Childcare needs as a barrier to healthcare among women in a safety-net health system.

BACKGROUND: Childcare needs are an understudied social determinant of health. The effect of childcare needs on access to healthcare must be understood to inform health system interventions and policy reform. This study sought to characterize childcare needs, access to childcare, and prior experience with navigating childcare needs in healthcare settings among women in a safety-net population. METHODS: We conducted a cross-sectional study of patient-reported survey data collected in-person between April and October 2019. Surveys were administered in waiting rooms of ambulatory services in a large, urban safety-net health system in Dallas, Texas. Survey respondents were derived from a random convenience sample of women waiting for outpatient appointments. Participants were screened for having children under the age of 13 and/or childcare responsibilities for inclusion in the sample. Outcomes of interest included self-reported delayed or missed care, reasons for delayed or missed care, perceived difficulty in accessing childcare, prior methods for managing childcare during healthcare appointments, and prior experience with childcare centers. RESULTS: Among the 336 respondents (96.7% response rate), 121 (36.0%) reported delaying or missing a mean 3.7 appointments/year. Among women with delayed or missed care, 54.5% reported childcare barriers as the primary reason for deferral of care, greater than transportation (33%) or insurance (25%) barriers. Respondents rated childcare access as more difficult than healthcare access. Delayed or missed care due to childcare was more common among White (68.8%) and Black (55.0%) women compared to Hispanic women (34.3%). Common methods of navigating childcare needs during scheduled appointments included bringing children to appointments (69.1%) and re-scheduling or missing the scheduled appointment (43.0%). 40.6% of patients reported leaving an appointment before completion due to childcare needs. CONCLUSIONS: Childcare needs are a leading barrier to healthcare among women accessing care in safety-net settings. Unmet childcare needs result in deferral of care, which may impact health outcomes. Childcare access is perceived as more challenging than healthcare access itself. Health system and policy interventions are needed to address childcare as a social determinant of health.

Association between Endometriosis and Surgical Complications among Benign Hysterectomies.

STUDY OBJECTIVE: To investigate the effect of endometriosis on perioperative outcomes in patients undergoing hysterectomy for benign disease. DESIGN: A retrospective cohort study. SETTING: The American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: A total of 127 556 hysterectomies performed for benign gynecologic indications INTERVENTIONS: Differences in the primary outcomes were compared between patients with and without endometriosis after adjustment for group differences in covariates using inverse probability of treatment weighting approach. MEASURES AND MAIN RESULTS: Of the 127 556 hysterectomies identified, 19 618 (15.4%) had a diagnosis of endometriosis. Patients with endometriosis were younger with a lower prevalence of chronic comorbidities but had higher rates of concurrent pelvic inflammatory disease and previous abdominal operations. The incidence of postoperative complications was higher in patients with endometriosis (9.9% vs 8.1%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.17-1.34). The incidence of 30-day mortality (0.1% vs 0.03%; OR, 1.98; 95% CI, 0.69-5.65) and reoperations (1.50% vs 1.36%; OR, 1.18; 95% CI, 0.98-1.42) were not different in patients with and without endometriosis. CONCLUSION: Postoperative complications are more likely in hysterectomies involving endometriosis than those without endometriosis, likely owing to anatomic distortion incurring increased surgical complexity. Patients and surgeons should be aware of the increased risk of complications and plan for mitigating these increased risks before and during surgery for suspected endometriosis.

Ice-POP: Ice Packs for Postoperative Pain: A Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate the benefit of ice packs as a supplement to standard pain management following laparoscopic hysterectomy (LH). DESIGN: This Institutional Review Board-approved randomized controlled trial involved patients undergoing LH for benign conditions. Subjects were randomized to receive standard enhanced recovery after surgery pain management or standard enhanced recovery after surgery plus ice packs. SETTING: Two academic tertiary care centers PATIENTS: Patients undergoing planned outpatient LH with the minimally invasive gynecologic surgery team between February 2019 and November 2020 were considered. Patients with chronic pain, current opioid use ≥1 week, or planned overnight hospitalizations were excluded. Primary outcome data were available for 51 subjects (24 control, 27 intervention). INTERVENTIONS: Ice packs were placed on the abdomen in the operating room. MEASUREMENTS AND MAIN RESULTS: Pain was assessed at multiple time points throughout the study using a visual analogue scale (VAS). Opioid requirement was assessed using morphine milligram equivalent. There was no difference between the groups on any demographic variables. Morphine milligram equivalent requirements were also not different between the groups (p = .63). Postoperative day 1 (POD#1) VAS scores were not different (p = .89). Eighty-five percent of subjects reported feeling that their pain was controlled. Subjects who reported that they did not feel their pain was controlled did not use more opioids on POD#1 (p = .37), nor did they have higher POD#1 VAS scores (p = .55). Eighty-seven percent of the intervention subjects said they would use ice again, and 82.6% of them said they would recommend ice to others. There were no adverse events related to ice. All subjects were prescribed 20 tablets oxycodone and averaged 2.9 (SD 3.4) tablets used after discharge. CONCLUSION: Ice packs are an acceptable supplement for postoperative pain control, but they do not reduce postoperative pain or opioid usage compared to standard pain management without ice packs.

Mass lesions of the myometrium: interpretation and management of unexpected pathology.

PURPOSE OF REVIEW: Uterine leiomyomas are the most common benign uterine smooth muscle tumors. On the basis of imaging, these masses are often presumed to be benign conventional leiomyomas and surgical excision is a common treatment choice. After myomectomy or hysterectomy for presumed leiomyomas, the surgical pathology report may reveal an unexpected diagnosis of another type of mesenchymal tumor. These can range from a variant of benign smooth muscle tumors to smooth muscle tumors of uncertain malignant potential to malignant sarcomas. This review describes these variant pathologies and reviews data on recurrence risk and postoperative management. RECENT FINDINGS: The majority of benign smooth muscle tumors will be classified as leiomyomas. Cellular, bizarre nuclei, mitotically active, epitheliod, myxoid, and dissecting are all terms that describe pathologic variants of benign leiomyomas. Smooth muscle tumors of uncertain malignant potential contain both benign and malignant features and should be referred to Gynecologic Oncology for follow-up. Leiomyosarcomas and low-grade endometrial stromal sarcomas may present preoperatively as benign tumors but are malignant with a high risk of recurrence and should be referred to Gynecologic Oncology. SUMMARY: We advocate for the continued benefits of minimally invasive procedures in appropriately selected patients. Despite these measures, unexpected pathologic diagnoses can occur and should be managed appropriately.

Preoperative Evaluation for Minimally Invasive Gynecologic Surgery: What Is the Best Evidence and Recommendations for Clinical Practice.

Preoperative evaluation for elective benign gynecologic procedures is a necessary step in reducing perioperative complications. Although a thorough history and physical examination are the foundation of this assessment, much evidence exists that physicians rely on unnecessary laboratory and diagnostic testing. Our goal was to perform a systematic review of the available literature regarding preoperative evaluation to better inform preoperative test selection and to identify deficiencies in the current literature. There is very limited data specific to preoperative testing for patients undergoing gynecologic surgeries. Abnormal test results are common when routine, unselected testing is applied. Using a protocol to guide preoperative testing improves patient care by eliminating unnecessary tests without compromising the efficacy of predicting adverse perioperative events or case cancellation and modifications.

Measuring Quality in Minimally Invasive Gynecologic Surgery: What, How, and Why?

In healthcare, the goal of maximizing value by improving the quality of care and lowering costs has been notoriously challenging to achieve. The fee-for-service model in gynecology and other fields has historically promoted the reduction of nonsurgical or minimally invasive approaches in favor of complex, often morbid procedures. In this review, we seek to define quality and value in the healthcare field and describe strategies that promote quality over production. We then discuss national, non-specialty-based efforts in the context of Surgical Care Improvement Project measures to improve quality of care. Finally, we present a case study through the Kaiser Permanente Minimally Invasive Hysterectomy Initiative, one such model that successfully built on the quality metrics of the foregoing strategies to improve patient care.

Minimally Invasive Adnexal Mass Extraction: Considerations and Techniques (With Videos).

Adnexal masses are a common indication for surgery in the United States. This article reviews the clinical features that may suggest an underlying malignancy, including ultrasound and biomarkers. The decision regarding how to remove an adnexal mass involves consideration of several factors, including body habitus, intra-abdominal anatomy, concomitant procedures planned, characteristics of the adnexal mass, and concern for underlying malignancy. Minimally invasive techniques for removal of adnexal masses are discussed in detail, with a review of the risk of an unexpected underlying malignancy.

Vaginal cuff dehiscence and evisceration: a review of the literature.

PURPOSE OF REVIEW: Vaginal cuff dehiscence and evisceration are rare but potentially serious complications of hysterectomy. In this article, we review the incidence, risk factors, management, and preventive measures for dehiscence based on available literature. RECENT FINDINGS: Identifying risk factors for dehiscence is challenging because studies lack comparison groups and most studies are largely underpowered to draw concrete conclusions. SUMMARY: High-quality data on cuff dehiscence after hysterectomy are limited. Potentially modifiable risks that optimize vaginal wound healing, minimize vaginal cuff strain, and minimize cuff infection should be optimized.

Surgical Treatment of Uterine Fibroids Within a Containment System and Without Power Morcellation.

Increased awareness regarding risks associated with intracorporeal electromechanical, or power, morcellation has urged surgeons to develop alternative methods for tissue extraction that may mitigate some of these risks during surgery. The use of containment systems during laparoscopic procedures has allowed surgeons to continue to offer and perform myomectomies that still benefit from being minimally invasive but which may minimize the risk of inadvertent tissue dispersion. Here, we will review techniques for performing contained tissue fragmentation without the use of a power morcellator.

Perforated intraperitoneal intrauterine contraceptive devices: diagnosis, management, and clinical outcomes.

STUDY OBJECTIVE: To describe a series of intraperitoneal perforated intrauterine contraception devices (IUDs) and to discuss associated findings, methods for diagnosis, and management of this complication. DESIGN: Retrospective review of surgical database between 1998 and 2012 (Canadian Task Force classification II-2). SETTING: University medical center. PATIENTS: Thirty-seven women with a perforated IUD in the intraperitoneal cavity. MEASUREMENTS AND MAIN RESULTS: Nineteen copper IUDs (51%), 17 levonorgestrel-releasing IUDs (LNG-IUDs) (46%), and 1 Lippes loop (3%) were identified. Twenty women (54%) had abdominal pain, 16 (43%) had no symptoms, and 1 (3%) was found to have strings protruding from her anus. Twenty-six women (70%) underwent laparoscopy to remove the IUD, and 6 (16%) underwent hysteroscopy along with laparoscopy. Conversion to laparotomy was required in 4 patients (11%). Two IUDs (5%) caused full-thickness rectouterine fistulas that required laparotomy for repair. Dense adhesions were found in 21 women (57%); and of those, 15 (71%) were associated with a copper IUD. Copper IUDs were significantly more likely than LNG-IUDs to be associated with dense adhesions (p = .02). CONCLUSIONS: Perforated IUDs can be asymptomatic or cause short-term and long-term symptoms. Long-term complications include abscess and fistula formation. Copper IUDs cause a greater inflammatory process than do LNG-IUDs. Even if asymptomatic, we advocate prompt removal of all IUDs that perforate into the peritoneal cavity once they are identified. Laparoscopic surgical removal of an intraperitoneal IUD is a safe and preferred method.

Video-Based Coaching for Laparoscopic Salpingectomy: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effect of video-based coaching on the gynecology resident performance of laparoscopic salpingectomy. METHODS: PGY-1 and PGY-2 residents were randomized before their gynecology rotations to standard gynecology curriculum (control group) or standard curriculum plus two video-coaching sessions by a fellowship-trained minimally invasive gynecologic surgeon (VBC group). Residents were video recorded intraoperatively performing three unilateral laparoscopic salpingectomies. Participants in the VBC group were coached between the procedures. The primary outcome was the improvement in modified GOALS (Global Operative Assessment of Laparoscopic Skills) and OSA-LS (Objective Structured Assessment of Laparoscopic Salpingectomy) scores, compared with baseline, in the VBC and control groups, with videos independently graded by three blinded minimally invasive gynecologic surgeons. A minimum sample size of 18 participants (nine per group) was needed to achieve 90% power to detect a difference of 5.0 points. RESULTS: From October 2021 to December 2022, 28 PGY-1 and PGY-2 residents completed the study with 14 participants per group. Baseline characteristics were similar between groups. In the VBC group, modified GOALS scores significantly improved by 3.0 points from video 1 to video 2 (P=.04) and by 3.2 points from video 1 to video 3 (P=.02). Modified OSA-LS scores also increased significantly in the VBC group, by 6.1 points from video 1 to video 3 (P=.02). In the control group, modified GOALS and OSA-LS scores improved from baseline but were not significant (P=.2, P=.5). Video-based coaching also enhanced resident comfort and confidence in performing laparoscopic surgery. CONCLUSION: Video-based coaching improves resident performance of laparoscopic salpingectomy and can be used as an adjunct to resident surgical training. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT05103449.

Pregnancy Outcomes After Laparoscopic Radiofrequency Ablation of Uterine Leiomyomas Compared With Myomectomy.

OBJECTIVE: To compare pregnancy outcomes after laparoscopic radiofrequency ablation and myomectomy. METHODS: The ULTRA (Uterine Leiomyoma Treatment With Radiofrequency Ablation) study is an ongoing multicenter prospective cohort study with longitudinal follow-up up to 5 years comparing outcomes of radiofrequency ablation with myomectomy in premenopausal women older than age 21 years with symptomatic uterine leiomyomas. Participants were queried every 6 months after surgery to assess the incidence of pregnancy and pregnancy outcomes. RESULTS: Among 539 women enrolled in ULTRA, a total of 37 participants (mean age at first pregnancy 35.0±4.7 years) conceived 43 times as of March 2023 (22 radiofrequency ablation, 21 myomectomy). The average length of follow-up time after all procedures was 2.5±1.0 years. The baseline miscarriage rate in the study population was 33.3%. In participants who underwent radiofrequency ablation, 9 of 22 pregnancies (40.9%, 95% CI, 20.3-61.5%) ended in first-trimester miscarriage, 11 resulted in live births (50.0%, 95% CI, 29.1-70.9%), one resulted fetal death at 30 weeks of gestation, and one resulted in uterine rupture during miscarriage treatment with misoprostol 10 weeks after radiofrequency ablation. Among the live births in the radiofrequency ablation group, 45.5% were by vaginal delivery. In the myomectomy group, 9 of 21 pregnancies (42.9%, 95% CI, 21.7-64.0%) ended in first-trimester miscarriage and 12 resulted in live births (57.1%, 95% CI, 36.0-78.3%). There were no significant differences in the likelihood of live birth or miscarriage between the study groups. CONCLUSION: Full-term pregnancy and vaginal delivery are achievable after radiofrequency ablation of leiomyomas. However, in this interim analysis, the miscarriage rate in both radiofrequency ablation and myomectomy groups was higher than expected for women in this age group. Long-term data collection in the ongoing ULTRA study aims to further understand pregnancy outcomes after radiofrequency ablation compared with myomectomy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT0210094.

Radiofrequency Ablation for Treatment of Leiomyomas: Review of the Manufacturer and User Facility Device Experience (MAUDE) Database.

Radiofrequency ablation (RFA) is a relatively novel, increasingly popular treatment option for leiomyomas. We studied medical device-related reports of leiomyoma RFA devices to determine whether there are emerging device-related issues. The Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database was queried from 2012 through November 2022. Sixty unique reports, including adverse events and device malfunctions, were analyzed for both laparoscopic and transcervical RFA devices. Forty-three injury reports were reviewed. The most common adverse event was infection. Of the injury cases, 34.9% required additional surgical intervention. Although the details of each event are limited, these reports highlight the importance of postmarket surveillance of new technologies and the necessity of improving the current system of implementation and monitoring.

Radiofrequency Ablation of Leiomyomas.

Radiofrequency ablation (RFA) of leiomyomas represents a significant advancement in the treatment of this common uterine condition. In the appropriately selected patient, both laparoscopic and transcervical options provide effective treatment for bleeding and bulk symptoms in a uterine-sparing manner. Compared with other minimally invasive leiomyoma treatment options, RFA procedures have comparable or favorable safety profiles, recovery timelines, and reintervention rates. Data on future fertility and pregnancy are limited, although early reports are promising.

Thoracic endometriosis: a case report.

BACKGROUND: Endometriosis is a benign gynecologic disorder that affects women of reproductive age. It can be asymptomatic or can cause pelvic pain or subfertility. On rare occasions it may manifest outside of the pelvis, leading to a multitude of symptoms that can be life-threatening if proper diagnosis is delayed. CASE: A 35-year-old, nulliparous female presented with dyspnea and pleuritic chest pain. She was diagnosed with a rare case of thoracic endometriosis. Her symptoms improved with combined surgical and medical management. CONCLUSION: The diagnosis of this rare entity often goes unrecognized unless physicians have a high clinical suspicion and make a temporal association between patients' pulmonary symptoms and menstruation. Diagnosis can be confirmed only by pathological examination and immunohistochemical staining. Management should be guided by symptom severity and the patient's desire to conserve future fertility.