Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes. DATA SOURCES: PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared. METHODS OF STUDY SELECTION: In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39). CONCLUSION: Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022326255.

Hysterectomy and Oophorectomy for Transgender Patients: Preoperative and Intraoperative Considerations.

OBJECTIVE: To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender patients. DESIGN: Stepwise demonstration of techniques with narrated video footage. SETTING: Approximately 0.3% of hysterectomies performed annually in the United States are for transgender men. While some transgender men choose hysterectomy for the same indications as cisgender women, the most prevalent diagnosis for the performed surgeries is gender dysphoria [1]. Hysterectomy with or without oophorectomy can be offered to patients who meet the World Professional Association for Transgender Health criteria [2]. INTERVENTIONS: Important perioperative counseling points for transgender patients include establishing the terminology for the relevant anatomy as well as the patient's name and pronouns; if applicable, discussing options for fertility preservation if the patient desires biological children [3,4] and discussing the use of hormone therapy post oophorectomy to reduce the loss of bone density [5,6]; and reviewing intraoperative and postoperative expectations. When performing an oophorectomy on a transgender patient for gender affirmation, it is especially important to minimize the risk of ovarian remnant syndrome and the need for additional surgery, as, for example, caused by persistent menstruation. A 2-layer vaginal cuff closure should be considered to reduce the risk of vaginal cuff complications and is preferable for patients whose pelvic organs cause gender dysphoria [7,8]. CONCLUSION: Special considerations outlined in this video and the World Professional Association for Transgender Health guidelines should be reviewed by gynecologic surgeons to minimize the transgender patient's experiences of gender dysphoria before, during, and after surgery.

Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review.

OBJECTIVE: To conduct a systematic review to evaluate the effect of procedural interventions for leiomyomas on pelvic floor symptoms. DATA SOURCES: PubMed, EMBASE, and ClinicalTrials.gov were searched from inception to January 12, 2023, searching for leiomyoma procedures and pelvic floor disorders and symptoms, restricted to primary study designs in humans. METHODS OF STUDY SELECTION: Double independent screening for studies of any study design in all languages that reported pelvic floor symptoms before and after surgical (hysterectomy, myomectomy, radiofrequency volumetric thermal ablation) or radiologic (uterine artery embolization, magnetic resonance-guided focused ultrasonography, high-intensity focused ultrasonography) procedures for management of uterine leiomyomas. Data were extracted, with risk-of-bias assessment and review by a second researcher. Random effects model meta-analyses were conducted, as feasible. TABULATION, INTEGRATION, AND RESULTS: Six randomized controlled trials, one nonrandomized comparative study, and 25 single-group studies met criteria. The overall quality of the studies was moderate. Only six studies, reporting various outcomes, directly compared two procedures for leiomyomas. Across studies, leiomyoma procedures were associated with decreased symptom distress per the UDI-6 (Urinary Distress Inventory, Short Form) (summary mean change -18.7, 95% CI -25.9 to -11.5; six studies) and improved quality of life per the IIQ-7 (Incontinence Impact Questionnaire, Short Form) (summary mean change -10.7, 95% CI -15.8 to -5.6; six studies). There was a wide range of resolution of urinary symptoms after procedural interventions (7.6-100%), and this varied over time. Urinary symptoms improved in 19.0-87.5% of patients, and the definitions for improvement varied between studies. Bowel symptoms were inconsistently reported in the literature. CONCLUSION: Urinary symptoms improved after procedural interventions for uterine leiomyomas, although there is high heterogeneity among studies and few data on long-term outcomes or comparing different procedures. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021272678.

Twitter Gynecologic Surgery Journal Club: Impact on Citation Scores and Social Media Attention.

STUDY OBJECTIVE: To study the impact of a Twitter-based gynecologic surgery journal club of articles published in the Journal of Minimally Invasive Gynecology (JMIG) on their social media attention and citation scores. DESIGN: A cross-sectional study. SETTING: N/A. PATIENTS: N/A. INTERVENTIONS: Comparison of citation and social media attention scores was conducted for all articles presented in the JMIG Twitter Journal Club (#JMIGjc), a monthly scientific discussion on Twitter of JMIG selected articles, between March 2018 and September 2021 (group A), with 2 matched control groups of other JMIG articles: group B, articles mentioned on social media but not promoted in any JMIG social media account, and group C, articles with no social media mentions and not presented in #JMIGjc. Matching was performed for publication year, design, and topic in a 1:1:1 ratio. Citation metrics included number of citations per year (CPY) and relative citation ratio (RCR). Altmetric Attention Score (AAS) was used to measure social media attention. This score tracks research articles' online activity from different sources such as social media platforms, blogs, and websites. We further compared group A with all JMIG articles published during the same period (group D). MEASUREMENTS AND MAIN RESULTS: Thirty-nine articles were presented in the #JMIGjc (group A) and were matched to 39 articles in groups B and C. Median AAS was higher in group A than groups B and C (10.00 vs 3.00 vs 0, respectively, p <.001). CPY and RCR were similar among groups. Median AAS was higher in group A than group D (10.00 vs 1.00, p <.001), as were median CPY and RCR (3.00 vs 1.67, p = .001; 1.37 vs 0.89, p = .001, respectively). CONCLUSION: Although citation metrics were similar among groups, #JMIGjc articles had higher social media attention metrics than matched controls. Compared with all publications within the same journal, #JMIGjc articles resulted in higher citation metrics.

Don't forget to look up: operating in the upper abdomen.

Given the marked improvement in laparoscopic technology, gynecologic surgeons feel comfortable operating in the pelvis for a variety of gynecologic pathologies. When pathology is found outside of the pelvis, however, gynecologic surgeons find operating in the upper abdomen challenging. Operating in the upper abdomen is difficult because of the loss of ergonomics and the impression of operating backward. It is prudent for gynecologic surgeons to master operating in the upper abdomen given the variety of pathologies a gynecologist can encounter outside of the pelvis, both benign, such as endometriosis and adhesions, and malignant, like staging procedures, omentectomy, and debulking. We aimed to describe our operating room modifications that help to simulate operating in the upper abdomen as if one was operating in the pelvic cavity. Strategies to improve efficiency and ergonomics when operating in the upper abdomen include operating room setup, switching monitors to the patient's shoulders bilaterally, changing surgeon location to the right side of the patient, port hopping, and 30-degree camera selection. We have also created an instructional video with the tools to improve surgeon confidence and ergonomics when operating in the upper abdomen.

Evaluating Surgical Complexity of Endoscopic Hysterectomy: An Inter-rater and Intra-rater Agreement Study of Novel Scoring Tool.

STUDY OBJECTIVE: Evaluate inter-rater and intrarater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy. DESIGN: Validation study. SETTING: Academic medical center. PARTICIPANTS: Total of 11 academic obstetrician-gynecologists with varying years of postresidency training, clinical practice, and surgical volumes. INTERVENTIONS: Application of a novel scoring tool to evaluate surgical complexity of 150 sets of images taken in a standardized fashion before surgical intervention (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Using only these images, raters were asked to assess uterine size, number, and location of myomas, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions in relevant locations. Surgical complexity was staged on a scale of 1 to 4 (low to high complexity). MEASUREMENTS AND MAIN RESULTS: Number of postresidency years in practice for participating surgeons ranged from 2 to 15, with an average of 8 years. A total of 8 obstetrician-gynecologists (72.7%) had completed a fellowship in minimally invasive gynecologic surgery. Six (54.6%) reported an annual volume of >50 hysterectomies. Raters reported that 95.4% of the images were satisfactory for assessment. Of the 150 sets of images, most were found to be stage 1 to 2 complexity (stage 1: 23.8%, stage 2: 41.6%, stage 3: 32.8%, stage 4: 1.8%). The level of inter-rater agreement regarding stage 1 to 2 vs 3 to 4 complexity was moderate (κ = 0.49; 95% confidence interval [CI], 0.42-0.56). Moderate inter-rater agreement was also found between surgeon raters with an annual hysterectomy volume >50 (κ = 0.49; 95% CI, 0.40-0.57) as well as between surgeon raters with fellowship experience (κ = 0.50; 95% CI, 0.42-0.58). Intrarater agreement averaged 80.2% among all raters and also achieved moderate agreement (mean weighted κ = 0.53; range, 0.38-0.72). CONCLUSION: This novel scoring tool uses clinical assessment of preintervention anatomic images to stratify the surgical complexity of endoscopic hysterectomy. It has rich and comprehensive evaluation capabilities and achieved moderate inter-rater and intrarater agreement. The tool can be used in conjunction with or instead of traditional markers of surgical complexity such as uterine weight, estimated blood loss, and operative time.

Malfunction Events in the US FDA MAUDE Database: How Does Robotic Gynecologic Surgery Compare with Other Specialties?

STUDY OBJECTIVE: To review malfunction events (MEs) related to the use of the da Vinci robot reported to the United States Food and Drug Administration Manufacturer and User Facility Device Experience in the last 10 years and compare gynecologic surgery with other surgical specialties. DESIGN: A retrospective review. SETTING: Manufacturer and User Facility Device Experience database. PATIENTS: Reports from 2010 to 2020 with keywords "Davinci" and "Intuitive". INTERVENTIONS: Report review. MEASUREMENTS AND MAIN RESULTS: There were 679 reports included in the final analysis. Most MEs occurred intraoperatively (81.7%) and were related to robotic instrument malfunction (84.5%), and 30% required an instrument switch to complete the procedure. Conversion to open and laparoscopic surgery was required in 3.1% and 1.3% of MEs, respectively. Injury to the patient occurred in 15.6% of MEs. Of the reported injuries to patients, 6.6% were related to robotic malfunction, 49.2% to instrument malfunction, and 18% to surgeon or staff misuse of the robotic system, and 15.6% were complications inherent to the procedure, not related to the robotic system. Of all the reported MEs, 4.4% were related to robot malfunction, 1.5% to console malfunction, 73.3% to Intuitive accessory malfunction, 11.2% to other accessory malfunction, 4% to surgeon or staff misuse of robotic system, and 3% to complications inherent to the procedure. Comparison between gynecologic surgery and other surgical specialties showed that 14.4% of issues were solved intraoperatively in gynecologic surgery vs 13.7% in other specialties (p = .185). The procedure was completed robotically in 85.2% in gynecologic surgery vs 84% in other specialties, laparoscopically 4.6% vs 3.7%, and open in 10.2% vs 12.4%, respectively (p = .883). In gynecologic surgery, reported MEs were made by patients in 14.8% vs 4.8% in other specialties, manufacturer in 78.4% vs 74.2%, and operating room staff in 2.3% vs 16.1%, respectively (p = .007). Injury to patient was similar in gynecologic surgery compared with other specialties (35.1% vs 23.4%, p = .122). Gynecologic and other specialty MEs did not state the need for procedure rescheduling (0% vs 0%). CONCLUSION: Most reported robotic MEs occurred intraoperatively, were related to robotic instrument malfunctions, and required an instrument switch. Most surgeries are completed robotically, but conversion to either an open or laparoscopic approach was reported in 4.4%. Of the 114 reported injuries, 47.4% were Clavien-Dindo grade III+. There were no differences noted in patient injury between gynecologic surgery and other specialties.

Health Information in the Era of Social Media: An Analysis of the Nature and Accuracy of Posts Made by Public Facebook Pages for Patients with Endometriosis.

STUDY OBJECTIVE: To analyze the nature and accuracy of social media (Facebook) content related to endometriosis. DESIGN: Retrospective content analysis. SETTING: Social media platform, Facebook. PARTICIPANTS: Social media posts on Facebook endometriosis pages. INTERVENTIONS: A search of public Facebook pages was performed using the key word "endometriosis." Posts from the month-long study period were categorized and analyzed for accuracy. Two independent researchers used thematic evaluation to place posts into the following 11 categories: educational, emotional support, advocacy, discussion, events, humor, promotional, recipes, resources, surveys, and other. Posts categorized as educational were further subcategorized and reviewed. Each posted fact was cross-referenced in peer-reviewed scientific journals to determine whether the claim made was evidence-based. Engagement in a post was calculated by taking the sum of comments, shares, and reactions. MEASUREMENTS AND MAIN RESULTS: A total of 53 Facebook pages meeting inclusion criteria were identified and 1464 posts from the study period were evaluated. Emotional support posts comprised the largest category of posts (48%) followed by educational posts (21%). Within the educational category, the epidemiology and pathophysiology subcategory comprised the largest group (42.0%) followed by the symptom's subcategory (19.6%). Post category had an effect on the amount of post engagement (p-value <.001) with emotional posts generating 70% of the overall engagement. The subcategories of the educational posts demonstrated a similar effect on engagement (p-value <.001). Posts were more engaging if they contained epidemiology and pathophysiology information with 44% of all engagement of educational posts occurring within this subcategory. Educational posts were found to be 93.93% accurate. There was no correlation between post engagement and post information accuracy (p-value = .312). CONCLUSION: Facebook pages offer emotional support and education to people with endometriosis. Most information found in these Facebook pages is evidence-based. Clinicians should consider discussing the use of Facebook pages with their patients diagnosed with endometriosis.

Does closure of fascia, type, and location of trocar influence occurrence of port site hernias? A literature review.

BACKGROUND: Since the introduction of laparoscopic surgery, it has become more popular with many advantages over open surgery including faster recovery, shorter hospital stays, and decreased tissue trauma. Despite its benefits, laparoscopic surgery can result in its own unique complications, such as the formation of a trocar site hernia (TSH), which have been reported in approximately 0-1.0% of laparoscopic cases when using non-bladed trocars. METHODS: A literature review was performed from June 1990 to June 2019. PubMed was searched using the keywords "laparoscopic surgery," "trocar site hernia," and "port site hernia." Only articles in English were identified but not limited to the USA. RESULTS: The total number of patients in all articles was 18,533 with a mean follow-up period of 22.50 ± 1.76 months. The overall trocar site hernia rate was 0.104%. When comparing open vs. closed ports, there was no significant difference in the hernia incidence rate for 5-mm and 10-mm ports. When comparing bladed versus non-bladed trocars left open, there was a statistically significant difference with lower hernia incidence rates for non-bladed trocars over bladed trocars for 5-mm, 10-mm, and 12-mm ports. And when comparing trocar location from midline versus off-midline, there was a statistically significant higher TSH incidence in midline trocar locations. CONCLUSION: Results suggest that TSH rate is lower when using non-bladed trocars for any size of trocar. When comparing whether fascial closure had an effect, the 5-mm and 10-mm ports had no difference in incidence rates and leaving the fascia open can reduce operative time, risk of needlestick injuries, and overall procedural cost. In addition, trocars at midline locations resulted in higher TSH incidence rates. Future research is still needed to assess for other factors that may influence hernia formation and how it can be minimized.

Hormone Replacement Therapy Prescription after Premature Surgical Menopause.

STUDY OBJECTIVE: To assess hormone replacement therapy (HRT) prescription pattern in patients undergoing premature surgical menopause on the basis of surgical indication. DESIGN: Retrospective cohort study. SETTING: Academic tertiary care center. PATIENTS: Surgically menopausal patients aged ≤45 years who underwent a minimally invasive hysterectomy with salpingo-oophorectomy. INTERVENTIONS: HRT prescription in the 6-week postoperative period. MEASUREMENTS AND MAIN RESULTS: A total of 63 patients met inclusion criteria. Of these, 52% (n = 33) were prescribed HRT in the 6-week postoperative period. Indications for surgical menopause included pelvic pain or endometriosis (31.7%), gynecologic malignancy (20.6%), BRCA gene mutation (17.4%), breast cancer (9.5%), Lynch syndrome (4.8%), and other (15.8%). In total, 80% of patients with pelvic pain, 25% with gynecologic malignancies, 45% with BRCA gene mutations, 33.3% with breast cancer, and 66.6% with Lynch syndrome used HRT postoperatively. In patients who used HRT postoperatively, 76% were offered preoperative HRT counseling. This is in contrast with those patients who did not use HRT postoperatively, of whom only 33% were offered HRT counseling (p <.001). Perioperative complications were not predictive of HRT use postoperatively. In patients who did not use HRT postoperatively, 13.3% used alternative nonhormonal therapy. CONCLUSION: In patients who underwent premature surgical menopause, 52% used HRT postoperatively. Patients with pelvic pain and Lynch syndrome were more likely to use HRT, whereas those with gynecologic or breast malignancies and BRCA gene mutations were less likely to use HRT. Preoperative HRT counseling was associated with postoperative HRT use.