Uterine Fibroid-Induced Compressive Neuropathy of Lumbar Plexus and Obturator Nerve.

Introduction: Uterine fibroids are the most common gynecologic tumors in reproductive-aged women with a prevalence of up to 80%. Symptoms can range from heavy vaginal bleeding and bulk symptoms to, less frequently, deep vein thrombosis and bowel obstruction. Case Description: A 32-year-old female patient presented with acute-onset of right groin and knee pain, and difficulty ambulating. A large posterior uterine fibroid was found to be compressing branches of the lumbar plexus, including the obturator nerve. The patient underwent gynecologic evaluation and an urgent laparoscopic myomectomy. Postoperatively, she had significant improvement in neurologic symptoms. She continued physical therapy for residual mild paresthesia and pain with prolonged ambulation. Discussion: Large pelvic masses such as uterine fibroids should be considered on the differential diagnosis for acute-onset non-gynecologic symptoms such as compressive neuropathy, which require urgent evaluation and possible surgical management.

Outcomes after a Uterine-Sparing Approach to Essure Contraceptive Device Removal.

Background and Objective: To analyze long-term effectiveness of a conservative, uterine-sparing approach to laparoscopic Essure removal. Specific outcomes of interest include patient satisfaction, symptom resolution, and subsequent surgical intervention. Methods: A retrospective case series and follow-up survey. Patients who underwent laparoscopic Essure removal without concomitant hysterectomy between January 1, 2016 and December 31, 2019 were identified. Greater than 18 months after removal participants completed a survey assessing outcomes. Results: Twenty-nine patients underwent conservative Essure removal and there were 19 survey respondents. Among survey respondents, the mean length of time from Essure placement to removal was 56.7 months (range 5 - 117), and the mean length of time from removal to survey administration was 48.3 months (range 23 - 63). The most frequently reported symptoms were pain (100%), bleeding (52.6%), headache (42.1%), and dyspareunia (42.1%). Methods for removal included laparoscopic salpingectomy (58.6%), a combined hysteroscopic and laparoscopic approach (34.4%), and cornuectomy (6.9%). Regarding symptom improvement after Essure removal, 47.4% of patients reported total improvement, 36.8% reported almost total improvement, 5.3% reported some improvement, and 10.5% reported no improvement. Most patients (89.5%) reported satisfaction with their surgical results, and only two patients required subsequent surgical intervention for symptom management. Conclusions: Most patients in our cohort reported total or almost total improvement in symptoms almost two years after Essure removal, with low rates of reintervention. A uterine-sparing approach to Essure removal, using laparoscopic and hysteroscopic modalities, may be a feasible and effective approach to addressing Essure-attributed symptoms.

Applications of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologic surgery.

PURPOSE OF REVIEW: Natural orifice transluminal endoscopic surgery (NOTES) is an emerging approach used across surgical disciplines. This review seeks to assess the growing body of literature on experiences and outcomes using vaginal NOTES (vNOTES) in gynecologic surgery. RECENT FINDINGS: Many limitations of vaginal surgery including lack of descensus or restricted vaginal space can be overcome with vNOTES whereas avoiding risks of abdominal incisions in traditional laparoscopy. vNOTES may have superior outcomes in pain, length of stay, and satisfaction for multiple gynecologic indications however additional data is needed to assess cost-effectiveness and long-term outcomes. Surgeons implementing this technique should have adequate experience with both traditional vaginal and laparoscopic approaches. The current body of high-quality studies is heavily influenced by single site, single surgeon studies and as such may not be fully applicable to all practices incorporating this novel technique, and adequate training should precede implementation of Vnotes. SUMMARY: Vaginal surgery is considered the least invasive approach, however, may not be appropriate in all cases. vNOTES presents a novel approach that combines the access and visualization afforded by endoscopy whereas avoiding the risks associated with transabdominal entry and can be considered as a feasible option in gynecologic surgery.

Trends in Opioid Prescriptions after Laparoscopic Sterilization.

BACKGROUND AND OBJECTIVES: Examine trends in opioid prescriptions after laparoscopic sterilization over time, and identify any individual patient, provider, or procedural factors influencing prescribing. METHODS: A retrospective observational cohort analysis of laparoscopic sterilizations between January 1, 2016 and December 31, 2019 at Montefiore Medical Center. A review of the medical records was performed and information on patient demographics, comorbid conditions, and surgical characteristics were collected. The number of opioid pills prescribed postoperatively and any pain related patient calls, visits, or refills was recorded. RESULTS: Between January 1, 2016 and December 31, 2019, 615 laparoscopic sterilizations were performed. The median number of opioid pills prescribed was 10, ranging from 0 to 40. There was a significant decrease in the number of opioid pills prescribed (p < .0001) and refill incidence (p < .001) over time. Patients with a documented diagnosis of pelvic pain received significantly more opioid pills (p = .02), as did patients who underwent tubal occlusion versus salpingectomy (p = .01). There was no association between the number of opioid pills prescribed and other patient or procedural characteristics. Finally, the number of pills prescribed was not associated with urgent patient contact (p = .34). CONCLUSIONS: The overall number of opioid pills prescribed after laparoscopic sterilization decreased at our institution over time, which paralleled a decrease in refills and urgent postoperative patient contact. Further, few clinical characteristics influenced postoperative prescribing and there was no association between number of pills prescribed and urgent patient contact. These findings suggest excess prescribing and highlight the need to identify and adopt an evidenced-based approach to postsurgical opioid prescriptions.

Examining Reduced Opioid Prescriptions after Gynecologic Laparoscopy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To examine whether prescribing 5 tablets, as opposed to 10 tablets, of 5-mg oxycodone adequately treats pain after gynecologic laparoscopy. DESIGN: Single-blinded randomized trial. SETTING: Academically affiliated ambulatory surgery center. PATIENTS: One hundred twenty women scheduled to undergo minor gynecologic laparoscopy. INTERVENTIONS: Patients scheduled for ambulatory gynecologic laparoscopy were allocated to the standard tablet or low-tablet number prescription groups (10 tablets or 5 tablets of 5-mg oxycodone). The patients also received prescriptions for acetaminophen and ibuprofen. MEASUREMENTS AND MAIN RESULTS: Telephone surveys were conducted on postoperative days 1 and 7 to assess medication use and pain. The primary outcome was the number of oxycodone tablets used by days 1 and 7. Prespecified secondary outcomes included unscheduled patient contacts and pain scores. With N = 50 in each group and assuming standardized effect sizes, the study was powered to detect a 0.6 difference or greater when comparing the primary outcome between the groups. Forty-five and 47 patients in the 5-tablet and 10-tablet groups, respectively, completed the day-7 survey. The median number of oxycodone tablets taken by day 7 was 2.0 (interquartile range 0.0, 4.0) in the 5-tablet group and 2.5 (interquartile range 0.0, 5.0) in the 10-tablet group (p = .36). Most of the patients in both groups reported taking 3 oxycodone tablets or fewer by day 7. There were no significant differences in unscheduled patient contacts, need for additional prescriptions, or pain scores. There were significantly fewer unused tablets in the 5-tablet group by day 7. CONCLUSION: Prescribing 5 tablets of 5-mg oxycodone, acetaminophen, and ibuprofen is likely sufficient for most patients after minor laparoscopic surgery.

Transversus Abdominis Plane Block for Laparoscopic Hysterectomy Pain: A Meta-Analysis.

OBJECTIVE: Review the analgesic effect of the transversus abdominis plane (TAP) block and its impact on postoperative pain scores and opioid usage for patients undergoing laparoscopic and robotic hysterectomies. METHODS: Systematic review with meta-analysis of randomized controlled trials that compared the effect of TAP block to either placebo or no block on narcotic use (in morphine equivalent units [MEq]) and pain (per visual analog scale) within 24] h after a laparoscopic or robotic hysterectomy for benign or malignant indications. Searches were conducted in PubMed and Embase through May 31, 2019. RESULTS: Nine randomized controlled trials met eligibility criteria; 7 evaluated laparoscopic hysterectomy and 2 robotic hysterectomy. A total of 688 subjects were included (559 laparoscopic hysterectomy, 129 robotic hysterectomy). Opioid consumption was similar in the first 24] h postoperative with or without TAP block (-0.8 MEq; 95% CI, -2.9, 1.3; 8 TAP arms; N] = 395). Pain scores (visual analog scale) were also similar with or without TAP block (-0.01 U; 95% CI, -0.34, 0.32; 10 TAP arms; N] = 636). Neither meta-analysis showed statistical heterogeneity across studies. CONCLUSIONS: The evidence does not support a benefit of TAP block to reduce pain or opioid use for patients receiving laparoscopic or robotic hysterectomies.

Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study.

To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB.