Chronic Pelvic Pain Educational Experience Among Minimally Invasive Gynecologic Surgery Fellows and Recent Graduates: A Needs Assessment.

STUDY OBJECTIVE: Learning to evaluate and treat chronic pelvic pain (CPP) is an established curriculum objective within the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Our aim was to investigate current educational experiences related to the evaluation and management of CPP and the impacts of those experiences on FMIGS fellows and recent fellowship graduates, including satisfaction, confidence in management, and clinical interest in CPP. DESIGN: The AAGL-Elevating Gynecologic Surgery Special Interest Group for pelvic pain developed a 33-item survey tool to investigate the following topics: (1) current educational experiences with the assessment and management of patients with CPP, (2) satisfaction with fellowship training in CPP, (3) perceived preparedness to treat patients with CPP, (4) plans to incorporate management of CPP into clinical practice, and (5) perceived desires to expand CPP exposure. Composite scores were created to examine experiences related to diseases associated with CPP and pharmaceutical and procedural treatment options. SETTING: Electronic survey. PATIENTS: Not applicable. INTERVENTIONS: The survey was distributed via AAGL email lists and offered on FMIGS social media sites from August 2017 to November 2017 to all active FMIGS fellows and individuals who graduated the fellowship during the preceding 5 years. MEASUREMENTS AND MAIN RESULTS: Fifty-three of 82 (65%) current FMIGS fellows and 104 of 169 (62%) recent fellowship graduates completed the survey. Only 66% of current fellows endorsed working with a fellowship faculty member whose clinical work focused on CPP. Most current fellows reported having a "good amount" of experience or "extensive" experience with superficial endometriosis (39/53, 74%) and deeply infiltrative endometriosis (34/53, 64%), whereas the majority reported having "no" or "little" experience with frequently comorbid conditions like irritable bowel syndrome (68%), pelvic floor tension myalgia (55%), and interstitial cystitis/painful bladder syndrome (51%). For both current fellows and recent graduates, increased CPP Disease Experience composite scores were associated with satisfaction with CPP training (current fellows odds ratio [OR] 1.9, p =.002; recent graduates OR 1.5, p < .001), perceived preparedness to treat patients with CPP (current fellows OR 2.0, p = .0021; recent graduates OR 1.5, p <.001), and the desire to incorporate the treatment of CPP into future clinical practice (current fellows OR 1.8, p = .0099; recent graduates OR 1.3, p = .0178). More than 80% (43/53) of current fellows indicated that they believed an expanded pelvic pain curriculum should be part of the FMIGS fellowship. CONCLUSION: This needs assessment of FMIGS fellows and recent graduates suggests that there are gaps between FMIGS curriculum objectives and current educational experiences, and that fellows desire increased CPP exposure. Expansion and standardization of the CPP educational experience is needed and could lead to increased focus on this disease process among subspecialty benign gynecologic surgeons.

Selecting the Appropriate Patient for Opioid Therapy: Risk Assessment and Treatment Strategies for Gynecologic Pain.

Chronic pelvic pain is a commonly encountered clinical entity, and many women with this chronic pain condition will be treated at some point in time with opioids for management of their pain. Clinicians in women's health are frequently asked and expected to participate in the care of women with chronic pelvic pain, as well as other gynecologic pain conditions, and should be familiar with the role of opioid therapy for these conditions. The goal of this article is to help determine which patients may be appropriate candidates for the initiation or continuation of opioid therapy for gynecologic pain. In addition, this article will help the clinician to establish treatment goals, select appropriate medications, monitor the efficacy of treatment, and to determine when discontinuation of medications is appropriate.

Prevention and management of urologic injury during gynecologic laparoscopy.

PURPOSE OF REVIEW: This article provides an update on the best practices for the prevention, recognition, and management of urinary tract injuries that may occur during gynecologic laparoscopic surgery. RECENT FINDINGS: Higher surgical volume is directly associated with improved surgical outcomes, denoted by consistently lower rates of complications for commonplace procedures such as hysterectomy. As a result, expert opinion on prevention of iatrogenic urologic injury suggests a real need for improved education and training of gynecologic surgeons. Discontinued manufacturing of indigo carmine has led to the utilization of alternative methods to assess ureteral patency during cystoscopy, such as phenazopyridine or sodium fluorescein. Intraoperative cystoscopy has been shown to detect approximately 50% of urinary tract injuries during hysterectomy, but has limited accuracy and does not necessarily decrease delayed postoperative complications. When identified, most urologic injuries can be managed in a minimally invasive fashion. SUMMARY: A thorough understanding of pelvic anatomy and early recognition of urinary tract injuries can significantly reduce surgical morbidity for women undergoing laparoscopic surgery.

Cornual placenta accreta managed by postpartum total laparoscopic hysterectomy.

The patient presented here delivered at 32 weeks' gestation after expectant management of spontaneous preterm membrane rupture. She had an unusually located placenta accreta at the left cornu that required a hysterectomy for treatment. The type of abnormal placentation and the laparoscopic approach to her surgery were unique features of her care.

Post-hysterectomy dyspareunia.

When appropriately performed, hysterectomy most often contributes substantially to quality of life. Postoperative morbidity is minimal, in particular after minimally invasive surgery. In a minority of women, pain during intercourse is one of the more long-lasting sequelae of the procedure. Complete evaluation and treatment of this complication requires a thorough understanding of the status and function of neighboring organ systems and structures (urinary system, gastrointestinal tract, and pelvic and hip muscle groups). Successful resolution of dyspareunia often may be facilitated with review of the patient's previous degree of comfort during sex and the nature of her relationship with her partner. Repeat surgery is needed in a small minority of patients.

Effect of extreme obesity on outcomes in laparoscopic hysterectomy.

STUDY OBJECTIVE: To estimate the effect of body mass index (BMI) on several outcomes in laparoscopic hysterectomy, in particular in the extremes of obesity. DESIGN: Retrospective cohort study (Canadian Task Force classification II-3). SETTING: Tertiary-care university-based teaching hospital. PATIENTS: Eight hundred thirty-four patients who underwent laparoscopic hysterectomy from January 2007 to October 2011. INTERVENTION: Laparoscopic hysterectomy for benign indications. MEASUREMENTS AND MAIN RESULTS: Demographic, operative, and postoperative data were abstracted from medical records. The primary outcome was a composite index score that took into account operative time, nonsurgical operating room time, estimated blood loss, length of hospital stay, number of complications, and severity of complications according to the Dindo-Clavien classification. We individually examined elements of the composite index as a secondary outcome. Models were developed to assess the association of BMI with the composite index score and the components of the index, controlling for age, presence of diabetes, tobacco use, surgeon, type of hysterectomy (total vs supracervical), use of robotics, uterine weight, number of additional procedures performed, presence of adhesions requiring lysis, and deeply infiltrating endometriosis as potential confounders. Mean (SD) BMI was 31.4 (8.1). Mean (SD) uterine weight was 345 (388) g. Mean operative time was 150 (61) minutes. Increasing BMI was associated with a worse composite score (p < .01); longer operative time (p = .03), nonsurgical operating room time (p = .02), and total operating room time (p < .01); greater estimated blood loss (p < .01); and complication severity (p = .01). CONCLUSION: These data suggest that there is a significant association of BMI with surgical outcomes in laparoscopic hysterectomy, and the effect is most pronounced in the morbidly obese. These patients may stand to gain the greatest differential benefit from a laparoscopic approach to surgery. However, they should be properly counseled about the challenge that obesity poses to the operation.

Cesarean Scar Ectopic Pregnancy: Current Management Strategies.

IMPORTANCE: Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate. OBJECTIVE: This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment options and outcomes. EVIDENCE ACQUISITION: A literature review was performed utilizing the term cesarean scar ectopic pregnancy and subsequently selecting only meta-analyses and systematic reviews. Only articles published in English were included. Relevant articles within the reviews were analyzed as necessary. RESULTS: Five basic pathways have been identified in treatment of CSEP: expectant management, medical therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery. Medical management often requires further treatment with additional medication or surgery. Different surgical methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success and depends on surgeon skill and patient presentation. CONCLUSIONS: Recent research supports any method that removes the pregnancy and scar to reduce morbidity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, although continued research is required to identify the optimal approach. RELEVANCE: As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics and gynecology.

Hysteroscopic morcellator to overcome cervical stenosis.

OBJECTIVE: To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. DESIGN: Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. SETTING: Academic-based practice. PATIENT(S): A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. INTERVENTION(S): A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. MAIN OUTCOME MEASURE(S): Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. RESULT(S): The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. CONCLUSION(S): Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications.

Mechanical bowel preparation before laparoscopic hysterectomy: a randomized controlled trial.

OBJECTIVE: To examine the influence of mechanical bowel preparation on surgical field visualization during laparoscopic hysterectomy. METHODS: The study's primary outcome was the percentage of operations rated "good" or "excellent" in terms of surgical field visualization at the outset of the case by the primary surgeon. Additional measures included assessment of visualization during the case and patient perioperative comfort. The study was powered to detect a 20% absolute difference in the proportion of cases rated as "good" or "excellent." RESULTS: Seventy-three patients were assigned to mechanical bowel preparation and 73 to no mechanical bowel preparation. The groups were comparable regarding patient and surgery characteristics. No differences were found for this rating between groups (mechanical bowel preparation, 64 of 73 patients [87.7%], compared with no mechanical bowel preparation, 60 of 73 patients [82.2%], P=.36). Surgeons guessed patient assignment correctly 59% of the time (42 of 71 patients) with mechanical bowel preparation and 55% of the time (41 of 75 patients) with no mechanical bowel preparation. CONCLUSION: Mechanical bowel preparation is well-tolerated but does not influence surgical field visualization for laparoscopic hysterectomy. CLINICAL TRIAL REGISTRATION: ClinialTrials.gov, www.clinicaltrials.gov, NCT01576965.

Short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve: a pilot randomized controlled trial.

OBJECTIVE: To examine the short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve when ovarian preservation is planned in view of determining the feasibility of conducting the study on a larger scale. DESIGN: Pilot randomized controlled trial. SETTING: Tertiary care, academic medical center. PATIENT(S): Thirty premenopausal women aged 18 to 45 years undergoing laparoscopic hysterectomy with ovarian preservation for benign indications from April 2012 to September 2012. INTERVENTION(S): Bilateral salpingectomy (n = 15) versus no salpingectomy (n = 15) at the time of laparoscopic hysterectomy with ovarian preservation. MAIN OUTCOME MEASURE(S): Antimüllerian hormone (AMH) measured preoperatively, at 4 to 6 weeks postoperatively, and at 3 months postoperatively, with operative time and estimated blood loss abstracted from the medical records. RESULT(S): The mean AMH levels were not statistically significantly different at baseline (2.26 vs. 2.25 ng/ml), 4 to 6 weeks postoperatively (1.03 vs. 1.25 ng/ml), or 3 months postoperatively (1.86 vs. 1.82 ng/ml) among women with salpingectomy versus no salpingectomy, respectively. There was also no statistically significant temporal change in the mean AMH level from baseline to 3 months postoperatively (-0.07 vs. -0.08 ng/ml) between the two groups. No difference in operative time (116 vs. 115 minutes) or estimated blood loss (70 vs. 91 mL) was observed. CONCLUSION(S): Salpingectomy at the time of laparoscopic hysterectomy with ovarian preservation is a safe procedure that does not appear to have any short-term deleterious effects on ovarian reserve, as measured by AMH level. Conducting a trial of this nature that is adequately powered with long-term follow-up evaluation would be feasible and is required to definitively confirm these results.