Determinants of Perioperative Complications in Day-Surgery for Endometriosis: A Retrospective Cohort.

OBJECTIVES: Endometriosis is a common gynaecologic disease for which surgery is often required. Our objective was to evaluate the potential determinants of perioperative complications in day-surgeries for endometriosis. METHODS: We conducted a retrospective cohort study of patients undergoing day-surgeries for endometriosis using Canadian administrative data from between 2015 and 2019. A multilevel logistic model with a random intercept at the centre level was created to assess the association between potential determinants, including age, site(s) of endometriosis lesion, centre-volume, surgical intervention, and a composite outcome of complications or specific complications. RESULTS: We observed a higher risk of complications associated with greater age (40-44 vs. 20-24 years, adjusted odds ratio [aOR] 1.58; 95% CI 1.26-1.98); hysterectomies (aOR 2.29; 95% CI 1.73-3.06) compared with minor conservative surgery; lesions of the bowel or urinary tract system (aOR 1.54; 95% CI 1.16-2.06), and extra-pelvic sites of endometriosis (aOR 1.24; 95% CI 1.07-1.52) compared with endometriosis of the uterus; and with comorbidities (aOR 1.59; 95% CI 1.09-2.32). Endometriosis lesions to the bowel and urinary tract system and to extra-pelvic sites (compared with no endometriosis at the site) were associated with a greater risk of accidental damages (aOR 1.84; 95% CI 1.43-2.37) and urinary system complications (aOR 1.75; 95% CI 1.24-2.48), respectively. Among patients undergoing hysterectomies compared with those undergoing minor conservative surgery, infectious complications (aOR 8.56; 95% CI 4.70-15.59) and accidental damages (aOR 2.31; 95% CI 1.70-3.14) were more frequent. CONCLUSIONS: Complications in day-surgeries for endometriosis are more frequent with older age, hysterectomy, comorbidities, and endometriosis of the bowel, urinary tract system, and extra-pelvic locations. More extensive disease is associated with more extensive surgical dissection and a higher risk of complications.

Applying graph theory to improve the quality of scientific evidence from textual information: Neural injuries after gynaecologic pelvic surgery for genital prolapse and urinary incontinence.

AIMS: To provide the overall rate for all types of neurologic iatrogenic injuries during urogynaecologic surgery from textual data. METHODS: Systematic research focused on complications of gynaecologic surgery and neurologic injuries in abstracts. Keywords concerning complications (cluster A), unspecific; neurologic issues (cluster B); surgery (generic words) (cluster C); specific gynaecologic operations (cluster D); and specific gynaecologic operations for pelvic organ prolapse and urinary incontinence (cluster E) were extracted. Associations among clusters of keywords were assessed by using multiple runs of text-mining software Semantic Brand Score (SBS, https://semanticbrandscore.com/#primary). Association scores were converted into probabilities. The rate of neurologic complications in urogynaecologic surgery was calculated ("a priori" probability) by applying Bayes' theorem. Textual estimates of neurological injuries in urogynaecologic surgery are 0.035554 (95% confidence intervals 0.019607-0.0515001; no quantitative data were found). To test if the probability calculated on textual information was the same as quantitative data reports ("a posteriori" probability), the rate of neurologic complication of all gynaecologic surgery was calculated using a meta-analytics approach and was compared with the textual analysis value. RESULTS: The rate of neurologic complications in gynaecologic surgery after meta-analytic data synthesis has been 0.016489 (95% confidence intervals 0.012163-0.022320), which is equal to the textual estimate (0.016889, 95% confidence intervals 0.019607-0.051501). Therefore, 0.035554 is a reliable likelihood to observe a neurologic complication in urogynaecologic surgery. CONCLUSION: Iatrogenic nerve injuries in urogynaecologic surgery are higher than whole gynaecologic surgery. Text-mining software SBS and probability conversion can provide reliable answers from overall scholars' opinions on unsolved clinical questions when better evidence is lacking.

The voiding VAS score is a simple and useful method for predicting POUR after laparoscopy for benign gynaecologic diseases: a pilot study.

The aim of this study was to identify an appropriate scoring system for predicting postoperative urinary retention (POUR) after gynaecological laparoscopic surgery for benign disease. We analysed 99 patients who underwent gynaecological laparoscopic surgery for benign disease. All patients were asked to complete self-administered questionnaires, including the International Prostate Symptom Score (IPSS), voiding visual analogue scale (VAS), and Brief Pain Inventory-Korean version. Of the 99 patients, 27 (27.3%) experienced urinary retention at least once, while 72 (72.7%) did not. The preoperative and postoperative IPSS scores were not associated with the development of POUR. However, the voiding VAS score was significantly lower in patients that developed POUR (p = .014). In conclusion, our results show that the voiding VAS score is a simple and useful method for identifying patients at risk of POUR after gynaecologic laparoscopic surgery for benign disease. IMPACT STATEMENTWhat is already known on this subject? Postoperative urinary retention (POUR) is an often underestimated complication defined as inability to void during the postoperative period despite a full bladder. Undetected POUR may lead to complications such as urinary tract infection, bladder distention, and bladder dysfunction. Routine assessment of POUR by bladder ultrasonography in all surgical patients places a larger workload on the nursing staff.What do the results of this study add? Among the self-scoring assessment tools, the voiding VAS provided the most accurate reflection of POUR in patients undergoing gynaecologic laparoscopic surgery for benign disease.What are the implications of these findings for clinical practice and/or further research? As laparoscopy is the most widely employed surgical procedure in gynaecology, our findings could have significant implications for postoperative care in daily clinical practice.

Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients.

OBJECTIVE: To investigate outcomes and ascertain the safety and efficacy on patients having total laparoscopic hysterectomy (TLH), stratified by body mass index (BMI), focusing on high-BMI patients. METHODS: This was a retrospective cohort study that reviewed 2,266 patients with benign gynecologic diagnoses, early cervical, endometrial, and ovarian carcinoma from September 1996 to October 2017. BMI was from 14.5 to 74.2 and were classified as normal or underweight (<24.9); overweight (25.0-29.9); class I obese (>30.0-34.9); class II obese (35-39.9); or class III obese (>40.0). All patients underwent TLH. RESULTS: Patients' characteristics were similar across all BMI classes except for age, postoperative pathological diagnoses, and whether a cystoscopy was performed. Surgical duration, and estimated blood loss were similar across BMI classes. Overweight and obese class III patients had lower odds of staying >1 day compared to patients of normal BMI (OR = 0.65, P = .015). Obese class II patients had fewer complications compared to normal BMI patients (OR = 0.27, P = .013), but patients from other high BMI categories did not show any difference compared to patients with normal BMI. The rate of unplanned laparotomy was statistically, but not clinically, higher in obese class III patients (1.8% versus .7%, P = 0.011), most often due to large fibroids. The mean reoperation rate was 2.7%, with the lowest rate (.5%) among obese class II patients, and the highest rate (3.9%) among the normal BMI patients. CONCLUSION: TLH is feasible and safe for obese women, regardless of BMI. Obesity is not a contraindication to good outcomes from laparoscopic surgery.

Senhance Robotic Platform System for Gynecological Surgery.

BACKGROUND AND OBJECTIVES: Laparoscopic hysterectomy provides patients and surgeons with benefits of less pain, quicker recovery, and better scar cosmesis. Previously, robotic surgical hysterectomy was reserved for patients with complicated disease issues. The objective of this case series was evaluating a new robotic surgical platform, Senhance Surgical System, as a surgical tool in common gynecological procedures. METHODS: The clinic routinely collects surgical and outcome data for all patients and procedures. Data on robotic surgery in hysterectomy, salpingectomy, endometriosis excision, and lysis of adhesions was evaluated. RESULTS: Fifteen consecutive patients that underwent gynecological surgery using the Senhance System were assessed. Average age was 47.27 years (31 - 63 years). Ten procedures were robotic total laparoscopic hysterectomy and 14 of 15 procedures had at least one salpingectomy. Average blood loss was 52.7 mL (10 - 100 mL). Pain scores at discharge averaged 1.42 and 2.73 at two weeks post-surgery. Minimal pain medication was used. Patient satisfaction with the surgery was 98% and satisfaction with scarring was 100%. Return to normal activities and to work averaged 7.93 and 11.1 days respectively. The haptic feedback and the platform visualization of the procedure was useful. The system provided more surgeon control over both camera and tools compared to previously used robotic systems and traditional laparoscopic surgery. CONCLUSION: This initial experience with Senhance Surgical System provided a stable, precise surgical technique with enhanced visualization within the confined space of the abdomen during gynecological surgery. The initial results suggest high patient satisfaction with gynecological surgery and resulting scars. Further study is needed to validate the findings.

Effects of sarcopenia and malnutrition on morbidity and mortality in gynecologic cancer surgery: results of a prospective study.

BACKGROUND: Malnutrition and sarcopenia often occur simultaneously in cancer patients and are thought to have harmful effects on both surgical and oncological outcomes. Therefore, we want to evaluate the effects of sarcopenia and malnutrition on severe postoperative complications and overall survival in gynecologic cancer patients. METHODS: We assessed nutritional parameters and run a bioelectrical impedance analysis in 226 women. Extracellular mass to body cell mass index, phase angle alpha, muscle mass, and fat mass were evaluated. To determine if patients suffer from sarcopenia, we ran the Timed 'Up and Go' test, performed hand grip strength, and calculated a skeletal muscle index. Postoperative complications were categorized using Clavien-Dindo Classification. Utilizing ROC analysis and logistic regression, we determined predictive clinical factors for severe postoperative complications. Kaplan-Meier method and log-rank test were used for overall survival analysis. RESULTS: Of the 226 female patients, 120 (53%) had a BMI ≥ 25 kg/m2 , 56 (26%) had a phase angle < 4.75°, and 68 (32%) were sarcopenic according to skeletal muscle index < 27%. Within 30 days after surgery, 40 (18%) patients developed severe postoperative complications, and 4% had died. According to multivariable regression analysis, ECOG status > 1 (OR 4.56, 95% CI: 1.46-14.28, P = 0.009), BMI ≥ 25 kg/m2 (OR 8.22, 95% CI: 3.01-22.48, P < 0.001), phase angle < 4.75° (OR 3.95, 95% CI: 1.71-9.10, P = 0.001), and tumour stage ≥ III A (OR 3.65, 95% CI: 1.36-9.76, P = 0.01) were predictors of severe postoperative complications. During 59 months of follow-up, 108 (48%) patients had died. According to multivariable Cox regression ECOG status > 1 (HR 2.51, 95% CI: 1.25-5.03, P = 0.01), hypoalbuminemia (HR 2.15, 95% CI: 1.28-3.59, P = 0.004), phase angle < 4.5° (HR 1.76, 95% CI 1.07-2.90, P = 0.03), tumour stage ≥ III A (HR 2.61, 95% CI: 1.53-4.45, P < 0.001), and severe postoperative complications (HR 2.82, 95% CI: 1.80-4.41, P < 0.001) were predictors of overall mortality. CONCLUSIONS: We observed that preoperatively assessed ECOG status > 1, BMI > 25 kg, as well as phase angle alpha < 4.75° and FIGO stage ≥ III A are significantly associated with severe postoperative complications within the first month. Whereas ECOG status > 1, hypoalbuminemia, phase angle < 4.5° as well as FIGO stage ≥ III A and severe postoperative complications within 30 days correlate significantly with poor overall survival.

Complicaciones en la cirugía ginecológica / Complications in gynecological surgery

Introducción: Los procedimientos quirúrgicos tienen riesgos y complicaciones, que determinan el pronóstico de los pacientes. La tasa de mortalidad de la cirugía ginecológica, es inferior al 1 por ciento, la de complicaciones varía de 0,2 a 26 por ciento. Ambas están determinadas por factores de riesgo como la edad, enfermedad médica preexistente, obesidad, cirugías previas, anemia y cáncer. Objetivo: Determinar las principales complicaciones, su asociación con el diagnóstico preoperatorio, el tipo de operación realizada y la comorbilidad en pacientes intervenidas por afecciones ginecológicas. Métodos: Estudio descriptivo en pacientes intervenidas quirúrgicamente por vía convencional y de forma electiva. Se seleccionó una serie de 616 pacientes tributarias de cirugía mayor electiva por vía convencional. Las variables utilizadas fueron la comorbilidad asociada, diagnóstico preoperatorio, operación realizada y complicaciones postquirúrgicas. Resultados: Se produjeron complicaciones postquirúrgicas en 96 pacientes (15,5 por ciento). Las de mayor frecuencia fueron el íleo paralítico (4,2 por ciento de la serie y 26,04 por ciento de las complicaciones) y el absceso de cúpula (2,75 por ciento de la serie y 17,7 por ciento de las complicaciones), fundamentalmente en quienes presentaron antecedentes de obesidad y asociación de factores de riesgo. Conclusiones: Las principales complicaciones de la cirugía ginecológica fueron el íleo paralítico y el absceso de la cúpula, las complicaciones se presentaron fundamentalmente en pacientes operadas por mioma uterino y tumor de ovario. De acuerdo con el tipo de operación, ocurrieron en pacientes operadas por histerectomía total abdominal con doble anexectomía y la histerectomía total abdominal sin anexectomía, y las comorbilidades más frecuentes fueron la obesidad y la asociación de comorbilidad(AU)

Introduction: Surgical procedures have risks and complications, which determine the prognosis of patients. The mortality rate of gynecological surgery is less than 1 percent, that of complications varies from 0.2 to 26 percent. Both are determined by risk factors such as age, pre-existing medical illness, obesity, previous surgeries, anemia, and cancer. Objective: To determine the main complications, their association with the preoperative diagnosis, the type of operation performed and the comorbidity in patients operated on for gynecological conditions. Methods: Descriptive study in patients operated on by conventional and elective route. A series of 616 tributary patients of major elective surgery by conventional route were selected. The variables used were associated comorbidity, preoperative diagnosis, operation performed, and postoperative complications. Results: Post-surgical complications occurred in 96 patients (15.5 percent). The most frequent were paralytic ileus (4.2 percent of the series and 26.04 percent of complications) and dome abscess (2.75 percent of the series and 17.7 percent of complications), mainly in who presented a history of obesity and association of risk factors. Conclusions: The main complications of gynecological surgery were paralytic ileus and abscess of the cupola, complications mainly occurred in patients operated on for uterine myoma and ovarian tumor. According to the type of operation, they occurred in patients operated on for total abdominal hysterectomy with double adnexectomy and total abdominal hysterectomy without adnexectomy, and the most frequent comorbidities were obesity and the association of comorbidity(AU)

Gynecological Benignities Causing Obstructive Uropathy. Review of the Literature.

BACKGROUND/AIM: Obstructive uropathy is defined the clinical entity that is characterized by changing the structural and functional feature of the urinary system due to interruption of normal urinary runoff. Gynecological benignities could rarely cause obstructive uropathy. Material and Methods: In this study the incidence and the severity of obstructive uropathy caused by gynecological benignities, was investigated. Additionally, we examined the spectrum of the contigent therapeutical procedures, in order to contend with this severe clinical entity, as well as the dangerous for life complication of urosepsis. Results: Gynecological benignities can cause obstructive uropathy. These conditions are rarely faced, composing a challenging problem for physicians. In the spectrum of these conditions are included adnexal masses, leiomyomas, pelvic inflammatory disease and endometriosis. Conclusions: Obstructive uropathy due to gynecological benignities is a very rare, difficult and challenging condition and physicians should always consider the existence of uropathy in such cases.

Insurance-Associated Disparities in Opioid Use and Misuse Among Patients Undergoing Gynecologic Surgery for Benign Indications.

OBJECTIVE: To compare perioperative use and persistent postoperative opioid use among Medicaid-insured women and commercially insured women who underwent gynecologic surgery for benign indications. METHODS: The Truven Health MarketScan database, a nationwide data source collecting commercial insurance claims across all states and Medicaid insurance claims from 12 states, was used to identify opioid-naïve women without cancer aged 18-64 years who underwent common gynecologic surgeries from 2012 to 2016 and filled a prescription for an opioid perioperatively. Persistent opioid use was defined as filling an opioid prescription 90-180 days after the surgery. Opioid use disorder (OUD) was defined as hospitalizations or emergency department visits for opioid dependence, misuse, or overdose. Multivariable models were developed to examine the insurance-associated disparity in persistent opioid use and OUD. RESULTS: A total of 31,155 Medicaid-insured women and 270,716 commercially insured women were identified. Medicaid-insured women received greater quantities of opioids and for longer durations than did commercially insured women. Persistent postoperative opioid use was identified in 14.1% of Medicaid-insured women and 5.8% of commercially insured women (P<.001). More opioid prescriptions filled, longer days supplied, and higher total doses perioperatively contributed most to the prediction of persistent opioid use. Medicaid-insured patients who persistently used opioids were two times more likely to develop OUD than commercially insured patients (16.8% vs 5.1% adjusted relative risk 1.99; 99% CI 1.26-3.15). CONCLUSION: Medicaid-insured women received larger quantities of opioids perioperatively, were more likely to use them persistently, and were more likely to develop OUD than commercially insured women.

Gynecologic Care in Women With Down Syndrome: Findings From a National Registry.

OBJECTIVE: To estimate receipt of recommended gynecologic care, including cancer screening and menstrual care, among women with Down syndrome in the United States. METHODS: We conducted a retrospective cohort study of women participating in DS-Connect, the National Institute of Health's registry of women with Down syndrome. Using 2013-2019 survey data, we estimated the proportion of women receiving recommended age-appropriate well-woman care (Pap tests, mammogram, breast examination, pelvic examination) and compared receipt of gynecologic care to receipt of other preventive health care. We also estimated proportion receiving care for menstrual regulation. RESULTS: Of 70 participants with Down syndrome, 23% (95% CI 13-33) of women received all recommended gynecologic components of a well-woman examination. Forty-four percent (95% CI 32-56) of women aged 18 years and older reported ever having a gynecologic examination, and 26% (95% CI 15-37) reported ever having a Pap test. Of women aged 40 years or older, 50% (95% CI 22-78) had had a mammogram. Fifty-two percent (95% CI 41-65) had tried medication for menstrual regulation, and 89% (95% CI 81-96) received all recommended components of nongynecologic routine health care. CONCLUSION: Women with Down syndrome received gynecologic care, including cancer screening, at lower-than-recommended rates and at substantially lower rates than other forms of health care. Efforts to improve gynecologic care in this vulnerable population are needed.

The use of the V-Care laparoscopic uterine manipulator to facilitate total abdominal hysterectomy: a novel approach and case-series.

Hysterectomy remains mostly performed via the abdominal route in the United Kingdom, despite advances in minimal access techniques and increased training in laparoscopic hysterectomy. The use of uterine manipulators remains a key component of the laparoscopic approach. During abdominal surgery, access to the pelvis can be challenging on occasion, and there may be a higher incidence of intraoperative complications. We describe the use of a laparoscopic uterine manipulator during total abdominal hysterectomy as a novel approach to facilitate the procedure by improving surgical exposure, reducing dissection, while safeguarding vital structures and maintaining vaginal length.Impact StatementWhat is already known on the subject? Hysterectomy remains mostly performed via the abdominal route in the United Kingdom, despite advances in minimal access techniques and increased training in laparoscopic hysterectomy. The use of uterine manipulators remains a key component of the laparoscopic approach.What do the results of this study add? We describe the use of a laparoscopic uterine manipulator during total abdominal hysterectomy as a novel approach to facilitate the procedure by improving surgical exposure, reducing dissection, while safeguarding vital structures and maintaining vaginal length.What are the implications of these findings for clinical practice and/or future research? The proposed technique is safe, easily reproducible and could be widely adopted. This approach may be considered as an option in morbidly obese women or those women with anticipated complex pelvic pathology.

The Effect of Bariatric Surgery on Perioperative Complications after Hysterectomy.

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

Changes in whole body pain intensity and widespreadness during urologic chronic pelvic pain syndrome flares-Findings from one site of the MAPP study.

OBJECTIVE: To investigate changes in whole body pain during urologic chronic pelvic pain syndrome (UCPPS) flares. MATERIALS AND METHODS: UCPPS participants at one site of the multidisciplinary approach to the study of chronic pelvic pain research network reported their daily flare status and pain levels in 7 pelvic/genital and 42 extrapelvic body areas (scale = 0-10) for 10 days at baseline and during their first flare. Linear mixed models and conditional logistic regression were used to investigate symptom changes during flares. Analyses were stratified by chronic overlapping pain condition (COPC) status. RESULTS: Fifty-five out of 60 participants completed the study, 27 of whom provided information on both nonflare (n = 281) and flare (n = 208) days. Pelvic/genital pain intensity (mean change = 3.20 of 10) and widespreadness (mean = 1.48) increased significantly during flares for all participants (all P interaction > .1), whereas extrapelvic pain intensity increased significantly only among participants with COPCs (mean = 2.09; P interaction < .0001). Pelvic/genital and extrapelvic pain also varied on nonflare days but symptom fluctuations were generally ≤1 point (80.0%-100% of participants). Increases of ≥2 points in pelvic/genital pain intensity (odds ratio (OR) = 22.0, 95% confidence interval (CI) = 4.0-118.6) and ≥1 point in urination-related pain (OR = 9.10, 95% CI = 1.74-47.7) were independently associated with flare onset for all participants. CONCLUSION: Our observations of extrapelvic pain increases during flares for patients with COPCs and our independent associations between pelvic/genital/urination-related pain intensity and flare onset may provide insight into mechanisms underlying flare development (eg, common biologic pathways between UCPPS phenotypes and flares), flare management (eg, local vs systemic therapies by COPC status), and patient flare definitions.

Guideline No. 386-Gynaecologic Surgery in the Obese Patient.

OBJECTIVE: To provide gynaecologic surgeons with a contemporary review on the pre-, intra-, and postoperative issues of the obese patient and to provide guidance for optimization and strategies for safer surgical care. INTENDED USERS: Physicians, including gynaecologists, family physicians, general surgeons; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers. TARGET POPULATION: Adult women (18 years and older) meeting criteria for obesity (body mass index ≥30) and undergoing gynaecologic surgery. OUTCOMES: Physiologic changes and comorbid conditions associated with obesity; the evidence for the impact of obesity on gynaecologic surgery; and preoperative, intraoperative, and postoperative interventions to reduce risk. EVIDENCE: For this guideline, relevant studies were searched in the PubMed, EMBASE, Medline, and Cochrane databases. MeSH search terms included Gynecology, Obesity, Obesity/morbid, Overweight, Body mass index, Surgery, Laparoscopy, Laparotomy, Anesthesia, Intraoperative complications, Postoperative complications, Morbidity, and Mortality. VALIDATION METHODS: The content and recommendations were drafted and agreed upon by the principal authors and members of the Gynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. BENEFITS, HARMS, AND COSTS: Obesity affects 1 in 5 Canadian adults. This guideline outlines strategies to improve outcomes in obese women undergoing gynaecologic surgery. GUIDELINE UPDATE: This SOGC clinical practice guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. SPONSORS: This guideline was developed with resources funded by the SOGC. SUMMARY STATEMENTS: RECOMMENDATIONS.

Study of the Apoptotic Effect in Patients with Urological versus Gynaecological Chronic Pelvic Pain.

The objective is to observe if it could be possible to use the apoptosis test to distinguish different aetiologies in chronic pelvic pain syndrome (CPPS). A prospective study was done, 106 patients, 57 had previously been diagnosed with urological chronic pelvic pain (UCPP)/interstitial cystitis (IC) and 49 patients with gynaecological chronic pelvic pain (GCPP). Neoplastic cells cultures were exposed to the urine of patients with UCPP/IC and patients with GCPP. The urine ability to provoque apoptosis on them was analysed. The apoptosis degree was measured by quantifying the percentage of cells in phase subG0, determined by a flow cytometry analysis. It is observed that the cell cultures exposed to urine of patients with UCPP had a significantly higher sub-G1 peak and G2 phase than those of the cells exposed to urine from patient's GCPP. The average values of apoptosis in patients with UCPP were significantly higher to that obtained in -patients having GCPP. With the apoptosis tests having a value >10%, it is considered as positive as well. This means that when we are faced with a patient who has UCPP or non-bladder chronic pelvic pain, the probability of having an UCPP increases by 45% when the apoptosis test is positive for a value >10%. Urine from patients with UCPP has significantly higher apoptotic effect over than the effect produced by urine from patients with GCPP. The apoptosis test could be useful as an illness biomarker.

Acute Pelvic Pain.

Acute pelvic pain has gynecologic and nongynecologic causes, and distinguishing between them can be difficult in the emergency department. Ovarian cysts, adnexal torsion, and pelvic inflammatory disease are conditions that emergency physicians must be able to identify. Pelvic pathologic condition can be readily assessed with ultrasound but has significant limitations. Adnexal torsion can occur despite normal vasculature on ultrasound with Doppler; patients with significant pain or risk factors may require exploratory laparotomy. Emergency physicians and clinicians must be prepared to manage all aspects of pelvic emergencies, both gynecologic and nongynecologic.

Type of Pelvic Disease as a Risk Factor for Surgical Site Infectionin Women Undergoing Hysterectomy.

STUDY OBJECTIVE: To quantify the relationship between type of benign pelvic disease and risk of surgical site infection (SSI) after hysterectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). PATIENTS: Women who underwent hysterectomy from 2006-2015 and recorded in NSQIP database. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: SSI risk was compared for type of benign pelvic disease, patient characteristics (i.e., age, race, and selected comorbidities) and process of care variables (i.e., admission status, type of hysterectomy, and operative time). SSI occurred in 2.48% of the 125,337 women who underwent hysterectomy. SSI was most frequent in patients with endometriosis and least frequent in those with genital prolapse (3.13% vs 1.39%; p <.0001). Following adjustment for potential confounders, the odds of SSI were higher in women undergoing hysterectomy for endometriosis (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.43- 2.25), uterine myomas (aOR, 1.28; 95% CI, 1.05-1.55), menstrual disorders (aOR, 1.46; 95% CI, 1.20-1.78), and pelvic pain (aOR, 1.75; 95% CI, 1.34-2.27) compared with women undergoing hysterectomy for genital prolapse. Other patient factors associated with SSI included age, body mass index, smoking, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and American Society of Anesthesiologists classification. Among process-of-care factors, inpatient status, route of hysterectomy, total vs subtotal hysterectomy, and operative time were also associated with SSI. CONCLUSION: In addition to various patient and process-of-care factors known to be associated with SSI, type of underlying pelvic disease is an independent risk factor for SSI in women undergoing hysterectomy for benign indications.