Uterine rupture and factors associated with adverse outcomes.

PURPOSE: To review cases of uterine rupture and identify risk factors associated with adverse outcomes. METHODS: This study is a retrospective cohort of complete uterine ruptures diagnosed in a large hospital system in Massachusetts between 2004 and 2018. Baseline demographics, labor characteristics and outcomes of uterine rupture were collected from medical records. RESULTS: A total of 173 cases of uterine rupture were identified. There were 30 (17.3%) women with an unscarred uterus, while 142 (82.1%) had a scarred uterus. Adverse outcomes (n = 89, 51.4% of cases) included 26 (15.0%) hysterectomies, 55 (31.8%) blood transfusions, 18 (10.4%) bladder/ureteral injuries, 5 (2.9%) reoperations, 25 (14.5%) Apgar scores lower than 5 at 5 min and 9 (5.2%) perinatal deaths. Uterine rupture of a scarred uterus was associated with decreased risk of hemorrhage (OR 0.40, 95% CI 0.17-0.93), blood transfusion (OR 0.27, 95% CI 0.11-0.69), hysterectomy (OR 0.23, 95% CI 0.08-0.69) and any adverse outcome (OR 0.34, 95% CI 0.13-0.91) compared with unscarred rupture. Uterine rupture during vaginal delivery was associated with increased risk of transfusion (OR 6.55, 95% CI 1.53-28.05) and hysterectomy (OR 8.95, 95% CI 2.12-37.72) compared with emergent C-section. CONCLUSIONS: Although rare, uterine rupture is associated with adverse outcomes in over half of cases. Unscarred rupture and vaginal delivery demonstrate increased risk of adverse outcomes, highlighting the need for early diagnosis and operative intervention.

Current Methods of Tissue Extraction in Minimally Invasive Surgical Treatment of Uterine Fibroids.

Background and Objectives: Since the 2014 Food and Drug Administration communication regarding the use of power morcellation, gynecologists have adopted alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by gynecologic surgeons for tissue extraction following minimally invasive hysterectomy or myomectomy for fibroids. Methods: An online survey was distributed to all AAGL members and responses were collected between March 26, 2019 and April 17, 2019. Results: Four hundred thirty-six respondents completed the survey. For hysterectomy, the most common methods of tissue extraction were manual morcellation through the colpotomy (72.4%) or minilaparotomy (66.9%). Nearly one-third (31.7%) endorsed using power morcellation. For myomectomy, manual morcellation via minilaparotomy (71.9%) was the most common approach, followed by power morcellation (35.7%). Use of containment bags was common. Minilaparotomy incisions were typically three cm and most often at the umbilicus.Geographic differences were detected, particularly with power morcellation. During hysterectomy, 18.4% of US-based surgeons reported its use, compared to 56.9% of nonUS-based surgeons. During myomectomy, 20.5% of US-based surgeons reported its use compared to 67.5% of their international counterparts. Age, years in practice, fellowship training, and practice location were all significantly associated with power morcellator use. Conclusion: A large majority of practitioners are performing manual morcellation through the colpotomy or minilaparotomy. Use of containment bags is common with all routes of tissue removal. Power morcellation use is less common in the United States than in other countries.

Risk-prediction Model for Patients Undergoing Laparoscopic Hysterectomy.

STUDY OBJECTIVE: Develop a model for predicting adverse outcomes at the time of laparoscopic hysterectomy (LH) for benign indications. DESIGN: Retrospective cohort study. SETTING: Large academic center. PATIENTS: All patients undergoing LH for benign indications at our institution between 2009 and 2017. INTERVENTIONS: LH (including robot-assisted and laparoscopically assisted vaginal hysterectomy) was performed per standard technique. Data about the patient, surgeon, perioperative adverse outcomes (intraoperative complications, readmission, reoperation, operative time >4 hours, and postoperative medical complications or length of stay >2 days), and uterine weight were collected retrospectively. Pathologic uterine weight was used as a surrogate for predicted preoperative uterine weight. The sample was randomly split, using a random sequence generator, into 2 cohorts, one for deriving the model and the other to validate the model. MEASUREMENTS AND MAIN RESULTS: A total of 3441 patients were included. The rate of composite adverse outcomes was 14.1%. The final logistic regression risk-prediction model identified 6 variables predictive of an adverse outcome at the time of LH: race, history of laparotomy, history of laparoscopy, predicted preoperative uterine weight, body mass index, and surgeon annual case volume. Specifically included were race (97% increased odds of an adverse outcome for black women [95% confidence interval (CI), 34%-110%] and 34% increased odds of an adverse outcome for women of other races [95% CI, -11% to 104%] when compared with white women), history of laparotomy (69% increased odds of an adverse outcome [95% CI, 26%-128%]), history of laparoscopy (65% increased odds of an adverse outcome [95% CI, 21%-124%]), and predicted preoperative uterine weight (2.9% increased odds of an adverse outcome for each 100-g increase in predicted weight [95% CI, 2%-4%]). Body mass index and surgeon annual case volume also had a statistically significant nonlinear relationship with the risk of an adverse outcome. The c-statistic values for the derivation and validation cohorts were 0.74 and 0.72, respectively. The model is best calibrated for patients at lower risk (<20%). CONCLUSION: The LH risk-prediction model is a potentially powerful tool for predicting adverse outcomes in patients planning hysterectomy.

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review.

OBJECTIVE: This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. DATA SOURCES: Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. METHODS OF STUDY SELECTION: Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. TABULATION, INTEGRATION, AND RESULTS: The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. CONCLUSION: Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

Minimally Invasive Surgical Techniques for Tissue Extraction.

STUDY OBJECTIVE: Morcellation is a technique to remove large specimens by means of small incisions and is commonly used in gynecologic procedures [1]. In this video, we demonstrate contained manual morcellation techniques in benign gynecologic surgeries. DESIGN: Stepwise demonstration of 4 techniques with narrated video footage. SETTING: Tertiary academic teaching hospital. INTERVENTIONS: This video showcases 4 contained manual morcellation techniques: abdominal extraction through an umbilical "mini-laparotomy" incision, abdominal extraction through a suprapubic "mini-laparotomy" incision, transvaginal extraction through the colpotomy, and transvaginal extraction through the posterior cul-de-sac with the uterus in place. A particular strategy should be selected on the basis of appropriate patient characteristics and surgical factors [2]. CONCLUSION: Minimizing risk during tissue extraction is critical to minimally invasive procedures. The morcellation techniques displayed in this video allow for tissue extraction through small incisions while reducing the risk of spreading an undiagnosed malignancy.

Risk of complication at the time of laparoscopic hysterectomy: a prediction model built from the National Surgical Quality Improvement Program database.

BACKGROUND: Although laparoscopic hysterectomy is well established as a favorable mode of hysterectomy owing to decreased perioperative complications, there is still room for improvement in quality of care. Previous studies have described laparoscopic hysterectomy risk, but there is currently no tool for predicting risk of complication at the time of laparoscopic hysterectomy. OBJECTIVE: This study aimed to create a prediction model for complications at the time of laparoscopic hysterectomy for benign conditions. STUDY DESIGN: This is a retrospective cohort study that included patients who underwent laparoscopic hysterectomy for benign indications between 2014 and 2017 in US hospitals contributing to the American College of Surgeons - National Surgical Quality Improvement Program database. Data about patient baseline characteristics, perioperative complications (intraoperative complications, readmission, reoperation, need for transfusion, operative time greater than 4 hours, or postoperative medical complication), and uterine weight at the time of pathologic examination were collected retrospectively. Postoperative uterine weight was used as a proxy for preoperative uterine weight estimate. The sample was randomly divided into 2 patient populations, one for deriving the model and the other to validate the model. RESULTS: A total of 33,123 women met the inclusion criteria. The rate of composite complication was 14.1%. Complication rates were similar in the derivation and validation cohorts (14.1% [2306 of 14,051] vs 13.9% [2289 of 14,107], P=.7207). The logistic regression risk prediction tool for hysterectomy complication identified 7 variables predictive of complication: history of laparotomy (21% increased odds of complication), age (2% increased odds of complication per year of life), body mass index (0.2% increased odds of complication per each unit increase in body mass index), parity (7% increased odds of complication per delivery), race (when compared with white women, black women had 34% increased odds and women of other races had 18% increased odds of complication), and American Society of Anesthesiologists score (when compared with American Society of Anesthesiologists 1, American Society of Anesthesiologists 2 had 31% increased odds, American Society of Anesthesiologists 3 had 62% increased odds, and American Society of Anesthesiologists 4 had 172% increased odds of complication). Predicted preoperative uterine weight also had a statistically significant nonlinear relationship with odds of complication. The c-statistics for the derivation and validation cohorts were 0.62 and 0.62, respectively. The model is well calibrated for women at all levels of risk. CONCLUSION: The laparoscopic hysterectomy complication predictor model is a tool for predicting complications in patients planning to undergo hysterectomy.

Reproductive Outcomes following Use of Barbed Suture during Laparoscopic Myomectomy.

STUDY OBJECTIVE: To review pregnancy outcomes after laparoscopic myomectomy with the use of barbed suture. DESIGN: Retrospective cohort study and follow-up survey. SETTING: Single, large academic medical center. PATIENTS: Patients who underwent laparoscopic myomectomy with the use of barbed suture for myometrial closure between 2008 and 2016. INTERVENTION: Laparoscopic myomectomy and a follow-up survey regarding pregnancy outcome. MEASUREMENTS AND MAIN RESULTS: A total of 486 patients met inclusion criteria and underwent a laparoscopic myomectomy between 2008 and 2016. Of the 428 with viable contact information, 240 agreed to participate (56%). Of those who responded to the survey, 101 (42%) attempted to get pregnant, and there were 4 unplanned pregnancies. There were 110 pregnancies among 76 survey respondents. In total, of the women attempting a postoperative pregnancy, 71% had at least 1 pregnancy. Comparing the women who did and did not conceive postoperatively, the group who got pregnant was on average younger, 33.8 ± 4.5 years vs 37.5 ± 6.5 years (p = .001); had fewer myomas removed, median = 2 (range 1-9) vs median = 2 (range 1-16) myomas (p = .038); and had a longer follow-up period, 30 months ( vs 30 (11-93 months) ± 20 (p <.001). The mean time to first postoperative pregnancy was 18.0 months (range 2-72 months). Of the 110 reported postoperative pregnancies, there were 60 live births (55%), 90% by means of cesarean section. The mean gestational age at birth was 37.8 weeks. In the cohort, there were 8 preterm births, 3 cases of abnormal placentation, 2 cases of fetal growth restriction, 3 cases of hypertensive disorders of pregnancy, and 2 cases of myoma degeneration requiring hospitalization for pain control. There were no uterine ruptures reported. CONCLUSION: According to our findings, pregnancy outcomes after laparoscopic myomectomy with barbed suture are comparable with available literature on pregnancy outcomes with conventional smooth suture.

Important considerations for women in the late reproductive and perimenopausal years desiring myomectomy.

PURPOSE OF REVIEW: To review important considerations in the counseling and management of women over the age of 40 desiring a myomectomy for symptomatic fibroids. RECENT FINDINGS: Women in the late reproductive and perimenopausal years may choose a myomectomy over a hysterectomy for reasons of fertility preservation or a personal desire to retain their uterus. Data suggest that laparoscopic myomectomy is a low-risk procedure that can be offered to older women, though the age-related risk of uterine malignancy must be evaluated. SUMMARY: When assessing the surgical candidacy of older women desiring myomectomy, it is important to weigh a woman's fertility potential, surgical risk, and concerns about malignancy with her desire to preserve the uterus and autonomy to choose a procedure type.

Clinical characteristics and outcomes after bowel surgery and ostomy formation at the time of debulking surgery for advanced-stage epithelial ovarian carcinoma.

OBJECTIVE: There are limited data on clinical outcomes of patients with advanced-stage epithelial ovarian cancer who require ostomy formation at the time of either primary cytoreductive surgery or interval cytoreductive surgery. The objective of this study was to evaluate patients undergoing bowel surgery and ostomy formation after primary or interval surgery. METHODS: Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC-IV epithelial ovarian cancer who underwent cytoreductive surgery between January 2010 and December 2014 were identified retrospectively. Patients with non-epithelial histology, low-grade serous histology or incomplete medical records were excluded. Demographic and clinical data were collected and analyzed. Age, stage, co-morbidity index, pre-operative CA125, pre-operative albumin, and Aletti surgical complexity score were included in a multivariable logistic regression model to assess independent associations with ostomy formation. RESULTS: A total of 554 patients were included in the study. Of these, 261 (47%) underwent primary cytoreduction and 293 (53%) underwent interval cytoreduction. Patients undergoing primary surgery were more likely to undergo bowel resection, compared with interval surgery patients (37.2% vs 14%, p<0.001). Of the 139 (25.1%) patients who underwent bowel surgery, 25 (18%) underwent ostomy formation (11 ileostomies and 14 colostomies). Rates of ostomy formation were similar between the groups (6.1% primary vs 3.1% interval, p=0.10). Patients undergoing ostomy formation were more likely to have longer mean operative time (335 vs 229 min, p<0.001) and undergo small and large bowel resections at the time of cytoreductive surgery (44% vs 14%, p<0.001). Multivariate analysis revealed that a high surgical complexity score was associated with ostomy formation. Of the patients who underwent ostomy formation, 13 (43.3%) underwent stoma reversal including 11 ileostomies and two colostomies. Median time to ostomy reversal was 7 months. CONCLUSION: Bowel surgery is more common among patients undergoing primary surgery as compared with interval surgery, but this does not result in an increased risk of ostomy formation.

Surgical skills assessment tools in gynecology.

PURPOSE OF REVIEW: The purpose of this review is to outline surgical skills assessment tools for the purpose of training and competency evaluation, with a focus on recent literature in gynecology. RECENT FINDINGS: Objective standardized surgical skills assessment tools are increasingly being explored in multiple surgical disciplines including gynecology. Several small studies in gynecology have validated procedure-specific checklists, global rating scales, and other surgical proficiency examinations in their ability to differentiate trainee skill level or correlate with other standardized tests. Few studies have included gynecologic surgeons in practice, and no studies have investigated their use in credentialing and maintenance of certification. SUMMARY: Surgical skills assessment tools may be a useful adjunct to gynecology training programs, with promising applications for practicing gynecologists.

Intensive care admissions among ovarian cancer patients treated with primary debulking surgery and neoadjuvant chemotherapy-interval debulking surgery.

OBJECTIVE: Admissions to intensive care units (ICU) are costly, but are necessary for some patients undergoing radical cancer surgery. When compared to primary debulking surgery (PDS), neoadjuvant chemotherapy (NACT) with interval debulking surgery, is associated with less peri-operative morbidity. In this study, we compare rates, indications and lengths of ICU stays among ovarian cancer patients admitted to the ICU within 30days of cytoreduction, either primary or interval. METHODS: A retrospective chart review was performed of patients with stage III-IV ovarian cancer who underwent surgical cytoreduction at two large academic medical centers between 2010 and 2014. Chi square tests, Student t-tests, and Mann-U Whitney tests were used. RESULTS: A total of 635 patients were included in the study. There were 43 ICU admissions, 7% of patients. Compared to NACT, a higher percentage of PDS patients required ICU admission, 9.4% vs 3.9% of patients (P=0.004). ICU admission indications did not vary between PDS and NACT patients. NACT patients admitted to the ICU had comparable mean surgical complexity scores to those PDS patients admitted to the ICU, 6.2 (95%CI 5.3-7.1) vs 4.5 (95%CI 3.1-6.0) (P=0.006). Length of ICU admission did not vary between groups, PDS 2.7days (95%CI 2.3-3.2) vs 3.5days (95%CI 1.5-5.6) for NACT (P=0.936). CONCLUSIONS: The rate of ICU admissions among patients undergoing PDS is higher than for NACT. Among patients admitted to the ICU, indications for admission, length of stay and surgical complexity were similar between patients treated with NACT and PDS.

Management for Elderly Women With Advanced-Stage, High-Grade Endometrial Cancer.

OBJECTIVE: To examine the treatment and survival of elderly women diagnosed with advanced-stage, high-grade endometrial cancer. METHODS: We performed a retrospective cohort study of women diagnosed between 2003 and 2011 with advanced-stage, high-grade endometrial cancers (grade 3 adenocarcinoma, carcinosarcoma, clear-cell carcinoma, and uterine serous carcinoma) using the National Cancer Database. Women were stratified by age: younger than 55, 55-64, 65-74, 75-84, and 85 years old or older. Multivariate logistic regression models and Cox proportional hazards survival methods for all-cause mortality were used for analyses. RESULTS: Twenty thousand four hundred sixty-eight patients were included, 14.9% younger than 55 years, 30.9% 55-64 years, 31.1% 65-74 years, 18.8% 75-84 years, and 4.3% 85 years old or older. Patients younger than 55 years had surgery more frequently compared with patients 75-84 years (97.2% compared with 95.8%; P<.001) and 85 years or older (97.2% compared with 94.8%; P<.001) and a higher rate of lymph node dissection (78.7% compared with 70.5%; P<.001 and 78.7% compared with 59.5%; P<.001, respectively). Women younger than 55 years old were more likely to receive chemotherapy compared with those 75-84 years (63.9% compared with 42.2%; P<.001) and 85 years old or older (63.9% compared with 22%; P<.001). After adjusting for prognostic factors, women ages 75-84 and 85 years or older were less likely to have received chemotherapy compared with women younger than 55 years (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.29-0.38 and OR 0.12, 95% CI 0.10-0.14). The same was true with surgery (OR 0.63, 95% CI 0.45-0.88 and OR 0.46, 95% CI 0.30-0.70) and radiotherapy (OR 0.61, 95% CI 0.53-0.70 and OR 0.45, 95% CI 0.37-0.56). The Cox regression model showed that in women with stage III disease, women 75-84 years had a twofold higher risk of death (hazard ratio [HR] 2.38, 95% CI 2.14-2.65) and those 85 years or older had a threefold higher risk (HR 3.16, 95% CI 2.76-3.61) compared with patients younger than 55 years. Patients with stage IV and age 75-84 years had a 24% increased risk of death (HR 1.24, 95% CI 1.11-1.40) and those 85 years or older had a 52% increased risk (HR 1.52, 95% CI 1.29-1.79). CONCLUSION: Elderly women with high-grade endometrial cancer are less likely to be treated with surgery, chemotherapy, or radiation. LEVEL OF EVIDENCE: II.