Guideline No. 449: Diagnosis and Impact of Endometriosis - A Canadian Guideline.

OBJECTIVE: To provide a contemporary approach to the understanding of the impact and methods for the diagnosis of endometriosis in Canada. TARGET POPULATION: Individuals, families, communities, health care providers, and health care administrators who are affected by, care for patients with, or manage delivery of services for endometriosis. OPTIONS: The diagnosis of endometriosis is facilitated by a detailed history, examination, and imaging tests with providers who are experienced in endometriosis care. Surgical evaluation with pathology confirms a diagnosis of endometriosis; however, it is not required for those whose diagnosis was confirmed with imaging. OUTCOMES: There is a need to address earlier recognition of endometriosis to facilitate timely access to care and support. Education directed at the public, affected individuals and families, health care providers, and health care administrators are essential to reduce delays in diagnosis and treatment. BENEFITS, HARMS, AND COSTS: Increased awareness and education about the impact and approach to diagnosis may support timely access to care for patients and families affected by endometriosis. Earlier and appropriate care may support a reduced health care system burden; however, improved clinical evaluation may require initial investments. EVIDENCE: Each section was reviewed with a unique search strategy representative of the evidence available in the literature related to the area of focus. The literature searches for each section of this guideline are listed in Appendix A and include information from published systematic reviews described in the text. VALIDATION METHODS: The recommendations were developed following two rounds of review by a national expert panel through an iterative 2-year consensus process. Further details on the process are shared in Appendix B. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix C (Table C1 for definitions and Table C2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE: This guideline is intended to support health care providers and policymakers involved in the care of those impacted by endometriosis and the systems required to support them. TWEETABLE ABSTRACT: Endometriosis impact and diagnosis updated guidelines for Canadian health care providers and policymakers. SUMMARY STATEMENTS: RECOMMENDATIONS.

Surgical Outcomes between Routes of Hysterectomy in Patients with a Previous Cesarean Section.

STUDY OBJECTIVE: To determine the difference in surgical complications for patients with a previous cesarean section (CS) undergoing abdominal, vaginal, or laparoscopic hysterectomy. DESIGN: A population-based retrospective cohort study. SETTING: Province of Ontario, Canada. PATIENTS: 10 300 patients with at least 1 CS between July 1, 1991, and February 17, 2018. INTERVENTIONS: Benign, nongravid hysterectomy between Apr 1, 2002, and March 31, 2018. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite of all surgical complications within 30 days of surgery. Secondary outcomes were rate of genitourinary complications, readmission to hospital, and emergency department visit occurring within 30 days of surgery. Of 10 300 patients who had at least one previous CS, who underwent subsequent hysterectomy for a benign indication, 7370 underwent an abdominal hysterectomy (71.55%), 813 (7.9%) had a vaginal hysterectomy, and 2117 (20.55%) underwent a laparoscopic hysterectomy. The adjusted odds of any surgical complication from hysterectomy was significantly lower when performed by the vaginal approach than the laparoscopic approach (odds ratio, 0.32; 95% confidence interval, 0.20-0.51; p <.0001). There was no difference in the odds of surgical complication between abdominal and laparoscopic approaches (odds ratio, 1.09; 95% confidence interval, 0.87-1.37; p = .45). CONCLUSION: Our retrospective population-based study demonstrates that, after previous CS, patients selected to undergo vaginal hysterectomy experienced lower risk than either abdominal or laparoscopic approaches. This suggests that CS alone should not be a contraindication to vaginal hysterectomy.

Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies.

STUDY OBJECTIVE: The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. DESIGN: A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. SETTING: Canada. PATIENTS: All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different. CONCLUSION: The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.

Impact of Resident Overnight Duty Hour Changes on Obstetrical Outcomes: A Population-Based Cohort Study.

OBJECTIVE: To determine whether obstetrical patient outcomes have changed following the introduction of restricted resident work hours. METHODS: A population-based retrospective cohort study of the effects of restricted duty hours for residents in July 2013 at three academic hospitals in Toronto, ON using linked health care databases. The study included 6763 deliveries in the 2 years pre-exposure and 5548 deliveries in the 2 years post-exposure. RESULTS: The primary outcome, planned prior to data collection, was a composite index of 29 maternal/fetal outcomes including maternal transfusion/postpartum hemorrhage, maternal infection, fetal mortality, NICU admissions, and surgical/obstetrical complications. There were seven secondary outcomes analysed: NICU admissions; neonatal death; maternal transfusion or postpartum hemorrhage; maternal infection; and three composite measures. A generalized estimating equation model, clustered by institution, was utilized to assess for differences post-intervention. We found no significant differences in baseline demographics between groups. After the implementation of duty hour restrictions, no significant difference was seen in the primary outcome. However, an increased incidence of composite maternal surgical/obstetrical outcomes (OR 1.191; 95% CI 1.037-1.367, P = 0.013) and transfusion/postpartum hemorrhage (OR 1.232; 95% CI 1.074-1.413, P = 0.003) was found. There were no significant differences in other secondary outcomes. CONCLUSION: Since the implementation of resident duty hour restrictions, there was no overall change in patient outcomes. However, there was an increase in surgical/obstetrical complications and transfusion/postpartum hemorrhage. This suggests that duty hour restrictions may not be beneficial to patient outcomes. It highlights the need to further investigate the clinical impact of a change in resident duty hours.

Trends over time in the use of laparoscopic hysterectomy for the treatment of endometrial cancer.

OBJECTIVE: To determine the rates of laparoscopy compared to laparotomy over time for the treatment of endometrial cancer in the province of Ontario, Canada, and to determine factors associated with having laparoscopic surgery. METHODS: This was a population-based retrospective cohort study using healthcare administrative databases. Incident cases of endometrial cancer from April 2002-March 2011 were identified in the provincial cancer registry. Record linkages were made with other healthcare databases to determine type of hysterectomy (laparoscopic or abdominal±staging), year of diagnosis, comorbidities, location of residence, surgeon and hospital type. RESULTS: 12,104 patients with endometrial cancer treated with hysterectomy were identified, of which 2116 had laparoscopic surgery (17.5%). Rates of laparoscopy increased over time from 6.5% in 2002 to 30.2% in 2011 (p<0.0001). The median length of hospital stay after abdominal hysterectomy was significantly longer (3 days vs 1 day, p<0.0001). Adjusting for age, comorbidity score, income quintile and type of hospital (community versus academic), the probability of admission or emergency room visit within 30 days of surgery was significantly higher in patients with abdominal surgery (OR 1.61) (95% CI 1.36-1.92) (p<0.0001). The odds of having laparoscopic surgery was higher with a gynecologic oncologist (OR 2.85, 95% CI 1.61-5.85) or a general gynecologist at an academic hospital (OR 2.07, 95% CI 1.09-3.95) compared to a general gynecologist at a community hospital. CONCLUSIONS: This population-based cohort study confirms the increased use over time of laparoscopic surgery to treat endometrial cancers in Ontario, and demonstrates the benefits of decreased hospital stay and decreased patient morbidity.

First- versus second-generation endometrial ablation devices for treatment of menorrhagia: a systematic review, meta-analysis and appraisal of economic evaluations.

OBJECTIVE: To estimate the clinical and economic effect of using second-generation endometrial ablation devices compared to first-generation devices for treatment of menorrhagia in pre-menopausal women. The secondary objective was to compare the second-generation devices with one another. DATA SOURCES: We searched Medline and EMBASE, and other sources of unpublished literature, and screened references from relevant articles. STUDY SELECTION: We included only randomized controlled trials or full economic evaluations of premenopausal women with menorrhagia undergoing endometrial ablation using first-generation compared with second-generation devices. DATA EXTRACTION AND DATA SYNTHESIS: Data extraction and risk of bias assessment was carried out for all clinical studies, and data were pooled using the random effects model. A qualitative narrative synthesis was used to combine results from the economic review. Eleven studies met eligibility criteria (n = 1679). There was no difference in the rate of amenorrhea between first- and second-generation ablation (5 studies with 998 patients, rate ratio 1.15, 95% CI 0.96 to 1.38; P = 0.14), but second-generation devices had a lower complication rate (7 studies with 1272 patients, rate ratio 0.52, 95% CI 0.35 to 0.76; P < 0.001), decreased operating time by 16.6 minutes (3 studies with 486 patients, 95% CI 12.1 to 21.2 minutes; P < 0.001), and could more commonly be used with local anaesthesia (3 studies with 558 patients, rate ratio 1.87, 95% CI 1.04 to 3.37; P = 0.04). There was a higher rate of amenorrhea in patients treated with Novasure than with other second-generation devices (4 studies with 407 patients, rate ratio 2.60, 95% CI 1.63 to 4.14; P < 0.001). Three European studies were included in the economic synthesis, which found that second-generation devices were more cost-effective than first-generation devices. CONCLUSION: Second-generation endometrial ablation devices seem to be as effective as first-generation devices but likely reduce operating time, can be used more often with local anaesthesia, and have fewer complications. They also seem to be more cost-effective than first-generation devices, but further economic evaluations need to be carried out in Canada.

Objectif : Estimer les effets cliniques et économiques de l'utilisation de dispositifs d'ablation endométriale de deuxième génération, par comparaison avec l'utilisation de dispositifs de première génération, pour ce qui est de la prise en charge de la ménorragie chez les femmes préménopausées. Nous avions pour objectif secondaire de comparer les dispositifs de deuxième génération les uns aux autres. Sources de données : Nous avons mené des recherches dans Medline, EMBASE et d'autres sources de littérature non publiée; nous avons également analysé les références des articles pertinents. Sélection d'études : Nous n'avons inclus que les essais comparatifs randomisés ou les évaluations économiques exhaustives comparant l'utilisation de dispositifs d'ablation endométriale de deuxième génération à l'utilisation de dispositifs de première génération chez des femmes préménopausées présentant une ménorragie. Extraction et synthèse des données : L'extraction des données et l'évaluation du risque de biais ont été menées pour toutes les études cliniques, et les données ont été regroupées au moyen du modèle à effets aléatoires. Une synthèse descriptive qualitative a été utilisée pour combiner les résultats issus de l'analyse économique. Onze études ont satisfait aux critères d'admissibilité (n = 1 679). Aucune différence n'a été constatée en matière de taux d'aménorrhée entre les dispositifs d'ablation de première et de deuxième génération (5 études comptant 998 patientes, ratio des taux 1,15, IC à 95 %, 0,96 - 1,38; P = 0,14); cependant, les dispositifs de deuxième génération présentaient un taux de complication moindre (7 études comptant 1 272 patientes, ratio des taux 0,52, IC à 95 %, 0,3 5 - 0,76; P < 0,001), une réduction de 16,6 minutes de la durée de l'opération (3 études comptant 486 patientes, IC à 95 %, 12,1 - 21,2 minutes; P < 0,001) et pouvaient plus couramment être utilisés en présence d'une anesthésie locale (3 études comptant 558 patientes, ratio des taux 1,87, IC à 95 %, 1,04 - 3,37; P = 0,04). Les patientes traitées au moyen du dispositif Novasure ont présenté un taux d'aménorrhée plus élevé que les patientes traitées au moyen d'autres dispositifs de deuxième génération (4 études comptant 407 patientes, ratio des taux 2.60, IC à 95 %, 1,63 - 4,14; P < 0,001). Trois études européennes ont été incluses dans la synthèse économique, laquelle a constaté que les dispositifs de deuxième génération étaient plus rentables que les dispositifs de première génération. Conclusion : Bien que les dispositifs d'ablation endométriale de deuxième génération et de première génération semblent présenter une efficacité comparable, les dispositifs de deuxième génération sont susceptibles de réduire la durée de l'opération, peuvent plus souvent être utilisés en présence d'une anesthésie locale et donnent lieu à un moins grand nombre de complications. Ils semblent également être plus rentables que les dispositifs de première génération; toutefois, la tenue d'autres évaluations économiques au Canada s'avère requise.

A novel approach to the surgical management of clitoral phimosis.

BACKGROUND: The objective of this case series was to outline a novel method for surgical correction of clitoral phimosis caused by vulvar lichen sclerosus (LS) or lichen planus (LP) and to review the postoperative outcomes. CASE SERIES: We used the CO2 laser to treat clitoral phimosis in 20 women with LS and three women with LP. All patients underwent individualized preoperative and postoperative topical therapy with steroids or immunomodulators. Five women with LS had mild reagglutination during follow-up but were satisfied with the results, and three required reoperation, with satisfactory results in follow-up. Two women with LP required reoperation. CONCLUSION: This novel surgical technique has enabled the treatment of clitoral phimosis secondary to LS or LP, but further studies are required. Medical maintenance therapy postoperatively is a vital component of treatment.

Canadian hysterectomy educational experience: survey of recent graduates in obstetrics and gynecology.

STUDY OBJECTIVES: To determine the hysterectomy surgical training acquired by 289 recent (2005-2010) Canadian graduates in obstetrics and gynecology, their comfort level in performing various types of hysterectomy, and their practice plans. DESIGN: Electronically distributed national survey (Canadian Task Force classification III). MEASUREMENTS AND MAIN RESULTS: The response rate was 37% (107 respondents). In the laparoscopic hysterectomy categories, during residency, 56% performed 5 laparoscopic subtotal hysterectomies (LSTHs) or fewer, 69.1% performed 5 total laparoscopic hysterectomies (TLHs) or fewer, and 43.9% performed 5 laparoscopic-assisted vaginal hysterectomies (LAVHs) or fewer. In contrast, 64.5% performed at least 50 abdominal hysterectomies, and 57.1% performed at least 21 vaginal hysterectomies. Although most respondents reported they were comfortable performing abdominal hysterectomy (99%) and vaginal hysterectomy (87%), fewer were comfortable performing LAVH (63.4%), LSTH (42%), and TLH (26%). Only 40.2%, 60.9%, and 69.7%, respectively, plan to perform LSTH, TLH, and LAVH in their practices. There was a trend toward increasing comfort level with laparoscopic hysterectomy as the years since graduation increased, but no difference in practice plans. Most respondents gain further surgical proficiency through fellowship training and colleague preceptorship. CONCLUSIONS: Although laparoscopic hysterectomy has substantial benefits compared with laparotomy, Canadian residents in obstetrics and gynecology are not receiving adequate training to feel comfortable using the laparoscopic approach as opposed to the vaginal and abdominal routes. To improve patient care, further educational initiatives are needed to ensure that graduates are capable of performing all types of hysterectomy.

Unexplained amenorrhea in a patient taking methotrexate for the treatment of rheumatoid arthritis.

BACKGROUND: The cause of secondary amenorrhea in the following case cannot be explained by traditional etiologies. We therefore questioned whether long-term methotrexate treatment played a role as an endometrial inhibitor. CASE: A 44-year-old G4P2, with a 5-year history of rheumatoid arthritis, presented with a 2-year history of secondary amenorrhea. The patient took methotrexate since diagnosis. Her FSH, estrogen, prolactin, TSH and T4 levels were normal, her B-HCG was negative, her BMI was 22 and she had no history of Asherman's syndrome. CONCLUSION: There is no information, based on our search, on whether long-term methotrexate treatment has an effect on the menstrual cycle. This case highlights the need for the elucidation of the effects of long-term methotrexate treatment on the menstrual cycle in patients with rheumatoid arthritis.

A novel regimen of combination transdermal estrogen and intermittent vaginally administered progesterone for relief of menopausal symptoms.

OBJECTIVES: To determine the safety and efficacy of a novel regimen of transdermal estrogen and vaginally administered progesterone for treatment of menopausal symptoms. STUDY METHODS: A retrospective chart review was conducted of menopausal patients aged 46-65, using an oestradiol patch and vaginally administered prometrium for at least 1 year. Available transvaginal ultrasound (TVUS) measurements of endometrial thickness and endometrial biopsy results after at least 1 year of treatment were collated. Symptom relief, bleeding and side effects were reviewed. RESULTS: Forty-one patients were identified, using an estrogen patch ranging from 25 to 100 µg twice weekly and vaginal prometrium either continuously 3-5 days weekly (36 patients), or sequentially 12 days/month (5 patients). Seventeen patients were lost to follow-up or discontinued therapy within 1 year. Only 23.5% (4/17 patients) of patients who had a TVUS after 1 year (or sooner if bleeding occurred) had a thickened endometrial lining on ultrasound (>5 mm), and all of these had normal endometrial biopsies. By 1 year of follow-up, 91.7% of patients were amenorrhoeic. All patients had relief of menopausal symptoms. CONCLUSIONS: Vaginal administration of progesterone as part of combined estrogen plus progestin therapy has the potential for decreasing side effects while maintaining endometrial safety and amenorrhoea. Larger prospective trials are warranted.

Urological issues in pregnancy: A review for urologists.

Urological issues in the pregnant patient present a unique clinical dilemma. These patients may be challenging to treat due to risks associated with medications and surgical procedures. This review aims to provide an update on the physiological changes and surgical risks in pregnancy. In addition, we review the approach for management of urolithiasis and urinary tract infections in pregnancy. Lastly, we highlight the importance of a multidisciplinary approach to placenta percreta, a condition not commonly addressed in urological education.

Incidence, Treatment, and Implications of Kidney Stones During Pregnancy: A Matched Population-Based Cohort Study.

Purpose: To determine the incidence of kidney stones in pregnancy, the risk of adverse birth outcomes, and treatment trends. Methods: We performed a population-based matched cohort study using Ontario's health care databases. All pregnancies in Ontario from 2004 to 2014 were identified. The study exposure was hospital admission, emergency room visit, or intervention for kidney stones during pregnancy. Each pregnancy with a stone was matched to up to six pregnancies without a stone based on age, region of residence, income quintile, year of cohort entry, prior births, and multibirths. The primary outcome was adverse birth outcome defined as preterm birth, low birth weight, or infant death. Secondary outcomes included premature rupture of membranes (PROM), pre-eclampsia, and cesarean section (C/S), as well as the type/frequency of intervention for stones in pregnancy. Logistic regression models, with generalized estimating equations, were used to assess any differences in study outcomes across groups. Results: Of 1.39 million pregnancies identified, there were 2863 pregnancies with stones (0.2%), which were matched with 17,171 pregnancies without stones. Pregnancies with stones had an increased risk for adverse birth outcome compared with matched pregnancies without stones (odds ratio [OR] 1.62, confidence interval [95% CI] 1.43-1.82, p < 0.0001). Pregnancies with stones also had a greater risk for pre-eclampsia (OR 1.42, 95% CI 1.02-1.99, p = 0.04) and C/S (OR 1.39, 95% CI 1.27-1.51, p < 0.0001), but not PROM. Twenty-six percent of pregnant patients admitted for a stone had an intervention, most commonly a stent or ureteroscopy. Conclusion: Our study demonstrated an increased risk of adverse birth outcomes in pregnancies with kidney stones. These results will be important for counseling pregnant patients with kidney stones and women of reproductive age who are at risk of developing stones.

Laparoscopic peritoneal entry preferences among Canadian gynaecologists.

OBJECTIVES: To understand current laparoscopic entry practices among Canadian gynaecologists and to raise awareness of patient safety in accordance with the Society of Obstetricians and Gynaecologists of Canada clinical practice guideline, "Laparoscopic Entry: A Review of Techniques, Technologies, and Complications," published in May 2007. METHODS: A national survey was designed to determine different laparoscopic entry methods used by practising gynaecologists, to determine entry locations, and to gather information about mishaps. The survey was translated into French for francophone practitioners. In total, the survey was forwarded to 590 SOGC members. RESULTS: Of 269 responses (a 45.6% response rate), 224 responses were from obstetrician-gynaecologists who identified themselves as currently practising laparoscopy. Seventy-five percent of these respondents reported that they had read the SOGC laparoscopic entry guideline. There was no significant difference in practice patterns when comparing geographic practice location, gender, and number of years in practice. For laparoscopy in an unscarred abdomen, the most common entry method is Veress needle insufflation with closed trocar entry (78.9%). When adhesions are suspected, only 25.4% utilize the left upper quadrant. Of respondents, 28.7% use an insufflation pressure of 20-25 mm Hg. CONCLUSIONS: Our survey had a significant response rate and was able to delineate current laparoscopic entry practice patterns of gynaecologists, which were consistent across Canada. Despite 72.9% of respondents reporting familiarity with the recent SOGC clinical practice guideline, it appears that clinical practice does not necessarily coincide with current recommendations. These variances in gynaecological practice emphasize the need for further educational initiatives to ensure that the evidence from research is used to make clinical practice safer.

Preoperative Practice Paired With Instructor Feedback May Not Improve Obstetrics-Gynecology Residents' Operative Performance.

BACKGROUND: There is evidence that preoperative practice prior to surgery can improve trainee performance, but the optimal approach has not been studied. OBJECTIVE: We sought to determine if preoperative practice by surgical trainees paired with instructor feedback improved surgical technique, compared to preoperative practice or feedback alone. METHODS: We conducted a randomized controlled trial of obstetrics-gynecology trainees, stratified on a simulator-assessed surgical skill. Participants were randomized to preoperative practice on a simulator with instructor feedback (PPF), preoperative practice alone (PP), or feedback alone (F). Trainees then completed a laparoscopic salpingectomy, and the operative performance was evaluated using an assessment tool. RESULTS: A total of 18 residents were randomized and completed the study, 6 in each arm. The mean baseline score on the simulator was comparable in each group (67% for PPF, 68% for PP, and 70% for F). While the median score on the assessment tool for laparoscopic salpingectomy in the PPF group was the highest, there was no statistically significant difference in assessment scores for the PPF group (32.75; range, 15-36) compared to the PP group (14.5; range, 10-34) and the F group (21.25; range, 10.5-32). The interrater correlation between the video reviewers was 0.87 (95% confidence interval 0.70-0.95) using the intraclass correlation coefficient. CONCLUSIONS: This study suggests that a surgical preoperative practice with instructor feedback may not improve operative technique compared to either preoperative practice or feedback alone.

Peripheral Nerve Injury during Abdominal-Pelvic Surgery: Analysis of the National Surgical Quality Improvement Program Database.

Peripheral nerve injury (PNI) is a rare but preventable complication of surgery. We sought to assess whether the use of minimally invasive surgery (MIS) affects the occurrence of PNI. Using the American College of Surgeons National Surgical Quality Improvement Program database, we examined rates of PNI among patients undergoing appendectomy, hysterectomy, colectomy, or radical prostatectomy between 2005 and 2012. We assessed the effect of MIS, as compared with open surgery, on PNI occurrence using logistic regression. Among 297,532 patients, of whom 175,884 (59.1%) underwent MIS, the rate of PNI was 0.03 per cent. Forty-four patients treated using MIS had PNI (0.03%) as compared with 63 who underwent open surgery (0.05%; P = 0.0002). There was a significant decrease in the proportion of surgeries resulting in PNI (P < 0.0001) over time. In univariate analysis, MIS was associated with a decreased occurrence of PNI (odds ratio 0.48, 95% confidence interval 0.33-0.71), but this became nonsignificant on multivariable analysis (odds ratio 0.71, 95% confidence interval 0.47-1.09). Increased operative time and smoking status were the only factors independently associated with an increased risk of PNI on multivariable analysis. MIS techniques during common abdominal-pelvic surgeries do not appear to increase the risk of PNI. Prolonged operative time and smoking are independently associated with an increased risk of PNI. Quality improvement initiatives to increase awareness of PNI and identify patients at increased risk of this preventable complication should be considered.

Occurrence of and Risk Factors for Urological Intervention During Benign Hysterectomy: Analysis of the National Surgical Quality Improvement Program Database.

OBJECTIVE: To determine the occurrence of lower genitourinary tract (LGUT) injury during hysterectomy for benign disease and identify risk factors for LGUT injury, with a specific focus on the effect of hysterectomy modality. METHODS: We performed a retrospective cohort study of patients undergoing hysterectomy for benign disease from 2010 t o 2014 using the American College of Surgeons National Surgical Quality Improvement Program, a multi-institutional prospective registry that captures perioperative surgical outcomes. We identified the occurrence of concomitant cystoscopy and therapeutic urologic interventions including endoscopic ureteric stenting, ureteric repair, bladder repair, cystectomy, and urinary diversion as a proxy for LGUT injuries. Adjusted odds ratios and 95% confidence intervals were calculated using multivariate logistic regression. RESULTS: We identified 101,021 patients treated with hysterectomy for benign disease: 18,610 (18.4%), 27,427 (27.2%), and 54,984 (54.4%) underwent vaginal, open, and laparoscopic hysterectomy, respectively. Cystoscopy was performed in 16,493 cases (16.3%). There were 2427 patients (2.4%) who underwent concomitant urologic intervention. Patients undergoing laparoscopic hysterectomy had increased occurrence of urologic intervention, excluding cystoscopy (adjusted odds ratio 1.47, 95% confidence interval 1.29-1.69), compared to vaginal hysterectomy; no differences were found between open and vaginal hysterectomy or laparoscopic and open hysterectomy. Larger uteri, a postoperative diagnosis of endometriosis, increasing comorbidity, and African American race were associated with an increased odd of urologic intervention whereas concomitant cystoscopy was associated with a decreased chance. CONCLUSION: The incidence of lower genitourinary tract intervention in benign hysterectomy is significant and may be higher than previously reported. Predisposing patient factors and operative technique are key risk factors.

The norepinephrine transporter gene and attention-deficit hyperactivity disorder.

The adrenergic system plays a known role in attentional systems and a suspected causal role in attention-deficit hyperactivity disorder (ADHD), based on evidence from pharmacological interventions and animal models. The efficacy of the highly selective noradrenergic reuptake inhibitor, tomoxetine, in treating ADHD symptoms supports the system's role in ADHD and points to the norephinephrine transporter as a candidate gene. This study tested the gene for the norepinephrine transporter (NET1) as a susceptibility factor in ADHD using three polymorphisms located in exon 9, intron 9, and intron 13. We examined the inheritance of these polymorphisms in a sample of 122 families with a total of 155 children with ADHD identified through an ADHD proband. Use of the transmission disequilibrium test failed to show significant evidence for biased transmission of any of the alleles or the haplotypes of these polymorphisms. We further investigated this gene by screening the probands for five known amino acid variants to determine if they contributed to the ADHD phenotype but observed only one (Thr99Ile) in our sample. Since the frequency of this variant (1.8%) was similar to that previously reported in a control sample (2.2%), it is unlikely that this variant is related to the ADHD phenotype. Our results do not support the NET1 gene as a major genetic susceptibility factor in ADHD.