Medical management of endometriosis.

Endometriosis is a benign gynecologic disorder that is defined as functional endometrial tissue outside of the uterine cavity. It is an estrogen-dependent, inflammatory disease that leads to symptoms of pelvic pain, dysmenorrhea, dyspareunia, and infertility, occurring in 6-10% of reproductive aged women. The severity of the disease ranges from asymptomatic to debilitating symptoms that have a major impact on women's lives. It is a chronic, recurrent disease, frequently requiring long term management until menopause and beyond. It is considered a chronic disorder that is managed with surgery, medical treatment, and oftentimes, both. Current medical therapy for endometriosis is considered suppressive of the disease, rather than curative. Fortunately, many patients do experience improvement and control of their symptoms with medical therapy. However, long-term efficacy of the medical treatments is often limited by side effects and the cost of therapy, and symptoms do tend to recur after discontinuation of these medications. This review summarizes our understanding of the pathogenesis of endometriosis and provides more in-depth discussion of specific medical management options used to treat endometriosis, including mechanism of action and side effects. It also provides recommendations on strategy with a forward look to novel endometriosis treatments in the future. The authors emphasized that endometriosis is a chronic disorder requiring long term medical therapy. Early diagnosis of endometriosis is key in preventing severe, debilitating symptoms and progression of disease. By utilizing our current knowledge of the pathophysiology of endometriosis and by correctly implementing currently available medical and surgical therapies we can significantly reduce the physical, psychosocial and financial burden of this chronic, recurrent and indolent disease. Current available medications are suppressive therapies, but the authors are looking forward to future therapies that can effectively cure or at least control endometriosis with minimal side effects. Future research should continue to look for the genetic trigger for endometriosis which can lead us to its underlying pathogenesis and eventually a cure or prevention.

A Systematic Review of Validity Evidence for the Fundamentals of Laparoscopic Surgery Examination in Gynecology.

OBJECTIVE: The Fundamentals in Laparoscopic Surgery (FLS) examination is designed to test laparoscopic surgery skills. Our aim for this systematic review was to examine validity evidence supporting or refuting the FLS examination specifically as a high-stakes summative assessment tool in gynecology. DATA SOURCES: The data sources were PubMed, MEDLINE, Embase, and Scopus. METHODS OF STUDY SELECTION: The study eligibility criterion was the subject of the FLS examination as an assessment tool in gynecology. We developed a data extraction tool and assigned articles for screening and extraction to all authors, who then abstracted data independently. Conflicts that arose during the extraction process were resolved by consensus. We organized validity evidence for the cognitive and manual skills portions on the basis of the categories of current validation standards. TABULATION, INTEGRATION, AND RESULTS: From 1971 citations identified, 9 studies were included, involving 319 participants. For the cognitive portion of the test, the results were mixed in 5 studies in relationships with the other variables category. For the manual portion of the test, most of the studies focused on the relationships with other variables evidence with mixed findings. The concerning findings in the manual skills portion included the lack of transferability of skills to the operating room, limited mixed evidence for improvement in operating room performance, and worse performance by obstetrics and gynecology surgeons compared with other specialties. We did not find supportive content-based, response process, or consequential evidence in either the cognitive or manual skills portion of the test. CONCLUSION: Validity evidence for the FLS examination was either mixed, as it pertained to relationships with other variables, or lacking in other important evidence categories. Further evidence is required to justify the use of the FLS examination scores as a high-stakes summative assessment.

Updates in uterine artery embolization for leiomyomas.

PURPOSE OF REVIEW: Uterine leiomyomas are a common condition estimated to affect 70-80% of reproductive-aged women. An evolving body of evidence continues to guide our understanding of various surgical and interventional treatment options, such as uterine artery embolization (UAE). This article provides an updated review of novel findings regarding UAE. RECENT FINDINGS: Despite an abundance of observational studies and several small randomized controlled trials, large scale long-term comparative efficacy studies are lacking. Although short-term outcomes continue to be favorable, recent trials show reoperation rate of up to 35% in 10 years and may raise some concerns regarding ovarian reserve, fertility and pregnancy outcomes. SUMMARY: UAE remains a safe and effective alternative to surgery in the management of leiomyomas. A deeper investigation into understanding this treatment's optimal use in various patient populations is needed.

A Low-Cost Platform for Laparoscopic Simulation Training.

BACKGROUND: With the new requirement for Fundamentals of Laparoscopic Surgery certification among graduating obstetrics and gynecology residents, there has been an increased interest in simulation training. The Fundamentals of Laparoscopic Surgery curriculum uses a commercial laparoscopic box trainer to practice and assess laparoscopic skills. We created a low-cost, space-efficient, portable and versatile training platform that allows for the breakdown of complex tasks, and we studied its user acceptability. METHOD: A rectangular piece of pine wood purchased at a hardware store was used as a base; metal eye hooks were used as ports, and a blueprint was created to simulate placement of Fundamentals of Laparoscopic Surgery inserts. In addition to the Fundamentals of Laparoscopic Surgery skills, this platform can be used for any laparoscopic task (such as hysterectomy or cuff closure). Additionally, this platform can be used with or without a camera to allow for task breakdown into simpler components for faster learning. EXPERIENCE: A usability and acceptability survey was administered to a convenient sample of faculty and trainees. Trainees and faculty responded favorably to the model. Residents, fellows, and attendings felt that the laparoscopic platform closely simulated the feel of performing live laparoscopy surgery. CONCLUSION: This is a novel low-cost laparoscopic platform to add to the gynecologic surgical education simulation toolkit.

A Laparoscopic Approach to Postcoital Vaginal Perforation in an Adolescent with Peritonitis and Hypovolemic Shock.

BACKGROUND: Vaginal laceration during coitus is not a rare occurrence; however, vaginal perforation from coitus is uncommon and occurs in less than 1% of nonobstetric genital tract injuries. Limited case reports exist discussing the recognition and management of vaginal perforation. Previously described management is commonly performed with laparotomy. CASE: We report a case of postcoital vaginal laceration and posterior fornix perforation in an adolescent with hemoperitoneum, pneumoperitoneum, and subsequent hypovolemic shock, and describe a laparoscopic approach for repair. SUMMARY AND CONCLUSION: Vaginal perforation with subsequent peritonitis and hemodynamic instability is a rare outcome in an adolescent who presents to the emergency department with pain or bleeding in the setting of recent penile intercourse. Delays in recognition can lead to further patient compromise, with potential morbidity or mortality. In this patient cohort, we suggest maintaining a high clinical suspicion for this sequela, and a low threshold for surgery with perforations greater than 1 cm. In the event that surgical management is warranted, we recommend a laparoscopic approach to increase visibility and to improve postoperative outcomes.

A Novel Porcine Stomach Tissue Model for Laparoscopic Colpotomy Simulation.

BACKGROUND: Hysterectomies are the most common benign gynecologic surgical procedures performed in the United States. Currently, there are no tissue models that exist to teach trainees the techniques for colpotomy during laparoscopic hysterectomy. To address this educational gap, we have created a laparoscopic colpotomy model using a porcine stomach attached to a uterine manipulator. METHODS: A segment of a porcine stomach is secured onto a uterine manipulator to simulate the cervicovaginal junction. A uterus model created with craft materials and reused in subsequent sessions is placed above the porcine stomach onto the uterine manipulator tip. Porcine stomach was obtained from a local butcher or meat market costing less than $1.00 per model. The tissue can be refrigerated or frozen for storage, then thawed before each use. This model can be used with any energy device and any laparoscopic platform to teach and perform the colpotomy. Usability survey showed that trainees responded positively to the model and attendings thought it was a useful teaching tool. EXPERIENCE: Trainees and faculty responded favorably to the model and stated that the use of actual tissue enhanced the realism of a colpotomy simulation. CONCLUSION: The porcine stomach laparoscopic colpotomy model is an innovative, low-cost teaching tool to add to a gynecologic surgical education simulation toolkit.

Informed Consent Education in Obstetrics and Gynecology: A Survey Study.

OBJECTIVE: The practice of obstetrics and gynecology poses specific ethical challenges for informed consent (IC). Data regarding resident confidence with the IC process are lacking. Our objective was to evaluate obstetrics and gynecology residents' education, experience, and confidence related to IC. DESIGN: This was a cross-sectional survey of obstetrics and gynecology residents. Descriptive analyses were performed using mean and standard deviation or frequency expressed as a percentage. The results were analyzed for statistical significance using chi-square or Fisher's exact tests for categorical variables and Student t or Mann-Whitney U tests, as appropriate, for continuous variables; all results yielding p < 0.05 were deemed statistically significant. SETTING: Electronic survey. RESULTS: Two hundred eighty-one trainees completed the survey. The majority of participants were female (84.3%) and from an academic training program (65.1%). Two hundred seventy-seven trainees (98.6%) reported that they had obtained IC for operating room procedures; the majority had first done this in the first postgraduate year (PGY) (n = 258, 91.8%). Trainees most commonly obtain IC for resident and general gynecology attending cases. Most trainees primarily learn how to obtain IC via observation of their coresidents and attendings. Nearly 90% of trainees have obtained IC for a procedure for which they were unsure of all the risks. One hundred seventy-three trainees (61.6%) reported that they would like to have more training in IC. Increasing PGY was significantly associated with increasing confidence in obtaining IC for gynecologic, obstetric, and office procedures (all p < 0.01). There were no differences based on PGY in frequency of reviewing who will perform the surgical procedure (p = 0.75), how trainees will be involved in the procedure (p = 0.35), review of alternative treatments (p = 0.91), or in documentation of the IC process (p = 0.16). CONCLUSIONS: Based on the findings of this survey study, education related to the IC process is warranted and curriculum development should be the focus of future study.

Elevated Postvoid Residual Urine Volume: Identifying Risk Factors and Predicting Resolution in Women With Pelvic Organ Prolapse.

OBJECTIVES: This study aims to identify risk factors for elevated preoperative postvoid residual (PVR) and persistently elevated postoperative PVR and to evaluate the resolution rate of elevated PVR urine volume in patients undergoing reconstructive surgery for pelvic organ prolapse (POP). METHODS: This was a retrospective cohort study comparing 50 women with elevated preoperative PVR (≥100 mL) and 50 women with normal PVR (<100 mL). Preoperative demographic, physical examination, urodynamic data, type of surgery performed, and postoperative trial of void data were collected. Variables were evaluated for association with elevated PVR using Student t test or Mann-Whitney U test, and χ or Fisher exact test. RESULTS: The elevated PVR cohort was older (65.5 ± 13.3 vs 60.6 ± 10.1 years, P = 0.04). The cohorts did not differ by body mass index, parity, number of cesarean deliveries, prior hysterectomy, incontinence, prolapse surgery, menopausal status, hormone replacement therapy, history of recurrent urinary tract infections, diabetes mellitus, or maximum bladder capacity. Most patients had preoperative anterior prolapse stage 2 or 3. Complaints of incontinence, incomplete bladder emptying, and overactive bladder did not differ between groups. Performed Surgical procedures, cystoscopy findings, and rate of postoperative trial of void failures did not differ between groups. One patient per cohort learned clean intermittent self-catheterization for persistently elevated PVR. CONCLUSIONS: All women undergoing surgery for POP had postoperative resolution of elevated PVR. Patients with nonneurogenic-elevated PVR can be reassured that bladder emptying will improve after surgical repair of POP.

Does the Difference in Fascial Closure Technique Affect Postoperative Pain?

STUDY OBJECTIVE: To compare postoperative incisional pain on postoperative days (PODs) 1 and 14 when using a fascial closure device (FCD) versus a traditional fascial closure (TFC) of the 12-mm upper quadrant port during robotic surgery. Time required to close the incision was also compared. DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTING: Two academic affiliated hospitals, The Hospital of Central Connecticut and The University of Connecticut. PATIENTS: Women undergoing robotic surgery for benign indications by minimally invasive gynecologists at our institutions between November 2012 and October 2014 were enrolled in the study at their preoperative visit. INTERVENTIONS: Patients were randomized to either an FCD or TFC immediately before closure of the fascial incision. Pain score using a 10-point analog pain scale was recorded on POD 1 and POD 14. Time to close the fascial incision, length of surgery, and body mass index were also recorded. MEASUREMENTS AND MAIN RESULTS: Sixty-seven patients were enrolled, and 65 were randomized at the time of the fascial closure, whereas 2 enrolled patients converted to laparotomy. Statistical analysis demonstrated that pain scores differed by fascial closure technique. Mean pain scores on POD 1 were 3.43 ± 2.48 and 2.06 ± 2.03 for the FCD and TFC, respectively (p = .028). On POD 14 the mean pain scores were 1.97 ± 2.48 and .83 ± 1.42 for the FCD and TFC, respectively (p = .102). Times to close fascia were 106.5 ± 102.28 seconds and 141.97 ± 102.85 seconds for the FCD and TFC, respectively (p = .138). CONCLUSION: Our study demonstrates that at POD 1 the use of the fascia closure device results in higher pain scores without a significant difference in closure time.