Validation of the Canadian Institute for Health Information Diagnostic Codes for Benign Gynaecologic Surgery.

We investigated the validity of the 10th Revision Canadian modification of International Statistical Classification of Disease and Related Health Problems (ICD-10-CA) diagnostic codes for surgery for benign gynaecologic conditions in the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD), the main source of routinely collected data in Canada. Reabstracted data from patient charts was compared to ICD-10-CA codes and measures of validity were calculated with 95% confidence intervals. A total of 1068 procedures were identified. More objective, structural diagnoses (fibroids, prolapse) had higher sensitivity and near-perfect Kappa coefficients, while more subjective, symptomatic diagnoses (abnormal uterine bleeding, pelvic pain) had lower sensitivity and moderate-substantial Kappa coefficients. Specificity, positive predictive values, and negative predictive values were generally high for all diagnoses. These findings support the use of CIHI-DAD data for gynaecologic research.

The learning curve of introduced robotic-assisted hysterectomy versus skilled laparoscopic hysterectomy for benign gynecologic diseases.

AIM: This study aimed to compare introduced robotic-assisted hysterectomy (RAH) and skilled total laparoscopic hysterectomy (TLH) for the treatment of benign gynecological diseases. METHODS: Patients who underwent RAH or TLH by two surgeons at the Tottori University Hospital between January 2018 and May 2022 were included in this retrospective study. Inclusion criteria were patients with 100-300 g of uterine weight. The exclusion criteria were patients with stage IV endometriosis. Mean operative time and learning curve were compared among the first-half RAH, second-half RAH, and TLH groups. RESULTS: There were 40 eligible cases (first-half RAH: 20 cases, second-half RAH: 20 cases) in the RAH group and 44 cases in the TLH group. The total operative time (TOT) of the second half of RAH was significantly shorter than that of the first half of RAH (p = 0.021) and was comparable to that of the TLH group. The operative time (OT) of the second half of RAH was shorter than that of TLH (p = 0.023). The preparation time of TLH was shorter than that of the RAH group (p < 0.01). The learning curve of the TOT in RAH crossed that of TLH on the 31st case of RAH. In contrast, both curves of the OT crossed on the 11th case of RAH. CONCLUSION: The TOT of the introduced RAH was equivalent to that of skilled TLH in approximately 30 cases since the first RAH. Furthermore, the OT of RAH was comparable to that of TLH in approximately 10 cases of surgery since the first RAH.

Robotic single-port hysterectomy versus robotic multisite hysterectomy in benign gynecologic diseases: A retrospective comparison of clinical and surgical outcomes.

BACKGROUND: This study aimed to compare clinical and surgical outcomes of robotic single-port hysterectomy (RSPH) using the da Vinci® SP surgical system and robotic multisite hysterectomy (RMSH) with the da Vinci Xi system in benign gynecologic disease. METHODS: The retrospective study included 134 patients who underwent RSPH or RMSH between November 2019 and December 2020. Total operation time, amount of blood loss, and the change in hemoglobin (Hb) after surgery and the weight of the removed uteri were also measured. Data on complications such as post-operative fever and length of hospitalization were also compared and analyzed. RESULTS: There was no significant difference in the total operation time between the two groups, although the operation time was slightly longer in the RSPH group. Results in the RSPH group were superior to the RMSH group in docking time and wound incision time (1.67 ± 0.79 vs. 5.46 ± 2.25 min, p-value <0.01; 6.48 ± 4.29 vs. 9.10 ± 4.64 min, p-value <0.01, respectively). On the other hand, wound suture time took longer in the RSPH group (18.12 ± 5.66 vs. 10.69 ± 3.18 min, p-value <0.01). The weights of the removed specimens were higher in the RMSH group (302.64 ± 190.56 vs. 369.24 ± 181.70 g, p-value <0.04). The amount of blood loss during surgery and the difference in hemoglobin (Hb) before and after surgery were less in the RSPH group (97.39 ± 113.79 vs. 224.93 ± 152.29 mL, p-value <0.01, 1.51 ± 1.08 vs. 2.54 ± 1.08 g/dL, p-value <0.01). When considering the weight difference as a correction between the two surgical groups (because there were many heavier samples in the RMSH group), the blood loss of the RSPH group was also less than that of the RMSH group by 115.95 ± 23.78 mL (p-value <0.01). CONCLUSIONS: On the basis of our data, the robotic hysterectomy using the da Vinci SP surgical system might be feasible and safe, even if the hysterectomy is complex, and comparable to robotic multisite surgery by the da Vinci Xi system.

Impact of the COVID-19 pandemic on surgery for benign diseases in gynecology: A nationwide survey by the Japan Society of Obstetrics and Gynecology.

AIM: This study aimed to clarify the impact of coronavirus disease 2019 on gynecology practice in Japan, in particular, on surgeries for benign gynecological diseases. METHODS: An online questionnaire was distributed to 966 facilities in Japan, including core facilities, facilities participating in perinatal and gynecologic oncology registries, and facilities certified for training by the Japanese Society of Obstetrics and Gynecology Endoscopy. The number of surgeries performed was compared between 2019 and 2020, when the novel coronavirus disease was prevalent. RESULTS: Five hundred and eighty (58.2%) facilities responded. The total number of surgeries decreased from 129 648 in 2019 to 118 565 in 2020, by 8.5%, for all surgical procedures. However, there was a clear increase in the number of robotic surgeries performed in 2020 compared to that in 2019 for all populations. The number of total hysterectomies decreased markedly from 15 385 in 2019 to 12 531 in 2020, a fall of 10.1%. CONCLUSIONS: The number of surgeries for benign gynecological diseases decreased by 8.5% in 2020 compared to that in 2019. This value is among the lowest in the world.

Historical perspective of vaginal hysterectomy: the resilience of art and evidence-based medicine in the age of technology.

OBJECTIVE: The aim of this study was to describe, from a historical perspective, the relevance, resilience and outcomes of vaginal hysterectomy (VH) in gynecology in the age of technological scenario. METHODS: The authors searched records from January 2011 to January 2021 on the following databases: Medline, EMBASE, and CENTRAL (The Cochrane Library) for combinations of the terms "vaginal hysterectomy," "outcomes" AND "history"; and before that period, if the search had historical relevance. INCLUSION CRITERIA: randomized clinical trials; hysterectomy performed for benign gynecological conditions; and VH outcomes compared with Abdominal Hysterectomy (AH), Laparoscopic Hysterectomy (LH) or Robotic Hysterectomy (RH). RESULTS: The VH combines sequences of reproducible techniques which have been developed over the years to safely and effectively overcome the limitations of difficult cases of vaginal extirpation from the uterus. CONCLUSION: The authors support endoscopic surgical approaches in complex surgery for benign indications, urogynecology, and gynecologic oncology when appropriate. However, what makes the gynecological surgeon different from the general surgeon is the vaginal access. It is essential to continue to train residents in vaginal surgical skills and provide safe and cost-effective patient care. The art of technology is the resilience of keeping only the patient at the center of innovation.

Predictive factors of return to work after hysterectomy: a retrospective study.

PURPOSE: Although hysterectomy is one of the most frequently performed gynaecological surgeries, there is a dearth of evidence on perioperative care. The aim of the current study was to identify sociodemographic, surgical-related and work-related predictors of recovery following different approaches of hysterectomy. METHODS: Eligible patients for this retrospective cohort study were women who underwent vaginal, abdominal or laparoscopic hysterectomy for both benign and malignant gynaecological disease in 2014 in Máxima Medical Centre in the Netherlands. The main outcome measure was full return to work (RTW). Data were collected using a patient survey. Potential prognostic factors for time to RTW were examined in univariate Cox regression analyses. The strongest prognostic factors were combined in a multivariable model. RESULTS: In total 83 women were included. Median time to full return to work was 8 weeks (interquartile range [IQR] 6-12). The multivariable analysis showed that higher age (hazard ratio [HR] 1.053, 95% confidence interval [CI] 1.012-1.095) and same day removal of indwelling catheter (HR 0.122, 95% CI 0.028-0.539) were predictors of shorter duration until full RTW after hysterectomy. CONCLUSIONS: This study provided insight in the predictors of recovery after hysterectomy. By identifying patient specific factors, pre-operative counselling can be individualized, changes can be made in perioperative care and effective interventions can be designed to target those factors.

Outcomes of robotic and laparoscopic surgery for benign gynaecological disease: a systematic review.

Benign gynaecological diseases are usually treated with minimally invasive approaches. Robotic surgery seems an alternative to laparoscopic surgery. No definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases. In this scenario, we performed a systematic review in order to assess the advantages and disadvantages of laparoscopy versus robotic surgery and conclude whether laparoscopy should be replaced by robotic surgery for the treatment of benign gynaecological conditions, following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Statement. We included 64 studies: no significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeons, while it is more expensive and characterised by longer operative time. In conclusion, current evidence indicates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic surgeries for benign gynaecological diseases. Impact statementWhat is already known on this subject? Benign gynaecological diseases are usually treated with minimally invasive approaches. Nevertheless, no definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases.What do the results of this study add? No significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeon, while it is more expensive and characterised by longer operative time.What are the implications of these findings for clinical practice and/or further research? Robotic surgery should not replace laparoscopy for the treatment of benign gynaecological conditions; in addition, gynaecologic surgeon should offer robotic surgery for benign diseases only after a proper counselling and a balanced decision-making process involving the patient.

Impact of past surgical history on perioperative outcomes in gynecologic surgery.

OBJECTIVE: We sought to determine if past surgical history is associated with perioperative outcomes for patients undergoing hysterectomy. METHODS: A retrospective cohort study was conducted at a single, tertiary, academic health system of women who underwent hysterectomy from May 2016 - May 2017. Past surgical history (PSH) involving any abdominal or pelvic surgery, baseline demographics and perioperative outcomes were collected. For purposes of analyses, PSH was defined using three algorithms: 1) any prior abdominopelvic surgery, 2) having had abdominopelvic surgeries likely to cause adhesive disease, 3) anatomic location of prior PSH (none; pelvic; abdominal; or abdominal+pelvic). Descriptive, bivariable and multivariable analyses were performed. RESULTS: 1256 patients underwent hysterectomy. In adjusted analyses, PSH defined by any prior abdominopelvic surgery was associated with length of stay (LOS) (2.1 days (95%CI 1.9, 2.2) vs. 1.8 (95%CI 1.6, 2.0), (p=0.02)). PSH of procedures likely to cause adhesive disease was associated with greater estimated blood loss (EBL) (243.2 mL (95%CI 208.1, 278.3) vs. 189.0 (95%CI 1734, 204.7), (p=0.01)), longer LOS (2.5 days (95%CI 2.2, 2.8) vs. 1.9 (95%CI 1.7, 2.0), (p<0.01)), and more readmissions (OR 2.4, 95%CI 1.3, 4.5) (p<0.01). PSH defined by anatomic location revealed a trend (p=0.07) towards greater EBL in those with prior pelvic or abdominal+pelvic surgery compared to none or abdominal only, whereas LOS, readmissions and operative times did not differ. Increased total number of prior open surgeries was associated with operative time (p<0.0001), EBL (p<0.0001), hospital LOS (p<0.0001) and readmission (p=0.026). CONCLUSIONS: Prior abdominopelvic surgery is associated with worse perioperative outcome measures in women undergoing hysterectomy.

National trends and outcomes of morbidly obese women who underwent inpatient hysterectomy for benign gynecological disease in the USA.

INTRODUCTION: The US population has witnessed an epidemic expansion of obesity in the past several decades; nearly 50% of the population is projected to be obese by 2030 and 25% morbidly obese. This study examined trends, characteristics and outcomes of morbidly obese women who underwent benign hysterectomy. MATERIAL AND METHODS: This is a population-based retrospective observational study querying the National Inpatient Sample from January 2012 to September 2015. The study population included 509 395 women who underwent hysterectomy for benign gynecological disease: 430 865 (84.6%) non-obese women, 50 435 (9.9%) women with class I-II obesity and 28 095 (5.5%) women with class III obesity. Main outcome measures were (i) cohort-level trends of obesity and perioperative complications assessed by piecewise linear regression with log transformation and (ii) patient-level perioperative complication risk by body habitus assessed with a generalized estimating equation after using a multiple-group generalized boosted model. RESULTS: The rate of class III obesity increased by 40.4%, higher than the rate of class I-II obesity (22.2%) (both, P < .001). In parallel, cohort-level rates of perioperative complication and prolonged hospitalization for ≥7 days increased by 19.4% and 54%, respectively (P < .001). In a weighted model, class I-II obesity (16.4% vs 14.6%, odds ratio 1.15, 95% confidence interval 1.08-1.21) and class III obesity (19.2% vs 14.6%, odds ratio 1.39, 95% confidence interval 1.28-1.51) had a significantly increased risk of perioperative complications compared with non-obesity. Larger body habitus was associated with higher total charge (median, $35 180, $36 094 and $39 382; all values cited in US dollars) and prolonged admission rate for ≥7 days (2.9%, 3.1% and 3.9%) (both, P < .001). CONCLUSIONS: The rate of obesity, particularly morbid obesity, has significantly increased among women undergoing benign hysterectomy in the USA. Morbidly obese women had adverse perioperative outcomes, and the increasing number of morbidly obese women resulted in both an increased perioperative morbidity and total charges as a cohort. National and society-based approaches are necessary to reduce the obesity rate and hysterectomy morbidity.

Decreasing trend and changing indications of hysterectomy in Finland.

INTRODUCTION: Hysterectomy has been one of the most common surgical procedures in women in Finland. We studied the population-based trends of hysterectomy and its indications from 1986 to 2017. MATERIAL AND METHODS: A retrospective population-based cohort was created from the Care Register for Health Care by identifying women who had a hysterectomy from 1986 to 2017 and calculating the number of women from the Digital and Population Data Services Agency. We estimated the number and incidence of hysterectomy by period and age as well as by indication. We considered the primary diagnosis at the time of surgery as the indication of hysterectomy. RESULTS: The number of hysterectomies increased from 7492 procedures in 1986 to 12 404 procedures in 1998, and reduced substantially after that to 5971 procedures in 2017, the turning point being in 1999. The incidence rate of hysterectomy has decreased on average by 2.5% annually from 432.6 per 100 000 women in 1998-2001 to 224.5 per 100 000 women in 2014-2017. The median age at the time of hysterectomy has increased from 51 years in 1998-2001 to 55 years in 2014-2017. The cumulative burden of hysterectomy by age of 60 years has nearly halved from the first 4-year period (23%) to the last (12%). After 2010, the most common indication has been genital prolapse and incontinence, whereas earlier it was uterine fibroids. CONCLUSIONS: The number and incidence of hysterectomies have fluctuated during the observation period 1986-2017 and decreased considerably during the past 17 years in Finland. This is probably a result of the availability of hormonal and other conservative treatment options for bleeding disorders and uterine fibroids. As hysterectomy practically removes the risk for endometrial cancer, the change in hysterectomy incidence over time emphasizes the importance of correcting endometrial cancer incidence according to hysterectomy incidence.

Impact of Surgical Wait Time to Hysterectomy for Benign Gynecologic Disease.

STUDY OBJECTIVE: To determine the impact of surgical wait time on healthcare use and surgical outcomes for patients undergoing hysterectomy for benign gynecologic indications. DESIGN: Retrospective cohort study. SETTING: Urban, academic tertiary care center. PATIENTS: Patients who underwent hysterectomy for benign disease between 2012 and 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were categorized into 2 groups, dichotomized by surgical wait times >30 days or ≤30 days. Healthcare use was measured by the number of discrete patient interactions with the healthcare system through phone calls, secure electronic messaging, and office and emergency room visits. Univariate and multivariable logistic regression models were performed to assess the association between surgical wait time and healthcare use and perioperative outcomes while controlling for confounders. A total of 277 patients were included in our analysis: 106 (38.3%) had surgical wait times >30 days (median 47 days, range 24-68 days), and 171 (67.1%) had surgical wait times ≤30 days (median 19 days; range 12-26 days). The groups did not differ by age, insurance status, substance use, or comorbid conditions. Patients in the group with surgical wait times >30 days were more likely to have increased healthcare use (69 of 106, 65% vs 43 of 171, 25%; odds ratio 5.55; 95% confidence interval, 3.27-9.41). There were no differences in intraoperative complications (9 of 106, 8% vs 19 of 171, 11%; p = .482) or postoperative complications (28 of 106, 26% vs 32 of 171, 19%; p = .13) between the groups; however, after controlling for potential confounders, patients with surgical wait times >30 days were 3.22 times more likely to be readmitted than patients with surgical wait times ≤30 days (95% confidence interval, 1.27-8.19). CONCLUSION: A surgical wait time >30 days in patients undergoing a hysterectomy for benign disease is associated with increased healthcare use in the interim. Although patients who experience longer surgical wait times do not experience worse surgical outcomes, they may be at higher risk for readmission after surgery. Targeted interventions to optimize perioperative coordination of care for patients undergoing a hysterectomy for benign disease, especially those within vulnerable populations, are needed to improve quality of care, decrease any redundant or inefficient healthcare use, and reduce any unnecessary delays.

Risk of Upper-body Adverse Events in Robot-assisted Total Laparoscopic Hysterectomy for Benign Gynecologic Disease.

STUDY OBJECTIVE: Recent studies suggest that prolonged Trendelenburg positioning during robot-assisted total laparoscopic hysterectomy (RA-TLH) may lead to fluid shifts and pulmonary, airway, head and neck, and cranial complications in the upper body. This study examined the upper-body complications during RA-TLH for benign gynecologic disease. DESIGN: Population-based retrospective study. SETTING: The National Inpatient Sample. PATIENTS: A total of 771 412 women who had total hysterectomy for benign gynecologic disease from October 2008 to September 2015, including 661 284 women who had total abdominal hysterectomy (TAH), 51 544 women who had traditional TLH, and 58 584 women who had RA-TLH. INTERVENTIONS: A multiple-group generalized boosted model to balance the measured baseline covariates across the 3 hysterectomy groups and a generalized estimating equation model to assess the effect size of complication risk (overall and upper-body complications). MEASUREMENTS AND MAIN RESULTS: Women in the RA-TLH group were more likely to be older, white, and have a higher comorbidity index (all, p <.001). The overall rate of upper-body complications was 4.6% across the 3 groups. RA-TLH was not associated with increased risk of upper-body complications compared with traditional TLH (odds ratio [OR] 1.06; 95% confidence interval [CI], 0.90-1.26) or TAH (OR 0.98; 95% CI, 0.87-1.11). In contrast, RA-TLH was associated with decreased risk of overall perioperative complications compared with TAH (12.0% vs 18.6%; OR 0.64; 95% CI, 0.59-0.70; p <.001). RA-TLH and traditional TLH had similar risk of overall perioperative complications (12.0% vs 13.1%; OR 0.91; 95% CI, 0.8-1.02; p = .099). Women who developed upper-body complications had a higher perioperative mortality rate (0.4% vs <0.01%; OR 79.1; 95% CI, 36.0-174). The highest rates of complications (62.5%) were observed in morbidly obese women aged 70-79 with a comorbidity index of ≥4. CONCLUSION: In hysterectomy for benign gynecologic disease, RA-TLH was not associated with an increased risk of upper-body complications compared with TAH or traditional TLH. However, older age and higher comorbidity are key risk factors that increase the risk of upper-body complications which carry a disproportionally high mortality rate.

Meta-analysis of Laparoendoscopic Single-site and Vaginal Natural Orifice Transluminal Endoscopic Hysterectomy Compared with Multiport Hysterectomy: Real Benefits or Diminishing Returns?

OBJECTIVE: Because minimally invasive hysterectomy has become increasingly performed by gynecologic surgeons, strategies to further improve outcomes have emerged, including innovations in surgical approach. We sought to evaluate the intraoperative and perioperative outcomes and success rates of laparoendoscopic single-site surgery (LESS) and vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy in comparison with those of conventional multiport laparoscopic (MPL) hysterectomy. DATA SOURCES: A librarian-led search of PubMed, Scopus, CINAHL, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials was performed for case-control, retrospective cohort, and randomized controlled trials through May 2020. METHODS OF STUDY SELECTION: The inclusion criterion was publications comparing LESS or vNOTES hysterectomy with conventional MPL hysterectomy for the management of benign or malignant gynecologic disease. Four authors reviewed the abstracts and selected studies for full-text review. The manuscripts were reviewed, separately, by 2 authors for final inclusion and assessment of bias using either the risk-of-bias assessment tool or the Newcastle-Ottawa scale. Any disagreement was resolved by discussion with, or arbitration by, a third reviewer. The titles of 2259 articles were screened, and 108 articles were chosen for abstract screening. Full-text screening resulted in 29 studies eligible for inclusion. TABULATION, INTEGRATION, AND RESULTS: Extracted data were placed into REDCap (Vanderbilt University, Nashville, TN), and MPL hysterectomy was compared with single-port hysterectomy using meta-analysis models. The outcomes included estimated blood loss (EBL); operative (OP) time; transfusion; length of hospital stay (LOS); conversion to laparotomy; visual analog scale pain scores at 12 hours, 24 hours, and 48 hours; any complications; and 7 subcategories of complications. Random-effects models were built for continuous outcomes and binary outcomes, and the results are reported as standardized mean difference (SMD) or odds ratio (OR) and their corresponding 95% confidence intervals, respectively. Meta-analysis could not be performed for vNOTES vs MPL, given that only 3 studies met the eligibility criteria. When LESS and MPL were compared, there was a shorter OP time for MPL (SMD = -0.2577, p <.001) and lower rate of transfusion (OR = 0.1697, p <.001), without a significant difference in EBL (SMD = -0.0243, p = .689). There was a nonsignificant trend toward higher risk of conversion to laparotomy in the MPL group (OR = 2.5871, p = .078). Pain scores were no different 12 or 24 hours postoperatively but were significantly higher at 48 hours postoperatively (SMD = 0.1861, p = .035) in the MPL group. There were no differences in overall or individual complications between the LESS and MPL groups. In the vNOTES comparison, 2 studies demonstrated shorter OP times, with reduced LOS and no difference in complications. CONCLUSION: In this meta-analysis, we identified that LESS hysterectomy has comparable and low overall rates of complications and conversion to laparotomy compared with MPL. Notably, the OP time seems longer, and the pain scores at 48 hours may be lower with LESS hysterectomy than with MPL hysterectomy. Limited data suggest that vNOTES hysterectomy may have shorter OP times and improved EBL, transfusion rates, LOS, and pain scores compared with MPL hysterectomy, but further study is needed. There remains a deficit in high-quality data to understand the differences in cosmesis among these surgical approaches. The quality of data for this analysis seems to be low to moderate.

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.

Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper.

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.

Evaluate construct validity of the Revised American Pain Society Patient Outcome Questionnaire in gynecological postoperative patients using confirmatory factor analysis.

BACKGROUND: The Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) evaluates the patient-reported quality of pain management in adults. A validated APS-POQ-R is pivotal to guide effective pain management with better patient satisfaction. Previous studies revealed that subscales of "patients' perception of pain management" were unstable cross-culturally. This study aims to evaluate the construct validity of the APS-POQ-R in gynecological postoperative patients with a multi-cultural background using confirmatory factor analysis to allow comparisons among different a priori models at the latent factor level. METHODS: Patients aged 18 years old or above and who were scheduled for gynecology surgery were selected. Three different models with a combination of latent factors were based on a priori hypotheses from previous studies. The root-mean-squared error of approximation, comparative fit index, Tucker-Lewis Index, Chi-squared test, and change in Chi-squared statistic given a change in degrees of freedom between models were used to assess the model fit to the present data. RESULTS: A total of 302 patients completed the questionnaire. The five-factor model which was based on Gordon's study has an acceptable fit for the data and was superior when compared to the one-factor baseline model. Although the four-factor model, which originated from Botti's study, also demonstrates a good model fit, the "perception of care" construct was excluded in this model. The "perception of care" construct is conceptually important as patient-centered care has become the focus of quality improvement of pain service. CONCLUSIONS: The APS-POQ-R is easy to administer and is useful for quality evaluation in postoperative pain management. The present study demonstrates that a five-factor structure of the APS-POQ-R is the best fitting model in our patient sample. The results of this study provide further evidence to support the use of APS-POQ-R as a measurement tool for pain management evaluation in acute postoperative patients with a multi-cultural background.

Ultrasound-guided de-roofing of epithelialised tunnels of hidradenitis suppurativa.

Hidradenitis Suppurativa is a chronic inflammatory disease manifesting in painful nodules, abscesses and malodorous draining tunnels with a pre-disposition to flexural regions of skin. Traditional surgical interventions include excision of clinically visible lesions and in severe cases - excision down to fascia of entire anatomical regions (axilla, groin) and repair with split-thickness grafting or skin substitutes. However, such techniques are plagued by long healing times (up to several months), extensive tissue loss and high recurrence rates given that a large proportion of disease is not clinically visible. Deroofing is a tissue-saving surgical technique, ideal for Hurley Stage 2 disease, which when combined with bedside pre-operative sonography can allow for the accurate identification and removal of occult dermal tunnels whilst minimising the risks of pain, infection, minimising healing times and can be safely conducted in the setting of immunomodulatory therapy.

Correlation between the number of laparoscopy-qualified gynecologists and the proportion of laparoscopic surgeries for benign gynecological diseases in Japan: An ecological study.

AIM: We aimed to evaluate regional disparities in the proportion of the three main laparoscopic surgeries for benign gynecological diseases among 47 prefectures in Japan and their correlation with the number of laparoscopy-qualified gynecologists per population. METHODS: In this retrospective ecological study, we collected the data of patients from 47 prefectures in 2017 using "The National Database of Health Insurance Claims and Specific Health Checkups of Japan" Open Data from the Ministry of Health, Labor and Welfare in Japan. The primary outcome of the study was the proportion of laparoscopic surgeries conducted for benign gynecologic diseases (hysterectomy, myomectomy and surgery for the benign ovarian diseases). The main exposure was the number of laparoscopy-qualified gynecologists per 100 000 females. RESULTS: The average proportion of laparoscopic hysterectomies, myomectomies and surgeries for the benign ovarian disease were 38% (standard deviation (SD) 16, range 12-74), 48% (SD 18, range 9-81) and 60% (SD 11, range 36-79), respectively. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists per 100 000 females and the proportion of the three main laparoscopic surgeries. CONCLUSION: There are obvious regional disparities in the proportion of the three main laparoscopic procedures for benign gynecological diseases among 47 prefectures. The number of laparoscopy-qualified gynecologists correlated significantly with these regional disparities. The academic society should monitor these regional disparities and make an effort to reduce these regional disparities by increasing laparoscopy-qualified gynecologists in areas where the widespread use of laparoscopic techniques is lagging.

5,926 hysterectomies: complications described by Clavien-Dindo classification.

Hysterectomy is the most common major gynaecological surgery. Due to its high volume, the analysis of its results is relevant. The objective of this study was to describe intraoperative complications and reoperations, for both benign and malignant causes, using the Clavien-Dindo classification (approved by local ethics committee, number 100220). Between 2000 and 2019, 5926 elective hysterectomies were performed, of which 90.2% were for benign aetiology and 9.8% for malignant causes. The abdominal route was 52.7%, vaginal 40.1% and laparoscopic 7.2%. Intraoperative complications and reoperations (grade III Clavien-Dindo) were 4% and 2.1%, respectively. Oncological surgery had significantly more intraoperative complications (10% vs. 3.4%) and reoperations (3.6% vs. 1.9%) than benign procedures. Noteworthy, intraoperative complications required a new operation in only 3.4% for malignant and 2.8% for benign surgery. Our data showed the relevance of detecting and rectifying intraoperative complications during surgery, which consequently leads to a lower reoperation rate, minimising postoperative morbidity and mortality for patients.Impact StatementWhat is already known on this subject? The surgical complications of hysterectomy, both intraoperative and postoperative, are extensively described. However, this information is not well systematised, in which elective and emergency surgery are mixed. In addition to the above, there are few documents comparing the results of hysterectomies due to benign versus malignant causes.What the results of this study add? Using the Clavien-Dindo classification, this study adds an organised description of intraoperative complications and reoperations of hysterectomy in the context of elective surgery. In addition, it provides information on the comparison between surgery for benign versus malignant causes, as well as information on intraoperative complications requiring a new operation.What the implications are of these findings for clinical practice and/or further research? These findings provide clear and orderly data about the risks of elective hysterectomy and showed the relevance of detecting and rectifying intraoperative complications during the procedure. This is useful for specialists to preoperatively identify the risks for each hysterectomy group and provide their patients with more detailed information during informed consent.

The incidence of unexpected gynaecological malignancies in hysterectomies carried out for benign indications.

The aim of the present study was to determine the incidence of unexpected gynaecological malignancies in patients undergoing hysterectomy for benign indications and to evaluate their clinical characteristics. Data from 6448 cases who had undergone hysterectomy for benign indications between the dates of 01.01.2008-01.01.2018 were recorded retrospectively from the database of the institution. The mean age of the cases with malignancy was 59.2 ± 9.66 (45-80) and 76,31% were (29/38) postmenopausal. The mean gravidity was 3.94 ± 1.73 and parity was 3.31 ± 1.45. Their mean BMI was 29.6 ± 4.26 kg/m2 (22.4-41.9 kg/m2 range). These patients were followed for a mean duration of 60.68 ± 37.66 months and during this period death associated with malignancy occurred in 4/38 (%10.52) cases, all of whom had leiomyosarcoma. The benign indications of procedure were as follows: myoma uteri (2675, 41.48%), abnormal uterine bleeding (1508, 23.38%), uterine prolapsus (793, 12.29%), ovarian cyst (619, 9.59%), endometriosis (303, 4.69%), endometrial polyp (264, 4.09%), pelvic pain (238, 3.69%) and other benign causes (48, 0.74%). Unexpected gynaecological malignancy was found in 20 cases (0.31%) with endometrial cancer, in eight cases (0.12%) with uterine sarcoma, in seven cases (0.10%) with ovarian cancer, in one case (0.01%) with tubal cancer and in two (0.03%) with cervical cancer. Gynaecological malignancy was found in 38 of 6648 cases who underwent hysterectomy for benign indications, yielding an incidence rate of 0.58%.IMPACT STATEMENTWhat is already known on this subject? Hysterectomy is the most common gynaecological surgery in the world and although most are performed for benign indications, unexpected gynaecological malignancy is possible in the final pathology results.Although there are available publications investigating unexpected gynaecological malignancy incidences after hysterectomies for benign reasons, the incidence is still not clear. We aimed to contribute to the existing literature with this study, which includes a large number of cases.What do the results of this study add? Our study adds new findings to the body of the knowledge on the incidence of unexpected gynaecological malignancies in hysterectomies for benign indications. Gynaecological malignancy was found in 38 of 6648 cases who underwent hysterectomy for benign indications, yielding an incidence rate of 0.58%.What are the implications of these findings for clinical practice and/or further research? There is an unexpected possibility of gynaecological malignancy even in cases where it is expected to be benign with current diagnostic methods. In cases that are expected to be benign, detailed preoperative evaluation should be performed in all patients to prevent unexpected gynaecological malignancies. More sensitive screening methods should be developed especially in the preoperative differential diagnosis of leiomyoma and leiomyosarcoma.