Opportunities for change and levelling up: a trust wide retrospective analysis of 8 years of laparoscopic and abdominal myomectomy.

Background: Laparoscopic myomectomy is increasingly considered the gold standard uterine preserving procedure and has well documented benefits over the open approach. Barriers that women have in accessing the most appropriate treatment need to be addressed to ensure optimal patient care and outcomes. Objectives: To analyse rates of open and laparoscopic myomectomy at a large NHS trust and identify how many cases could potentially have been performed laparoscopically, and any variation between sites. Materials and Methods: A retrospective review of preoperative imaging reports and a surgical database containing information for all myomectomies performed between 1st January 2015 and 31st December 2022. Main outcome measures: Number of procedures suitable for alternative surgical approach; length of hospital stay; estimated blood loss; cost differences. Results: 846 myomectomies were performed; 656 by laparotomy and 190 by laparoscopy. 194/591 (32.8%) open myomectomies could have been performed laparoscopically and 26/172 (15.1%) laparoscopic myomectomies may have been better performed via an open approach. Length of hospital stay, and estimated blood loss were significantly higher in the open group. Had cases been performed as indicated by pre-operative imaging, the cost differences ranged from -£115,752 to £251,832. Conclusions: There is disparity in access to the gold standard care of laparoscopic myomectomy. Due to multifactorial reasons, even at sites where the rate of laparoscopic myomectomy is high, there is still underutilisation of this approach. It is clear that there is scope for change and "levelling up" of this imbalance. What is new?: Robust pathways and guidelines must be developed, and more laparoscopic surgeons should be trained to optimise care for women with fibroids.

Current opinion on large-scale prospective myomectomy databases toward evidence-based preconception and antenatal counselling utilising a standardised myomectomy operation note.

Background: No large-scale databases exist of pregnancy outcomes and rate of uterine rupture for women after myomectomy, resulting in inconsistent antenatal counselling and decision-making regarding mode and timing of delivery. Standardising information collected at myomectomy may facilitate data collection, informing prenatal/ antenatal counselling. Objectives: To determine clinician opinions regarding standardisation of myomectomy operation notes to allow comprehensive data input into a prospective database of pregnancy outcomes, toward an evidence-based approach to decision making regarding timing and mode of delivery in subsequent pregnancies. Materials and Methods: A google forms survey was emailed to all consultant (attending-level) obstetricians and gynaecologists across 25 hospitals in London, Kent, Surrey, and Sussex (UK) between March and May 2022. To enhance response rates, two further email reminders were sent alongside in-person reminders from selected local unit representatives. Main outcome measures: Senior clinician opinion for characteristics necessary to collect at time of surgery to develop a widescale database of post myomectomy pregnancy outcomes. Results: 209/475 (44%) responses received; 95% (198/209) agreed with standardising operation notes. Criteria selected for inclusion included cavity breach (98%, 194/198), location (98%, 194/198), number of fibroids removed (93%, 185/198) and number of uterine incisions (96%, 190/198). Conclusions: Gynaecologists support standardising myomectomy operation notes to inform the development of prospective large-scale databases of pregnancy outcomes after myomectomy. What is new?: Acquisition of clinician opinions on the development and content of a standardised myomectomy operation note to aid the development of a pregnancy-outcome database for women after myomectomy.

Towards a clinical consensus on the management of pregnancy and birth after laparoscopic and open myomectomy: A survey of obstetricians and gynaecologists.

OBJECTIVES: The primary aim was to assess if a clinical consensus regarding the management of pregnancy post myomectomy existed amongst consultant obstetricians and gynaecologists. Secondary objectives were to evaluate factors which influence the clinician's decision making in this group of women. STUDY DESIGN: Electronic survey sent to all consultants working in the North Central and East London deanery, Kent Surrey and Sussex deanery and Imperial NHS Trust to assess opinions on mode of birth post myomectomy, intervals advised to pregnancy post myomectomy, factors influencing the management of delivery in the scarred uterus post myomectomy, opinions on induction of labour and questions relating to operative notes. RESULTS: 209 consultant responses received between 07/03/2022-07/05/2022 (44% response rate); 77% (161/209) practicing obstetricians and gynaecologists, 10% (21/109) pure gynaecologists and 13% (27/209) pure obstetricians. The majority would support a vaginal birth after open myomectomy (75%) and laparoscopic myomectomy (79%). No consensus was found as to the optimal time interval between myomectomy and pregnancy. Higher frequency of performing myomectomy and a greater level of experience were significantly associated with a shorter interval to pregnancy advised. The most important operative factors influencing decision to support trial of labour post myomectomy were breach of uterine cavity; location of fibroids removed and number of incisions on the uterus. 77% believe women should be given a choice regarding mode of delivery post myomectomy in a similar way to previous LSCS. 82.8% would support enrolment of patients into a prospective trial to investigate delivery post myomectomy. CONCLUSIONS: We present a comprehensive survey of clinician opinions on pregnancy post myomectomy demonstrating that the majority of consultant obstetricians and gynaecologists sampled would support vaginal birth post myomectomy; counselling patients in a similar way to VBAC; a standardised myomectomy operation note and enrolment of patients in a future prospective trial. Wide variation in opinion regarding interval to pregnancy post myomectomy has been highlighted. We believe this information will facilitate counselling discussions and empower women with subsequent pregnancies after myomectomy to make an informed decision on mode of birth post myomectomy.

The impact of COVID-19 on O&G trainees; where are we now?

Background and Objectives: Obstetrics and Gynaecology (O&G) training continues to face challenges caused by the COVID-19 pandemic, particularly in gynaecological surgical training. This follow-up survey captures the ongoing effect on O&G trainees and highlights the future recovery plan considering the historical training gaps in benign gynaecology. Materials and Methods: an anonymised survey was emailed to all O&G trainees in Kent, Surrey and Sussex (KSS). Responses were collected over 6 weeks. Main Outcome Measures and Results: 53% of trainees responded. In total, 78% of trainees agreed that the pandemic had an ongoing negative effect on their physical and mental wellbeing respectively. Trainees felt the prior negative impact on obstetric training is improving, whilst 88% still experience a negative impact on their gynaecology surgical training despite the resumption of elective services in the National Health Service (NHS). 80% continue to feel the negative impact on their educational activities and 88% felt their overall training continues to be negatively impacted. 70% were positive that they would recover from this. Responses were representative of each training year. Interestingly, 95% of trainees had accepted the COVID vaccine. Conclusion: despite "restoration" of normal services, the negative impact on trainees particularly benign gynaecology surgical training continues. Addressing pre-pandemic training gaps whilst tackling the surgical back-log and the needs of service provision will continue for years to follow. What is new?: Future training needs to incorporate creative ways of acquiring surgical skills. It is imperative to imbed simulation training into O&G training programmes. Pastoral support is key to ensure trainees' mental and physical well-being are prioritised and the already high burn-out rates do not worsen.

Visualising surgical training in O&G following the COVID-19 pandemic - The European view.

Background & Objectives: Obstetrics and Gynaecology (O&G) training programmes that traditionally relied on the hands-on apprenticeship-training model, became crippled with the global response to the COVID-19 pandemic. Methods: Web-based anonymised survey was circulated to trainee members of the European Society for Gynaecological Endoscopy (ESGE) over 8-weeks period commencing June 2021. Results: 213 trainees from 20 countries responded. Trainees from medium Human Development Index (HDI) countries were less represented. 78% (166/213) were in approved training programmes and 81% (174/213) had access to personal PPE. The vaccine uptake was 87% (185/213). 39% (89/213) and 55% (118/213) experienced negative impact on their physical and mental wellbeing with 36% (76/213) COVID-19 related absence. 15% (32/213) were redeployed to areas outside O&G. 25% (53 /213) had negative impact on their obstetric experience compared to 54% (114/213) reported lower gynaecology surgical exposure and 43% (91/213) failed to meet their gynaecology surgical competencies during the pandemic. 64% (137/213) perceived simulation training as an alternative training tool. Conclusion: In the post-pandemic recovery phase, gynaecological societies and national institutes across Europe continue to develop training curricula implementing virtual and hybrid training modules. The aim is to develop a robust blueprint to safeguard the gynaecological surgical training in the future. What is new?: The ongoing impact on the training in the post pandemic era remains to be evaluated. Our pan Europe survey highlights areas that remain affected from trainees' perspective and assesses differences in the healthcare systems across continent. We then discuss the novel initiatives taken to overcome training gaps.

Impact of severe acute respiratory syndrome coronavirus 2 on ectopic pregnancy management in the United Kingdom: a multicentre observational study.

OBJECTIVE: To describe the impact of coronavirus disease 2019 (COVID-19) on the management of women with ectopic pregnancy. DESIGN: A multicentre observational study comparing outcomes from a prospective cohort during the pandemic [COVID-19-ectopic pregnancy registry (CEPR)] compared with a historical pre-pandemic cohort [non-COVID-19-ectopic pregnancy registry (NCEPR)]. SETTING: Five London university hospitals. POPULATION AND METHODS: Consecutive patients diagnosed clinically and/or radiologically with ectopic pregnancy (March 2020-August 2020) were entered into the CEPR and results were compared with the NCEPR cohort (January 2019-June 2019). An adjusted analysis was performed for potentially confounding variables. MAIN OUTCOME MEASURES: Patient demographics, management (expectant, medical and surgical), length of treatment, number of hospital visits (non-surgical management), length of stay (surgical management) and 30-day complications. RESULTS: Three hundred and forty-one women met the inclusion criteria: 162 CEPR and 179 NCEPR. A significantly lower percentage of women underwent surgical management versus non-surgical management in the CEPR versus NCEPR (58.6%; 95/162 versus 72.6%; 130/179; P = 0.007). Among patients managed with expectant management, the CEPR had a significantly lower mean number of hospital visits compared with NCEPR (3.0, interquartile range [IQR] [3, 5] versus 9.0, [5, 14]; P = <0.001). Among patients managed with medical management, the CEPR had a significantly lower median number of hospital visits versus NCEPR (6.0, [5, 8] versus 9, [6, 10]; P = 0.003). There was no observed difference in complication rates between cohorts. CONCLUSION: Women were found to undergo significantly higher rates of non-surgical management during the COVID-19 first wave compared with a pre-pandemic cohort. Women managed non-surgically in the CPER cohort were also managed with fewer hospital attendances. This did not lead to an increase in observed complication rates. TWEETABLE ABSTRACT: A higher rate of non-surgical management of ectopic pregnancy during the COVID-19 pandemic did not increase complication rates.

The impact of COVID-19 on obstetrics and gynaecology trainees; how do we move on?

BACKGROUND: Obstetrics and Gynaecology (O&G) is an evolving specialty that encompasses women's health at its core. The COVID-19 pandemic has caused significant patient care challenges, however simultaneously it has resulted in the interruption of clinical training and cessation of all elective work. Our primary aim was to assess the impact of the pandemic on the experiences of O&G trainees. METHODS: An email invite was sent to all 127 O&G trainees in Kent, Surrey and Sussex (KSS), inviting them to participate in an anonymous 33-question survey. The survey data was collected and analysed over a 4-week period. RESULTS: Of the 127 trainees sent the survey, 87 responded (69%). 39% and 75% of trainees agreed that the pandemic had a negative impact on their overall physical and mental wellbeing respectively. 43% agreed that the COVID-19 pandemic had adversely affected their obstetric training experience whilst almost all trainees stated a significant negative impact on benign gynaecology surgical training. Reassuringly, over 80% were positive they would recover from the negative impacts of COVID-19. CONCLUSIONS: It is evident that COVID-19 has impacted O&G trainees in several ways. Whilst we face uncertain times, we must firstly ensure the physical and mental well-being of all trainees. It is encouraging that non-emergency consultations and benign surgery are being restarted nationwide and whilst this will inevitably help with re-booting surgical training, we must also think "outside" the box and utilise other modes of teaching and training to safeguard learning whilst mitigating against the negative impacts of subsequent waves.

Getting back to business: considerations for restarting non-cancer gynaecological surgery following the COVID-19 peak.

As we begin to pass the first peak of the coronavirus pandemic, the backlog of routine gynaecological surgical work is becoming more apparent and continues to build day by day. The potential for further pandemic surges remain; however it is imperative that elective gynaecological surgery is restored safely, ethically and in a timely manner. The risks of COVID-19 transmission and potential increased surgical morbidity must be weighed up against the patient's ongoing symptoms and quality of life. Universal screening and testing of patients attending for routine surgery, as well as staff testing and retesting, will be fundamental to reducing the risks to both patients and staff, and avoiding the higher morbidity encountered when operating on asymptomatic infected patients. The aim of this paper is to explore pathways to safely reintroduce elective benign gynaecological surgery and the challenges that will be encountered including patient counselling and informed consent, surgical prioritisation and the screening and testing of patients and staff, as well as the logistical and ethical challenges of reintroducing benign surgery during COVID-19 times.

Caesarean section in women following an abdominal myomectomy: a choice or a need?

Delivery options following both open and laparoscopic myomectomy remains a controversial topic and opinions vary between obstetricians and gynaecologists. The historical advice of planned caesarean section before 39-weeks persists despite the movement towards the minimal access approach for myomectomy. The main concern remains the small, but potentially catastrophic risk of uterine rupture. Unfortunately, there remains a paucity of data assessing factors that can affect the uterine integrity following laparoscopic myomectomy, such as number, size and type of fibroids, uterine cavity breach and electro-cautery usage. Despite this, the cited 1% overall risk of rupture following myomectomy is similar to the quoted risk following trial of labour after caesarean section, and a successful and safe vaginal delivery can be achieved in as high as 90%. Patient choice and informed consent are essential in the holistic approach to managing these women and safely supporting their delivery choices.

Covid 19 pandemic and gynaecological laparoscopic surgery: knowns and unknowns.

The worldwide impact of COVID 19 continues to be felt as hospitals in all countries reduce elective and non-urgent cases to allow staffing and resources to be deployed elsewhere. Urgent gynaecological and cancer procedures are continuing, and it is imperative all theatre staff are protected and risks of SARS-CoV-2 viral transmission reduced when operating on asymptomatic, suspected or confirmed COVID 19 patients. In particular, there are concerns relating to the transmission of COVID 19 during gynaecological laparoscopic surgery, arising from the potential generation of SARS-CoV-2 contaminated aerosols from CO2 leakage and the creation of smoke from the use of energy devices. The aim of this paper is to review all the up to date evidence, including experiences from China and Italy, to guide the safe management of such patients when undergoing gynaecological procedures.

Google searches and medical publication trends since the 2014 US Food and Drug Administration position on power morcellation: Do these translate into patient awareness?

OBJECTIVES: Our primary objective was to assess patient awareness by observing Google Trends comparing search terms used in relation to morcellation rather than morcellation alone. Our secondary objective was to review trends and locations of publications on leiomyosarcoma and morcellation following the US Food and Drug Administration (FDA) position statement. STUDY DESIGN: To assess Internet trends, we obtained the relative search volume (RSV) for each month from 1 January 2004 to 1 March 2019 from Google Trends using the terms 'fibroid', 'morcellation', and 'fibroid cancer'. RSV ranges from 0 to 100 with 100 being peak popularity for the term, and all other monthly search activity relative to the peak. To assess academic trends, we performed a systematic review of published literature discussing fibroid morcellation within the same time period. We used a two-way independent t-test to compare median RSV, and chi-squared test to compare academic output. P < 0.05 was considered statistically significant. RESULTS: Search volume for 'morcellation' peaked during the FDA statement (RSV 0.5 to 2.9, t = 17.5, p < 0.05) but was not sustained. There is an increase in 'fibroid' activity post-FDA statement (RSV 68.8 to 76.3, t = 3.9, p < 0.05). 'Fibroid cancer' remained static throughout (t = 1.5, p = 0.1 and t=-0.5, p = 0.6). Afro-Caribbean countries had the highest RSV for 'fibroid', whereas 'morcellation' RSV was highest in predominantly Western countries. There was a significant increase in the rate of papers published on the subject following the FDA statement (6.8 vs 55.6 papers per year, 95% CI -53.96 to -43.64, p < 0.0001). No academic papers on morcellation were published from countries with the highest RSV for 'fibroid'. CONCLUSION: Our study suggests that interest in uterine fibroids has increased since the FDA statement, but the public are perhaps unaware or not concerned of the consequent potential risk of leiomyosarcoma following morcellation. Countries where fibroid interest is highest are not necessarily those that can offer power morcellation. Further studies are required to address how the Internet influences patient choice and informed consent, and how medical professionals can use it to further educate patients on the risks and benefits of laparoscopic myomectomy and power morcellation.

Severe morbidity with ectopic pregnancy is associated with late presentation.

This article investigates if severe morbidity associated with ectopic pregnancy (EP) is related to patient characteristics or the quality of patient care after presentation. This is a retrospective study of women who had surgical management of tubal EP between 2008 and 2012. Severe maternal morbidity was defined as a blood loss ≥800 mL. Women of a white ethnicity were statistically more likely to have a blood loss of <800 mL (p = .0228). The patient related risk factors were significantly higher in the women with a blood loss of <800 mL (p = .0139). The incidence of substandard care was low in both groups although a substandard care due to a misdiagnosis of EP was significantly higher in the patients with a blood loss ≥800 mL (p = .0150). We found that a severe morbidity from EP is multifactorial involving patient awareness of risk factors and timely diagnosis by healthcare professionals. IMPACT STATEMENT What is already known on the subject? Ectopic pregnancy (EP) can be associated with severe maternal morbidity with up to a third of women with EP being managed after the pregnancy has ruptured. To try and reduce severe maternal morbidity and improve management for these women it is vital to identify the important risk factors associated with severe maternal morbidity. What do the results of this study add? We found ethnicity to be a predictive factor of severe maternal morbidity, with women of white ethnicity significantly more likely to have reduced severe maternal morbidity compared to other ethnicities. We also found multiple risk factors for an EP were statistically protective of severe maternal morbidity. We found the rate of substandard care to be low in our study but identified that where there was substandard care it was associated with diagnostic and therapeutic delays. Our findings lead us to conclude that a severe maternal morbidity from EP is multifactorial, and an improvement will involve both a patient awareness of risk factors and a timely diagnosis by health care professionals. What are the implications of these findings for clinical practice and/or further research? We believe that this to be an important article as it identifies the importance of the increasing knowledge both of women in the community but also educating health care professionals on the signs and symptoms of EP. These steps are vital to improve severe maternal morbidity associated with EP.

Laparoscopic treatment of uterine fibroids: a comparison of peri-operative outcomes in laparoscopic hysterectomy and myomectomy.

PURPOSE: To compare peri-operative outcomes between laparoscopic myomectomy (LM) and laparoscopic hysterectomy (LH) for the treatment of uterine fibroids. METHODS: Retrospective cohort study including 400 women who underwent LH or LM for the management of uterine fibroids. RESULTS: LH patients were older, with higher BMI and larger uterine size but LH was associated with shorter operative duration (80.2 vs. 115.7 min, p < 0.0001), lower blood loss (215 vs. 316 ml, p < 0.0001), and shorter hospital stay (1.81 vs. 2.12 days, p = 0.0003). Seven LM patients (3.2%) had blood loss >1000 ml compared with no LH patients and five LM patients (2.3%) required blood transfusion compared to 1 (0.5%) LH patient. Three LM patients (1.9%) and no LH patients required conversion to laparotomy. Bladder injury occurred in three LH cases (1.6%) and no LM cases. When the data was restricted only to women aged 44 years or over, LH was again associated with significantly lower operative duration and estimated blood loss. CONCLUSIONS: Particularly in perimenopausal women, the decision to perform myomectomy can be controversial. These data suggest that there are potential advantages to LH over LM, including reduced operation length, blood loss and hospital stay but increased risk of urinary tract injury.

Prospective evaluation of 125 consecutive laparoscopic myomectomies.

With technological advancement and increasing skill in minimal access surgery, laparoscopic myomectomy is increasingly performed for the management of symptomatic fibroids in appropriately selected women. We present a series of 125 consecutive laparoscopic myomectomies to assess whether the number, size and location of fibroids affect the length of hospital stay. Total of 462 myomas were removed from 125 patients. The mean size of fibroids removed was 7.6 cm and the mean number of fibroids was 3.69. None of our patients had major intraoperative complication involving bladder or bowel. Our laparotomy conversion rate was 1.6% (2 out of 125). There was no significant difference based on size, number or weight of fibroids removed in relation to the day of discharge in our series. We conclude that the size and number of fibroids removed do not affect the day of discharge.