Prostaglandin Injection for Myoma Expulsion (PRIME): Case Series of a Novel Approach to Hysteroscopic Resection of FIGO Type 2 Myomas.

STUDY OBJECTIVE: To evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure. DESIGN: Case series. SETTING: Single high-volume academic medical center. PATIENTS: Seven patients aged 32 to 51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 to July 2023. INTERVENTION: Dilute injection of carboprost tromethamine (10 µg/mL) at time of hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and postoperative pharmacologic side effects and/or surgical complications. Among our 7 patients, all had successful single procedure complete resections of myomas ranging from 0.9 to 4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30 to 180 µg. One patient experienced prolonged postoperative nausea and vomiting that resolved with antiemetics. One patient experienced postoperative endometritis that improved with antibiotics. CONCLUSION: In this pilot study, injection of dilute carboprost intraoperatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

Informational Preferences of Women Seeking Treatment for Symptomatic Uterine Fibroids: A Qualitative Study.

STUDY OBJECTIVE: To establish the informational needs and preferences of women navigating treatment options for symptomatic uterine fibroids. DESIGN: Qualitative study using semistructured interviews. SETTING: Academic institution. PATIENTS: Participants had a diagnosis of symptomatic uterine fibroids with an active treatment plan. INTERVENTIONS: Semistructured video interviews were conducted with female patients undergoing treatment for symptomatic uterine fibroids (n = 20). Women were recruited from the outpatient Center for Complex Gynecology in Chicago, IL. Interviews were recorded and transcribed verbatim. A codebook was developed based on the interview transcripts, and the finalized coding was used to conduct a thematic analysis. MEASUREMENTS AND MAIN RESULTS: Four distinct themes emerged from the interviews: (1) Social supports-including social media-play an important role in informing patients' treatment choices; (2) Patients spend significant energy seeking additional information beyond their obstetrician-gynecologist; (3) Patients prioritize receiving full and complete information from their provider; and (4) Patients experience information-related delays in receiving care. CONCLUSION: Patients seeking care for symptomatic uterine fibroids have strong preferences about both the quality and extent of information they receive from their gynecologists. Physicians treating these conditions must adapt to changing informational desires and consider expanding physician engagement with patients' social media needs.

Attitudes and Beliefs about Hysterectomy in Patients with Uterine Fibroids.

STUDY OBJECTIVE: To investigate the attitudes toward and beliefs about hysterectomy that influence the decision of women with symptomatic uterine fibroids regarding hysterectomy. DESIGN: A prospective survey study. SETTING: An outpatient clinic. PATIENTS: Patients in an urban, academic complex gynecology outpatient clinic at the age of 35 years or older with uterine fibroids and without previous hysterectomy were invited to participate. A total of 67 participants were surveyed between December 2020 and February 2022. INTERVENTIONS: Data were collected on demographics, Uterine Fibroid Symptom Health-Related Quality of Life (UFS-QOL) Questionnaire scores, and beliefs regarding hysterectomy via a web-based survey. Participants were posed with clinical scenarios and asked to indicate a preference for hysterectomy or myomectomy and stratified into groups by acceptability of hysterectomy as a treatment option for fibroids. MEASUREMENTS AND MAIN RESULTS: Data were analyzed using chi-square or Fisher exact tests, t tests, or Wilcoxon tests as appropriate. The mean age of participants was 46.2 (SD 7.5) years, and 57% of participants self-identified as White/Caucasian. The mean UFS-QOL symptoms score was 50 (SD 26) and the mean overall health-related quality of life score was 52 (SD 28). Notably, 34% of participants preferred hysterectomy whereas 54% preferred myomectomy assuming equivalent efficacy; 44% of those who preferred myomectomy did not desire future fertility. There were no differences observed in UFS-QOL scores. Participants opting for a hysterectomy believed that it would improve their mood/emptions, relationship with partner, general quality of life, sense of femininity, feeling whole, identity/body image, sexuality, and relationships. Those who opted for a myomectomy believed all those factors would worsen with a hysterectomy, and in addition, it would worsen their vaginal moisture and their partner's experience. CONCLUSION: Many factors affect a patient's decisions regarding hysterectomy for uterine fibroids beyond those related to fertility, including factors related to body image, sexuality, and relationships. Physicians should consider these factors when counseling patients and recognize their importance to facilitate improved shared decision making.

Improving Colposcopy Education Through Images: A Preliminary Assessment of an Image-Based Mobile App for Colposcopic Education.

OBJECTIVES: Colposcopy is an indispensable part of cervical cancer screening. However, in most training programs, there is little by way of a formalized curriculum. We created an image-based teaching tool and hypothesized that this tool, in a mobile app format, would increase resident comfort with colposcopic practice and quantitatively increase their ability to correlate colposcopic images with impressions. MATERIALS AND METHODS: This was a pilot study conducted among ObGyn residents during March 2021. Thirty-eight residents participated and were randomized to either an app user or an independent study control group. Both groups were surveyed before and after their assigned training and completed a postintervention standardized cognitive examination. The primary end points were subjective improvements in comfort with colposcopy. The secondary end point was performance on a standardized image quiz. RESULTS: Of the 46 targeted residents, 38 participated and 26 completed all elements of the study. On the image examination, app users performed slightly better when compared with the independent study group (mean score, 14.9/25 [SD = 2.15] vs 14.0/25 [SD = 3.27], p = .39). App users also were more likely to be confident in providing an overall colposcopic impression (73% vs 30%, p = .111). One hundred percent of the participants in the app user group said that they would recommend the tool to other residents and residency programs. CONCLUSIONS: Image-based teaching tools, such as the ICE-TI app, are valued by learners and can be a useful adjunct to standardized colposcopy curricula. In addition, making use of a mobile platform facilitated convenience learning.

Female sterilization reversal in the era of in-vitro fertilization.

PURPOSE OF REVIEW: Regret after female sterilization is not uncommon in the United States. Prior to the development of assisted reproductive technology (ART), surgical reversal of sterilization was the only option for patients interested in fertility. First performed in 1972, this procedure has since been refined over the years by gynaecologic surgeons. With in-vitro fertilization (IVF) gaining popularity, interest in sterilization reversal has waned. However, sterilization reversal should remain an important option in patients seeking pregnancy after tubal ligation. RECENT FINDINGS: A direct comparison between IVF and sterilization reversal is challenging due to inherent differences in reporting fertility outcomes. However, sterilization reversal may optimize fertility in younger women, whereas IVF may be more effective in older women. The surgical approach to sterilization reversal can be laparotomic, laparoscopic or robotic. Clinical decision making should include consideration of the risk of ectopic pregnancy, interval from sterilization to reversal, type of sterilization procedure, planned anastomotic site and projected remaining tubal length. SUMMARY: In the era of IVF, sterilization reversal still has a place in the management in restoring fertility. Creating awareness of the role of sterilization reversal is the first step in improving access to adequate training in this procedure for the next generation of reproductive surgeons.

Body Image and Sexual Function Improve after Both Myomectomy and Hysterectomy for Symptomatic Fibroids.

OBJECTIVES: To determine the factors that influence the choice of myomectomy, uterine fibroid embolization (UFE), or hysterectomy in women with symptomatic uterine fibroids and to assess women's perception of body image and sexual functioning before and after treatment. METHODS: In this prospective observational cohort pilot study, women scheduled to undergo hysterectomy, myomectomy, or UFE were surveyed before surgery and again at 3 to 6 months after their procedure to assess body image and sexual function using the validated 10-item Body Image Scale and 19-item Female Sexual Function Index. Logistic regression was used to determine predictive factors for surgery choice and paired t tests were used to determine changes in perceived sexual function and body image. RESULTS: Of the 71 women surveyed, 69 underwent their scheduled procedure and 68 participants completed the preoperative questionnaire completely (98%). A total of 33 participants completed the postoperative questionnaire (49%). The predictive factor for hysterectomy versus myomectomy/UFE was older age (odds ratio 1.13, P = 0.017, 95% confidence interval [CI] 1.02-1.24). Regardless of surgery type, there were significant improvements in perceived body image and sexual function, including an increase in the overall sexual satisfaction of the participant (mean difference 0.50, P = 0.021, 95% CI 0.92-0.08) and less likely to feel less sexually attractive because of their menstrual bleeding problem (P < 0.0001, 95% CI 0.637-1.675). CONCLUSIONS: Women of older age are more likely to choose hysterectomy over myomectomy or UFE for the treatment of symptomatic uterine fibroids. In addition, women who underwent any treatment for fibroids have increases in perception of body image and sexual functioning after their procedure.

Factors that Influence Applicants Pursuing a Fellowship in Minimally Invasive Gynecologic Surgery.

STUDY OBJECTIVE: The Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) has been the most competitive fellowship in Obstetrics and Gynecology since 2015. Since its inception, it has served to provide advanced endoscopic training and addresses the need for additional proficiency beyond residency. We sought to identify factors that influence applicants in choosing to pursue minimally invasive gynecologic surgery training. DESIGN: Cross-sectional study. SETTING: 2018 FMIGS application cycle. PATIENTS: Not applicable. INTERVENTIONS: A novel, 32-item Web-based survey was distributed to all FMIGS applicants during the 2018 application cycle. MEASUREMENTS AND MAIN RESULTS: Descriptive statistics were used to characterize the applicant sample and responses. Our survey response rate was 47.4% (37/78). Interest in the subject area of minimally invasive gynecologic surgery was the single most influential factor driving applicants to pursue FMIGS, followed by an interest in an academic career. Income level was the least important factor in their decision, with 37.8% rating this as not important. There were no differences in motivational factors between male and female applicants. Few applicants felt "very comfortable" performing laparoscopic hysterectomy (16.2%) or laparoscopic myomectomy (3.0%) on completion of residency training. CONCLUSION: FMIGS applicants are motivated by their interest in minimally invasive gynecologic surgery, academia and research, and the opportunity to increase their proficiency with advanced endoscopic procedures.

A Game Show-Based Curriculum for Teaching Principles of Reproductive Infectious Disease (GBS PRIDE Trial).

OBJECTIVES: The purpose of this study was to evaluate whether a game show-based curriculum improves obstetrics and gynecology (OBGYN) residents' confidence in and understanding of the principles of reproductive infectious disease (RID), clinical manifestations and sequelae of sexually transmitted infection (STI), and management of serious long-term consequences of STIs. METHODS: A game show-based curriculum was developed from the basic principles of RID, which include the following: (1) distinguishing between clinical manifestations of STIs and management of long-term sequelae of STIs; (2) evaluation and management of common gynecologic infectious diseases, including chronic vaginitis, pelvic inflammatory disease, and other pelvic infections; (3) diagnosis and management of perinatal infectious diseases, such as parvovirus, varicella-zoster virus, cytomegalovirus, human immunodeficiency virus, toxoplasmosis, and infection-mediated prematurity; (4) evaluation and management of obstetric and gynecologic postoperative infections; and (5) diagnosis and management of acute and chronic human immunodeficiency virus and hepatitis C virus infections in pregnancy. OBGYN residents at a large urban academic training program were randomized to either a Jeopardy-style educational game show intervention plus a traditional didactic-based curriculum or traditional didactic-based curriculum alone. The study team recruited participants by sending out an e-mail to all of the residents, detailing the study and consent process. Participants from both the intervention and control groups completed confidence and knowledge-based pretests. Posttests were administered 4 weeks after completion of the pretests. Statistical methods were applied to analyze the data. RESULTS: Thirty-eight residents were randomized to a Jeopardy-style game show-based educational intervention (n = 19) or to a traditional didactic-based curriculum (n = 19). All of the participants (100%) completed the pre- and posttests. Pretest median scores were similar between both groups, in which the Jeopardy group had a median score of 48.5 and the traditional group had a median score of 51.4 (P = 0.091). The Jeopardy group median test scores improved between the pretest and posttest (48.5 vs 62.8, P ≤ 0.001). The traditional didactic-based curriculum had a minimal increase in its median posttest scores (51.4 compared with 54.2, P = 0.773). The Jeopardy group had significantly higher posttest median scores and confidence scores than the traditional didactic-based curriculum (Jeopardy = 62.8, traditional = 54.2, P = 0.002). CONCLUSIONS: A game show-based curriculum improves OBGYN residents' confidence and retention of knowledge regarding RIDs, clinical manifestations and sequelae of STIs, and management of serious long-term consequences of STIs. Additional studies that include longer posttest time intervals are needed to assess the longer-term impact of game show-based curriculum on knowledge retention among OBGYN residents.

Patient-reported outcome measures in benign gynecologic surgery: updates and selected tools.

PURPOSE OF REVIEW: Use of patient-reported outcome measures in clinical practice and research is becoming more prevalent and reflects initiatives to center the patient in healthcare delivery and outcomes assessment. The purpose of this review is to provide a summary description of selected, validated tools used to assess outcomes related to several benign gynecologic conditions: abnormal uterine bleeding, fibroids and endometriosis. RECENT FINDINGS: Given the availability of several validated instruments to assess patient outcomes in benign gynecology, there is still significant heterogeneity in tools used in trials. SUMMARY: Patient outcomes assessment should be an integral part of clinical practice and research in order to treat the whole patient and address any health-related impacts on quality of life. More attention is needed to increase standardization of tools used in research to facilitate assessment of comparative efficacy between treatments.

Surgeon Volume in Benign Gynecologic Surgery: Review of Outcomes, Impact on Training, and Ethical Contexts.

It is becoming increasingly clear that surgeon volume affects surgical outcomes. High-volume surgeons demonstrate reduced perioperative complications, shorter operative times, and reduced blood loss during multiple modalities of benign gynecologic surgery. Furthermore, high-volume surgeons consistently demonstrate higher rates of minimally invasive approaches, low rates of conversion to laparotomy, and lower per-procedure case costs. It is suggested that surgeons who have completed postresidency training have improved surgical outcomes, although these data are limited. Surgical exposure in obstetrics and gynecology residency is varied and does not consistently meet demonstrated surgical learning curves. Deficiencies in residency surgical training may be related to the volume-outcome relationship. We suggest reforming residency surgical training and tracking postresidency practice to provide optimal surgical care. Additionally, surgeons may have an ethical obligation to inform patients of their surgical volume and outcomes, with options for referrals if needed.

Economics of gynecologic morcellation.

PURPOSE OF REVIEW: As the Food and Drug Administration raised concern over the power morcellator in 2014, the field has seen significant change, with patients and physicians questioning which procedure is safest and most cost-effective. The economic impact of these decisions is poorly understood. RECENT FINDINGS: Multiple new technologies have been developed to allow surgeons to continue to afford patients the many benefits of minimally invasive surgery while minimizing the risks of power morcellation. At the same time, researchers have focused on the true benefits of the power morcellator from a safety and cost perspective, and consistently found that with careful patient selection, by preventing laparotomies, it can be a cost-effective tool. SUMMARY: Changes since 2014 have resulted in new techniques and technologies to allow these minimally invasive procedures to continue to be offered in a safe manner. With this rapid change, physicians are altering their practice and patients are attempting to educate themselves to decide what is best for them. This evolution has allowed us to refocus on the cost implications of new developments, allowing stakeholders the opportunity to maximize patient safety and surgical outcomes while minimizing cost.

Hysteroscopic myomectomy: a comparison of techniques and review of current evidence in the management of abnormal uterine bleeding.

PURPOSE OF REVIEW: Submucosal uterine leiomyomas are a common benign pelvic tumor that can cause abnormal uterine bleeding and may contribute to infertility and miscarriage. Hysteroscopic myomectomy is the treatment of choice to alleviate bleeding from these myomas and to normalize the uterine cavity. This review discusses the techniques and recent evidence for hysteroscopic myomectomy and examines the two primary surgical tools employed today: the bipolar resectoscope and hysteroscopic mechanical morcellator. RECENT FINDINGS: Hysteroscopic myomectomy has been a popular treatment for symptomatic submucosal fibroids for decades; it is a minimally invasive, low-cost, low-risk procedure, and is associated with high patient satisfaction. There have been rapid advances in the surgical technology available for this procedure. Both the bipolar resectoscope and the hysteroscopic mechanical morcellator are appropriate tools to remove submucosal myomas. Although the hysteroscopic morcellators have been associated with shortened operative time and a decreased learning curve, the data are limited for their use on type 2 fibroids. The strength of the bipolar resectoscope lies in its ability to resect deeper type 2 fibroids. SUMMARY: The evidence suggests that no one technique should be used for all patients, but rather a choice of technique should be taken on a case-by-case basis, depending on the myoma number, size, type, and location. Gynecologists must become knowledgeable about each of these techniques and their associated risks to safely offer these surgeries to their patients.

Matching Trends for the Fellowship in Minimally Invasive Gynecologic Surgery Since Participation in the National Residency Match Program.

OBJECTIVE: To evaluate the level of interest in the fellowship in minimally invasive gynecologic surgery (FMIGS) using data from the National Residency Match Program (NRMP) over the past 5 years. DESIGN: Retrospective report (Canadian Task Force classification II-2). SETTING: Publicly reported data from the NRMP. PARTICIPANTS: Applicants using the NRMP to match into fellowship training. INTERVENTIONS: Reporting matching trends for the gynecologic surgical subspecialty programs starting in 2014, when the FMIGS programs began participating in the NRMP. MEASUREMENTS AND MAIN RESULTS: From 2014 to 2018, the number of FMIGS positions increased from 28 to 38. Over the 5 application cycles, the FMIGS programs had the highest ratio of applicants to positions overall (range, 1.7-2.0 for FMIGS) of the surgical gynecologic subspecialty programs analyzed (Gynecologic Oncology, Female Pelvic Medicine and Reconstructive Surgery, and Reproductive Endocrinology and Infertility). CONCLUSIONS: Since the FMIGS programs began participating in the NRMP in 2014, the FMIGS match has been highly competitive as a gynecologic surgical subspecialty, suggesting a high level of interest from residency graduates. This may reflect growing recognition that there is a body of knowledge unique to minimally invasive gynecologic surgeons.

Trends in malpractice claims for obstetric and gynecologic procedures, 2005 through 2014.

BACKGROUND: Interest in medical malpractice and areas of medicolegal vulnerability for practicing obstetricians and gynecologists has grown substantially, and many providers report changing surgical practice out of fear of litigation. Furthermore, education on medical malpractice and risk management is lacking for obstetrics and gynecology trainees. Recent obstetric and gynecologic malpractice claims data are lacking. We report on recent trends in malpractice claims for obstetrics and gynecology procedures, and compare these trends to those of other medical specialties. OBJECTIVE: We sought to evaluate recent trends in malpractice claims for obstetrics and gynecology procedures and compare these to other medical specialties. STUDY DESIGN: A search was performed on all medicolegal claims data for obstetrics and gynecology procedures from Jan. 1, 2005, through Dec. 31, 2014, using the Physician Insurers' Association of America data-sharing project, which was created to identify medical professional liability trends. Data from 20 insurance carriers were reviewed based on a search using International Classification of Diseases, Ninth Revision codes and unique database-specific codes. RESULTS: Of the 10,915 total claims closed from 2005 through 2014, the majority (59.5%) were dropped, withdrawn, or dismissed. The average indemnity of the remaining paid claims (31.1%) was $423,250. The most frequently litigated procedure was operative procedures on the uterus; 27.8% of cases were paid with an average indemnity of $279,384. The procedure associated with the highest proportion of paid claims was vacuum extraction. The average indemnity for paid obstetrics and gynecology procedural claims was 27% higher than that for all medical specialties combined. Obstetrics and gynecology procedural claims had the second highest average indemnity payment and the fifth highest paid-to-closed ratio of all medical specialties. CONCLUSION: Litigation claims for obstetrics and gynecology procedures have higher average indemnity payments and higher paid-to-closed ratios than most other medical specialties. Claims most frequently relate to gynecologic surgery, but obstetric procedures are more expensive. Possible factors may include procedural experience and unique perioperative complications. We encourage efforts addressing procedures, litigation, and quality interventions to improve outcomes, mitigate risk, and potentially lower indemnity payments.

Specialty-Specific Values Affecting the Management of Symptomatic Uterine Fibroids.

PURPOSE: To better understand why interventional radiologists and gynecologists differ in their approaches to symptomatic uterine fibroids. METHODS: Conversational interviews were conducted with 26 interventional radiologists and gynecologists about their professional roles, clinical reasoning, and practice variation within and outside their specialty. Interview transcripts were systematically analyzed using NVivo 10 software (QSR International, Burlington, Massachusetts) according to grounded theory and content analysis to identify key themes and compare themes across specialties and practice environments. Data were supplemented with retrospective analysis of 7,659 patients with symptomatic uterine fibroids treated at a large academic center over 11 years. RESULTS: Interventional radiologists' shares of symptomatic uterine fibroid treatment and endovascular stent treatments have remained constant (P > .05) for 11 y at a large medical center, whereas minimally invasive gynecologic fibroid treatments and the percentage of interventional radiology (IR) procedures reimbursed by Medicaid/Medicare have increased significantly (r > .90, P < .001 and r = .93, P < .001). Interventional radiologists and gynecologists shared a commitment to do "the right thing" for patients, but each group possessed distinct professional values affecting how they viewed medical evidence, outcomes, and their colleagues. When differences were apparent and concerning, physicians tended to suspect ulterior motives not in patients' best interests. CONCLUSIONS: Interventional radiologists and gynecologists demonstrated wide-ranging perspectives regarding their role in caring for patients with symptomatic uterine fibroids. To promote genuine collaboration and adoption of shared goals, stakeholders should seek and promote a deeper understanding of specialty-specific values and culture.

New paradigms in the conservative surgical and interventional management of adenomyosis.

PURPOSE OF REVIEW: Adenomyosis is commonly diagnosed in women of reproductive age. Interest in conservative interventions has grown as more women desire fertility preservation or avoidance of hysterectomy. This review discusses surgical and interventional methods for treatment of symptomatic adenomyosis. The technique, evidence, and utility of each method are described. RECENT FINDINGS: Hysteroscopic ablative techniques are associated with lower morbidity than with hysterectomy but may result in an unacceptable risk of treatment failure. Surgical adenomyomectomy may provide good symptomatic improvement, especially when combined with preoperative gonadotropin-releasing hormone agonist treatment. Laparoscopic myometrial coagulation is associated with high rates of future pregnancy complications. Uterine artery ligation has limited value as an isolated approach but, coupled with other techniques, provides adequate therapeutic control. Bilateral uterine artery embolization may improve symptoms, without significantly compromising fertility. Focused ultrasonic surgical methods also show promise in alleviating symptoms without compromising reproductive outcomes. SUMMARY: A multitude of surgical and interventional options are available for young women with symptomatic adenomyosis. These treatment methods have unique associated risks and benefits, and may have varying impacts on long-term symptom control, fertility, and reproductive outcomes.

Feasibility of Washings at the Time of Laparoscopic Power Morcellation: A Pilot Study.

STUDY OBJECTIVE: To determine the feasibility and role of abdominopelvic washings at the time of laparoscopic power morcellation and to determine if endometrial or myometrial tissue will be detected before and after laparoscopic power morcellation. DESIGN: A prospective pilot study (Canadian Task Force classification II-3). SETTING: An academic medical center. PATIENTS: All women who underwent laparoscopic myomectomy by a single provider at Northwestern Prentice Women's Hospital between August 2014 and October 2015. INTERVENTIONS: Abdominopelvic washings were performed before and after laparoscopic power morcellation in a specimen bag. Washings were evaluated for the presence of intra-abdominal endometrial or myometrial tissue using cell block and cytospin techniques. MEASUREMENTS AND MAIN RESULTS: A total of 13 cases were performed. Eleven subjects underwent multiport laparoscopy, and 2 underwent laparoendoscopic single-site surgery. Morcellation was performed within a 15 mm Tissue Retrieval System 100SB2 (Anchor Products, Addison, IL). Two sets of abdominopelvic washings were performed after completion of myomectomy: one before morcellation and the second after morcellation. As a control, washings of the inside of the empty specimen bag were performed after completion of morcellation in 1 patient. The operative outcomes analyzed included a median specimen weight of 313 g (range, 43-940 g), a median operative time in minutes of 161 minutes (range, 94-243 minutes), and a median estimated blood loss of 200 mL (range, 100-700 mL). There was no visual or cytologic evidence of intra-abdominal dissemination of uterine tissue before or after enclosed morcellation on evaluation by cytospin or cell block techniques. Only the washings from the inside of the specimen bag were found to have myometrial tissue on evaluation using the cell block technique. CONCLUSION: Performing abdominopelvic washings at the time of laparoscopic power morcellation is a feasible method by which to evaluate and document the presence or absence of microscopic dissemination, with comparable operative parameters to what is already reported in the literature. When abdominopelvic washings are used as an intermediate outcome measure, enclosed bag morcellation appears to minimize tissue dissemination during laparoscopic power morcellation; however, additional and larger studies are needed.

Reproductive Outcomes After Hysteroscopic Resection of Retained Products of Conception.

STUDY OBJECTIVE: To characterize pregnancy outcomes after hysteroscopic resection of retained products of conception (RPOCs), especially as it relates to abnormal placentation. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Academic medical center. PATIENTS: All women who underwent hysteroscopic resection of RPOCs at Northwestern Prentice Women's Hospital between January 2004 and December 2014. INTERVENTIONS: Hysteroscopic resection of RPOCs. MEASUREMENTS AND MAIN RESULTS: The medical records of all cases of hysteroscopic resection of RPOCs between January 2004 and December 2014 were reviewed. Demographic characteristics, operative findings, surgical procedure, surgical pathology, and pregnancy outcomes for preceding and subsequent pregnancies were obtained. Our primary outcome was abnormal placentation in the pregnancy after the procedure. There were a total of 55 subsequent pregnancies and 38 live births. Among these pregnancies, 54.5% (30/55) were vaginal deliveries, 34.5% (19/55) were cesarean deliveries, and 7.3% (4/55) were early pregnancy losses. Abnormal placentation was present in 18.1% of subsequent pregnancies (10/55). This consisted of 3 patients with placenta previa, 2 with placenta accreta, and 5 with retained placenta. CONCLUSION: Women who undergo hysteroscopic resection of RPOCs have a higher rate of abnormal placentation in subsequent pregnancies when compared with the general population. Although the etiology is likely multifactorial, the underlying pathology leading to the initial diagnosis of RPOCs is believed to play a major role.

Fertility-preserving management of a uterine arteriovenous malformation: a case report of uterine artery embolization (UAE) followed by laparoscopic resection.

Herein is presented a fertility-preserving approach in the management of a uterine arteriovenous malformation (AVM) resistant to endovascular management. The patient had a documented AVM and underwent 2 uterine artery embolization procedures, with subsequent recurrence of symptoms. Doppler ultrasound demonstrated recanalization of the AVM. Ultimately, laparoscopic resection of the AVM was performed after laparoscopic ligation of the uterine arteries. Postoperatively, the patient has remained asymptomatic. Laparoscopic resection of a uterine AVM may offer a fertility-preserving alternative to hysterectomy in patients in whom endovascular management has failed.