Oxycodone Use During the Postoperative Period After Hysterectomy for Benign Indications.

OBJECTIVES: The objective of this study was to estimate the amount of oxycodone tablets required for pain control in the 2-week postoperative period after laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) for benign disease. METHODS: We conducted a prospective cohort study of English-speaking women 18 years or older undergoing hysterectomy for benign indications. Participants completed a pain survey at baseline and daily for 2 weeks postoperatively. In addition, they recorded the number of oxycodone tablets and other pain medications taken daily for 2 weeks. The primary outcome was the median number of oxycodone tablets (5 mg) consumed after LH or VH during 2 weeks postoperative. RESULTS: Eighty-one women underwent VH and 82 underwent LH. Women who underwent VH were older (mean ± SD, 64.2 ± 10.3 years vs 47.5 ± 7.7 years), more parous (2 [interquartile range (IQR), 2-3] vs 2 [IQR, 1-2]), and less likely to be sexually active (51.9% vs 79.3%, P < 0.02). Women in the VH group also had significantly lower baseline pain levels (0 [IQR, 0-1] vs 1 [IQR, 0-4], P < 0.001). All VH participants had surgery for prolapse, whereas only 12.2% in the LH group had surgery for this indication (P < 0.001). Most in the LH group had surgery for fibroids (61%) or abnormal uterine bleeding (15.9%). Women in the VH group consumed significantly less oxycodone tablets postoperatively (median, 4.5 [IQR, 1-9] vs 7 [IQR, 2-18]; P = 0.047) and took oxycodone for less days after discharge (median, 1 [IQR, 0-3] vs 3 [IQR, 1-6]; P < 0.001). CONCLUSIONS: Women consume less oxycodone after minimally invasive hysterectomy than previously thought. Those who undergo VH may consume less oxycodone than those who undergo LH.

Superior Hypogastric Plexus Block to Reduce Pain After Laparoscopic Hysterectomy: A Randomized Controlled Trial.

OBJECTIVE: To assess whether a superior hypogastric plexus block performed during laparoscopic hysterectomy reduces postoperative pain. METHODS: We conducted a multicenter, randomized, single-blind, controlled trial of superior hypogastric plexus block at the start of laparoscopic hysterectomy. Women undergoing a laparoscopic hysterectomy for any indication and with any other concomitant laparoscopic procedure were eligible. Standardized preoperative medications and incisional analgesia were provided to all patients. Our primary outcome was the proportion of patients with a mean visual analog scale (VAS) pain score lower than 4 within 2 hours postoperatively. Patients but not surgeons were blinded to the treatment group. Twenty-nine patients per group was estimated to be sufficient to detect a 38% absolute difference in the proportion of patients with a VAS score lower than 4 at 2 hours postoperatively, with 80% power and an α of 0.05. To account for loss to follow-up and potential imbalances in patient characteristics, we planned to enroll 50 patients per group. All analyses were intention to treat. RESULTS: Between January 2018 and February 2019, 186 patients were eligible; 100 were randomized and analyzed. Demographic and clinical characteristics were similar between the two groups. There was no significant difference in the proportion of patients with a mean VAS score lower than 4 within 2 hours postoperatively between patients who received a superior hypogastric plexus block (57%) and patients who did not (43%) (odds ratio 1.63, 95% CI 0.74-3.59; adjusted odds ratio 1.84, 95% CI 0.75-4.51). CONCLUSION: Among patients undergoing laparoscopic hysterectomy with standardized enhanced perioperative recovery pathways, superior hypogastric plexus block did not significantly reduce postoperative pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03283436.

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.

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.

Factors Associated with Negative Patient Experiences with Essure Sterilization.

STUDY OBJECTIVE: The objective of the study was to identify factors associated with negative patient experiences with Essure. DESIGN: This was a retrospective cohort study and follow-up survey. SETTING: The study was conducted in an academic setting. PATIENTS: Patients included women who had an Essure placed between 2002 and 2017. METHODS: The hospitals' database was queried to identify subjects and charts were reviewed to confirm medical information. Subjects were invited by mail, e-mail, or phone call to participate a survey regarding symptoms and satisfaction with Essure. A comparison was made between women who reported a negative experience with Essure versus those who did not. A multivariable logistic regression analysis was performed to identify subject or procedural characteristics associated with any negative experience with Essure sterilization. RESULTS: Two hundred eighty-four women underwent Essure sterilization between 2002 and 2017, 42.3% of whom responded to the follow-up survey. Satisfaction with Essure was reported by 61.9% of respondents. Thirty-three percent of the respondents have undergone removal or desire removal of the device. The most frequent symptoms attributed to Essure were pelvic pain, dyspareunia, and vaginal bleeding. Forty-eight percent of the respondents were identified as having any negative experience with Essure. Factors associated with negative experiences with Essure included young age at placement (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.79-0.94; P < .001), high gravidity (OR 1.39; 95% CI 1.14-1.71; P = .002), and absent history of abdominal surgery (OR 0.35; 95% CI 0.12-1.00; P = .049). CONCLUSION: Young age at placement, high gravidity, and absent history of abdominal surgery are factors associated with negative patient experiences following Essure sterilization. A negative experience with Essure is common, although dissatisfaction with the device is not always attributable to symptoms. This information could be considered when counseling women who plan removal of Essure. IMPLICATIONS STATEMENT: Our study provides new follow-up data with respect to hysteroscopic sterilization. This research is the first to examine any cause for negative patient experiences with Essure. Understanding factors associated with negative patient experiences could improve patient counseling regarding the extent to which symptoms could be attributed to Essure as well as counseling women who want to undergo removal of the device. These factors could in turn prove to be predictors for successful resolution of symptoms after removal of Essure. Results of this study could also be used for developing future hysteroscopic sterilization techniques.

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.

Laparoscopic treatment of endometriosis and predictors of major complications: A retrospective cohort study.

INTRODUCTION: Patients with advanced endometriosis may be at an increased risk of surgical complications following laparoscopic treatment of endometriosis; however, this relationship has not been examined. We sought to identify predictors of major complications following laparoscopic treatment of endometriosis. MATERIAL AND METHODS: A retrospective cohort study of women who underwent laparoscopic treatment of suspected endometriosis between 2009 and 2016 within the Division of Minimally Invasive Gynecologic Surgery at Brigham and Women's Hospital, Boston, MA, USA. Predictors of major perioperative complications were assessed by comparing the characteristics of women who had any major intraoperative or postoperative complication with those of women who had no complication. RESULTS: A total of 397 women underwent laparoscopic treatment of suspected endometriosis including excision of superficial endometriosis (55.4%), excision of deep-infiltrating endometriosis (24.9%), fulguration of endometriosis (38.3%), hysterectomy (23.2%), ovarian cystectomy (35.5%), salpingectomy (18.6%), oophorectomy (15.1%), and bowel resection (1.0%). Women were followed for 60 days following surgery, over which time 18 women (4.5%) had a major perioperative complication. Patient characteristics and preoperative imaging were similar between women with and without complications. Women with advanced endometriosis, including stage III or IV endometriosis, deep-infiltrating endometriosis, or rectovaginal disease, were more likely to have a complication, though this did not reach statistical significance (77.8% of women with a complication versus 56.7% of women without a complication had advanced endometriosis, P = 0.077). Women who had a complication were more likely to have undergone adhesiolysis or ureterolysis (88.9% of women with a complication versus 52.5% without a complication underwent adhesiolysis, P = 0.002; and 61.1% of women with a complication versus 28.8% without a complication underwent ureterolysis, P = 0.003). The total number of procedures was greater for women who had a complication (4.3 ± 1.2 vs 3.2 ± 1.5, P = 0.003). All other procedure characteristics were similar between women with and without complications. CONCLUSIONS: Complications following laparoscopic treatment of suspected endometriosis could not be predicted by preoperative patient characteristics or surgical findings of advanced endometriosis. Adhesiolysis, ureterolysis, and an increased number of total procedures may be predictive of perioperative complications, suggesting that surgical complexity as measured by the procedures performed, rather than the disease severity, may increase the risk of a complication compared with women who do not undergo these procedures.

Two-dimensional (2D) versus three-dimensional (3D) laparoscopy for vaginal cuff closure by surgeons-in-training: a randomized controlled trial.

BACKGROUND: Objective evidence is lacking as to the benefit of the addition of 3D vision to conventional laparoscopy in Gynecologic surgery. This study aims to compare 3-D visual system to traditional 2-D laparoscopic visualization for the laparoscopic closure of the vaginal cuff during total laparoscopic hysterectomy by surgeons-in-training [defined as senior OBGYN resident or Minimally Invasive Gynecologic Surgery (MIGS) fellow]. METHODS: 51 patients undergoing total laparoscopic hysterectomy at two tertiary care academic hospitals were randomized to two-dimensional or three-dimensional vision system with cuff closure performed by surgeons-in-training. The primary outcome was the time taken for vaginal cuff closure. Secondary outcomes included peri-operative outcomes and assessment of surgeon's perception of ease of cuff closure. RESULTS: 27 (52.9%) cases were allocated to cuff closure with the 2D system and 24 (47.1%) cases to closure with the 3D vision system. Patient baseline characteristics were similar between the vision systems. Mean vaginal cuff closure time was not significantly different between 2D and 3D vision (10.1 min for 2D versus 12 min for 3D, p = 0.31). An additional 24 s was added to cuff closure time with each 1 kg/m2 increase in BMI, after controlling for potential confounders (p = 0.003). There was no difference in the surgeon rating of ease of cuff closure between 2D and 3D. Peri-operative outcomes are similar among the two groups. CONCLUSION: We did not demonstrate any benefits of 3D vision system over conventional 2D for the task of laparoscopic vaginal cuff suturing performed by surgeons-in-training. RCT Registration Number NCT02192606 https://clinicaltrials.gov/ct2/show/NCT02192606 (July 17, 2014).

Career Interest and Psychomotor Aptitude Among Medical Students.

OBJECTIVE: The primary objective is to assess psychomotor aptitude of medical students interested in pursuing a procedural career. Secondary objectives include exploring the relationship between actual and perceived aptitude, and identifying predictors of superior aptitude. DESIGN: This is a cross-sectional, multisite study in which participants completed a paper survey, four visuospatial aptitude assessments, and a laparoscopic simulation modeled after the Fundamentals of Laparoscopic Surgery (FLS) peg transfer test (used as a proxy for psychomotor aptitude). SETTING: Johns Hopkins University School of Medicine and Mayo Clinic School of Medicine. PARTICIPANTS: All second-year medical students who had not yet initiated clinical rotations were eligible. Sixty-four students participated. RESULTS: Students interested in a procedural career exhibited superior psychomotor aptitude (faster FLS task completion time), and a majority of these students correctly identified themselves as having above-average aptitude compared with peers. However, over one quarter of all students, regardless of career interest, incorrectly over- or under-rated their psychomotor aptitude. Upon completing their preclinical curriculum, a minority of students felt prepared to participate or assist in their surgical clinical rotations. CONCLUSIONS: Prior to embarking on their clinical rotations, over one quarter of medical students lack awareness of their psychomotor aptitude and many do not feel prepared to participate in the next phase of their training. Early aptitude testing and introduction to laparoscopic training may assist in career selection, preparedness, and success.

Perioperative Antibiotic Use and Associated Infectious Outcomes at the Time of Myomectomy.

OBJECTIVE: To report the frequency of perioperative antibiotic use at time of myomectomy and associated risk of infectious outcomes. METHODS: We conducted a retrospective cohort study including all women who underwent any route of myomectomy from 2009 to 2016 at two academic hospitals in Boston, Massachusetts. Cases involving chromopertubation or conversion to hysterectomy were excluded from further analysis. Medical records were queried for the use or nonuse of perioperative antibiotics, as well as baseline patient factors and perioperative outcomes. Statistical analyses included univariate comparisons between treatment groups, as well as multivariable logistic regression analyses of infectious morbidity controlling for patient age, route of surgery, presence of high-risk factors, any intraoperative complication, myoma weight, and entrance into the endometrial cavity. Matched cohort analysis also was performed to confirm findings in the setting of underlying differences between groups. RESULTS: A total of 1,211 patients were included in the myomectomy cohort, 92.7% of whom received perioperative antibiotics at the time of surgery. Demographic characteristics were similar between the group that received and the group that did not receive antibiotics. The cases with antibiotic use were associated with longer operative times, higher estimated blood loss, and greater myoma burden. No difference was noted with regard to intraoperative or postoperative complications. Surgical site infection occurred more commonly in the group that did not receive antibiotics (2.9% vs 6.8% in the antibiotic and no-antibiotic groups, respectively; effect size 0.43, 95% CI 0.18-0.97 P=.04), representing a nearly fourfold increase in odds of any surgical site infection in the absence of perioperative antibiotic use (adjusted odds ratio 3.77, 95% CI 1.30-10.97, P=.015). CONCLUSION: A high frequency of antibiotic use was noted at time of myomectomy, despite lack of clear evidence supporting the practice. Patients who received perioperative antibiotics had fewer postoperative infectious outcomes and, in particular, experienced a lower incidence of surgical site infection.

Vaginal or laparoscopic hysterectomy: Do perioperative outcomes differ? A propensity score-matched analysis.

INTRODUCTION: There are assertions that vaginal mode may be the preferred approach of minimally invasive hysterectomy, yet rates of laparoscopic hysterectomy (LH) continue to rise while vaginal hysterectomy (VH) rate remains relatively unchanged. The aim of this study is to compare the perioperative outcomes of LH vs VH. MATERIAL AND METHODS: We identified women who underwent either LH or VH for benign indications between 2009 and 2015 at a large academic institution. A propensity score-matched analysis was used to adjust for differences between women undergoing VH vs LH. Outcome parameters were perioperative complications (both intraoperative and postoperative), operative time, blood loss, hospital length of stay, conversion and readmission. RESULTS: A total of 1921 patients underwent either LH or VH during the study period. In all, 155 patients from each group were successfully matched using propensity score match analysis. While most intra- and postoperative characteristics did not differ between groups, LH was associated with lower blood loss during surgery (102.8 ± 166.5 mL vs 185.0 ± 179.0 mL, P < 0.001) and shorter hospital stay (0.9 ± 1 days vs 1.2 ± 0.9 days, P < 0.0001). Concomitant adnexal surgery was performed more frequently during LH (47.7% vs 12.3%, P < 0.0001), and concomitant prolapse surgery was performed more frequently at the time of VH (14.2% vs 68.4%, P < 0.0001). CONCLUSIONS: Both VH and LH have overall favorable perioperative outcomes; however, LH is associated with lower blood loss and a shorter hospital stay. The results support the trend toward increasing rates of laparoscopic approach to hysterectomy when appropriate.

Prospective Evaluation of Manual Morcellation Techniques: Minilaparotomy versus Vaginal Approach.

STUDY OBJECTIVE: To compare the number of days required to return to daily activities after laparoscopic hysterectomy with 2 tissue extraction methods: manual morcellation via colpotomy or minilaparotomy. Secondary outcomes were additional measures of patient recovery, perioperative outcomes, containment bag integrity, and tissue spillage. DESIGN: Multicenter prospective cohort study and follow-up survey (Canadian Task Force classification II-2). SETTING: Two tertiary care academic centers in northeastern United States. PATIENTS: Seventy women undergoing laparoscopic hysterectomy with anticipated need for manual morcellation. INTERVENTIONS: Tissue extraction by either contained minilaparotomy or contained vaginal extraction method, along with patient-completed recovery diary. MEASUREMENTS AND MAIN RESULTS: Recovery diaries were returned by 85.3% of participants. There were no significant differences found in terms of average pain at 1, 2, or 3 weeks after surgery or in time to return to normal activities. Patients in both groups used narcotic pain medication for an average of 3 days. After adjusting for patient body mass index, history of prior surgery, uterine weight, and surgeon, there were no differences found for blood loss, operative time, length of stay, or incidence of any intra- or postoperative complication between groups. All patients had benign findings on final pathology. More cases in the vaginal contained extraction group were noted to have bag leakage on postprocedure testing (13 [40.6%] vs 3 [8.3%] tears in vaginal and minilaparotomy groups, respectively; p = .003). CONCLUSION: Regarding route of tissue extraction, contained minilaparotomy and contained vaginal extraction methods are associated with similar patient outcomes and recovery characteristics.

Perioperative Outcomes of Myomectomy for Extreme Myoma Burden: Comparison of Surgical Approaches.

STUDY OBJECTIVE: To describe the perioperative outcomes of various modes of myomectomy (abdominal [AM], laparoscopic [LM], or robotic [RM]) in cases of extreme myoma burden. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: A tertiary academic center in Boston, Massachusetts. PATIENTS: All women who underwent an AM, LM, or RM for extreme myoma burden, defined as representing the upper quartile for specimen weight (≥434.6 g) or myoma count (≥7 myomas), between 2009 and 2016. INTERVENTIONS: Baseline demographics and perioperative outcomes were collected from review of medical records, including estimated blood loss, operative time, length of stay, and complications. Univariate linear and logistic regression analyses were conducted. MEASUREMENTS AND MAIN RESULTS: During the study period 659 women underwent myomectomy for extreme myoma burden; 47.2% of cases were AM, 28.1% LM, and 24.7% RM. Overall myoma burden differed across the 3 routes and was greatest in the AM group (mean weight: 696.2 ± 784.5 g for AM vs 586.6 ± 426.1 g for LM and 586.6 ± 426.1 g for RM; mean number: 16.8 ± 15.0 for AM vs 7.2 ± 7.0 for LM and 6.7 ± 4.7 for RM; p <.001 for both). The 3 routes differed in operative time and length of stay, with RM having the longest operative time (mean, 239.7 minutes; p <.001) and AM the longest length of stay (mean, 2.2 ± .9 days; p <.001). Other perioperative outcomes were similar across the surgical approaches. Increasing myoma burden was associated with an increased risk of perioperative complications for all surgical approaches, with a threshold of 13 myomas associated with an almost 2-fold higher risk of perioperative complications (odds ratio, 1.77; 95% confidence interval, 1.17-2.70; p = .009). Cumulative incidence of perioperative complications with increasing specimen weight was greater in the RM cases as compared with AM (p = .002) or LM (p = .020), whereas the cumulative incidence of perioperative complications with increasing myoma count was lowest with AM compared with LM (p <.001) or RM (p <.001). CONCLUSION: Myomectomy for extreme myomas is feasible using an abdominal, laparoscopic, or robotic approach. Increased myoma burden is associated with an increased risk of perioperative complications. A threshold of 13 myomas was associated with an almost 2-fold higher risk of perioperative complications for all modes. Perioperative complication outcomes were more favorable in AM or LM over RM with increased myoma weight and AM over LM or RM with increased myoma number.

Persistence of Symptoms After Total vs Supracervical Hysterectomy in Women with Histopathological Diagnosis of Adenomyosis.

STUDY OBJECTIVE: To compare symptom persistence in women with adenomyosis based on retention or removal of the cervix at the time of hysterectomy. DESIGN: Retrospective cohort study and follow-up survey (Canadian Task Force classification xx). SETTING: Tertiary care academic hospital in Boston, Massachusetts. PATIENTS: Women (n = 1580) who underwent laparoscopic hysterectomy for benign indications between 2008 and 2012 at Brigham and Women's Faulkner Hospital and Brigham and Women's Hospital. INTERVENTION: Retrospective chart review and follow-up survey. MEASUREMENTS AND MAIN RESULTS: Among the 1580 women contacted, 762 (48%) responded to the postoperative symptom resolution survey. Of these 762 women, 623 agreed to participate in the study. Menopausal women or those who had undergone bilateral salpingo-oophorectomy were excluded. Adenomyosis was identified on histopathologic evaluation of the uterus in 171 of the remaining 443 women (39%). Compared with women without adenomyosis, those with adenomyosis were older on average (mean age, 46.6 ± 6.8 years vs 45.0 ± 5.5 years; p = .009) and more likely to report that abnormal bleeding and pain led to their hysterectomy (87.7% vs 79.8%; p = .03 and 64.9% vs 51.4%; p = .009, respectively). The rates of total and supracervical hysterectomies were similar in the 2 groups. Following surgery, women with adenomyosis were less likely than those without adenomyosis to report persistent pain (adjusted odds ratio [aOR], 0.43; 95% confidence interval [CI], 0.20-0.93; p = .03). Persistent bleeding was similar in the 2 groups (aOR, 0.97; 95% CI, 0.49-1.93; p = .94). Among women with adenomyosis, multivariable logistic regression showed no difference in persistence of symptoms with cervical removal or retention at the time of hysterectomy. CONCLUSION: Compared with women without adenomyosis, those with histopathologically proven adenomyosis were less likely to report persistent pain following hysterectomy. Retention of the cervix does not appear to increase the risk of symptom persistence or postprocedure patient satisfaction.

Reintervention risk and quality of life outcomes after uterine-sparing interventions for fibroids: a systematic review and meta-analysis.

OBJECTIVES: To compare uterine-sparing treatment options for fibroids in terms of reintervention risk and quality of life. DESIGN: Systematic review and meta-analysis according to PRISMA guidelines. SETTING: Not applicable. PATIENT(S): Women with uterine fibroids undergoing a uterine-sparing intervention. INTERVENTIONS(S): Not applicable. MAIN OUTCOME MEASURE(S): 1) Reintervention risk after uterine-sparing treatment for fibroids after 12, 36, and 60 months; and 2) quality of life outcomes, based on validated questionnaires. Two separate analyses were performed for the procedures that used an abdominal approach (myomectomy, uterine artery embolization [UAE], artery ligation, high-intensity focused ultrasound [HIFU], laparoscopic radiofrequency ablation [RFA]) and for the procedures managing intracavitary fibroids (hysteroscopic approach, including hysteroscopic myomectomy and hysteroscopic RFA). RESULT(S): There were 85 articles included for analysis, representing 17,789 women. Stratified by treatment options, reintervention risk after 60 months was 12.2% (95% confidence interval [CI] 5.2%-21.2%) for myomectomy, 14.4% (95% CI 9.8%-19.6%) for UAE, 53.9% (95% CI 47.2%-60.4%) for HIFU, and 7% (95% CI 4.8%-9.5%) for hysteroscopy. For the other treatment options, no studies were available at 60 months. For quality of life outcomes, symptoms improved after treatment for all options. The HIFU procedure had the least favorable outcomes. CONCLUSION(S): Despite the substantial heterogeneity of the study population, this meta-analysis provides valuable information on relative treatment efficacy of various uterine-sparing interventions for fibroids, which is relevant when counseling patients in daily practice. Furthermore, this study demonstrates that long-term data, particularly for the newest uterine-sparing interventions, are urgently needed.

Visuospatial Aptitude Testing Differentially Predicts Simulated Surgical Skill.

OBJECTIVE: To determine whether visuospatial perception (VSP) testing is correlated to simulated or intraoperative surgical performance as rated by the American College of Graduate Medical Education (ACGME) milestones. DESIGN: (Canadian Task Force classification II-2). SETTING: Two academic training institutions. PARTICIPANTS: Forty-one residents, including 19 from Brigham and Women's Hospital and 22 from the Mayo Clinic, from 3 different specialties: obstetrics and gynecology, general surgery, and urology. INTERVENTION: Participants underwent 3 different tests: visuospatial perception testing (VSP), Fundamentals of Laparoscopic Surgery (FLS) peg transfer, and da Vinci robotic simulation peg transfer. Surgical grading from the ACGME milestones tool was obtained for each participant. Demographic and background information was also collected, including specialty, year of training, previous experience with simulated skills, and surgical interest. Standard statistical analyses were performed using Student's t test, and correlations were determined using adjusted linear regression models. MEASUREMENTS AND MAIN RESULTS: In univariate analysis, Brigham and Women's Hospital and Mayo Clinic training programs differed in times and overall scores for both the FLS peg transfer and da Vinci robotic simulation peg transfer tests (p < .05 for all). In addition, type of residency training affected time and overall score on the robotic peg transfer test. Familiarity with tasks correlated with higher score and faster task completion (p = .05 for all except VSP score). There were no differences in VSP scores by program, specialty, or year of training. In adjusted linear regression modeling, VSP testing was correlated only to robotic peg transfer skills (average time, p = .006; overall score, p = .001). Milestones did not correlate to either VSP or surgical simulation testing. CONCLUSION: VSP score was correlated with robotic simulation skills, but not with FLS skills or ACGME milestones. This suggests that the ability of VSP score to predict competence differs between tasks. Therefore, further investigation of aptitude testing is needed, especially before its integration as an entry examination into a surgical subspecialty.

Incisional Outcomes of Umbilical vs Suprapubic Mini-laparotomy for Tissue Extraction: A Retrospective Cohort Study.

STUDY OBJECTIVE: To compare outcomes following umbilical minilaparotomy and suprapubic minilaparotomy for tissue extraction. DESIGN CLASSIFICATION: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Two large academic medical centers. PATIENTS: Women who underwent a minilaparotomy for tissue extraction following a laparoscopic hysterectomy or myomectomy between 2014 and 2016. INTERVENTIONS: Umbilical or suprapubic minilaparotomy for tissue extraction. MEASUREMENTS AND MAIN RESULTS: A total of 374 women underwent laparoscopic hysterectomy or myomectomy with minilaparotomy, including 289 (77.3%) with an umbilical minilaparotomy and 85 (22.7%) with a suprapubic minilaparotomy. The 2 groups were similar in terms of age, body mass index, parity, surgical history, procedure type, surgical approach, and surgical indication. The size of the minilaparotomy incision and the specimen weight were significantly smaller in the umbilical minilaparotomy group (mean, 3.3 ± 0.8 cm vs 4.2 ± 0.6 cm [p < .001] and 472.6 ± 357.1 g vs 683.0 ± 475.7 g [p < .001], respectively). Two women in the suprapubic minilaparotomy group sustained a bladder injury during creation of the incision. There were no other complications related to the minilaparotomy in either group. Postoperative outcomes related to the minilaparotomy incision were compiled using the medical record and a follow-up survey. Of the 374 women in this cohort, 163 responded to a detailed survey about their minilaparotomy incision (response rate, 43.5%). With regard to the minilaparotomy, 52.7% of women reported incisional symptoms; 25.9% had increased pain at the incision, 8.3% had an incisional infection, and 2.7% reported an incisional hernia. There was no significant between-group difference in incisional outcomes; however nearly 3 times as many women in the umbilical minilaparotomy group reported concerns about incisional hernia (3.1% vs 1.2%; p = .833). These findings were maintained in a multivariable logistic regression analysis. No patient or procedure characteristics were significantly associated with the development of hernia. CONCLUSION: There were no significant difference in incisional symptoms, pain, or infection following umbilical minilaparotomy vs a suprapubic minilaparotomy for tissue extraction. Although not statistically significant, the rate of incisional hernia was higher at the umbilical site compared with the suprapubic site.