Uterine rupture and factors associated with adverse outcomes.

PURPOSE: To review cases of uterine rupture and identify risk factors associated with adverse outcomes. METHODS: This study is a retrospective cohort of complete uterine ruptures diagnosed in a large hospital system in Massachusetts between 2004 and 2018. Baseline demographics, labor characteristics and outcomes of uterine rupture were collected from medical records. RESULTS: A total of 173 cases of uterine rupture were identified. There were 30 (17.3%) women with an unscarred uterus, while 142 (82.1%) had a scarred uterus. Adverse outcomes (n = 89, 51.4% of cases) included 26 (15.0%) hysterectomies, 55 (31.8%) blood transfusions, 18 (10.4%) bladder/ureteral injuries, 5 (2.9%) reoperations, 25 (14.5%) Apgar scores lower than 5 at 5 min and 9 (5.2%) perinatal deaths. Uterine rupture of a scarred uterus was associated with decreased risk of hemorrhage (OR 0.40, 95% CI 0.17-0.93), blood transfusion (OR 0.27, 95% CI 0.11-0.69), hysterectomy (OR 0.23, 95% CI 0.08-0.69) and any adverse outcome (OR 0.34, 95% CI 0.13-0.91) compared with unscarred rupture. Uterine rupture during vaginal delivery was associated with increased risk of transfusion (OR 6.55, 95% CI 1.53-28.05) and hysterectomy (OR 8.95, 95% CI 2.12-37.72) compared with emergent C-section. CONCLUSIONS: Although rare, uterine rupture is associated with adverse outcomes in over half of cases. Unscarred rupture and vaginal delivery demonstrate increased risk of adverse outcomes, highlighting the need for early diagnosis and operative intervention.

Deep Pelvic Side Wall Anatomy: A Case of Laparoscopic Management of Vaginal Vault Fistula to the Presacral Area.

STUDY OBJECTIVE: Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy [1-3]. DESIGN: Case presentation with showing anatomic structures in detail. SETTING: Tertiary academic teaching hospital. INTERVENTIONS: A 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension 9 years ago presented with fever and was found to have bacteremia. Abdomen and pelvic magnetic resonance imaging showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. Transgluteal drain placed with cultures growing Streptococcus constellatus and Gemella morbillorum. Blood cultures grew same bacteria. She was started on vancomycin, cefepime, and metronidazole and was transitioned to ceftriaxone with a plan for 6-week antibiotic course. Her blood sugar levels were well controlled during hospitalization with baseline insulin and moderate sliding scale. Physical therapy started preoperative and continued postoperative. She was managed with an interdisciplinary team of gynecologists, urogynecologists, orthopedic doctors, neurosurgeons, nutritionists, infectious disease doctors, endocrinologists, hematologists, rehabilitation specialists, and physical therapists. This video showcases laparoscopic resection of sacrospinous fistula tract. Postoperative pathology result showed squamous mucosa, submucosa, and deep soft tissue with a submucosal abscess surrounded by fibrosis, consistent with a fistula tract. CONCLUSION: Preoperative planning is of paramount importance in cases with multiple comorbidities. Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection. Knowing the precise anatomy of critical structures close to the area of interest is crucial.

Very Low Rates of Ureteral Injury in Laparoscopic Hysterectomy Performed by Fellowship-trained Minimally Invasive Gynecologic Surgeons.

STUDY OBJECTIVE: The objective of this case series is to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. DESIGN: A retrospective chart review was performed, evaluating laparoscopic hysterectomy cases between 2009 and 2019 performed exclusively by fellowship-trained surgeons. SETTING: Division of Minimally Invasive Gynecologic Surgery (MIGS) at the Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital, a Harvard Medical School teaching hospital in Boston. PATIENTS: All patients undergoing laparoscopic hysterectomy by one of 5 surgeons with fellowship training in MIGS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 5160 cases were handled by MIGS surgeons between 2009 and 2019 at our institution. Of these cases, 2345 were laparoscopic hysterectomy cases with available intraoperative and postoperative documentation. Most patients had undergone previous surgeries, and the most common indications for hysterectomy included uterine myomas, pelvic pain/endometriosis, and abnormal uterine bleeding. At the time of hysterectomy, 1 ureteral injury (0.04%) was noted. No additional delayed ureteral injuries were observed. Most patients were discharged home the same day (64.9%) and did not have any postoperative complications (63.9%) as designated by the Clavien-Dindo classification. CONCLUSION: Ureteral injury, although rare, is more prevalent in gynecologic surgery than in other surgical disciplines that have some focus on the pelvis. No study to date has evaluated the effect of surgical training and volume on rates of ureteral injuries. This study retrospectively examined ureteral injury rates for one group of high-volume fellowship-trained surgeons and found their rates to be lower than the national average. Proposals are presented for optimizing training and delivery of gynecologic surgical care to minimize complications.

Endometriosis Classification Systems: An International Survey to Map Current Knowledge and Uptake.

OBJECTIVE: In the field of endometriosis, several classification, staging and reporting systems have been developed, but do clinicians routinely use these classification systems, which system do they use and what are the clinicians' motivations? DATA SOURCES: A cross-sectional study was performed to gather data on the current use of endometriosis classification systems, problems encountered and interest in a new simple surgical descriptive system for endometriosis. Of particular focus were three systems most commonly used: the Revised American Society for Reproductive Medicine (rASRM) classification, the Endometriosis Fertility Index (EFI), and the ENZIAN classification. Data were analysed by SPSS. A survey was designed using the online SurveyMonkey tool consisting of 11 questions concerning three domains-participants background, existing classification systems and intentions with regards to a new classification system for endometriosis. Replies were collected between 15 May and 1 July 2020. METHODS OF STUDY SELECTION: na TABULATION, INTEGRATION AND RESULTS: The final dataset included the replies of 1178 clinicians, including surgeons, gynecologists, reproductive endocrinologists, fertility specialists and sonographers, all managing women with endometriosis in their clinical practice. Overall, 75.5% of the professionals indicate that they currently use a classification system for endometriosis. The rASRM classification system was the best known and used system, the EFI system and ENZIAN system were known by a majority of the professionals but used by only a minority. The lack of clinical relevance was most often selected as a problem with using any system. The findings of the survey suggest that clinicians worldwide are open to using a new classification system for endometriosis that can achieve standardized reporting, and is clinically relevant and simple. The findings therefore support future initiatives for the development of a new descriptive system for endometriosis and provide information on user expectations and conditions for universal uptake of such a system. CONCLUSION: Even with a high uptake of the existing endometriosis classification systems (rASRM, ENZIAN and EFI), most clinicians managing endometriosis would like a new simple surgical descriptive system for endometriosis.

Minimally Invasive Surgical Techniques for Tissue Extraction.

STUDY OBJECTIVE: Morcellation is a technique to remove large specimens by means of small incisions and is commonly used in gynecologic procedures [1]. In this video, we demonstrate contained manual morcellation techniques in benign gynecologic surgeries. DESIGN: Stepwise demonstration of 4 techniques with narrated video footage. SETTING: Tertiary academic teaching hospital. INTERVENTIONS: This video showcases 4 contained manual morcellation techniques: abdominal extraction through an umbilical "mini-laparotomy" incision, abdominal extraction through a suprapubic "mini-laparotomy" incision, transvaginal extraction through the colpotomy, and transvaginal extraction through the posterior cul-de-sac with the uterus in place. A particular strategy should be selected on the basis of appropriate patient characteristics and surgical factors [2]. CONCLUSION: Minimizing risk during tissue extraction is critical to minimally invasive procedures. The morcellation techniques displayed in this video allow for tissue extraction through small incisions while reducing the risk of spreading an undiagnosed malignancy.

Peri- and Postoperative Outcomes of Outpatient vs Inpatient Laparoscopic Apical Prolapse Repair.

STUDY OBJECTIVE: To assess the feasibility of outpatient laparoscopic management of apical pelvic organ prolapse along with indicated vaginal repairs and anti-incontinence procedures. DESIGN: Retrospective cohort study. SETTING: Tertiary-care academic center, Boston, MA. PATIENTS: Total of 112 patients seen in the minimally invasive gynecologic surgery and urogynecology clinics with symptomatic pelvic organ prolapse. INTERVENTIONS: Laparoscopic hysterectomy, sacrocervico- or sacrocolpopexy along with vaginal prolapse and anti-incontinence procedures as indicated from 2013 to 2017 at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital performed by a minimally invasive gynecologic surgery and urogynecology team. MEASUREMENTS AND MAIN RESULTS: Of the 112 patients, 52 were outpatient and 60 were admitted (median stay in admission group = 1 day; range 1-3). Patient baseline characteristics, American Society of Anesthesiologists' class, and pelvic organ prolapse quantification stage were similar between the outpatient and admitted cohorts. Most patients underwent hysterectomy at the time of the sacropexy (65.4% outpatient vs 73.3% admitted, p = .08). Concomitant apical prolapse repair was more common in the outpatient group (98.1% vs 85%, p = .02). The proportion of outpatient procedures increased from 17% in 2013 to a peak of 70% in 2016. Operating room time was shorter for the outpatient cohort (103.9 minutes vs 115.5 minutes, p = .04), but other perioperative outcomes were similar. There were no intraoperative complications. The numbers of postoperative complications, readmission, and reoperations were low and similar between outpatient and admitted cohorts. No factor was predictive of admission on regression analysis. CONCLUSION: Laparoscopic apical prolapse repair with concomitant vaginal repairs can be performed safely as an outpatient procedure. A unique team approach may foster a shorter, more efficient procedure without compromising short-term outcomes.

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review.

OBJECTIVE: This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. DATA SOURCES: Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. METHODS OF STUDY SELECTION: Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. TABULATION, INTEGRATION, AND RESULTS: The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. CONCLUSION: Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

An International Terminology for Endometriosis, 2021.

OBJECTIVE: Different classification systems have been developed for endometriosis, using different definitions for the disease, the different subtypes, symptoms and treatments. In addition, an International Glossary on Infertility and Fertility Care has been published in 2017 by the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) in collaboration with other organisations. An international working group convened over the development of a classification or descriptive system for endometriosis. As a basis for such system, a terminology for endometriosis was considered a condition sine qua non. The aim of the current study was to develop a set of terms and definitions be prepared on endometriosis that would be the basis for standardization in disease description, classification and research. DATA SOURCES: The working group listed a number of terms relevant to be included in the terminology, documented currently used and published definitions, and discussed and adapted them until consensus was reached within the working group. Following stakeholder review, further terms were added, and definitions further clarified. Although definitions were collected through published literature, the final set of terms and definitions is to be considered consensus-based. After finalization of the first draft, the members of the international societies and other stakeholders were consulted for feedback and comments, which lead to further adaptations. METHODS OF STUDY SELECTION: na TABULATION, INTEGRATION, AND RESULTS: A list of 49 terms and definitions in the field of endometriosis is presented, including a definition for endometriosis and its subtypes, different locations, interventions, symptoms and outcomes. Endometriosis is defined as a disease characterized by the presence of endometrium-like epithelium and/or stroma outside the endometrium and myometrium, usually with an associated inflammatory process. CONCLUSION: The current paper outlines a list of 49 terms and definitions in the field of endometriosis. The application of the defined terms aims to facilitate harmonization in endometriosis research and clinical practice. Future research may require further refinement of the presented definitions.

Endometriosis Classification, Staging and Reporting Systems: A Review on the Road to a Universally Accepted Endometriosis Classification.

OBJECTIVE: In the field of endometriosis, several classification, staging and reporting systems have been developed. Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice? DATA SOURCES: A systematic PUBMED literature search was performed. Data were extracted and summarized. METHODS OF STUDY SELECTION: na TABULATION, INTEGRATION AND RESULTS: Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose. CONCLUSION: Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated for the purpose for which they were developed. The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.

Two-dimensional (2D) versus three-dimensional (3D) laparoscopy for vaginal cuff closure by surgeons-in-training: a randomized controlled trial.

BACKGROUND: Objective evidence is lacking as to the benefit of the addition of 3D vision to conventional laparoscopy in Gynecologic surgery. This study aims to compare 3-D visual system to traditional 2-D laparoscopic visualization for the laparoscopic closure of the vaginal cuff during total laparoscopic hysterectomy by surgeons-in-training [defined as senior OBGYN resident or Minimally Invasive Gynecologic Surgery (MIGS) fellow]. METHODS: 51 patients undergoing total laparoscopic hysterectomy at two tertiary care academic hospitals were randomized to two-dimensional or three-dimensional vision system with cuff closure performed by surgeons-in-training. The primary outcome was the time taken for vaginal cuff closure. Secondary outcomes included peri-operative outcomes and assessment of surgeon's perception of ease of cuff closure. RESULTS: 27 (52.9%) cases were allocated to cuff closure with the 2D system and 24 (47.1%) cases to closure with the 3D vision system. Patient baseline characteristics were similar between the vision systems. Mean vaginal cuff closure time was not significantly different between 2D and 3D vision (10.1 min for 2D versus 12 min for 3D, p = 0.31). An additional 24 s was added to cuff closure time with each 1 kg/m2 increase in BMI, after controlling for potential confounders (p = 0.003). There was no difference in the surgeon rating of ease of cuff closure between 2D and 3D. Peri-operative outcomes are similar among the two groups. CONCLUSION: We did not demonstrate any benefits of 3D vision system over conventional 2D for the task of laparoscopic vaginal cuff suturing performed by surgeons-in-training. RCT Registration Number NCT02192606 https://clinicaltrials.gov/ct2/show/NCT02192606 (July 17, 2014).

Laparoscopic treatment of endometriosis and predictors of major complications: A retrospective cohort study.

INTRODUCTION: Patients with advanced endometriosis may be at an increased risk of surgical complications following laparoscopic treatment of endometriosis; however, this relationship has not been examined. We sought to identify predictors of major complications following laparoscopic treatment of endometriosis. MATERIAL AND METHODS: A retrospective cohort study of women who underwent laparoscopic treatment of suspected endometriosis between 2009 and 2016 within the Division of Minimally Invasive Gynecologic Surgery at Brigham and Women's Hospital, Boston, MA, USA. Predictors of major perioperative complications were assessed by comparing the characteristics of women who had any major intraoperative or postoperative complication with those of women who had no complication. RESULTS: A total of 397 women underwent laparoscopic treatment of suspected endometriosis including excision of superficial endometriosis (55.4%), excision of deep-infiltrating endometriosis (24.9%), fulguration of endometriosis (38.3%), hysterectomy (23.2%), ovarian cystectomy (35.5%), salpingectomy (18.6%), oophorectomy (15.1%), and bowel resection (1.0%). Women were followed for 60 days following surgery, over which time 18 women (4.5%) had a major perioperative complication. Patient characteristics and preoperative imaging were similar between women with and without complications. Women with advanced endometriosis, including stage III or IV endometriosis, deep-infiltrating endometriosis, or rectovaginal disease, were more likely to have a complication, though this did not reach statistical significance (77.8% of women with a complication versus 56.7% of women without a complication had advanced endometriosis, P = 0.077). Women who had a complication were more likely to have undergone adhesiolysis or ureterolysis (88.9% of women with a complication versus 52.5% without a complication underwent adhesiolysis, P = 0.002; and 61.1% of women with a complication versus 28.8% without a complication underwent ureterolysis, P = 0.003). The total number of procedures was greater for women who had a complication (4.3 ± 1.2 vs 3.2 ± 1.5, P = 0.003). All other procedure characteristics were similar between women with and without complications. CONCLUSIONS: Complications following laparoscopic treatment of suspected endometriosis could not be predicted by preoperative patient characteristics or surgical findings of advanced endometriosis. Adhesiolysis, ureterolysis, and an increased number of total procedures may be predictive of perioperative complications, suggesting that surgical complexity as measured by the procedures performed, rather than the disease severity, may increase the risk of a complication compared with women who do not undergo these procedures.

Reproductive Outcomes following Use of Barbed Suture during Laparoscopic Myomectomy.

STUDY OBJECTIVE: To review pregnancy outcomes after laparoscopic myomectomy with the use of barbed suture. DESIGN: Retrospective cohort study and follow-up survey. SETTING: Single, large academic medical center. PATIENTS: Patients who underwent laparoscopic myomectomy with the use of barbed suture for myometrial closure between 2008 and 2016. INTERVENTION: Laparoscopic myomectomy and a follow-up survey regarding pregnancy outcome. MEASUREMENTS AND MAIN RESULTS: A total of 486 patients met inclusion criteria and underwent a laparoscopic myomectomy between 2008 and 2016. Of the 428 with viable contact information, 240 agreed to participate (56%). Of those who responded to the survey, 101 (42%) attempted to get pregnant, and there were 4 unplanned pregnancies. There were 110 pregnancies among 76 survey respondents. In total, of the women attempting a postoperative pregnancy, 71% had at least 1 pregnancy. Comparing the women who did and did not conceive postoperatively, the group who got pregnant was on average younger, 33.8 ± 4.5 years vs 37.5 ± 6.5 years (p = .001); had fewer myomas removed, median = 2 (range 1-9) vs median = 2 (range 1-16) myomas (p = .038); and had a longer follow-up period, 30 months ( vs 30 (11-93 months) ± 20 (p <.001). The mean time to first postoperative pregnancy was 18.0 months (range 2-72 months). Of the 110 reported postoperative pregnancies, there were 60 live births (55%), 90% by means of cesarean section. The mean gestational age at birth was 37.8 weeks. In the cohort, there were 8 preterm births, 3 cases of abnormal placentation, 2 cases of fetal growth restriction, 3 cases of hypertensive disorders of pregnancy, and 2 cases of myoma degeneration requiring hospitalization for pain control. There were no uterine ruptures reported. CONCLUSION: According to our findings, pregnancy outcomes after laparoscopic myomectomy with barbed suture are comparable with available literature on pregnancy outcomes with conventional smooth suture.

Vaginal or laparoscopic hysterectomy: Do perioperative outcomes differ? A propensity score-matched analysis.

INTRODUCTION: There are assertions that vaginal mode may be the preferred approach of minimally invasive hysterectomy, yet rates of laparoscopic hysterectomy (LH) continue to rise while vaginal hysterectomy (VH) rate remains relatively unchanged. The aim of this study is to compare the perioperative outcomes of LH vs VH. MATERIAL AND METHODS: We identified women who underwent either LH or VH for benign indications between 2009 and 2015 at a large academic institution. A propensity score-matched analysis was used to adjust for differences between women undergoing VH vs LH. Outcome parameters were perioperative complications (both intraoperative and postoperative), operative time, blood loss, hospital length of stay, conversion and readmission. RESULTS: A total of 1921 patients underwent either LH or VH during the study period. In all, 155 patients from each group were successfully matched using propensity score match analysis. While most intra- and postoperative characteristics did not differ between groups, LH was associated with lower blood loss during surgery (102.8 ± 166.5 mL vs 185.0 ± 179.0 mL, P < 0.001) and shorter hospital stay (0.9 ± 1 days vs 1.2 ± 0.9 days, P < 0.0001). Concomitant adnexal surgery was performed more frequently during LH (47.7% vs 12.3%, P < 0.0001), and concomitant prolapse surgery was performed more frequently at the time of VH (14.2% vs 68.4%, P < 0.0001). CONCLUSIONS: Both VH and LH have overall favorable perioperative outcomes; however, LH is associated with lower blood loss and a shorter hospital stay. The results support the trend toward increasing rates of laparoscopic approach to hysterectomy when appropriate.

Perioperative Outcomes of Myomectomy for Extreme Myoma Burden: Comparison of Surgical Approaches.

STUDY OBJECTIVE: To describe the perioperative outcomes of various modes of myomectomy (abdominal [AM], laparoscopic [LM], or robotic [RM]) in cases of extreme myoma burden. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: A tertiary academic center in Boston, Massachusetts. PATIENTS: All women who underwent an AM, LM, or RM for extreme myoma burden, defined as representing the upper quartile for specimen weight (≥434.6 g) or myoma count (≥7 myomas), between 2009 and 2016. INTERVENTIONS: Baseline demographics and perioperative outcomes were collected from review of medical records, including estimated blood loss, operative time, length of stay, and complications. Univariate linear and logistic regression analyses were conducted. MEASUREMENTS AND MAIN RESULTS: During the study period 659 women underwent myomectomy for extreme myoma burden; 47.2% of cases were AM, 28.1% LM, and 24.7% RM. Overall myoma burden differed across the 3 routes and was greatest in the AM group (mean weight: 696.2 ± 784.5 g for AM vs 586.6 ± 426.1 g for LM and 586.6 ± 426.1 g for RM; mean number: 16.8 ± 15.0 for AM vs 7.2 ± 7.0 for LM and 6.7 ± 4.7 for RM; p <.001 for both). The 3 routes differed in operative time and length of stay, with RM having the longest operative time (mean, 239.7 minutes; p <.001) and AM the longest length of stay (mean, 2.2 ± .9 days; p <.001). Other perioperative outcomes were similar across the surgical approaches. Increasing myoma burden was associated with an increased risk of perioperative complications for all surgical approaches, with a threshold of 13 myomas associated with an almost 2-fold higher risk of perioperative complications (odds ratio, 1.77; 95% confidence interval, 1.17-2.70; p = .009). Cumulative incidence of perioperative complications with increasing specimen weight was greater in the RM cases as compared with AM (p = .002) or LM (p = .020), whereas the cumulative incidence of perioperative complications with increasing myoma count was lowest with AM compared with LM (p <.001) or RM (p <.001). CONCLUSION: Myomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications. A threshold of 13 myomas was associated with an almost 2-fold higher risk of perioperative complications for all modes. Perioperative complication outcomes were more favorable in AM or LM over RM with increased myoma weight and AM over LM or RM with increased myoma number.

Prospective Evaluation of Manual Morcellation Techniques: Minilaparotomy versus Vaginal Approach.

STUDY OBJECTIVE: To compare the number of days required to return to daily activities after laparoscopic hysterectomy with 2 tissue extraction methods: manual morcellation via colpotomy or minilaparotomy. Secondary outcomes were additional measures of patient recovery, perioperative outcomes, containment bag integrity, and tissue spillage. DESIGN: Multicenter prospective cohort study and follow-up survey (Canadian Task Force classification II-2). SETTING: Two tertiary care academic centers in northeastern United States. PATIENTS: Seventy women undergoing laparoscopic hysterectomy with anticipated need for manual morcellation. INTERVENTIONS: Tissue extraction by either contained minilaparotomy or contained vaginal extraction method, along with patient-completed recovery diary. MEASUREMENTS AND MAIN RESULTS: Recovery diaries were returned by 85.3% of participants. There were no significant differences found in terms of average pain at 1, 2, or 3 weeks after surgery or in time to return to normal activities. Patients in both groups used narcotic pain medication for an average of 3 days. After adjusting for patient body mass index, history of prior surgery, uterine weight, and surgeon, there were no differences found for blood loss, operative time, length of stay, or incidence of any intra- or postoperative complication between groups. All patients had benign findings on final pathology. More cases in the vaginal contained extraction group were noted to have bag leakage on postprocedure testing (13 [40.6%] vs 3 [8.3%] tears in vaginal and minilaparotomy groups, respectively; p = .003). CONCLUSION: Regarding route of tissue extraction, contained minilaparotomy and contained vaginal extraction methods are associated with similar patient outcomes and recovery characteristics.

Persistence of Symptoms After Total vs Supracervical Hysterectomy in Women with Histopathological Diagnosis of Adenomyosis.

STUDY OBJECTIVE: To compare symptom persistence in women with adenomyosis based on retention or removal of the cervix at the time of hysterectomy. DESIGN: Retrospective cohort study and follow-up survey (Canadian Task Force classification xx). SETTING: Tertiary care academic hospital in Boston, Massachusetts. PATIENTS: Women (n = 1580) who underwent laparoscopic hysterectomy for benign indications between 2008 and 2012 at Brigham and Women's Faulkner Hospital and Brigham and Women's Hospital. INTERVENTION: Retrospective chart review and follow-up survey. MEASUREMENTS AND MAIN RESULTS: Among the 1580 women contacted, 762 (48%) responded to the postoperative symptom resolution survey. Of these 762 women, 623 agreed to participate in the study. Menopausal women or those who had undergone bilateral salpingo-oophorectomy were excluded. Adenomyosis was identified on histopathologic evaluation of the uterus in 171 of the remaining 443 women (39%). Compared with women without adenomyosis, those with adenomyosis were older on average (mean age, 46.6 ± 6.8 years vs 45.0 ± 5.5 years; p = .009) and more likely to report that abnormal bleeding and pain led to their hysterectomy (87.7% vs 79.8%; p = .03 and 64.9% vs 51.4%; p = .009, respectively). The rates of total and supracervical hysterectomies were similar in the 2 groups. Following surgery, women with adenomyosis were less likely than those without adenomyosis to report persistent pain (adjusted odds ratio [aOR], 0.43; 95% confidence interval [CI], 0.20-0.93; p = .03). Persistent bleeding was similar in the 2 groups (aOR, 0.97; 95% CI, 0.49-1.93; p = .94). Among women with adenomyosis, multivariable logistic regression showed no difference in persistence of symptoms with cervical removal or retention at the time of hysterectomy. CONCLUSION: Compared with women without adenomyosis, those with histopathologically proven adenomyosis were less likely to report persistent pain following hysterectomy. Retention of the cervix does not appear to increase the risk of symptom persistence or postprocedure patient satisfaction.

Surgical skills assessment tools in gynecology.

PURPOSE OF REVIEW: The purpose of this review is to outline surgical skills assessment tools for the purpose of training and competency evaluation, with a focus on recent literature in gynecology. RECENT FINDINGS: Objective standardized surgical skills assessment tools are increasingly being explored in multiple surgical disciplines including gynecology. Several small studies in gynecology have validated procedure-specific checklists, global rating scales, and other surgical proficiency examinations in their ability to differentiate trainee skill level or correlate with other standardized tests. Few studies have included gynecologic surgeons in practice, and no studies have investigated their use in credentialing and maintenance of certification. SUMMARY: Surgical skills assessment tools may be a useful adjunct to gynecology training programs, with promising applications for practicing gynecologists.

Trends in readmission rate by route of hysterectomy - a single-center experience.

INTRODUCTION: The aim of this study was to assess the 60-day readmission rates after hysterectomy according to route of surgery and analyze risk factors for postoperative readmission. MATERIAL AND METHODS: This retrospective study included all women who underwent hysterectomy due to benign conditions from 2009 to 2015 at a large academic center in Boston. Readmission rates were compared among the following four types of hysterectomies: abdominal, laparoscopic, robotic and vaginal. RESULTS: There were 3981 hysterectomy cases over the study period (628 abdominal hysterectomy, 2500 laparoscopic hysterectomy, 155 robotic hysterectomy and 698 vaginal hysterectomy). Intraoperative complications occurred more frequently in women undergoing abdominal hysterectomy (4.8%), followed by robotic hysterectomy (3.9%), vaginal hysterectomy (1.9%) and laparoscopic hysterectomy (1.6%) (p < 0.0001). Readmission rates were not significantly different among the groups; women receiving abdominal hysterectomy had an overall readmission rate of 3.5%, compared with 3.2% after robotic hysterectomy, 2.9% after vaginal hysterectomy and 1.9% after laparoscopic hysterectomy (p = 0.06). When stratifying for relevant variables, women who had an laparoscopic hysterectomy had a twofold reduction of readmission compared with abdominal hysterectomy (odds ratio 0.52, 95% confidence interval 0.31-0.87; p = 0.01). There was no significant difference in readmission when robotic hysterectomy or vaginal hysterectomy were compared individually with abdominal hysterectomy. Regarding risk factors related to readmission it was observed that perioperative complications were the largest driver of readmissions (odds ratio 667, 95% confidence interval 158-99; p < 0.0001). CONCLUSION: The laparoscopic approach to hysterectomy was associated with fewer hospital readmissions compared with the abdominal route; vaginal, robotic and abdominal approaches had a similar risk of readmission. Perioperative complications represent the main driver of readmissions. After adjusting for perioperative factors such as surgeon type and complications, no difference in readmissions between the different routes of hysterectomy were found.

Incisional Outcomes of Umbilical vs Suprapubic Mini-laparotomy for Tissue Extraction: A Retrospective Cohort Study.

STUDY OBJECTIVE: To compare outcomes following umbilical minilaparotomy and suprapubic minilaparotomy for tissue extraction. DESIGN CLASSIFICATION: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Two large academic medical centers. PATIENTS: Women who underwent a minilaparotomy for tissue extraction following a laparoscopic hysterectomy or myomectomy between 2014 and 2016. INTERVENTIONS: Umbilical or suprapubic minilaparotomy for tissue extraction. MEASUREMENTS AND MAIN RESULTS: A total of 374 women underwent laparoscopic hysterectomy or myomectomy with minilaparotomy, including 289 (77.3%) with an umbilical minilaparotomy and 85 (22.7%) with a suprapubic minilaparotomy. The 2 groups were similar in terms of age, body mass index, parity, surgical history, procedure type, surgical approach, and surgical indication. The size of the minilaparotomy incision and the specimen weight were significantly smaller in the umbilical minilaparotomy group (mean, 3.3 ± 0.8 cm vs 4.2 ± 0.6 cm [p < .001] and 472.6 ± 357.1 g vs 683.0 ± 475.7 g [p < .001], respectively). Two women in the suprapubic minilaparotomy group sustained a bladder injury during creation of the incision. There were no other complications related to the minilaparotomy in either group. Postoperative outcomes related to the minilaparotomy incision were compiled using the medical record and a follow-up survey. Of the 374 women in this cohort, 163 responded to a detailed survey about their minilaparotomy incision (response rate, 43.5%). With regard to the minilaparotomy, 52.7% of women reported incisional symptoms; 25.9% had increased pain at the incision, 8.3% had an incisional infection, and 2.7% reported an incisional hernia. There was no significant between-group difference in incisional outcomes; however nearly 3 times as many women in the umbilical minilaparotomy group reported concerns about incisional hernia (3.1% vs 1.2%; p = .833). These findings were maintained in a multivariable logistic regression analysis. No patient or procedure characteristics were significantly associated with the development of hernia. CONCLUSION: There were no significant difference in incisional symptoms, pain, or infection following umbilical minilaparotomy vs a suprapubic minilaparotomy for tissue extraction. Although not statistically significant, the rate of incisional hernia was higher at the umbilical site compared with the suprapubic site.

Review of Sterilization Techniques and Clinical Updates.

Sterilization is the most common form of contraception used worldwide and is highly effective in preventing unintended pregnancy. Each of the available sterilization methods has unique advantages and disadvantages that influence the choice of approach for each individual patient. Salpingectomy for sterilization has become more popular in recent years, with mounting evidence suggesting a protective effect against ovarian cancers originating in the fallopian tube. At the same time, Essure hysteroscopic sterilization has come under scrutiny because of increasing reports of possible adverse effects associated with its use. Here we review clinical updates in sterilization techniques, with a focus on salpingectomy and Essure hysteroscopic sterilization.