Analysis of Sociodemographic Factors Affecting Ambulatory Surgical Center Discharge Patterns for Endometrial Cancer Hysterectomies.

STUDY OBJECTIVE: Investigate outcomes for patients undergoing minimally invasive hysterectomies (MIHs) performed for endometrial cancer at ambulatory surgery centers (ASCs). DESIGN: Our study aimed to explore the feasibility and discharge outcomes for MIHs for endometrial cancer in an ASC setting by using same-day discharge data. SETTING: The prevalence of MIH for endometrial cancer between 2016 and 2019 was estimated from the Nationwide Ambulatory Surgery Sample. PATIENTS: Patients who underwent MIHs for endometrial cancer at an ASC were included. INTERVENTIONS: N/A MEASUREMENTS MAIN RESULTS: Weighted estimates of prevalence and association between discharge status and sociodemographic factors were explored. Same-day discharge was defined as discharge on the day of surgery, and delayed discharge was defined as discharge after the day of surgery. An estimated 95 041 MIHs for endometrial cancer were performed at ASCs between 2016 and 2019. Notably, 91.9% (n = 87 372) resulted in same-day discharge, 1.2% (n = 1121) had delayed discharge, and 6.9% (n = 6548) had missing discharge information; 78.7% procedures (n = 68 812) were performed at public hospitals. The proportion of delayed discharges were lower in private, not-for profit ASCs (0.8%, p = .03) than public hospitals. Patients who had delayed discharges on average were older (69.7 vs 62.4 years, p <.001), more likely to have comorbid conditions including diabetes (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.25-1.75) and overweight or obese body mass indices (aOR 1.18, 95% CI 1.01-1.39), and more likely to have public insurance (aOR 1.78, 95% CI 1.40-2.25). CONCLUSION: MIHs for endometrial cancer are feasible in an ASC. Optimal candidates for receipt of MIHs for endometrial cancer at an ASC are patients who are younger and have less comorbidities, lower body mass index, and private insurance.

Racial and ethnic disparities in access to minimally invasive gynecologic surgery for benign pathology.

PURPOSE OF REVIEW: To review current US literature and describe the extent, source, and impact of disparities that exist among Black, Indigenous, and people of color (BIPOC) in surgical route and outcomes for hysterectomy, myomectomy, and endometriosis surgery. RECENT FINDINGS: Despite the nationwide trend toward minimally invasive surgery (MIS), BIPOC women are disproportionally less likely to undergo MIS hysterectomy and myomectomy and have higher rates of perioperative complications. African American women, in particular, receive significantly disparate care. Contemporary literature on the prevalence of endometriosis in BIPOC women is lacking. Further, there is little data on the racial and ethnic differences in endometriosis surgery access and outcomes. SUMMARY: Racial and ethnic disparities in access to minimally invasive gynecologic surgery for benign pathology exist and these differences are not fully accounted for by patient, socioeconomic, or healthcare infrastructure factors. Initiatives that incentivize hiring surgeons trained to perform complex gynecologic surgery, standardized pathways for route of surgery, quality improvement focused on increased hospital MIS volume, and hospital-based public reporting of MIS volume data may be of benefit for minimizing disparities. Further, initiatives to reduce disparities need to address racism, implicit bias, and healthcare structural issues that perpetuate disparities.

Reliability and Validity of 2 Surgical Prioritization Systems for Reinstating Nonemergent Benign Gynecologic Surgery during the COVID-19 Pandemic.

STUDY OBJECTIVE: Scientifically evaluate the validity and reproducibility of 2 novel surgical triaging systems, as well as offer modifications to the Medically-Necessary, Time-Sensitive (MeNTS) criteria for improved application in gynecologic surgeries. DESIGN: Retrospective cohort study. SETTING: Academic university hospital. PATIENTS: Ninety-seven patients with delayed benign gynecologic procedures owing to the coronavirus disease 2019 pandemic. INTERVENTION(S): Surgical prioritization was assessed using 2 novel scoring systems, the Gynecologic Medically-Necessary Time-Sensitive (Gyn-MeNTS) and modified Elective Surgery Acuity Scale (mESAS) systems for all 93 patients included. MEASUREMENTS AND MAIN RESULTS: The interrater reliability and validity of 2 novel surgical prioritization systems (Gyn-MeNTS and mESAS) were assessed. The Gyn-MeNTS scores were calculated by 3 raters and analyzed as continuous variables, with a lower score indicating more urgency/priority. The mESAS score was calculated by 2 raters and analyzed as a 3-level ordinal variable with a higher score indicating more urgency/priority. All 5 raters were blinded to reduce bias. The Gyn-MeNTS interrater reliability was tested using Spearman r and paired t tests were used to detect systematic differences between raters. Weighted κ indicated mESAS reliability. Concurrent validity with mESAS and surgeon self-prioritization (SSP) was examined with Spearman r and logistic regression. Spearman r's for all Gyn-MeNTS rater pairs were above 0.80 (0.84 for 1 vs 2; 0.82 for 1 vs 3; and 0.82 for 2 vs 3, all p <.001) indicating strong agreement. The weighted κ for the 2 mESAS raters was 0.57 (95% confidence interval, 0.40-0.73) indicating moderate agreement. When used together, both scores were significantly independently associated with SSP, with strong discrimination (area under the curve, 0.89). CONCLUSION: Interrater reliability is acceptable for both scoring systems, and concurrent validity of each is moderate for predicting SSP, but discrimination improves to a high level when they are used together.

Ob/Gyn resident self-perceived preparedness for minimally invasive surgery.

BACKGROUND: Very little is known regarding the readiness of senior U.S. Ob/Gyn residents to perform minimally invasive surgery. This study aims to evaluate the self-perceived readiness of senior Ob/Gyn residents to perform complex minimally invasive gynecologic surgery as well as their perceptions of the minimally invasive gynecologic surgery subspecialty. METHODS: We performed a national survey study of 3rd and 4th year Ob/Gyn residents. A novel 58-item survey was developed and sent to residency program directors and coordinators with the request to forward the survey link along to their senior residents. RESULTS: We received 158 survey responses with 84 (53.2%) responses coming from 4th year residents and 74 (46.8%) responses from 3rd year residents. Residents who train with graduates of a fellowship in minimally invasive gynecologic surgery felt significantly more prepared to perform minimally invasive surgery compared to residents without this exposure in their training. The majority of senior residents (71.5%) feel their residency training adequately prepared them to be a competent minimally invasive gynecologic surgeon. However, only 50% feel prepared to perform a laparoscopic hysterectomy on a uterus greater than 12 weeks size, 29% feel prepared to offer a vaginal hysterectomy on a uterus 12-week size or greater, 17% feel comfortable performing a laparoscopic myomectomy, and 12% feel prepared to offer a laparoscopic hysterectomy for a uterus above the umbilicus. CONCLUSIONS: The majority of senior U.S. Ob/Gyn residents feel prepared to provide minimally invasive surgery for complex gynecologic cases. However, surgical confidence in specific procedures decreases when surgical complexity increases.

Applications of Tranexamic acid in benign gynecology.

PURPOSE OF REVIEW: Bleeding at the time of benign gynecologic surgery, as well as from benign gynecologic conditions, is a major source of morbidity for many women. Few nonhormonal medical options exist for the treatment of heavy menstrual bleeding, and to reduce surgical bleeding during major gynecologic surgery. Interest in Tranexamic acid (TXA) as a means to reduce surgical blood loss has been growing across many surgical specialties. This review focuses on applications for TXA as a means to reduce heavy menstrual bleeding (HMB) as well as to reduce surgical bleeding during benign gynecologic surgery. RECENT FINDINGS: Tranexamic acid is an effective treatment to reduce the volume of bleeding during menstruation. Tranexamic acid was found to be superior to both placebo and oral progestins, and as good as combined oral contraceptives at reducing menstrual blood volume. Tranexamic acid has also been show to reduce the volume of bleeding during abdominal myomectomy as well as hysterectomy. There is a major need for prospective studies evaluating the utility of TXA for reducing blood loss during benign gynecologic surgery. SUMMARY: Tranexamic acid has been found to be an excellent affordable nonhormonal treatment option for women with HMB and should be considered during major gynecologic surgery.

Hysterectomy for the Transgendered Male: Review of Perioperative Considerations and Surgical Techniques with Description of a Novel 2-Port Laparoscopic Approach.

Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed.

Review of strategies and factors to maximize cost-effectiveness of robotic hysterectomies and myomectomies in benign gynecological disease.

Common benign gynecologic procedures include hysterectomies and myomectomies, with hysterectomy being the most common gynecologic procedure in the United States [1]. While historically performed via laparotomy, the field of gynecologic surgery was revolutionized with the advent of laparoscopic techniques, with the most recent advancement being the introduction of robotic-assisted surgery in 2005. Robotic surgery has all the benefits of laparoscopic surgery such as decreased blood loss, quicker return to activities, and shorter length of hospital stay. Additional robotic-specific advantages include but are not limited to improved ergonomics, 3D visualization, and intuitive surgical movements. Despite these advantages, one of the most commonly cited drawbacks of robotic surgery is the associated cost. While the initial cost to purchase the robotic console and its associated maintenance costs are relatively high, robotic surgery can be cost-effective when utilized correctly.This article reviews application strategies and factors that can offset traditional costs and maximize the benefits of robotic surgery.