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.

Approach to radical hysterectomy for cervical cancer after the LACC trial and associated complications: a NSQIP study.

BACKGROUND: The Laparoscopic Approach to Cervical Cancer (LACC) study results revolutionized our understanding of the best surgical management for this disease. Following its publication, guidelines state that the standard and recommended approach for radical hysterectomy is with an open abdominal approach. Nevertheless, the impact of the LACC trial on real-world changes in the surgical approach to radical hysterectomy remains elusive. OBJECTIVE: We aimed to study the trends and routes of radical hysterectomies and to evaluate post-operative complication rates before and after the LACC trial (2018). STUDY DESIGN: The National Surgical Quality Improvement Program registry was used to examine radical hysterectomies performed for cervical cancer between 2012-2022. We excluded vaginal radical hysterectomies and simple hysterectomies. The primary outcome measures were the trends in route of surgery [minimally invasive surgery (MIS) vs. laparotomy] and surgical complications rate, stratified by periods before and after the publication of the LACC trial in 2018 (2012-2017 vs. 2019-2022). The secondary outcome measure was major complications associated specifically with the different routes of surgery. RESULTS: Of the 3,611 patients included, 2,080 (57.6%) underwent laparotomy and 1,531 (42.4%) underwent MIS radical hysterectomy. There was a significant increase in the MIS approach from 2012 to 2017 (45.6% MIS in 2012 to 75.3% MIS in 2017, p<.001), and a significant decrease in MIS from 2018 to 2022 (50.4% MIS in 2018 to 11.4% MIS in 2022, p<.001). The rate of minor complications was lower in the period before the LACC trial [317 (16.9%) vs. 288 (21.3%), p=.002]. Major complications rate was similar before and after the LACC trial [139 (7.4%) vs. 78 (5.8%), p=.26]. The rates of blood transfusions and superficial surgical site infections were lower in the period before the LACC trial [137 (7.3%) vs. 133 (9.8%), p=.012 and 20 (1.1%) vs. 53 (3.9%), p<.001, respectively]. In a comparison of MIS vs. laparotomy radical hysterectomy during the entire study period, patients in the MIS group had lower rates of minor complications [190 (12.4%) vs. 472 (22.7%), p<.001] and the rate of major complications was similar in both groups [100 (6.5%) in the MIS group vs. 139 (6.7%) in the laparotomy group, p=.89]. In a specific complications analysis, the rates of blood transfusion and superficial surgical site infections were lower in the MIS groups (2.4% vs. 12.7%, and 0.6% vs. 3.4%, p<.001 for both comparisons) and the rate of deep incisional surgical site infections was lower in the MIS group (0.2% vs. 0.7%, p=.048). In a multiple logistic regression analysis, the route of radical hysterectomy was not independently associated with occurrence of major complications [aOR 95% CI 1.02 (0.63-1.65)]. CONCLUSION: While the proportion of MIS radical hysterectomy decreased abruptly following the LACC trial, there was no change in the rate of major post-operative complications. In addition, hysterectomy route was not associated with major post-operative complications.

Surgical treatment of colorectal endometriosis: an updated review.

PURPOSE OF REVIEW: This review aims to summarize recent literature on the surgical treatment of colorectal endometriosis. RECENT FINDINGS: The last decade has seen a surge in the number of studies on bowel endometriosis, with a focus on preoperative evaluation, perioperative management, surgical approach, and surgical outcomes. Many of these studies have originated from large-volume referral centers with varying surgical approaches and philosophies. Colorectal surgery for endometriosis seems to have a positive impact on patient symptoms, quality of life, and fertility. However, these benefits must be weighed against a significant risk of postoperative complications and the potential for long-term bowel or bladder dysfunction, especially for more radical procedures involving the lower rectum. Importantly, most studies regarding surgical technique and outcomes have been limited by their observational design. SUMMARY: The surgical management of bowel endometriosis is complex and should be approached by a multidisciplinary team. Methodical preoperative evaluation, including appropriate imaging, is vital for surgical planning and patient counseling. The decision to perform a more conservative or radical excision is nuanced and remains an area of controversy. High quality studies in the form of multicenter randomized controlled trials are needed before clear recommendations can be made.

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.

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.

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.

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.

E. faecalis Sepsis and Asherman's Syndrome as Complications of Sonata System Transcervical Fibroid Ablation.

The Sonata System is a minimally invasive, ultrasound-guided transcervical fibroid ablation procedure for the management of symptomatic uterine fibroids. Since its approval by the US Food and Drug Administration in 2018, this procedure has demonstrated an excellent safety profile and postprocedure satisfaction rate. We present the case of a patient treated with Sonata, who subsequently developed bacterial sepsis and Asherman's syndrome-serious complications with long-term sequelae and implications for fertility. A nulligravid woman in her 40s presented in the outpatient setting with dysmenorrhea and bulk symptoms, with imaging showing an enlarged myomatous uterus compressing the urinary bladder. She desired minimally invasive, fertility-preserving management and underwent the Sonata procedure at an outside hospital. On postoperative day 3, she was admitted to our institution with abdominal pain, fever, tachycardia, and Enterococcus faecalis bacteremia. Despite 6 days of culture-directed antibiotic therapy, the patient remained septic with worsening symptoms and imaging findings and with persistent bacteremia. On hospital day 7, the patient underwent laparoscopic myomectomy and excision of hemorrhagic, infected myometrium. She recovered appropriately after surgery and was discharged home on hospital day 11 to continue 2 weeks of intravenous antibiotics. Nine months after myomectomy, the patient was diagnosed as having Asherman's syndrome. She subsequently had an early pregnancy loss with retained products of conception, requiring hysteroscopic lysis of adhesions and dilation and curettage. Ultimately, careful patient selection is critical for the optimal application of the Sonata procedure. Limiting the extent of fibroid necrosis after treatment is a reasonable goal to minimize the risk of secondary bacterial infection and adhesiogenesis as procedural sequelae.

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.

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.

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.

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.

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.

Postoperative Urinary Retention after Benign Gynecologic Surgery with a Liberal versus Strict Voiding Protocol.

STUDY OBJECTIVE: Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void before discharge). The primary objective of this study was to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol with more strict voiding protocols. Secondary outcomes included length of hospital stay (LOS) and urinary tract infection (UTI). DESIGN: Retrospective cohort study. SETTING: Quaternary-care academic hospital in the United States. PATIENTS: Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n = 652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded. INTERVENTIONS: Hysterectomy, myomectomy. MEASUREMENTS AND MAIN RESULTS: POUR, defined as the need for recatheterization within 24 hours of catheter removal, along with UTI and LOS were compared between liberal and strict voiding protocols. A subgroup analysis was performed for those undergoing minimally invasive surgery (MIS). A total of 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) women with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different between the groups (2.6% liberal vs. 4.9% strict, p = .14). UTIs also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p = .86). Similar results were seen specifically among those who underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p = .17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p = .28). The median LOS (interquartile range) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall [interquartile range 15 hours], 9 [4] hours liberal vs. 36 [34] hours strict, p <.01). Among those discharged the same day (72.6% of the MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean [standard deviation] 9.4 [2.5] hours vs. 10.6 [35] hours, p <.01). Postoperative complications occurred less frequently in those with MIS procedures (11.8% in MIS vs. 20.2% in laparotomies, p <.01) and those with liberal voiding protocols (11.2% liberal vs. 16.9% strict p = .04). CONCLUSION: Overall, POUR occurs infrequently after major benign gynecologic surgery and does not differ between those with liberal and strict voiding protocols. Our data suggest that same-day discharge after MIS hysterectomy and myomectomy without a requirement to void does not increase the risk of POUR and shortens LOS. Eliminating voiding protocols after these procedures may facilitate greater efficiency in the postanesthesia recovery unit and may contribute to enhanced recovery after surgery protocols.

Risk of Urinary Tract Infection Symptoms after Posthysterectomy Cystoscopy with 50% Dextrose as Compared with Saline Cystoscopy with Indigo Carmine.

STUDY OBJECTIVE: Compare odds of postoperative urinary symptoms in women who had cystoscopy after benign laparoscopic hysterectomy with 50% dextrose and with normal saline solution with intravenous indigo carmine. DESIGN: Retrospective cohort study. SETTING: Two tertiary care centers. PATIENTS: All women who underwent benign laparoscopic hysterectomy and intraoperative cystoscopy carried out by a single surgeon. INTERVENTIONS: We compared postoperative urinary symptoms in patients who received 50% dextrose cystoscopy fluid (January 2016-June 2017) with those who received saline cystoscopy with intravenous indigo carmine (November 2013-April 2014). MEASUREMENTS AND MAIN RESULTS: A total of 96 patients had cystoscopy with 50% dextrose and 104 with normal saline with intravenous indigo carmine. Differences in baseline characteristics of the two groups of participants mainly reflected institutional population diversity: age (45.2 vs 41.9, p = .01), body mass index (26.9 vs 33.4, p <.01), race, current smoking status (1% vs 7.8%, p = .04), diabetes (2.1% vs 11.5%, p = .01), history of abdominal surgery (53.1% vs 74%, p <.01), hysterectomy type, receipt of intraoperative antibiotics (92.7% vs 100%, p <.01), recatheterization (10.4% vs 0%, p <.01), and removal of catheter on postoperative day 0 (66.7% vs 12.5%, p <.01). Urinary symptoms were similar for 50% dextrose and saline (12.5% vs 7.7%, p = .19). After adjusting for age, body mass index, race, diabetes, and day of catheter removal, there remained no significant differences in urinary symptoms between the groups (odds ratio 3.19 [95% confidence interval, 0.82-12.35], p = .09). One immediate bladder injury was detected in the saline group and 1 delayed lower urinary tract injury in the 50% dextrose group. CONCLUSION: Overall, most women experienced no urinary symptoms after benign laparoscopic hysterectomy. There were no significant differences in postoperative urinary symptoms or empiric treatment of urinary tract infection after the use of 50% dextrose cystoscopy fluid as compared with normal saline. The previous finding of increased odds of urinary tract infection after dextrose cystoscopy may be due to use in a high-risk population.

Gynecologic surgery tracking in obstetrics and gynecology residency.

PURPOSE OF REVIEW: This review aims to describe the influence of changes in obstetrics and gynecology on residency training and how tracking may help address emerging concerns around quality and safety in gynecologic surgery. RECENT FINDINGS: As has been shown in a variety of other surgical fields, recent evidence confirms that surgeries with higher volume gynecologists are associated with fewer complications, decreased cost, and an increase in use of minimally invasive surgery. Attending physicians and residents feel graduating obstetrics and gynecology (OB/GYN) trainees are unprepared to perform major surgery independently. Tracking has demonstrated tremendous success in general surgery, enriching trainee careers, allowing for increased operative and clinical experiences, enhancing autonomy, and improving mentorship, all while achieving equivalent or improved milestone achievement, case numbers, and board certification. A majority of medical students, residents, and OB/GYN residency program directors support tracking in OB/GYN. Currently, a single OB/GYN program provides tracking in the United States, with measurable success similar to that seen in general surgery. SUMMARY: Enhanced surgical volume results in better outcomes in gynecologic surgery, but current training models are insufficient to meet these volume demands. Tracking provides an attractive solution to create a more appropriate practicing model for physicians in women's health.