Guideline No. 453: Endometrial Ablation in the Management of Abnormal Uterine Bleeding.

OBJECTIVE: To provide an update of the current evidence-based guideline on the techniques and technologies used in endometrial ablation, a minimally invasive technique for the management of abnormal uterine bleeding of benign origin. TARGET POPULATION: Women of reproductive age with abnormal uterine bleeding and benign pathology with or without structural abnormalities. BENEFITS, HARMS, AND COSTS: Implementation of the guideline recommendations will improve the provision of endometrial ablation as an effective treatment for abnormal uterine bleeding. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients. EVIDENCE: The guideline was updated with published literature retrieved through searches of Medline and the Cochrane Library from January 2014 to April 2023, using appropriate controlled vocabulary and keywords (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English. Grey (unpublished) literature was retrieved from the Association of Obstetricians and Gynecologists of Quebec (AOGQ) in 2023. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Obstetricians, gynaecologists, and primary care providers. SOCIAL MEDIA ABSTRACT: This is an updated version of the 2015 SOGC Endometrial Ablation guideline. The authors discuss special considerations, update evidence, and make new fluid deficit recommendations. SUMMARY STATEMENTS: RECOMMENDATIONS.

Good practice with fluid management in operative hysteroscopy.

Hysteroscopic surgery requires a balance of continuous controlled irrigation and aspiration to distend the endometrial cavity to a degree that provides the clear and stable visual environment necessary for diagnostic and therapeutic procedures. Whereas the preferred distending solution should be isotonic and isonatremic, radiofrequency (RF) electrosurgery with monopolar instrumentation can only be performed with non-ionic (hyponatremic) solutions. Absorption of as little as 500 mL and certainly more than 1000 mL of non-ionic solutions can result in fluid overload and/or dilutional hyponatremia with potentially serious adverse effects under certain conditions and patient characteristics. Both hysteroscopic RF electrosurgery with bipolar instrumentation and electro-mechanical morcellation and aspiration systems use isotonic and isonatremic solutions. Depending on the clinical context, absorption of more than 1500 mL of isonatremic solutions can also result in serious adverse effects. Automated fluid management systems are preferred and recommended, and surgeons should aim to maintain the maximum allowable intravasation of distending media below 1000 and 1500 mL for non-ionic and ionic fluids, respectively.

Guideline No. 453: endometrial ablation in the management of abnormal uterine bleeding

To provide an update of the current evidence-based guideline on the techniques and technologies used in endometrial ablation, a minimally invasive technique for the management of abnormal uterine bleeding of benign origin. Women of reproductive age with abnormal uterine bleeding and benign pathology with or without structural abnormalities. Implementation of the guideline recommendations will improve the provision of endometrial ablation as an effective treatment for abnormal uterine bleeding. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients. The guideline was updated with published literature retrieved through searches of Medline and the Cochrane Library from January 2014 to April 2023, using appropriate controlled vocabulary and keywords (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English. Grey (unpublished) literature was retrieved from the Association of Obstetricians and Gynecologists of Quebec (AOGQ) in 2023. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). Obstetricians, gynaecologists, and primary care providers. Social Media Abstract This is an updated version of the 2015 SOGC Endometrial Ablation guideline. The authors discuss special considerations, update evidence, and make new fluid deficit recommendations.

Preoperative Mechanical Bowel Preparation for Gynecologic Surgeries: A Systematic Review with Meta-analysis.

OBJECTIVE: To assess the efficacy and safety of mechanical bowel preparation (MBP) before benign laparoscopic or vaginal gynecologic surgeries. DATA SOURCES: Database searches of MEDLINE (PubMed), Embase (OVID), Cochrane Central Register of Controlled Trials, and Web of Sciences and citations and reference lists published up to December 2021. METHODS OF STUDY SELECTION: Randomized clinical trials in any language comparing MBP with no preparation were included. Two reviewers independently screened 925 records and extracted data from 12 selected articles and assessed the risk of bias with the Cochrane risk-of-bias tool for randomized trials tool. A random-effects model was used for the analysis. Surgeon findings (surgical field view, quality of bowel handling and bowel preparation), operative outcomes (blood loss, operative time, length of stay, surgical site infection), and patient's preoperative symptoms and satisfaction were collected. TABULATION, INTEGRATION, AND RESULTS: Thirteen studies (1715 patients) assessing oral and rectal preparations before laparoscopic and vaginal gynecologic surgeries were included. No significant differences were observed with or without MBP on surgical field view (primary outcome, risk ratio [RR] 1.01, 95% confidence interval [CI] 0.97-1.05, p = .66, I2 = 0%), bowel handling (RR 1.01, 95% CI 0.95-1.08, p = .78, I2 = 67%), or bowel preparation. In addition, there were no statistically significant differences in perioperative findings. MBP was associated with increased pain (mean difference [MD] 11.62[2.80-20.44], I2 = 76, p = .01), weakness (MD 10.73[0.60-20.87], I2 = 94, p = .04), hunger (MD 17.52 [8.04-27.00], I2 = 83, p = .0003), insomnia (MD 10.13[0.57-19.68], I2 = 82, p = .04), and lower satisfaction (RR 0.68, 95% CI 0.53-0.87, I2 = 76%, p = .002) compared with controls. CONCLUSIONS: MBP has not been associated with improved surgical field view, bowel handling, or operative outcome. However, in view of the adverse effects induced, its routine use before benign gynecologic surgeries should be abandoned.

Predictive Factors for Morcellation during Total Laparoscopic Hysterectomy: A Cohort Study.

OBJECTIVES: Our objective was to identify predictors of morcellation during a total laparoscopic hysterectomy (TLH). METHODS: A retrospective cohort study (Canadian Task Force classification II-2) taking place in a university hospital center in Quebec, Canada. Participants were women undergoing a TLH for a benign gynaecologic pathology from January 1, 2017, to January 31, 2019. All women underwent a TLH. If the uterus was too voluminous to be removed vaginally, surgeons favoured in-bag morcellation by laparoscopy. Uterine weight and characteristics were assessed before surgery by ultrasound or magnetic resonance imaging to predict morcellation. RESULTS: A total of 252 women underwent a TLH and the mean age was 46 ± 7 (30-71) years old. The main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17-1572) ± 272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least 1 leiomyoma. Among women with a uterine weight <250 grams, 120 (95%) did not require morcellation. On the opposite, among women with a uterine weight >500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (≥250 vs. <250 grams; OR 3.7 [CI 1.8 to 7.7, P < 0.01]), having ≥ 1 leiomyoma (OR 4.1, CI 1.0 to 16.0, P = 0.01) and leiomyoma of ≥5 cm (OR 8.6, CI 4.1 to 17.9, P < 0.01) were other significant predictors morcellation in multivariate logistic regression analysis. CONCLUSIONS: Uterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation.

Evaluation of a Standardized Questionnaire for Initial Assessment of Abnormal Uterine Bleeding in Premenopausal Women.

OBJECTIVE: To assess the effect of a standardized questionnaire for premenopausal women with abnormal uterine bleeding (AUB) on clinical information collection and duration of consultation. METHODS: We conducted a before and after study involving 100 premenopausal women undergoing consultation for AUB. During stage 1, 50 consultations were recorded on a consultation sheet with no specific template. During stage 2, 50 women completed a 26-item auto-administered standardized questionnaire before the consultation, which was then reviewed with the consultant and added to the medical record. The duration of consultation was assessed in subgroups of 27 women in each stage. Two independent evaluators assessed the quality and completeness of data collected in the medical records using a score sheet developed by experts. Outcomes from both stages were compared using the t test. RESULTS: The descriptive characteristics were similar in both groups. The mean global scores of the quality and completeness of data collected improved significantly between stages 1 and 2, from 67% ± 12% to 95% ± 5% (P < 0.0001), as did medical background scores (54% ± 29% vs. 85% ± 13%; P < 0.0001) and AUB-related symptoms scores (69% ± 13% vs. 97% ± 5%; P < 0.0001). A mean reduction in duration of consultation of nearly 4 minutes was observed (24.6 ± 4.3 min vs. 20.7 ± 4.8 min; P < 0.0001). CONCLUSION: The AUB-specific standardized questionnaire improves quality and completeness of data collected in medical records and reduces duration of consultation.

Effect of Postoperative Hormonal Suppression on Fertility in Patients With Endometriosis After Conservative Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the effect of hormonal suppression on fertility when administered to infertile patients or patient wishing to conceive after surgery for endometriosis. DATA SOURCES: A systematic search of MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov was performed by two independent reviewers from the databases' inception until December 2020. METHODS OF STUDY SELECTION: We included randomized controlled trials comparing any suppressive hormonal therapy to an inactive control (placebo or absence of treatment) after conservative surgery for endometriosis. Studies that did not report fertility outcomes after surgery were excluded. TABULATION, INTEGRATION AND RESULTS: This systematic review and meta-analysis was registered in PROSPERO. Two reviewers extracted data and assessed the risk of bias as well as the strength of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed. Relative risks (RRs) were pooled by quantitative random effect meta-analysis. From 3,138 citations, 19 trials (2,028 patients) were included. Overall, no difference was observed between the treatment and the control group for pregnancy (RR 1.15; 95% CI 1.00-1.32) and live births (RR 1.05; 95% CI 0.84-1.32). When pooling all hormonal therapies, the duration of administration of postoperative therapy was identified as a substantial source of heterogeneity between studies (I2 difference=74%) with increased chances of pregnancy compared with control when administered for at least 3 months (RR 1.22; 95% CI 1.04-1.43). Gonadotropin-releasing hormone (GnRH) agonists (14 trials, 1,721 patients) were associated with increased chances of pregnancy compared with placebo or no treatment (RR 1.20; 95% CI 1.03-1.41; I2=25%). Data were limited for other hormonal treatments with no significant difference between groups. Subgroup analyses taking into account the use of fertility treatments (insemination or in vitro fertilization), stages of the disease and risk of bias of included trials did not modify the results. CONCLUSION: Postoperative hormonal suppression should be considered on a case-by-case basis to enhance fertility while balancing this benefit with the risks of delaying conception. If chosen, GnRH agonists would be the treatment of choice, and a duration of at least 3 months should be favored. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021224424.

Is an abdominal cerclage indicated with a cervical myomectomy? A case report.

INTRODUCTION: Cervical myomectomy can compromise cervical integrity and the risk of subsequent cervical incompetence is unclear. In this case report, the literature on cervical myomectomies is reviewed as well as that on the potential benefits of cervical cerclage. CASE PRESENTATION: A 30-year-old woman, nulligravida, with a 12 cm cervical leiomyoma consulted for heavy menstrual bleeding and pelvic pain. After failure of multiple medical therapies, a laparoscopic cervical myomectomy was successfully performed after pre-operative uterine artery embolization using absorbable gelatin sponges to reduce surgical blood loss. DISCUSSION: A concomitant laparoscopic cerclage was achieved in order to prevent cervical incompetence, given that the full thickness of the anterior cervix was penetrated during the myomectomy.

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.

Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery.

OBJECTIVE: To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery. TARGET POPULATION: All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications. OPTIONS: The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars. OUTCOMES: Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery. EVIDENCE: We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A). INTENDED AUDIENCE: Surgeons performing laparoscopic gynaecological surgery. SUMMARY STATEMENTS: RECOMMENDATIONS.

Quality of ultrasonography reporting and factors associated with selection of imaging modality for uterine fibroids in Canada: results from a prospective cohort registry.

BACKGROUND: Uterine fibroids are common in women and their management is heavily influenced by information gathered through imaging. We aimed to evaluate the type and quality of imaging performed for assessment of uterine fibroids in Canada. METHODS: Starting in July 2015, premenopausal women with symptomatic fibroids were enrolled in a prospective, noninterventional, observational registry (Canadian Women With Uterine Fibroids Registry [CAPTURE]) that included 19 Canadian sites. Clinical characteristics were extracted from the baseline visit. We evaluated the association between demographic and clinical variables of interest with regard to imaging type using unadjusted and adjusted logistic regression models. RESULTS: Of 1493 women, 1148 had ultrasonography, 135 had magnetic resonance imaging (MRI), 80 had other types of imaging and 130 did not have imaging reported within 12 months of the baseline visit. After adjusting for demographic and clinical characteristics, patients who underwent MRI had larger fibroids (odds ratio [OR] per 1-cm increase 1.11, 95% confidence interval [CI] 1.05-1.17) and more numerous fibroids (1 v. > 1; OR 1.74, 95% CI 1.14-2.64) compared with those who underwent ultrasonography only. For ultrasonography reporting, quality criteria were met for 268 of 1148 patients (23.3%). There was a difference in the quality of reporting among the 19 sites (p < 0.001). Logistic regression model accounting for within-site variability showed that reporting results from ultrasonography in the province of Quebec were less likely to meet all quality criteria (OR 0.20, 95% CI 0.06-0.66) and those from sites in more populated cities (≥ 400 000 inhabitants) were more likely to do so (OR 6.15, 95% CI 2.20-17.18). INTERPRETATION: We determined that imaging modality for fibroids is associated with patient characteristics. The quality of reporting results for ultrasonography of fibroids in Canada falls short of internationally endorsed guidelines and needs improvement. STUDY REGISTRATION: ClinicalTrials.gov, no. NCT02580578.

Minimally Invasive Hysterectomy Rates in Québec: Trends Over the Last Decade and Predictors of Technicity.

OBJECTIVE: To assess trends and predictors of a high technicity index for hysterectomies performed in the province of Québec. METHODS: We conducted a retrospective study using the ADAM database to determine the annual number hysterectomies performed for a suspected benign condition and the surgical approach used across 81 hospitals in the province of Québec from 2007 to 2017. We calculated the technicity index for each hospital and analyzed trends in surgical approach using the Cochran-Armitage test. We used logistic regression to assess potential predictors of a high technicity index (>70%), including academic centre, urban area, high volume of hysterectomies performed, and greater number of gynaecologists per hospital. RESULTS: Fifty-nine hospitals were eligible for inclusion, representing 96 431 hysterectomies during the study period. Over the decade, the technicity index increased from 43% to 66% (P < 0.001, with a 198% increase in laparoscopic hysterectomies (from 685 to 2039 per year; P < 0.001), a 50% decrease in abdominal hysterectomies (from 5528 to 2790 per year; P < 0.001), and a 8% decrease in vaginal hysterectomies (form 3551 to 3257 per year; P < 0.001). Meanwhile, the total number of hysterectomies per year declined by 17% (P < 0.001). Being an academic centre was the only significant predictor of a high technicity index >70% (68% vs. 38%; OR 7.5; P = 0.047). CONCLUSION: Technicity is increasing in the province of Québec and the majority of hysterectomies are now performed using a minimally invasive approach. This shift has mainly occurred through an increase in the laparoscopic approach and a decrease in the abdominal approach. Academic centres are more likely to have high technicity indexes.

Morcellation During Total Laparoscopic Hysterectomies: Implications of the Use of a Contained Bag System.

OBJECTIVE: This study sought to report the feasibility and clinical implications of in-bag morcellation for total laparoscopic hysterectomy (TLH). METHODS: Women who required uterine morcellation during TLH from January 2017 to December 2018 (at the Centre Hospitalier Universitaire de Québec - CHUL, Québec, QC) were included. Women with a preoperative suspicion of malignancy were excluded (Canadian Task Force classification II-2). RESULTS: During the 2-year study period, uterine morcellation was required in 42% (106 of 252) of women undergoing TLH. Mean uterine weight of morcellated uterus was 541 ± 291 g, with 11 of 106 uteri weighing >1000 g. In-bag morcellation was attempted in 84 of 106 (79%) and successfully performed in 79 of 84 (94%) women. Failures resulted from inability to insert the specimen into the bag or apparent perforation. Uncontained morcellation was chosen for 22 of 106 (21%) women, most of whom underwent vaginal morcellation of the uterus. Total operative time was 40 minutes longer for the in-bag morcellation group (170 ± 48 vs. 130 ± 43 min; P < 0.001), although this difference can be partly explained by the higher mean uterine size compared with the uncontained morcellation group (580 ± 309 vs. 391 ± 122 g; P = 0.01). In a subgroup analysis of 16 women, the mean times of installation and extraction of the bag were estimated to be 17 ± 9 and 4 ± 3 minutes, respectively. Complications were infrequent (2 of 106) and occurred in the in-bag morcellation group. CONCLUSION: In-bag morcellation is feasible in a high proportion of women undergoing laparoscopic hysterectomy and is associated with an increase in operative time. Larger studies will be required in order to better assess the risk of complications with in-bag morcellation and the potential benefits of this technique, namely, reducing the spread of tissue.