Ovarian conservation vs removal at the time of benign hysterectomy.

Over the last 2 decades, the rate of oophorectomy at the time of hysterectomy in the United States has consistently been between 40-50%. A decline in hormone use has been observed since the release of the principal results of the Women's Health Initiative. Oophorectomy appears to be associated with an increased risk of coronary heart disease, as well as deleterious effects on overall mortality, cognitive functioning, and sexual functioning. Estrogen deficiency from surgical menopause is associated with bone mineral density loss and increased fracture risk. While hormone therapy may mitigate these effects, at no age does there appear to be a survival benefit associated with oophorectomy. Reduction of ovarian cancer risk may be accomplished with salpingectomy at the time of hysterectomy.

Executive Summary of the reVITALize Initiative: Standardizing Gynecologic Data Definitions.

Effective care coordination across the women's health continuum is critically important. Unlike obstetric care, which tends to be more episodic and limited to pregnant and postpartum women, women receive health care, whether around pregnancy or for nonobstetric issues, in a variety of care settings by members of multiple health disciplines. Having access to standardized clinical data is imperative to providing optimal patient care. The reVITALize Gynecology Data Definitions Initiative leads a national multidisciplinary movement to offer standard gynecologic data definitions for use in written and verbal clinical communication, electronic health record data capture, quality improvement, and clinical research.

Sexual and physical abuse and gynecologic disorders.

STUDY QUESTION: Is sexual and/or physical abuse history associated with incident endometriosis diagnosis or other gynecologic disorders among premenopausal women undergoing diagnostic and/or therapeutic laparoscopy or laparotomy regardless of clinical indication? SUMMARY ANSWER: No association was observed between either a history of sexual or physical abuse and risk of endometriosis, ovarian cysts or fibroids; however, a history of physical abuse was associated with a higher likelihood of adhesions after taking into account important confounding and mediating factors. WHAT IS KNOWN ALREADY: Sexual and physical abuse may alter neuroendocrine-immune processes leading to a higher risk for endometriosis and other noninfectious gynecologic disorders, but few studies have assessed abuse history prior to diagnosis. STUDY DESIGN, SIZE, DURATION: The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at 1 of the 14 surgical centers located in Salt Lake City, UT, USA or San Francisco, CA, USA. Women with a history of surgically confirmed endometriosis were excluded. PARTICIPANTS/MATERIALS, SETTING AND METHODS: Prior to surgery, women completed standardized abuse questionnaires. Relative risk (RR) of incident endometriosis, uterine fibroids, adhesions or ovarian cysts by abuse history were estimated, adjusting for age, race/ethnicity, education, marital status, smoking, gravidity and recruitment site. We assessed whether a history of chronic pelvic pain, depression, or STIs explained any relationships via mediation analyses. MAIN RESULTS AND ROLE OF CHANCE: 43 and 39% of women reported experiencing sexual and physical abuse. No association was observed between either a history of sexual or physical abuse, versus no history, and risk of endometriosis (aRR: 1.00 [95% confidence interval (CI): 0.80-1.25]); aRR: 0.83 [95% CI: 0.65-1.06]), ovarian cysts (aRR: 0.67 [95% CI: 0.39-1.15]); aRR: 0.60 [95% CI: 0.34-1.09]) or fibroids (aRR: 1.25 [95% CI: 0.85-1.83]); aRR: 1.36 [95% CI: 0.92-2.01]). Conversely, a history of physical abuse, versus no history, was associated with higher risk of adhesions (aRR: 2.39 [95% CI: 1.18-4.85]). We found no indication that the effect of abuse on women's adhesion risk could be explained by a history of chronic pelvic pain, depression or STIs. LIMITATIONS, REASONS FOR CAUTION: Limitations to our study include inquiries on childhood physical but not sexual abuse. Additionally, we did not inquire about childhood or adulthood emotional support systems, found to buffer the negative impact of stress on gynecologic health. WIDER IMPLICATIONS OF THE FINDINGS: Abuse may be associated with some but not all gynecologic disorders with neuroendocrine-inflammatory origin. High prevalence of abuse reporting supports the need for care providers to screen for abuse and initiate appropriate follow-up. STUDY FUNDING/COMPETING INTERESTS: Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.

Prevention, Recognition, and Management of Urologic Injuries During Gynecologic Surgery.

The urethra, bladder, and ureters are particularly susceptible to injury during gynecologic surgery. When preventive measures fail, prompt recognition and management of injury can avoid long-term sequelae such as fistula formation and loss of renal function. Intraoperative identification should be the primary goal when an injury occurs, although this is not always possible. Postoperative injury recognition requires a high level of suspicion and vigilance. In addition to history and physical examination, appropriate radiologic studies can be useful in localizing injury and planning management strategies. Some injuries may require Foley catheter drainage or ureteral stenting alone, whereas others will require operative intervention with ureteral resection and reanastomosis or reimplantation. Prompt restoration of urinary drainage or diversion will avoid further renal compromise.

Familiality analysis of provoked vestibulodynia treated by vestibulectomy supports genetic predisposition.

BACKGROUND: Provoked vestibulodynia is a poorly understood disease that affects 8-15% of women in their lifetime. There is significant inflammation and nerve growth in vestibular biopsies from affected women treated by vestibulectomy compared with matched female population controls without vestibulodynia. The triggers leading to this neurogenic inflammation are unknown, but they are likely multifactorial. OBJECTIVE: Our objective was to determine whether vestibulodynia is more common in close and distantly related female relatives of women diagnosed with the disease and those specifically treated by vestibulectomy. Excess familial clustering would support a potential genetic predisposition for vestibulodynia and warrant further studies to isolate risk alleles. STUDY DESIGN: Using population-based genealogy linked to University of Utah Hospital CPT coded data, we estimated the relative risk of vestibulectomy in female relatives of affected women. We also compared the average pairwise relatedness of cases to the expected relatedness of the population and identified high-disease-burden pedigrees. RESULTS: A total of 183 potential vestibulectomy probands were identified using CPT codes. The relative risk of vestibulectomy was elevated in first-degree (20 [6.6-47], P < .00001), second-degree (4.5 [0.5-16], P = .07), and third-degree female relatives (3.4 [1.2-8.8], P = .03). Seventy of these 183 CPT-based probands had available clinical history to confirm a diagnosis of moderate to severe vestibulodynia. Notably, this smaller group of confirmed probands (n = 70) revealed a similar familiality in first-degree (54 [17.5-126], P < .00001), second-degree (19.7 [2.4-71], P = .005), and third-degree relatives (12 [3.3-31], P = .0004), despite less statistical power for analysis. Overall, the average pairwise relatedness of affected women was significantly higher than expected (P < .001) and a number of high-disease-burden Utah families were identified. CONCLUSION: Our data suggest that vestibulodynia treated by vestibulectomy has a genetic predisposition. Future studies will identify candidate genes by linkage analysis in affected families and sequencing of distantly related probands.

Management of Postoperative Abdominal Wall Pain.

Postoperative incisional pain is expected after surgery. However, when a patient is complaining of pain months after surgery, this can be a source of frustration and confusion to the patient and the surgeon. Whether the pain is a result of myofascial pain, incisional hernia, or nerve injury, understanding potential sources of abdominal wall pain can simplify this diagnostic dilemma. This chapter will focus on the diagnosis, treatment, and prevention of postsurgical abdominal wall pain.

Recognition and Management of Urologic Injuries With Laparoscopic Hysterectomy.

Injuries to the urinary tract during laparoscopic hysterectomy are quite rare, but are among the most serious injuries that occur during gynecologic surgery. Injury rates among subtypes of laparoscopic hysterectomy have been found to be similar. The most effective way to avoid urinary tract injury is knowledge of urinary tract anatomy and careful and thoughtful dissection.

Management of complications encountered with Essure hysteroscopic sterilization: a systematic review.

Essure hysteroscopic sterilization has been US Food and Drug Administration-approved in the United States since 2002. Complications associated with the Essure device include improper placement (malpositioning), unintended pregnancy, pain, infection, and nickel allergy. The rarity of complications, compounded by underreporting, makes it difficult to determine best practices insofar as management. This systematic review synthesizes the national and global experience with management of Essure-related complications and suggests treatment options when data allow.

Urinary tract injuries in laparoscopic hysterectomy: a systematic review.

The aim of this review was to estimate the incidence of urinary tract injuries associated with laparoscopic hysterectomy and describe the long-term sequelae of these injuries and the impact of early recognition. Studies were identified by searching the PubMed database, spanning the last 10 years. The key words "ureter" or "ureteral" or "urethra" or "urethral" or "bladder" or "urinary tract" and "injury" and "laparoscopy" or "robotic" and "gynecology" were used. Additionally, a separate search was done for "routine cystoscopy" and "gynecology." The inclusion criteria were published articles of original research referring to urologic injuries occurring during either laparoscopic or robotic surgery for gynecologic indications. Only English language articles from the past 10 years were included. Studies with less than 100 patients and no injuries reported were excluded. No robotic series met these criteria. A primary search of the database yielded 104 articles, and secondary cross-reference yielded 6 articles. After reviewing the abstracts, 40 articles met inclusion criteria and were reviewed in their entirety. Of those 40 articles, 3 were excluded because of an inability to extract urinary tract injuries from total injuries. Statistical analysis was performed using a generalized linear mixed effects model. The overall urinary tract injury rate for laparoscopic hysterectomy was 0.73%. The bladder injury rate ranged from 0.05% to 0.66% across procedure types, and the ureteral injury rate ranged from 0.02% to 0.4% across procedure type. In contrast to earlier publications, which cited unacceptably high urinary tract injury rates, laparoscopic hysterectomy appears to be safe regarding the bladder and ureter.

Endometrial ablation: postoperative complications.

Endometrial ablation as a treatment for abnormal uterine bleeding has evolved considerably over the past several decades. Postoperative complications include the following: (1) pregnancy after endometrial ablation; (2) pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome); (3) failure to control menses (repeat ablation, hysterectomy); (4) risk from preexisting conditions (endometrial neoplasia, cesarean section); and (5) infection. Physicians performing endometrial ablation should be aware of postoperative complications and be able to diagnose and provide treatment for these conditions.

Hollow viscus injury during surgery.

Reproductive tract surgery carries a risk of injury to the bladder, ureter, and gastrointestinal (GI) tract. This is due to several factors including close surgical proximity of these organs, disease processes that can distort anatomy, delayed mechanical and energy effects, and the inability to directly visualize organ surfaces. The purpose of this article is to review strategies to prevent, recognize, and repair injury to the GI and urinary tract during gynecologic surgery.

Global endometrial ablation devices.

Since 1997, the US Food and Drug Administration has approved 5 global endometrial ablation (GEA) devices for the minimally invasive treatment of idiopathic menorrhagia. These include a variety of modalities to ablate the endometrium, including thermal balloon, circulated hot fluid, cryotherapy, radiofrequency electrosurgery, and microwave energy. Level I evidence is available to support high subjective satisfaction rates regardless of GEA method. There is a wide range of amenorrhea rates (13.9% to 55.3%) among GEA methods. Complication rates associated with GEA procedures are generally low when performed by physicians familiar with these devices, working under standard protocols compared with some of the major complications seen after these devices have been used by a broader range of physicians without study protocols. Adherence to patient selection and protocols is recommended.

Assessment of new technology in the treatment of idiopathic menorrhagia and uterine leiomyomata.

New technologies available for the treatment of idiopathic menorrhagia include five global endometrial ablation devices that use differing ablative methods, including thermal balloon, circulated hot fluid, cryotherapy, radiofrequency electrosurgery, and microwave energy. All have been compared with rollerball endometrial ablation by way of randomized clinical trials and are associated with high patient satisfaction rates, regardless of method, but a wide range of amenorrhea rates (13.9-55.3%). They are associated with low complication rates when performed by well-trained physicians following protocols in Food and Drug Administration trials. Some serious complications have been reported subsequently. Strict adherence to patient selection criteria and manufacturer protocols is strongly recommended. New technologies for the treatment of uterine leiomyomata include uterine artery embolization, magnetic resonance-guided focused ultrasonography, laparoscopic uterine artery occlusion, and cryomyolysis. There is sound evidence for shorter hospital stay, quicker return to work, and a similar major complication rate compared with hysterectomy. Uterine artery embolization appears to be effective for up to 5 years in reducing bulk symptoms and menorrhagia associated with leiomyomata. The chance of reoperation for leiomyoma-related symptoms within 5 years is 20-29%. Women who wish to become pregnant should be cautioned about potential complications during pregnancy. There is insufficient evidence to recommend uterine artery embolization in postmenopausal women. With regard to magnetic resonance-guided focused ultrasonography, cryomyolysis, and laparoscopic uterine artery occlusion, although the initial symptom reduction outcomes have been reported as favorable, more data are needed to better understand the durability of these results.

Complications associated with global endometrial ablation: the utility of the MAUDE database.

OBJECTIVE: To investigate the number and type of complications associated with global endometrial ablation using public-access governmental databanks. METHODS: MEDLINE (PubMed) and the US Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) databases were searched for entries for the four US Food and Drug Administration-approved global endometrial ablation devices. RESULTS: Traditional MEDLINE and bibliography searches yielded reports of two cases of hemorrhage, one case of pelvic inflammatory disease, 20 cases of endometritis, two cases of first-degree skin burns, nine cases of hematometra, and 16 cases of vaginitis and/or cystitis. A search of the US Food and Drug Administration MAUDE database yielded reports of 85 complications in 62 patients. These included major complications: eight cases of thermal bowel injury, 30 cases of uterine perforation, 12 cases in which emergent laparotomy was required, and three intensive care unit admissions. One patient developed necrotizing fasciitis and eventually underwent vulvectomy, ureterocutaneous ostomy, and bilateral below-the-knee amputations. One of the patients with thermal injury to the bowel died. CONCLUSION: Use of the US Food and Drug Administration MAUDE database is helpful in identifying serious complications associated with global endometrial ablation not yet reported in the medical literature.