Direct oral anticoagulants (DOACs) use for prolonged venous thromboembolism prophylaxis following surgery for gynaecological malignancies in Australia and New Zealand - A clinician survey.

BACKGROUND: Current international guidelines recommend 28 days of enoxaparin as venous thromboembolism (VTE) prophylaxis after surgery for gynaecologic cancer. Direct oral anticoagulants (DOACs) have been investigated as an alternative to enoxaparin for post-operative VTE prophylaxis. High-quality evidence to demonstrate safety and efficacy is lacking. AIMS: We aim to investigate the current practice regarding VTE prophylaxis among gynaecological oncologists in Australia and New Zealand following laparotomy for gynaecological malignancy, in particular the use of DOACs for VTE prophylaxis. MATERIALS AND METHODS: Sixty-seven practising gynaecologic oncologists (GO) were identified through Royal Australia and New Zealand College of Obstetricians and Gynaecologists database and emailed online surveys that asked about VTE prophylaxis practice and views of DOACs in this setting. Data were then collected through Survey Monkey and evaluated. RESULTS: The majority (77.1%) routinely prescribed 28 days of enoxaparin following laparotomy for gynaecological malignancies. In clinical circumstance such as laparoscopy for gynaecological malignancies and surgery for vulva malignancies, there was variation in thromboprophylaxis practices. No GO reported routine use of DOACs in any clinical circumstance. There were 56% of GOs who used a DOAC in their practice at some point. Barriers to routine use of DOACs in current practice included insufficient evidence (68%), issue with cost (40.4%) and concerns about safety (29.7%). CONCLUSIONS: Enoxaparin prescribed for 28 days remains the current clinical practice in preventing VTE following laparotomy for gynaecological malignancy. The main barrier to routine DOAC use as post-operative thromboprophylaxis is a lack of evidence which reflects the need for a larger prospective study.

The impact of the COVID-19 public health response on service demand and patient perceptions in a tertiary Australian gynaecology oncology unit.

INTRODUCTION: The public health response (PHR) to the COVID-19 pandemic significantly disrupted healthcare services worldwide. Our hospital, a major tertiary centre, is a unique two-state service across Queensland and New South Wales (NSW). OBJECTIVE: The primary objective is to describe changes in service demand and delivery in our hospital resulting from the COVID-19 PHR. The secondary objective is to investigate patient perceptions of this impact. MATERIALS AND METHODS: We performed a retrospective interrupted time series analysis and a population-based survey to examine patient perceptions of the impact of the COVID-19 PHR. The study periods were demarcated by the initiation of the COVID-19 PHR on 1 March 2020 with the 'pre' and 'during' COVID-19 periods defined as the 12 months before and after this date respectively. RESULTS: More patients were seen during the COVID-19 PHR period. The number or stage of cancer diagnoses was not different (P > 0.05). There was evidence (P = 0.03) of an increase in overall occasions of service and fewer failed attendances (P = 0.005). Fewer surgeries were performed on NSW patients (P = 0.005). The survey response rate was 19.3% (n = 185) with 48% stating that COVID-19 had negatively affected their emotional wellbeing. More participants from NSW than Queensland identified border closures as the most significant impact of the COVID-19 PHR. DISCUSSION: The COVID-19 PHR resulted in an unexpected increase in unit service demand and delivery. The necessary implementation of telephone appointments, while less preferred by patients, sustained service requirements. Cross-border tertiary healthcare services should consider the significant impact of border restrictions on patient wellbeing.

Information needs of women undergoing gynaecological risk reduction surgery: Applying patient-reported findings to improve service delivery.

BACKGROUND: Women with genetic mutations including BRCA1, BRCA2 and Lynch syndrome are at increased risk of developing gynaecological cancers with management options including surveillance and/or risk reduction surgery. Little is known about the information women require to inform their decisions around having risk reduction surgery, the implication this surgery has for them and the timing preferences to receive this information. AIMS: To identify the information needs of women who are considering or who have had risk reduction surgery due to having a diagnosed or suspected genetic mutation with subsequent increased risk of developing gynaecological cancer. MATERIALS AND METHODS: A pilot survey was undertaken in a tertiary, metropolitan hospital as part of a service improvement project. Women referred to the gynaecology-oncology service for gynaecological risk reduction surgery between January to December 2018 were invited to participate through completing either online or hard copy versions of a 12-item survey. RESULTS: A response rate of 60% (n = 32) was obtained from women between 27 and 77 years of age. Key information topics included sexuality and intimacy (90.6%; n = 29), the surgery itself (87.5%; n = 28) and surgical menopause (87.5%; n = 28). Over 90% (n = 31) of respondents stated they preferred to receive information about surgery pre-operatively and in written format (81.3%; n = 26). The importance of a multidisciplinary approach was recognised with women wanting information from allied health practitioners such as physiotherapists and social workers. CONCLUSIONS: Findings have enabled a better understanding of the type, timing and content of information desired by women making complex decisions about risk reduction surgery. Results have contributed to developing an information resource which will more adequately assist women to meet their information needs when considering gynaecological risk reduction surgery in our hospital.

Ovarian cysts in pregnancy: a narrative review.

Most adnexal masses are benign, incidental findings of pregnancy which resolve spontaneously. They may present clinically due to haemorrhage, rupture, torsion and mass effect. Aetiological classification includes ovarian benign, ovarian malignant, non-ovarian, gynaecological, non-ovarian non-gynaecological and an additional subset of pathologies unique to pregnancy. Ultrasound is the first-line imaging modality for the evaluation of adnexal masses. This may be supplemented with magnetic resonance imaging. Tumour markers support evaluation of malignant potential, but interpretation of results in pregnancy is challenging. Surgical intervention requires consideration of gestation, lesion characteristics and presence of complications. Laparoscopy is preferred owing to shorter operative time, quicker recovery and resultant lower thrombotic risk. Post-viability, fetal wellbeing and assessment must be considered. Management of the pregnancy may include cardiotocography, steroids, non-teratogenic antibiotics and tocolytics. In rare cases, particularly related to malignancy, termination of pregnancy may be required to enable immediate management where there are concerns for maternal wellbeing.

British Gynaecological Cancer Society recommendations and guidance on patient-initiated follow-up (PIFU).

The National Cancer Survivorship Initiative through the National Health Service (NHS) improvement in the UK started the implementation of stratified pathways of patient-initiated follow-up (PIFU) across various tumor types. Now the initiative is continued through the Living With and Beyond Cancer program by NHS England. Evidence from non-randomized studies and systematic reviews does not demonstrate a survival advantage to the long-established practice of hospital-based follow-up regimens, traditionally over 5 years. Evidence shows that patient needs are inadequately met under the traditional follow-up programs and there is therefore an urgent need to adapt pathways to the needs of patients. The assumption that hospital-based follow-up is able to detect cancer recurrences early and hence improve patient prognosis has not been validated. A recent survey demonstrates that follow-up practice across the UK varies widely, with telephone follow-up clinics, nurse-led clinics and PIFU becoming increasingly common. There are currently no completed randomized controlled trials in PIFU in gynecological malignancies, although there is a drive towards implementing PIFU. PIFU aims to individualize patient care, based on risk of recurrence and holistic needs, and optimizing resources. The British Gynaecological Cancer Society wishes to provide the gynecological oncology community with guidance and a recommendations statement regarding the value, indications, and limitations of PIFU in endometrial, cervical, ovarian, and vulvar cancers in an effort to standardize practice and improve patient care.

Optimizing Total Laparoscopic Hysterectomy for the Geriatric Population: A Practical Case Study and Comprehensive Literature Review.

Elderly patients represent a large cohort of patients requiring gynaecological surgery for benign and malignant indications. In recent years, several conventional gynaecological procedures have shifted towards minimally invasive alternatives such as laparoscopy, hysteroscopy, and robotic surgery. A recent Surveillance, Epidemiology, and End Results (SEER) analysis compared the outcomes of 25,000 women undergoing laparotomy versus laparoscopic approach to hysterectomy and found that laparoscopy is associated with a shorter duration of hospitalization (three days versus five days), less postoperative complications (76%), less requirement for blood transfusion, reduced operational costs, faster recovery, and an overall safer surgical experience. Although geriatric patients are affected by age-related comorbidities, physiologic changes, and altered pharmacodynamics and pharmacokinetics of administered drugs, these patients benefit most from minimally invasive surgery. In this paper, we present a comprehensive account of the interdisciplinary perioperative approaches employed to accomplish a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection in an 82-year-old patient who was diagnosed with grade I endometrial adenocarcinoma and multiple age-related medical comorbidities.

ERAS: An Audit of Existing Practices.

Objectives: Enhanced recovery after surgery (ERAS) is a set of multidisciplinary, evidence proven guidelines which enhance perioperative recovery in various surgical branches. This study was planned as a pilot effort with the aim of evaluating the surgical team's compliance to ERAS, in the absence of a structured programme, in the department of gynaecologic oncology of a tertiary care hospital in India. Methods: This is a retrospective audit of patients who underwent elective surgery, in the department of gynaecologic oncology, in a tertiary care centre in India, between 15th August 2019 to 15th October 2019. Emergency operations and those surgeries with palliative intent were excluded from the study. Electronic outpatient and inpatient records of patients chosen by convenient sampling were examined. Adherence to 18 components (pre-operative, intra-operative and post-operative) from the ERAS guidelines pertaining to surgical care were analysed. Results: A total of 50 patients were included. Mean age group was 50 years (22-76 years). Majority of patients (60%) had a Charlson Deyo score of 0. Excellent compliance was noted with respect to preoperative counselling (94%), intraoperative management (86%) and post-operative factors such as early ambulation, thromboprophylaxis and early discharge. Practices which required improvement included reduction of period of pre-operative fasting, prehabilitation, carbohydrate loading, gum chewing and coffee consumption and early initiation of feeding in post-operative period. Conclusion: Dedicated and co-ordinated team effort will ensure that an ERAS protocol is enforced. Periodic auditing will reveal inconsistencies in compliance and guarantee benefit to patients.

Clues to the diagnosis of borderline ovarian tumours: An imaging guide.

Borderline Ovarian Tumours (BOTs) are an interesting subset of epithelial neoplasms defined histologically by atypical epithelial proliferation without stromal invasion. These tumours typically affect young women in the reproductive age group and have a good prognosis. Although ultrasonography is the primary screening imaging technique in the evaluation of any suspected adnexal mass, grey-scale and colour Doppler have limited value in characterizing BOTs. Thus, a pelvic magnetic resonance imaging (MRI) is recommended for further characterization on account of its multiplanar capabilities, excellent soft-tissue contrast and high spatial resolution. BOTs histological subtypes display specific features on MRI that are useful in differential diagnosis. However, the final diagnosis and staging of BOTs require pathologic evaluation after surgical excision. Therefore, the purpose of this review is to describe, illustrate and compare the imaging characteristics of the different subtypes of BOTs - serous, mucinous and seromucinous - focusing on MRI, as well as to correlate with pathology findings considering the recent 2020 World Health Organization (WHO) classification, in order to improve the accuracy of preoperative diagnosis and facilitate optimal patient management.

Patient satisfaction with robotic surgery.

This study is a service evaluation of the robotic-assisted surgery service within the Gynaecology Oncology department at Sheffield Teaching Hospitals. The aim is not only to evaluate and improve this new service within the department, but also to add to the available literature that reviews patient satisfaction with robotic-assisted surgery. An anonymous questionnaire was developed with questions taken from the NHS User Experience Survey Question Bank and additional questions in the same format specific to robotic-assisted surgery. This was posted to the first 140 patients to have undergone robotic-assisted surgery within Gynae Oncology at STH. One hundred completed questionnaires were returned. Over 90% of patients were pleased with the care that they received pre-operatively and felt that they have enough input into the decisions made about treatment. Half of patients (51%) reported having pain post-procedure, with a quarter of these patients experiencing severe pain. The majority of patients (72%) felt that their length of stay in hospital was of the right duration. Almost all patients (99%) were pleased with the overall care that they received and 91% would recommend robotic-assisted surgery as a modality. Patients are very satisfied with the care that they receive when undergoing robotic-assisted surgery within Gynae Oncology at our center and the majority of patients would recommend robotic-assisted surgery as a modality.