Hysterectomy and Oophorectomy for Transgender Patients: Preoperative and Intraoperative Considerations.

OBJECTIVE: To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender patients. DESIGN: Stepwise demonstration of techniques with narrated video footage. SETTING: Approximately 0.3% of hysterectomies performed annually in the United States are for transgender men. While some transgender men choose hysterectomy for the same indications as cisgender women, the most prevalent diagnosis for the performed surgeries is gender dysphoria [1]. Hysterectomy with or without oophorectomy can be offered to patients who meet the World Professional Association for Transgender Health criteria [2]. INTERVENTIONS: Important perioperative counseling points for transgender patients include establishing the terminology for the relevant anatomy as well as the patient's name and pronouns; if applicable, discussing options for fertility preservation if the patient desires biological children [3,4] and discussing the use of hormone therapy post oophorectomy to reduce the loss of bone density [5,6]; and reviewing intraoperative and postoperative expectations. When performing an oophorectomy on a transgender patient for gender affirmation, it is especially important to minimize the risk of ovarian remnant syndrome and the need for additional surgery, as, for example, caused by persistent menstruation. A 2-layer vaginal cuff closure should be considered to reduce the risk of vaginal cuff complications and is preferable for patients whose pelvic organs cause gender dysphoria [7,8]. CONCLUSION: Special considerations outlined in this video and the World Professional Association for Transgender Health guidelines should be reviewed by gynecologic surgeons to minimize the transgender patient's experiences of gender dysphoria before, during, and after surgery.

Don't forget to look up: operating in the upper abdomen.

Given the marked improvement in laparoscopic technology, gynecologic surgeons feel comfortable operating in the pelvis for a variety of gynecologic pathologies. When pathology is found outside of the pelvis, however, gynecologic surgeons find operating in the upper abdomen challenging. Operating in the upper abdomen is difficult because of the loss of ergonomics and the impression of operating backward. It is prudent for gynecologic surgeons to master operating in the upper abdomen given the variety of pathologies a gynecologist can encounter outside of the pelvis, both benign, such as endometriosis and adhesions, and malignant, like staging procedures, omentectomy, and debulking. We aimed to describe our operating room modifications that help to simulate operating in the upper abdomen as if one was operating in the pelvic cavity. Strategies to improve efficiency and ergonomics when operating in the upper abdomen include operating room setup, switching monitors to the patient's shoulders bilaterally, changing surgeon location to the right side of the patient, port hopping, and 30-degree camera selection. We have also created an instructional video with the tools to improve surgeon confidence and ergonomics when operating in the upper abdomen.

Twitter Gynecologic Surgery Journal Club: Impact on Citation Scores and Social Media Attention.

STUDY OBJECTIVE: To study the impact of a Twitter-based gynecologic surgery journal club of articles published in the Journal of Minimally Invasive Gynecology (JMIG) on their social media attention and citation scores. DESIGN: A cross-sectional study. SETTING: N/A. PATIENTS: N/A. INTERVENTIONS: Comparison of citation and social media attention scores was conducted for all articles presented in the JMIG Twitter Journal Club (#JMIGjc), a monthly scientific discussion on Twitter of JMIG selected articles, between March 2018 and September 2021 (group A), with 2 matched control groups of other JMIG articles: group B, articles mentioned on social media but not promoted in any JMIG social media account, and group C, articles with no social media mentions and not presented in #JMIGjc. Matching was performed for publication year, design, and topic in a 1:1:1 ratio. Citation metrics included number of citations per year (CPY) and relative citation ratio (RCR). Altmetric Attention Score (AAS) was used to measure social media attention. This score tracks research articles' online activity from different sources such as social media platforms, blogs, and websites. We further compared group A with all JMIG articles published during the same period (group D). MEASUREMENTS AND MAIN RESULTS: Thirty-nine articles were presented in the #JMIGjc (group A) and were matched to 39 articles in groups B and C. Median AAS was higher in group A than groups B and C (10.00 vs 3.00 vs 0, respectively, p <.001). CPY and RCR were similar among groups. Median AAS was higher in group A than group D (10.00 vs 1.00, p <.001), as were median CPY and RCR (3.00 vs 1.67, p = .001; 1.37 vs 0.89, p = .001, respectively). CONCLUSION: Although citation metrics were similar among groups, #JMIGjc articles had higher social media attention metrics than matched controls. Compared with all publications within the same journal, #JMIGjc articles resulted in higher citation metrics.

Malfunction Events in the US FDA MAUDE Database: How Does Robotic Gynecologic Surgery Compare with Other Specialties?

STUDY OBJECTIVE: To review malfunction events (MEs) related to the use of the da Vinci robot reported to the United States Food and Drug Administration Manufacturer and User Facility Device Experience in the last 10 years and compare gynecologic surgery with other surgical specialties. DESIGN: A retrospective review. SETTING: Manufacturer and User Facility Device Experience database. PATIENTS: Reports from 2010 to 2020 with keywords "Davinci" and "Intuitive". INTERVENTIONS: Report review. MEASUREMENTS AND MAIN RESULTS: There were 679 reports included in the final analysis. Most MEs occurred intraoperatively (81.7%) and were related to robotic instrument malfunction (84.5%), and 30% required an instrument switch to complete the procedure. Conversion to open and laparoscopic surgery was required in 3.1% and 1.3% of MEs, respectively. Injury to the patient occurred in 15.6% of MEs. Of the reported injuries to patients, 6.6% were related to robotic malfunction, 49.2% to instrument malfunction, and 18% to surgeon or staff misuse of the robotic system, and 15.6% were complications inherent to the procedure, not related to the robotic system. Of all the reported MEs, 4.4% were related to robot malfunction, 1.5% to console malfunction, 73.3% to Intuitive accessory malfunction, 11.2% to other accessory malfunction, 4% to surgeon or staff misuse of robotic system, and 3% to complications inherent to the procedure. Comparison between gynecologic surgery and other surgical specialties showed that 14.4% of issues were solved intraoperatively in gynecologic surgery vs 13.7% in other specialties (p = .185). The procedure was completed robotically in 85.2% in gynecologic surgery vs 84% in other specialties, laparoscopically 4.6% vs 3.7%, and open in 10.2% vs 12.4%, respectively (p = .883). In gynecologic surgery, reported MEs were made by patients in 14.8% vs 4.8% in other specialties, manufacturer in 78.4% vs 74.2%, and operating room staff in 2.3% vs 16.1%, respectively (p = .007). Injury to patient was similar in gynecologic surgery compared with other specialties (35.1% vs 23.4%, p = .122). Gynecologic and other specialty MEs did not state the need for procedure rescheduling (0% vs 0%). CONCLUSION: Most reported robotic MEs occurred intraoperatively, were related to robotic instrument malfunctions, and required an instrument switch. Most surgeries are completed robotically, but conversion to either an open or laparoscopic approach was reported in 4.4%. Of the 114 reported injuries, 47.4% were Clavien-Dindo grade III+. There were no differences noted in patient injury between gynecologic surgery and other specialties.

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.

Health Information in the Era of Social Media: An Analysis of the Nature and Accuracy of Posts Made by Public Facebook Pages for Patients with Endometriosis.

STUDY OBJECTIVE: To analyze the nature and accuracy of social media (Facebook) content related to endometriosis. DESIGN: Retrospective content analysis. SETTING: Social media platform, Facebook. PARTICIPANTS: Social media posts on Facebook endometriosis pages. INTERVENTIONS: A search of public Facebook pages was performed using the key word "endometriosis." Posts from the month-long study period were categorized and analyzed for accuracy. Two independent researchers used thematic evaluation to place posts into the following 11 categories: educational, emotional support, advocacy, discussion, events, humor, promotional, recipes, resources, surveys, and other. Posts categorized as educational were further subcategorized and reviewed. Each posted fact was cross-referenced in peer-reviewed scientific journals to determine whether the claim made was evidence-based. Engagement in a post was calculated by taking the sum of comments, shares, and reactions. MEASUREMENTS AND MAIN RESULTS: A total of 53 Facebook pages meeting inclusion criteria were identified and 1464 posts from the study period were evaluated. Emotional support posts comprised the largest category of posts (48%) followed by educational posts (21%). Within the educational category, the epidemiology and pathophysiology subcategory comprised the largest group (42.0%) followed by the symptom's subcategory (19.6%). Post category had an effect on the amount of post engagement (p-value <.001) with emotional posts generating 70% of the overall engagement. The subcategories of the educational posts demonstrated a similar effect on engagement (p-value <.001). Posts were more engaging if they contained epidemiology and pathophysiology information with 44% of all engagement of educational posts occurring within this subcategory. Educational posts were found to be 93.93% accurate. There was no correlation between post engagement and post information accuracy (p-value = .312). CONCLUSION: Facebook pages offer emotional support and education to people with endometriosis. Most information found in these Facebook pages is evidence-based. Clinicians should consider discussing the use of Facebook pages with their patients diagnosed with endometriosis.

Does closure of fascia, type, and location of trocar influence occurrence of port site hernias? A literature review.

BACKGROUND: Since the introduction of laparoscopic surgery, it has become more popular with many advantages over open surgery including faster recovery, shorter hospital stays, and decreased tissue trauma. Despite its benefits, laparoscopic surgery can result in its own unique complications, such as the formation of a trocar site hernia (TSH), which have been reported in approximately 0-1.0% of laparoscopic cases when using non-bladed trocars. METHODS: A literature review was performed from June 1990 to June 2019. PubMed was searched using the keywords "laparoscopic surgery," "trocar site hernia," and "port site hernia." Only articles in English were identified but not limited to the USA. RESULTS: The total number of patients in all articles was 18,533 with a mean follow-up period of 22.50 ± 1.76 months. The overall trocar site hernia rate was 0.104%. When comparing open vs. closed ports, there was no significant difference in the hernia incidence rate for 5-mm and 10-mm ports. When comparing bladed versus non-bladed trocars left open, there was a statistically significant difference with lower hernia incidence rates for non-bladed trocars over bladed trocars for 5-mm, 10-mm, and 12-mm ports. And when comparing trocar location from midline versus off-midline, there was a statistically significant higher TSH incidence in midline trocar locations. CONCLUSION: Results suggest that TSH rate is lower when using non-bladed trocars for any size of trocar. When comparing whether fascial closure had an effect, the 5-mm and 10-mm ports had no difference in incidence rates and leaving the fascia open can reduce operative time, risk of needlestick injuries, and overall procedural cost. In addition, trocars at midline locations resulted in higher TSH incidence rates. Future research is still needed to assess for other factors that may influence hernia formation and how it can be minimized.

Robotic-Assisted Total Laparoscopic Supralevator Pelvic Exenteration: Steps in Excising the Pelvic Viscera.

STUDY OBJECTIVE: To illustrate the key steps involved in performing a supralevator pelvic exenteration robotically. DESIGN: Presentation of the steps involved in excising the pelvic viscera during robotic-assisted supralevator pelvic exenteration. SETTING: Tertiary care academic center. PATIENTS: A patient undergoing pelvic exenteration for uterine leiomyosarcoma. INTERVENTIONS: Robotic total supralevator pelvic exenteration. MEASUREMENTS AND MAIN RESULTS: In this woman undergoing pelvic exenteration for uterine leiomyosarcoma, the paravesical and pararectal spaces are shown, along with important pelvic landmarks, such as the major vessels and the ureters. Once the pararectal and paravesical spaces are identified, the parametrium in between is resected. The posterior dissection is then performed along the filmy presacral space to the level of the coccyx and levator muscles. Anteriorly, the bladder is dissected along the space of Retzius, and the urethra is transected. Once the pelvic organs are separated, the specimen is removed, and reconstruction of the pelvic floor is performed. The ileal conduit is created from a segment of small bowel approximately 20 cm from the terminal ileum measuring 15 cm long. The 2 ureters are spatulated and attached to the ileal conduit, and a stoma is created. The descending segment of colon is brought up through a separate stoma site on the other side of the abdomen to create the colostomy. The total operating time, including reconstruction with the ileal conduit, was 480 minutes, and the estimated blood loss was 250 mL. CONCLUSION: Total pelvic exenteration can be safely performed robotically with appropriate understanding of the key steps and anatomic landmarks.

Mortality Rates in Benign Laparoscopic and Robotic Gynecologic Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: To review mortality rates in benign gynecologic minimally invasive laparoscopic and robotic surgery (MIS) and the rates associated with commonly performed MIS procedures. DATA SOURCES: An electronic-based search was performed on PubMed, Embase, Scopus, Web of Science, and Cochrane Database for articles published in the last 10 years in English, French, German, Spanish, and Italian. METHODS OF STUDY SELECTION: All MIS articles in benign gynecology reporting operative mortality (within 30 days) were reviewed. TABULATION, INTEGRATION, AND RESULTS: The articles identified through the aforementioned search criteria were independently evaluated by the first 2 authors. The Newcastle-Ottawa scale for observational studies and Cochrane risk-of-bias assessment tool for randomized controlled trials were used to assess the risk of bias. Meta-analysis was applied to calculate pooled mortality rates using the inverse-variance method. Twenty-one articles (124 216 patients) were included. Operative mortality from any benign MIS (laparoscopy and robotics) procedure was 1:6456 (95% confidence interval [CI]: 1:3946-1:10 562). Studies were then grouped based on the surgical procedure. The mortality rate for hysterectomy (119 721 patients), sacrocolpopexy, and adnexal surgery and diagnostic laparoscopy was 1:6814 (95% CI: 1:4119-1:11 275), 1:1246 (95% CI: 1:36-1:44 700), and 1:2245 (95% CI: 1:45-1:113 372), respectively. Eighteen articles reported operative mortality for laparoscopic surgery and 4 for robotic surgery. CONCLUSION: Operative mortality in benign minimally invasive gynecologic surgery is low, and mortality for laparoscopic and robotic approaches appears to be similar.

Is Hysterectomy a Risk Factor for Urinary Retention? A Retrospective Matched Case Control Study.

STUDY OBJECTIVE: Compare the rates of urinary retention in patients undergoing endoscopic hysterectomy with those of patients undergoing nonhysterectomy endoscopic gynecologic surgery. DESIGN: Retrospective case control study matched by operative time. SETTING: Academic medical center. PATIENTS: All patients undergoing endoscopic gynecologic surgeries between January 2013 and December 2018. INTERVENTIONS: Outpatient endoscopic gynecologic surgery. MEASUREMENTS AND MAIN RESULTS: A total of 200 endoscopic hysterectomy cases were matched to endoscopic nonhysterectomy gynecologic surgery controls in a 1:1 ratio. The differences in baseline and operative characteristics between the 2 groups included age (48.6 years vs 45.7 years, p = .04), perioperative opioid administration (morphine milligram equivalents, 11.6 mg vs 7.6 mg, p = .01), and estimated blood loss (64.1 mL vs 31.8 mL, p = .001). The rate of urinary retention in the hysterectomy group was double that in the nonhysterectomy group (26.5% vs 13%, p = .01). In the hysterectomy group, age, perioperative opioids, operative time, and estimated blood loss did not differ between those who failed and those who passed the void trial. In the nonhysterectomy group, only operative time was significantly longer in those who failed the void trial (108 minutes vs 94.3 minutes, p = .04). After adjusting for perioperative opioid use and operative time, the relative risk of urinary retention in the hysterectomy group was 2.3 (p = .002, 95% confidence interval, 1.38-3.98). CONCLUSION: Hysterectomy appears to be an independent and major factor contributing to postoperative urinary retention. When compared with nonhysterectomy gynecologic surgical controls with similar operative times, the rate of urinary retention in patients who underwent hysterectomy was doubled.

Hormone Replacement Therapy Prescription after Premature Surgical Menopause.

STUDY OBJECTIVE: To assess hormone replacement therapy (HRT) prescription pattern in patients undergoing premature surgical menopause on the basis of surgical indication. DESIGN: Retrospective cohort study. SETTING: Academic tertiary care center. PATIENTS: Surgically menopausal patients aged ≤45 years who underwent a minimally invasive hysterectomy with salpingo-oophorectomy. INTERVENTIONS: HRT prescription in the 6-week postoperative period. MEASUREMENTS AND MAIN RESULTS: A total of 63 patients met inclusion criteria. Of these, 52% (n = 33) were prescribed HRT in the 6-week postoperative period. Indications for surgical menopause included pelvic pain or endometriosis (31.7%), gynecologic malignancy (20.6%), BRCA gene mutation (17.4%), breast cancer (9.5%), Lynch syndrome (4.8%), and other (15.8%). In total, 80% of patients with pelvic pain, 25% with gynecologic malignancies, 45% with BRCA gene mutations, 33.3% with breast cancer, and 66.6% with Lynch syndrome used HRT postoperatively. In patients who used HRT postoperatively, 76% were offered preoperative HRT counseling. This is in contrast with those patients who did not use HRT postoperatively, of whom only 33% were offered HRT counseling (p <.001). Perioperative complications were not predictive of HRT use postoperatively. In patients who did not use HRT postoperatively, 13.3% used alternative nonhormonal therapy. CONCLUSION: In patients who underwent premature surgical menopause, 52% used HRT postoperatively. Patients with pelvic pain and Lynch syndrome were more likely to use HRT, whereas those with gynecologic or breast malignancies and BRCA gene mutations were less likely to use HRT. Preoperative HRT counseling was associated with postoperative HRT use.

Predictors of Postoperative Urinary Retention in Outpatient Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: To identify risk factors associated with postoperative urinary retention in patients undergoing outpatient minimally invasive hysterectomy. DESIGN: A retrospective cohort study. SETTING: An academic medical center. PATIENTS: All patients undergoing outpatient minimally invasive hysterectomy between January 2013 and July 2018 were considered for inclusion in the study. INTERVENTIONS: Outpatient laparoscopic, vaginal, or robotically assisted laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: Four hundred forty-four patients met the inclusion criteria. Postoperative urinary retention occurred in 94 patients, and 347 patients successfully passed their voiding trial in the postanesthesia care unit for a pass rate of 79%. Demographic characteristics were similar, except patients who experienced postoperative urinary retention were less likely to be menopausal (23.4% vs 34.7%, p = .038). Those with urinary retention received more perioperative opioids (morphine milligram equivalent of 14.4 mg vs11.2 mg, p = .012), had longer operative times (122.9 ± 55.6 vs 95.7 ± 42.3 minutes, p < .01), and experienced more blood loss (105.3 ± 134.4 vs 78.5 ± 86.8 mL, p = .025). The rate of urinary tract infections was similar. Logistic regression analysis showed that the route of hysterectomy and age were not associated with an increased risk for urinary retention, whereas a longer operative time and higher doses of perioperative opioid use were. CONCLUSION: In patients undergoing minimally invasive outpatient hysterectomy, a longer operative time and increased perioperative narcotic use increases the risk of postoperative urinary retention.

Voiding Trial in Office after Unsuccessful Voiding Trial in Postoperative Unit: How Many More Days Is Enough?

STUDY OBJECTIVE: To determine the incidence of a successful in-office voiding trial after minimally invasive hysterectomy. DESIGN: A retrospective cohort study. SETTING: A tertiary care academic center. PATIENTS: All patients undergoing minimally invasive hysterectomies (vaginal, laparoscopic, or robotic) from January 2013 to July 2018 who have an unsuccessful voiding trial in the postoperative unit. INTERVENTIONS: A voiding trial. MEASUREMENTS AND MAIN RESULTS: Of 558 outpatient hysterectomies (with same-day discharge) performed in the time period of interest, 174 patients were discharged home with a Foley catheter (31%). Of those patients, 37% presented for a repeat in-office voiding trial at less than 3 postoperative days, 31% presented at 3 postoperative days, and 31.6% presented at more than 3 postoperative days. Eighty-six percent of patients presenting for their first in-office voiding trial were successful at voiding. There were no differences noted in age, gravity, parity, the use of hormone replacement therapy, menopausal status, smoking, hypertension, or diabetes in patients who passed their first in-office voiding trial compared with those who did not. Vaginal hysterectomy was the most common route of hysterectomy and was performed in 57% of cases followed by robotic hysterectomy in 32%. There were no differences noted in the indication or route of hysterectomy between patients who pass or fail their first in-office voiding trial. At the time of hysterectomy, 47% of patients had concomitant female pelvic medicine and reconstructive surgery procedures performed (midurethral sling, periurethral injections, or colporrhaphy). The incidence of urinary tract infections in this patient cohort was 12%, but the incidence was significantly higher in patients who failed compared with those who passed their first in-office voiding trial (37.3% vs 7.3%, p <.001). After adjusting for age, hysterectomy route, and concomitant female pelvic medicine and reconstructive surgery procedures performed, the number of postoperative days at the time of the first in-office voiding trial does not predict success. CONCLUSION: The timing of the repeat in-office voiding trial in posthysterectomy patients who fail their initial voiding trial in the postanesthesia care unit was not related to success. The incidence of urinary tract infections is higher in patients who fail their repeat voiding trial because recatheterization and a longer duration of catherization are necessary.

Mortality Rates in Laparoscopic and Robotic Gynecologic Oncology Surgery: A Systemic Review and Meta-analysis.

OBJECTIVE: To review early operative mortality (<30 days) for minimally invasive surgery (MIS), laparoscopic and robotic, in gynecologic oncology. DATA SOURCES: An electronic-based search was performed in PubMed, Embase, Scopus, Web of Science, and Cochrane Database in the last 10 years. METHODS OF STUDY SELECTION: All MIS studies in gynecologic oncology reporting operative mortality from any cause (within 30 days) were included. Studies were excluded if mortality was not reported for MIS or included benign gynecology. TABULATION, INTEGRATION, AND RESULTS: Meta-analysis was applied to calculate pooled mortality rates using the inverse-variance method. The relative risks and their corresponding 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method. Sixty-five studies were included (39 183 patients) for an operative mortality of 1:381 (95% CI, 1:306-1:474). Studies were subselected and analyzed by procedures, malignancy, and surgical approach. Of 39 183 patients, 38 619 underwent any type of hysterectomy for a mortality of 1:379 (95% CI, 1:304-1:472). The mortality was 1:281 (95% CI, 1:169-1:469) for a laparoscopic approach and 1:476 (95% CI, 1:365-1:620) for a robotic approach. There were 3369 patients with early cervical cancer undergoing radical hysterectomy with a mortality of 1:2049 (95% CI, 1:356-1:11 832). There were 3501 patients with endometrial cancer undergoing hysterectomy with lymph node dissection with a mortality of 1:195 (95% CI, 1:109-1:349). There were 418 patients with ovarian cancer undergoing MIS procedures with a mortality of 1 in 685 (95% CI, 1:44-1:10971). Eleven studies with 4037 patients compared mortality of gynecologic oncology surgery of any type (laparoscopic [1:626] vs robotic [1:716] for a relative risk of 1.12 [95% CI, 0.35-3.49]). CONCLUSION: The overall operative mortality for minimally invasive surgery in gynecologic oncology is 1 in 381 (95% CI, 1:306-1:474). For patients with early cervical cancer, it is 1:2049 (95% CI, 1:356-1: 11832), for endometrial cancer with node dissection it is 1:195 (95% CI, 1:109-1:349), and for ovarian cancer it is 1 in 685 (95% CI, 1:44-1:10 971). There is no difference between the type of MIS approach for patients undergoing any type of gynecologic oncology surgery.

The Effect of Intramural Myomas Without an Intracavity Component on In Vitro Fertilization Outcomes in Single Fresh Blastocyst Transfer Cycles.

STUDY OBJECTIVE: To assess clinical pregnancy rate (CPR) and live birth rate (LBR) in the presence of non-cavity-deforming intramural myomas in single fresh blastocyst transfer cycles. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Academic fertility center. PATIENTS: A total of 929 fresh single blastocyst transfer cycles were included, 94 with only non-cavity-distorting intramural myomas and 764 without myomas. Cleavage embryo transfers were excluded to reduce bias based on embryo quality. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: CPR and LBR were assessed. There were no differences noted in gravidity, parity, or body mass index between patients with myomas and those without myomas. Women with myomas required higher doses of gonadotropins (mean, 2653 ± 404 IU vs 2350 ± 1368 IU; p = .04) than women without myomas. However, the total number of mature oocytes collected and the total number of blastocysts created were similar. CPR (47% vs 32%; p = .005) and LBR (37.8% vs 25.5%; p = .02) were lower in patients who had intramural myomas compared with those without myomas. CPR and LBR were significantly reduced in the presence of even 1 myoma (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33-0.83 and OR, 0.56; 95% CI, 0.35-0.92, respectively). In patients with myomas >1.5 cm, LBR was also significantly reduced, even after adjusting for age, smoking, quality of embryo transferred, antral follicle count, and dose of gonadotropins (OR, 0.53; 95% CI, 0.29-0.97). This LBR finding was not significant if all myomas were included (including those <1.5 cm in diameter), but CPR was still significantly reduced. CONCLUSION: Relatively small (>1.5 cm) non-cavity-distorting intramural myomas negatively affect CPR and LBR in in vitro fertilization cycles, even in the presence of only 1 myoma.

Do trained reproductive endocrinologists perform better than their trainees? Comparing clinical pregnancy rates and live birth rates after transfer of single fresh blastocysts.

PURPOSE: To compare clinical pregnancy rates and live birth rates of single blastocyst transfers performed by attending physicians or fellows in reproductive endocrinology and infertility program. METHODS: Retrospective study in an academic reproductive center. We evaluated 932 fresh single blastocyst transfer cycles performed by fellows in training (389 embryo transfers) and by attending physicians (543 embryo transfers). RESULTS: There were no differences in the baseline characteristics and IVF cycle parameters between patients who had transfers performed by fellows or attending physicians. Transfers performed by attending physicians or fellows resulted in similar CPR (46.5 vs. 42.9%, p = 0.28) and LBR (38.3 vs. 34.2%, p = 0.11). Multivariate logistic regression analysis showed that even after adjusting for possible confounders (age, gravity, parity, baseline FSH, antral follicle count, dose of gonadotropins, stimulation protocol, and quality of embryo transferred), CPR (OR 0.81, CI 0.62-1.07) and LBR (OR 0.79, CI 0.6-1.05) in the two groups were comparable. CONCLUSION: Clinical pregnancy rate and live birth rate after embryo transfer performed by attending staffs or fellows are comparable. This finding reassures fellowship programs that allowing fellows to perform embryo transfers does not compromise the outcome.