Myomectomy-the Impact of Surgical Approach: A Statewide Population-based Cohort Study from 2005-2018.

STUDY OBJECTIVE: To assess rates of and factors associated with complications and reoperation after myomectomy. DESIGN: Population-based cohort study. SETTING: All non-Veterans Affairs facilities in the state of California from January 1, 2005, to December 31, 2018. PARTICIPANTS: Women undergoing abdominal or laparoscopic myomectomy for myoma disease were identified from the Office of Statewide Health Planning and Development datasets using appropriate International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. INTERVENTIONS: Demographics, surgery facility type, facility surgical volume, and surgical approach were identified. Primary outcomes included complications occurring within 60 days of surgery and reoperations for myomas. Patients were followed up for over an average of 7.3 years. Univariate and multivariable associations were explored between the above factors and rates of complications and reoperation. All odds ratios (ORs) are adjusted ORs. MEASUREMENTS AND MAIN RESULTS: Of the 66 012 patients undergoing myomectomy, 5265 had at least one complication (8.0%). Advanced age, black, Asian race, MediCal and Medicare payor status, academic facility, and medical comorbidities were associated with increased odds of a complication. Minimally invasive myomectomy (MIM) was associated with decreased complications compared with abdominal myomectomy (AM) (OR, 0.29; 95% confidence interval [CI], 0.25-0.33; p <.001). Overall, 17 377 patients (26.3%) underwent reoperation. Medicare and MediCal payor status and medical comorbidities were associated with increased odds of a repeat surgery. Reoperation rates were higher in the MIM group over the entire study period (OR, 2.33; 95% CI, 1.95-2.79; p <.001). However, the odds of reoperation after MIM decreased each year (OR, 0.93; 95% CI 0.92-0.95; p <.001), with the odds of reoperation after AM surpassing MIM in 2015. CONCLUSION: This study identifies outcome disparities in the surgical management of myomas and describes important differences in the rates of complications and reoperations, which can be used to counsel patients on surgical approach. These findings suggest that MIM can be considered a lasting and safe approach in properly selected patients.

The Impact of Race and Ethnicity on Use of Minimally Invasive Surgery for Myomas.

STUDY OBJECTIVE: To determine whether minimally invasive surgery (MIS) for uterine myomas is used differentially based on race and ethnicity. DESIGN: Retrospective cohort study. SETTING: Quaternary care academic hospital in the United States. PATIENTS: Patients undergoing hysterectomy or myomectomy for uterine myomas between March 15, 2015, and March 14, 2020 (N = 1311). Cases involving correction of pelvic organ prolapse, malignancy, peripartum hysterectomy, or combined procedures with nongynecologic specialties were excluded. Racial/ethnic composition of the study population was 40.0% non-Hispanic white (white), 27.9% non-Hispanic black (black), 14.0% Hispanic, 13.7% non-Hispanic Asian (Asian), and 4.3% non-Hispanic American Indian/Alaska Native/Pacific Islander/Other. INTERVENTIONS: Hysterectomy, myomectomy. MEASUREMENTS AND MAIN RESULTS: Of the 1311 cases, 35.9% were minimally invasive hysterectomy, 16.4% abdominal hysterectomy, 35.6% minimally invasive myomectomy, and 12.1% abdominal myomectomy. MIS rates were 94.7% among fellowship-trained minimally invasive gynecologic surgery subspecialists, 44.2% among obstetrics and gynecology specialists, and 46.8% among gynecologic oncologists. There were disparities in surgeon type based on race/ethnicity, with 59.8% of white patients having undergone surgery with a minimally invasive gynecologic surgery subspecialist vs 44.0% of black patients and 45.7% of Hispanic patients. Black and Hispanic patients were less likely to undergo MIS overall vs white patients (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.22-0.48 and aOR 0.44, 95% CI 0.28-0.72, respectively). Black and Hispanic patients undergoing hysterectomy were less likely than white patients to undergo MIS (aOR 0.33, 95% CI 0.21-0.51 and aOR 0.35, 95% CI 0.20-0.60, respectively). There were no significant differences in rates of MIS based on race/ethnicity for myomectomies nor differences in major or minor complications by race/ethnicity overall. CONCLUSION: At a quaternary care institution, black and Hispanic patients were significantly less likely than white patients to undergo MIS for uterine myomas, particularly for hysterectomy.

Evaluating Surgical Complexity of Endoscopic Hysterectomy: An Inter-rater and Intra-rater Agreement Study of Novel Scoring Tool.

STUDY OBJECTIVE: Evaluate inter-rater and intrarater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy. DESIGN: Validation study. SETTING: Academic medical center. PARTICIPANTS: Total of 11 academic obstetrician-gynecologists with varying years of postresidency training, clinical practice, and surgical volumes. INTERVENTIONS: Application of a novel scoring tool to evaluate surgical complexity of 150 sets of images taken in a standardized fashion before surgical intervention (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Using only these images, raters were asked to assess uterine size, number, and location of myomas, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions in relevant locations. Surgical complexity was staged on a scale of 1 to 4 (low to high complexity). MEASUREMENTS AND MAIN RESULTS: Number of postresidency years in practice for participating surgeons ranged from 2 to 15, with an average of 8 years. A total of 8 obstetrician-gynecologists (72.7%) had completed a fellowship in minimally invasive gynecologic surgery. Six (54.6%) reported an annual volume of >50 hysterectomies. Raters reported that 95.4% of the images were satisfactory for assessment. Of the 150 sets of images, most were found to be stage 1 to 2 complexity (stage 1: 23.8%, stage 2: 41.6%, stage 3: 32.8%, stage 4: 1.8%). The level of inter-rater agreement regarding stage 1 to 2 vs 3 to 4 complexity was moderate (κ = 0.49; 95% confidence interval [CI], 0.42-0.56). Moderate inter-rater agreement was also found between surgeon raters with an annual hysterectomy volume >50 (κ = 0.49; 95% CI, 0.40-0.57) as well as between surgeon raters with fellowship experience (κ = 0.50; 95% CI, 0.42-0.58). Intrarater agreement averaged 80.2% among all raters and also achieved moderate agreement (mean weighted κ = 0.53; range, 0.38-0.72). CONCLUSION: This novel scoring tool uses clinical assessment of preintervention anatomic images to stratify the surgical complexity of endoscopic hysterectomy. It has rich and comprehensive evaluation capabilities and achieved moderate inter-rater and intrarater agreement. The tool can be used in conjunction with or instead of traditional markers of surgical complexity such as uterine weight, estimated blood loss, and operative time.

Acute kidney injury e-alerts in pregnancy: rates, recognition and recovery.

BACKGROUND: Acute kidney injury (AKI) in pregnancy (Pr-AKI) is associated with substantial maternal morbidity and mortality. E-alerts are routinely used for detection of AKI in non-pregnant patients but their role in maternity care has not been explored. METHODS: All pregnant or postpartum women with AKI e-alerts for AKI Stages 1-3 (Kidney Disease Improving Global Outcomes (KDIGO) criteria) were identified at a tertiary centre >2 years. Two women matched by delivery date for each case were selected as controls. AKI stage, recognition of AKI, pregnancy outcomes, renal recovery, AKI aetiology and risk factors were extracted from electronic patient records. RESULTS: 288 of 11 922 (2.4%) women had AKI e-alerts, of which only 118 (41%) were recognized by the obstetric team. Common Pr-AKI causes included infection (48%), pre-eclampsia (26%) and haemorrhage (25%), but no cause was identified in 15% of women. Renal function recovered in 213 (74%) women, but in 47 (17%) repeat testing was not undertaken and 28 (10%) did not recover function. Hypertensive disorders of pregnancy and Caesarean section were associated with increased incidence of Pr-AKI compared with controls. CONCLUSIONS: Pr-AKI e-alerts were identified in ∼1 in 40 pregnancies. However, a cause for Pr-AKI was not identified in many cases and e-alerts may have been triggered by gestational change in serum creatinine. Pregnancy-specific e-alert algorithms may be required. However, 1 in 10 women with Pr-AKI had not recovered kidney function on repeat testing. Better understanding of long-term impacts of Pr-AKI on pregnancy and renal outcomes is needed to inform relevant Pr-AKI e-alert thresholds.

Innovating patient care and gynecologic surgery instruction through tele-education.

PURPOSE OF REVIEW: Effects of the coronavirus disease 2019 pandemic prompted the need for rapid, flexible change in the delivery of care, education, and commitment to the well-being of obstetrics and gynecology (OB/GYN) residents. RECENT FINDINGS: Published literature shows multiple models for surge scheduling for residency programs in other specialties. We describe our experience creating a surge schedule for OB/GYN residents that allowed for sufficient coverage of inpatient care while minimizing resident exposure and limited hospital resources, respecting work hour requirements, and plans for coverage due to illness or need for home quarantine. We also report innovative approaches to trainee education through the use of remote-learning technology and gynecologic surgery skills training in absence of normal clinical exposure. SUMMARY: Our approach serves as a model for adapting to unprecedented challenges and offers suggestions for creative transformations of traditional teaching that can be continued beyond the immediate crisis.