Occult residual ovarian tissue at the time of minimally invasive risk reducing surgery in women with BRCA mutations.

OBJECTIVE: To describe extension of ovarian tissue beyond visible and National Comprehensive Cancer Network recommended margins among patients with BRCA mutations undergoing minimally invasive risk-reducing salpingo-oophorectomy. METHODS: A prospective study of patients with BRCA mutations who underwent minimally invasive risk-reducing bilateral salpingo-oophorectomy was conducted. Patient enrollment occurred between October 2021 and 2023. Tissue specimens were analyzed according to the Sectioning and Extensively Examining the Fimbriated End protocol. RESULTS: Twenty women with BRCA mutations were prospectively enrolled. All patients underwent minimally invasive surgery with 70% undergoing concurrent hysterectomy (n = 14). Approximately half of these procedures were performed with robotic assistance (n = 9, 45%). One patient was admitted overnight (5%); the other nineteen were discharged on the day of surgery (95%). One patient experienced a major complication and required readmission (5%). Extension of ovarian tissue beyond the visible ovary was noted on pathologic examination of six specimens (30%). In one patient this was observed on the left (17%), in three on the right (50%), and in two bilateral extension (33%) was noted. The distance ovarian stroma extended microscopically beyond the visible ovary was between 2 and 14 mm, with a median of 5 mm. Among patients with microscopic extension of ovarian tissue, the majority (n = 5, 83%) had a BRCA2 mutation. CONCLUSION: In women with BRCA mutations undergoing risk-reducing minimally invasive surgery, approximately one third had microscopic extension of ovarian stroma beyond the visible ovary. Current guidelines which recommend resection of at least 20 mm of tissue beyond the visible ovary are likely adequate in this population.

Contemporary Parental Leave Policies and Practice Among Obstetrics and Gynecology Trainees and Faculty.

This article aims to describe contemporary parental leave among obstetrics and gynecology trainees and early-career faculty. Here, we present results of a survey that collected information about parental leave policies and contemporary practice, as well as beliefs about surgical and clinical experience for those who take leave. Faculty and trainees were equally well represented among respondents, with half of each group self-identifying as a parent. Most reported that childbearing trainees currently take 6 weeks or less of parental leave and believed that childbearing and nonchildbearing residents should be able to take 12 weeks of leave without extending training.

Postoperative complications in women with ovarian cancer stratified by cytoreductive surgery outcome.

OBJECTIVE: To compare 30-day postoperative complications for patients with advanced ovarian cancer who underwent resection to no gross residual disease versus optimal and suboptimal cytoreduction. METHODS: A retrospective cohort study of women drawn from the National Surgical Quality Improvement Program who underwent cytoreductive surgery for advanced ovarian cancer between 2014 and 2019 was performed. Exposure of interest was extent of surgical resection defined as no gross residual disease; residual disease <1 cm (optimal); and residual disease >1 cm (suboptimal). Primary outcome was postoperative complication. Associations were examined with bivariable tests and multivariable logistic regression. RESULTS: A total of 2248 women underwent cytoreductive surgery; 68.4% (n = 1538) underwent resection to no gross residual disease, 22.4% (n = 504) had an optimal, and 9.2% (n = 206) had a suboptimal cytoreduction. Optimal cytoreduction patients had the highest rates of any postoperative complication (35.5%, p < 0.001). They also had the longest operative times and procedures that were most surgically complex (203 min, 43.6 relative value units, both p < 0.05). However, patients who underwent optimal cytoreduction did not have increased odds of major complications (adjusted odds ratio: 1.20, 95% confidence interval: 0.91-1.58). CONCLUSION: Patients who underwent optimal cytoreduction had more postoperative complications, required the most operating room time, and represented more complex surgeries compared with suboptimal cytoreduction or resection to no gross residual disease.

Enrollment of Individuals From Racial and Ethnic Minority Groups in Gynecologic Cancer Precision Oncology Trials.

OBJECTIVE: To characterize whether enrollment patterns in precision oncology clinical trials for gynecologic cancers reflect the racial and ethnic diversity of patients with gynecologic cancers in the United States. METHODS: ClinicalTrials.gov was queried to perform this cross-sectional review. We included precision oncology trials -defined as trials using molecular profiling of a tumor or the patient genome to identify targetable alterations to guide treatment-of ovarian, uterine, cervical, and vulvar cancers in the United States. National Cancer Institute Surveillance, Epidemiology, and End Results and United States Census Bureau data were used to estimate cancer burden and the expected number of trial participants by race and ethnicity for each gynecologic cancer. The ratio of actual-to-expected participants was calculated. A ratio greater than 1 signified overenrollment. A random effects meta-analysis was performed to assess the relative weights of individual trials. RESULTS: We identified 493 trials, 61 of which met inclusion criteria. There were 2,573 patients enrolled in ovarian cancer trials, 1,197 in uterine cancer trials and 162 in cervical cancer trials. Non-Hispanic White women were overrepresented overall (enrollment ratio 1.26, 95% CI 1.20-1.32) and across all cancer types on subgroup analysis. Asian women, non-Hispanic Black women, and Hispanic women were underrepresented overall (enrollment ratios 0.63, 95% CI 0.41-0.86; 0.51, 95% CI 0.36-0.66 and 0.30, 95% CI 0.23-0.36, respectively). In subgroup analyses, Asian women and non-Hispanic Black women were underrepresented in ovarian and uterine cancer trials and Hispanic women were underrepresented across all cancer types. CONCLUSION: Non-Hispanic Black women, Asian women, and Hispanic women with gynecologic cancers are underrepresented in precision oncology trials. Few U.S.-based precision oncology trials exist for uterine and cervical cancers, which have a high burden of morbidity and mortality among racial and ethnic minority groups. Failure to equitably enroll patients who belong to racial and ethnic minority groups may perpetuate existing disparities in gynecologic cancer outcomes.

The Motherhood Penalty in Obstetrics and Gynecology Training.

Since 2017, the number of women enrolled in medical schools in the United States has increased steadily. For the average female graduate, residency training will coincide with peak childbearing years. Despite increasingly well-defined parental leave policies in other industries, there is no standardized approach across graduate medical education programs. Physician mothers, particularly those in surgical specialties, have also been shown to be at increased risk for major pregnancy complications and postpartum depression. In addition, despite excellent initiation rates, the majority of breastfeeding trainees struggle with low milk supply, and as few as 7% of physician mothers continue to breastfeed for 1 year. Although the medical field routinely advocates for the benefits of parental leave and breastfeeding for our patients, significant and comprehensive change is needed to ensure that graduate medical education trainees can follow physician-recommended postpartum guidelines without meaningful implications for their careers. In February 2020, the American Board of Obstetrics and Gynecology changed its leave policy, allowing residents to take up to 12 weeks of paid or unpaid leave in a single year for vacation, parenting, or medical issues without extending their training. This change represents an important first step, and, as comprehensive women's health care professionals, our specialty should be leaders in normalizing family building for physicians-in-training. A culture change toward an environment of support for pregnant and parenting trainees and access to affordable, extended-hour childcare are also critical to enabling physicians at all levels to be successful in their careers.

Reimbursement for Female-Specific Compared With Male-Specific Procedures Over Time.

OBJECTIVE: To evaluate whether per-procedure work relative value units (RVUs) have changed over time and to compare time-based compensation for female-specific procedures compared with male-specific procedures. METHODS: Using the National Surgical Quality Improvement Program files for 2015-2018, we compared operative time and RVUs for 12 pairs of sex-specific procedures. Procedures were matched to be anatomically and technically similar. Procedure-assigned RVUs in 2015 were compared with 1997. Procedure compensation was determined using median dollars per RVU provided in SullivanCotter's 2018 Physician Compensation and Productivity Survey. This was compared with specialty-specific McGraw-Hill per-RVU data from 1994. Statistical analysis was performed with chi-square and Kruskal-Wallis tests. RESULTS: A total of 12,120 patients underwent 6,217 male-specific procedures and 5,903 female-specific procedures. Male-specific procedures had a median (interquartile range) RVU of 25.2 (21.4-25.2), compared with 7.5 (7.5-23.4) for female-specific procedures (P<.001). Male-specific procedures were 79 minutes longer (median [interquartile range] 136 minutes [98-186] vs 57 minutes [25-125], P<.001). Female-specific procedures were reimbursed at a higher hourly rate (10.6 RVU/hour [7.2-16.2] vs 9.7 RVU/hour [7.4-12.8], P<.001). However, male-specific procedures were better reimbursed ($599/h [$457-790] vs $555/h [$377-843], P<.001). Overall, per-procedure RVUs for male-specific surgeries have increased 13%, whereas, for female-specific surgeries, per-procedure RVUs have increased 26%. Reimbursement per RVU for male-specific procedures has decreased 8% ($67.30 to $61.65), whereas for female-specific procedures it has increased 14% ($44.50 to $52.02). CONCLUSION: Increases in RVUs and specialty-specific compensation have resulted in more equitable reimbursement for female-specific procedures. However, even with these changes, there is a lower relative value of work, driven by specialty-specific compensation rates, for procedures performed for women-only compared with equivalent men-only procedures.

Acceleration and plateau: two patterns and outcomes of isolated severe fetal cerebral ventricular dilation.

OBJECTIVES: We sought to characterize patterns of in utero dilation in isolated severe fetal ventriculomegaly (ISVM) and investigate their value in predicting obstetrical and postnatal outcomes. METHODS: This is a retrospective cohort study. ISVM was defined as a sonographic cerebral ventricle atrial with width ≥15 mm in the absence of additional cerebral or other anatomic anomalies. The aim of this study was to characterize two ISVM groups using a receiver operator curve to evaluate the rate of ventricular progression versus need for ventriculoperitoneal (VP) shunt postnatally. Outcomes were compared between the groups using Pearson's chi-squared test, Student t-test, and descriptive statistics. RESULTS: Based on the ROC analysis, ventricular growth of ≥3 mm/week versus <3 mm/week distinguished fetuses likely to require a postnatal VP shunt. Fetuses were characterized as accelerators if ventricle growth was ≥3 mm/week at any point and plateaus if <3 mm/week. Accelerators showed a greater average rate of ventricle progression than plateaus (4.1 vs. 1.0 mm/week, respectively, p = .031) and were more likely to be delivered at earlier gestational ages (34.7 vs. 37.1 weeks respectively, p = .02). Ninety percent of accelerators demonstrated a need for shunt placement compared with 18.8% of plateaus (p < .001). Significantly more plateaus (87.5%) underwent a trial of labor while accelerators were more likely to have planned cesareans (70%, p = .009). CONCLUSIONS: This study characterizes ISVM into two distinct populations based upon the rate of ventricle expansion, differentiated by the need for postnatal shunting. Once a ventricular growth pattern is determined, these distinctions should prove useful in prenatal management and delivery planning.

Minimally Invasive Surgery Rate as a Quality Metric for Endometrial Cancer.

STUDY OBJECTIVE: To determine the frequency with which Commission on Cancer-accredited hospitals met a metric of ≥80% minimally invasively performed hysterectomies for endometrial cancer and to compare the clinical outcomes of hospitals meeting this metric with those that did not. DESIGN: Retrospective cohort study. SETTING: Hospitals caring for ≥20 endometrial cancer patients per year recorded in the National Cancer Database in 2015 were included. PATIENTS: Women who had undergone hysterectomy for endometrial cancer and had an epithelial histology, a Charlson comorbidity score of 0, and stage I to III disease. INTERVENTION: Patient characteristics, patterns of care, and outcomes were compared between hospitals performing ≥80% minimally invasive hysterectomies and hospitals not meeting this metric. MEASUREMENTS AND MAIN RESULTS: The hospitals (n = 510) treated 20 670 women with endometrial cancer. In 283 (55%) hospitals ≥80% of hysterectomies were minimally invasively performed (high-minimally invasive surgery [MIS] hospitals, overall MIS rate 89%). In the 227 hospitals that did not meet this metric, 61% of hysterectomies for endometrial cancer were performed using a minimally invasive approach. In high-MIS hospitals, patients were more likely to be white (87% vs 82%, p<.001), privately insured (53% vs 49%, p <.001), and have stage I disease (84% vs 82%, p = .002) and an endometrioid histology (79% vs 76%, p <.001). Surgery was more often performed robotically (80% vs 71%), and conversion to laparotomy was less likely (1.5% vs 3.2%, adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.39-0.57) (both p <.001). Patients treated at high-MIS hospitals were more likely to have undergone lymph node assessment at the time of surgery (76% vs 69%; aOR, 1.43; 95% CI, 1.35-1.53) and been discharged on the same or next day (74% vs 57%; aOR, 2.27; 95% CI, 2.13-2.42) and were less likely to have an unplanned 30-day readmission (1.8% vs 2.9%; aOR, 0.64; 95% CI, 0.53-0.77). CONCLUSION: An MIS rate of ≥80% for endometrial cancer is feasible on a national scale and is associated with other hospital-level measurements of high-quality care.

Cystoscopy at the Time of Hysterectomy for Benign Indications and Delayed Lower Genitourinary Tract Injury.

OBJECTIVE: To compare the rate of delayed 30-day lower genitourinary tract injury in women who underwent cystoscopy at the time of hysterectomy for benign indications to those who did not. METHODS: This was a retrospective cohort study of patients who underwent hysterectomy without a concomitant procedure for prolapse or incontinence for benign pathology with a general obstetrician-gynecologist (ob-gyn) recorded in the National Surgical Quality Improvement Program targeted hysterectomy file between 2015 and 2017. The primary outcome was a delayed lower genitourinary tract injury in the 30 days after hysterectomy. Secondary outcomes included urinary tract infection and operative time. The exposure of interest was cystoscopy at the time of hysterectomy. Stratified analysis was performed by route of surgery. Bivariable tests were used to examine associations. RESULTS: We identified 39,529 women who underwent hysterectomy for benign indications with a general ob-gyn. Surgical approach was open (26%), laparoscopic or robotic assisted laparoscopic (46%), and vaginal or vaginally assisted (28%). Overall, 25% of women underwent cystoscopy at the time of hysterectomy; cystoscopy was more commonly performed in laparoscopic or robotic (32%) and vaginal hysterectomy (25%) as compared with open hysterectomy (11%) (P<.001). There was no difference in delayed lower genitourinary tract injury between patients who underwent cystoscopy at time of hysterectomy compared with those who did not undergo cystoscopy (0.27% vs 0.24%, P=.64). Patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (2.6% vs 2.0%, RR 1.27 95% CI 1.09-1.47). Median operative time was increased by 17 minutes in cases where cystoscopy was performed (132 vs 115 minutes, P<.001). CONCLUSION: Cystoscopy at the time of hysterectomy for benign indications does not result in a lower rate of 30-day delayed lower genitourinary tract injury compared with no cystoscopy.

Extent of lymphadenectomy and postoperative major complications among women with endometrial cancer treated with minimally invasive surgery.

BACKGROUND: In patients with endometrial cancer, sentinel lymphadenectomy is used to accurately prognosticate extent of disease, and has been proposed as a method to decrease the incidence of medical and surgical complications associated with more extensive lymphadenectomy. It is unknown whether patients who undergo traditional lymphadenectomy experience major postoperative complications at the same rates as those who undergo sentinel lymphadenectomy or those who do not undergo lymphadenectomy. OBJECTIVE: The aim of this study was to compare the incidence of major postoperative complications among endometrial cancer patients undergoing total laparoscopic hysterectomy with traditional lymphadenectomy vs sentinel or no lymphadenectomy. MATERIALS AND METHODS: Patients with endometrial cancer who underwent total laparoscopic hysterectomy recorded in the National Surgical Quality Improvement Program (NSQIP) database between 2015 and 2016 were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Primary exposure was extent of lymphadenectomy. The primary outcome was major postoperative complications as defined by the Clavien-Dindo scale. Associations were examined with bivariable tests and multivariable logistic regression. RESULTS: A total of 3282 women with endometrial cancer who underwent total laparoscopic hysterectomy were identified; of these, 2049 (62.4%) did not undergo lymphadenectomy, 1089 (33.2%) underwent traditional lymphadenectomy, and 144 (4.4%) underwent sentinel lymphadenectomy. Traditional lymphadenectomy had the highest rate of major complications (3.6%) compared with sentinel lymphadenectomy (2.0%) and no lymphadenectomy (2.0%) (P = .03). Patients who underwent traditional lymphadenectomy also had the longest operating room times and procedures that were most surgically complex (171 minutes, 30.6 relative value units [RVU]) compared with patients who underwent sentinel lymphadenectomy (166 minutes, 24.9 RVU) or no lymphadenectomy (141 minutes, 15.0 RVU) (all P < .001). Patients who underwent traditional lymphadenectomy had nearly twice the odds of a major complication (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.2-2.9) and need for readmission (aOR, 2.2; 95% CI, 1.5-3.4) compared to those who underwent sentinel or no lymphadenectomy. The incidence of readmission after traditional lymphadenectomy was higher (4.6%) than after sentinel lymphadenectomy (1.4%) and no lymphadenectomy (2.2%) (P < 0.001). CONCLUSION: Sentinel lymphadenectomy among patients undergoing total laparoscopic hysterectomy for endometrial cancer was associated with a decreased incidence of major postoperative complications and need for readmission when compared with traditional lymphadenectomy.