Training the gynecologic oncologists of the future - challenges and opportunities.

Several recent advances in gynecologic cancer care have improved patient outcomes. These include national screening and vaccination programs for cervical cancer as well as neoadjuvant chemotherapy for ovarian cancer. Conversely, these advances have cumulatively reduced surgical opportunities for training creating a need to supplement existing training strategies with evidence-based adjuncts. Technologies such as virtual reality and augmented reality, if properly evaluated and validated, have transformative potential to support training. Given the changing landscape of surgical training in gynecologic oncology, we were keen to summarize the evidence underpinning current training in gynecologic oncology.In this review, we undertook a literature search of Medline, Google, Google Scholar, Embase and Scopus to gather evidence on the current state of training in gynecologic oncology and to highlight existing evidence on the best methods to teach surgical skills. Drawing from the experiences of other surgical specialties we examined the use of training adjuncts such as cadaveric dissection, animation and 3D models as well as simulation training in surgical skills acquisition. Specifically, we looked at the use of training adjuncts in gynecologic oncology training as well as the evidence behind simulation training modalities such as low fidelity box trainers, virtual and augmented reality simulation in laparoscopic training. Finally, we provided context by looking at how training curriculums varied internationally.Whereas some evidence to the reliability and validity of simulation training exists in other surgical specialties, our literature review did not find such evidence in gynecologic oncology. It is important that well conducted trials are used to ascertain the utility of simulation training modalities before integrating them into training curricula.

Evaluation of the Safety and Efficacy of Resection of Endometrial Polyps and Submucosal Fibroids in an Outpatient Setting in a Large District General Hospital in the UK.

Background: Conventionally, endometrial pathologies of varying complexity have been surgically treated as inpatients under a general or regional anesthetic. Aim: In this paper, we evaluate the safety and efficacy of hysteroscopic morcellation of endometrial pathology in the form of endometrial polyps (EPs) and submucosal fibroids in an outpatient setting for both simple and complex lesions using the Myosure™ device. Methods: Two hundred and forty-nine hysteroscopic resections were performed in an outpatient setting at the < BLINDED FOR REVIEW > from May 2014 to March 2021. The median age of the patients was 54 years. More than half of the patients presented with postmenopausal bleeding; 64% were diagnosed with EPs and 24% with submucous fibroids (SMFs). The size, topography, extension, penetration, and wall classification system scoring system were used to grade them as simple (≤4) or complex (≥5) pathologies. Results: 90% of pathologies were simple (≤4), of which complete resection was carried out in 95% of patients; 10% of the pathologies were complex (≥5), of which 63% had complete resection. Two patients with complex pathologies returned for completion surgery as a two-step procedure. No procedure was abandoned due to the patient intolerance. The median intraprocedure pain score visual analog scale was 5/10 and immediate postprocedure pain score was 1/10. Notably, there was no intra- or post-procedure complications. Conclusion: Outpatient resection of endometrial pathology, both simple and complex, can be safely and effectively performed using hysteroscopic morcellator (Myosure™) and is accepted and well tolerated by patients.

Vaginal Intraepithelial Neoplasia: A Retrospective Study of Treatment and Outcomes Among a Cohort of UK Women.

OBJECTIVES: The aim of the study was to analyze the clinical features of women found to have vaginal intraepithelial neoplasia (VaIN), the treatment modalities that they were offered, and clinical outcomes after treatment and follow-up. MATERIALS AND METHODS: This is a retrospective review of all cases of biopsy-proven or treated VaIN occurring for a 15-year period at Southend University Hospital, United Kingdom. RESULTS: Eighty-eight cases of VaIN were identified. The age range was from 24 to 76 years, and 39% of cases were low grade (VaIN 1) and 60% high grade (VaIN 2 and 3). Sixty-five percent of patients had either already undergone or would go on to have treatment for cervical intraepithelial neoplasia. Of those with low-grade disease, 86% were managed conservatively with a 97% success rate. Similarly, with high-grade disease, 77% were managed with laser treatment with a success rate of 76% for primary treatment. Of the 6 cases of high-grade disease treated conservatively, 50% subsequently needed active treatment. There was 1 case of progression to vaginal cancer (1.3%). CONCLUSIONS: Vaginal intraepithelial neoplasia remains an uncommon premalignant condition. It can affect women of all ages and is commoner in those who are immunosuppressed. Observation of low-grade disease is safe and the abnormality often resolves spontaneously. For persistent disease or higher-grade abnormalities, there are many treatment options but laser vaporization is the most commonly used. However, because of the nature of VaIN, recurrence is common even after treatment and further management can be challenging. The overall rate of malignant progression is small but protracted follow-up may be necessary.

Primary non-Hodgkin's lymphoma of the vagina (PNHLV): a gynaecologist's enigma!

Primary lymphoma of the female genital tract is very rare, particularly those presenting primarily in the vagina are even rarer. We report a case of a 60-year-old woman who presented with generalised abdominal pain, vaginal discharge and a thickening of the posterior vaginal wall. Prompt radiological investigations and biopsy led to early diagnosis and appropriate treatment. Complete metabolic remission was obtained with three cycles of chemotherapy and radiotherapy. This case highlights the need for increasing the awareness about lymphomas presenting as vaginal lesion(s) and for clinicians to keep an open mind when working up such patients.

Toxic Shock Syndrome within 24 H of an Office Hysteroscopy.

Office hysteroscopy is now a common procedure performed to look at the endometrial cavity and is relatively free of serious complications. A 68-year-old lady, previously fit and well, presented with abdominal pain, rigors, sweats, and vomiting within 24 h of an outpatient hysteroscopy for postmenopausal bleeding. She was diagnosed with streptococcal toxic shock syndrome (STSS) due to Group A beta-hemolytic streptococci. She was managed in the Intensive Care Unit, with inotropic and antibiotic support. She recovered eventually and was discharged home with oral antibiotics. Toxic shock syndrome due to Streptococci is an unusual occurrence, whose incidence has been slowly increasing over the years. However, this appears to be the first case of STSS manifesting within 24 h following an outpatient hysteroscopy.