Preoperative Mechanical Bowel Preparation for Gynecologic Surgeries: A Systematic Review with Meta-analysis.

OBJECTIVE: To assess the efficacy and safety of mechanical bowel preparation (MBP) before benign laparoscopic or vaginal gynecologic surgeries. DATA SOURCES: Database searches of MEDLINE (PubMed), Embase (OVID), Cochrane Central Register of Controlled Trials, and Web of Sciences and citations and reference lists published up to December 2021. METHODS OF STUDY SELECTION: Randomized clinical trials in any language comparing MBP with no preparation were included. Two reviewers independently screened 925 records and extracted data from 12 selected articles and assessed the risk of bias with the Cochrane risk-of-bias tool for randomized trials tool. A random-effects model was used for the analysis. Surgeon findings (surgical field view, quality of bowel handling and bowel preparation), operative outcomes (blood loss, operative time, length of stay, surgical site infection), and patient's preoperative symptoms and satisfaction were collected. TABULATION, INTEGRATION, AND RESULTS: Thirteen studies (1715 patients) assessing oral and rectal preparations before laparoscopic and vaginal gynecologic surgeries were included. No significant differences were observed with or without MBP on surgical field view (primary outcome, risk ratio [RR] 1.01, 95% confidence interval [CI] 0.97-1.05, p = .66, I2 = 0%), bowel handling (RR 1.01, 95% CI 0.95-1.08, p = .78, I2 = 67%), or bowel preparation. In addition, there were no statistically significant differences in perioperative findings. MBP was associated with increased pain (mean difference [MD] 11.62[2.80-20.44], I2 = 76, p = .01), weakness (MD 10.73[0.60-20.87], I2 = 94, p = .04), hunger (MD 17.52 [8.04-27.00], I2 = 83, p = .0003), insomnia (MD 10.13[0.57-19.68], I2 = 82, p = .04), and lower satisfaction (RR 0.68, 95% CI 0.53-0.87, I2 = 76%, p = .002) compared with controls. CONCLUSIONS: MBP has not been associated with improved surgical field view, bowel handling, or operative outcome. However, in view of the adverse effects induced, its routine use before benign gynecologic surgeries should be abandoned.

Surgical Indication and Approach are Associated with Transfusion in Hysterectomy for Benign Disease.

Objective: To identify pre-operative and intraoperative factors associated with the risk of red blood cell transfusion among women undergoing hysterectomy. Methods: A retrospective cohort study of hysterectomy for benign indications between January 1, 2011 - December 31, 2017. Patients receiving blood transfusion within 30 days of surgery were compared to patients who did not receive any transfusion. Multivariate logistic regression analysis was performed to identify clinical and surgical variables associated with blood transfusion. Results: Among 171,940 women who underwent hysterectomy for benign indication, 4,667 (2.7%) required blood transfusion. The rate of transfusion was highest among patients with uterine fibroids (4.3%) and lowest in patients with genital prolapse (1.1%) (p < 0.05). Odds of blood transfusion were significantly elevated in patients undergoing hysterectomy for uterine fibroids compared to patients with genital prolapse (adjusted odds ratio [aOR] 1.36, 95% confidence interval [CI] 1.15 - 1.61). Other patient characteristics included body mass index, smoking, bleeding disorders, pre-operative sepsis, and American Society of Anesthesiologists score ≥ 2 (p < 0.05). Higher pre-operative hematocrit significantly decreased the risk of blood transfusion (aOR 0.84, 95% CI 0.84 - 0.85 per percent increase in hematocrit). Abdominal and vaginal hysterectomies were associated with greater odds of transfusion compared with laparoscopic approaches (aOR 5.06, 95% CI 4.70 - 5.44; aOR 1.87, 95% CI 1.67 - 2.10, respectively). Conclusions: Certain patient comorbidities, surgical indication, and approach to hysterectomy are associated with increased risk of blood transfusion. These results may have implications for pre-operative patient counseling, perioperative care, and health system planning.

Stepwise approach to the laparoscopic excision of bladder endometriosis.

OBJECTIVE: To describe a stepwise approach to the laparoscopic excision of bladder endometriosis. DESIGN: Narrated surgical video. SETTING: Academic tertiary care hospital. PATIENT(S): Surgical footage was obtained from three patients who underwent surgery for bladder endometriosis. Institutional review board approval was not required in accordance with the Tri-Council Policy Statement of Canada, article 2.5. INTERVENTION(S): Laparoscopic excision of bladder endometriotic nodules by partial cystectomy. MAIN OUTCOME MEASURE(S): Overview of the relevant anatomy, disease overview, surgical planning and perioperative care, and the approach to the excision of bladder endometriotic nodules. RESULT(S): The approach to excision of bladder endometriotic nodules can be standardized in six reproducible steps: cystoscopy with or without ureteral stent placement; abdominal survey and treatment of posterior compartment disease; bladder mobilization; partial bladder cystectomy under cystoscopic guidance; cystotomy closure; and water-leak test. CONCLUSION(S): The safe and complete excision of bladder endometriosis relies on the understanding of surgical anatomy, the multidisciplinary aspect of patient care, and the standardization of the surgical approach.

Laparoscopic excision of pericardial and diaphragmatic endometriosis.

OBJECTIVE: To present a five-step approach to the laparoscopic excision of pericardial and diaphragmatic endometriosis. DESIGN: Surgical video. SETTING: Academic tertiary care hospital. PATIENT(S): 35-year-old nulliparous woman observed for chronic pelvic pain and infertility with a diagnosis of diaphragmatic endometriosis at a prior laparoscopy. Symptoms included severe chest pain and right shoulder tip pain, refractory to multiple medical therapies. INTERVENTION(S): Laparoscopic excision of pericardial and diaphragmatic endometriosis. MAIN OUTCOME MEASURE(S): Description of the relevant anatomy, the literature surrounding pericardial and diaphragmatic endometriosis, and the approach to the surgical intervention and postoperative care. RESULT(S): The laparoscopic excision of the full-thickness pericardial and diaphragmatic endometriotic lesions was successfully completed according to five reproducible steps: upper abdominal survey, liver mobilization, excision of diaphragmatic endometriosis, intrathoracic laparoscopic exploration, and closure of the diaphragmatic defect. CONCLUSION(S): Although rare and challenging to diagnose and treat, pericardial and diaphragmatic endometriosis and its potentially debilitating symptoms can be successfully managed through a multidisciplinary and stepwise surgical intervention.

Venous Thromboembolism After Blood Transfusions in Women Undergoing Hysterectomy for Non-Malignant Indications: A Retrospective Cohort Study.

OBJECTIVE: To quantify the effect of blood transfusion on the risk of venous thromboembolism (VTE) among women undergoing hysterectomy for non-malignant indications. METHODS: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was conducted. Women who underwent hysterectomy for non-malignant indications between 2011 and 2016 were identified using the Current Procedural Terminology and Internationally Classification of Diseases codes. The primary outcome was development of VTE. Data on patient demographics and perioperative variables were obtained. Pair-wise comparison using χ2 tests were performed to compare women with and without VTE. Multivariable logistic regression was performed to adjust for potential confounders and identify independent predictors of VTE. RESULTS: Between 2011 and 2016, 169 593 women underwent hysterectomy for non-malignant indications. The overall incidence of VTE was 0.32%. Patient characteristics associated with VTE included obesity and higher American Society of Anesthesiologists (ASA) status. Associated operative factors included abdominal surgery, blood transfusion, and prolonged operative time (P < 0.05 for all). Following adjustment for potential confounders, abdominal hysterectomy was associated with greater odds of VTE than laparoscopic or vaginal approaches (adjusted odds ratio [aOR] 1.81; 95% CI 1.48-2.21 and aOR 2.31; 95% CI 1.62-3.28, respectively). Greater odds of VTE were also observed with OR time >150 minutes (aOR 1.88; 95% CI 1.46-2.42), ASA class ≥III (aOR 1.53; 95% CI 1.05-2.26), and intra- and postoperative transfusion (aOR 2.65; 95% CI 1.78-3.95 and aOR 2.98; 95% CI 1.95-4.55, respectively). CONCLUSION: The risk of VTE is low in women undergoing hysterectomy for non-malignant indications. Blood transfusion was associated with the highest risk of VTE.

Outpatient uterine assessment and treatment unit in patients with abnormal uterine bleeding: an economic modelling study.

BACKGROUND: Most often in Canada, the evaluation and management of abnormal uterine bleeding occurs under general anesthesia in the operating room. We aimed to assess the potential cost-effectiveness of an outpatient uterine assessment and treatment unit (UATU) compared with the current standard of care when diagnosing and treating abnormal uterine bleeding in women. METHODS: We performed a cost-effectiveness analysis and developed a probabilistic decision tree model to simulate the total costs and outcomes of women receiving outpatient UATU or usual care over a 1-year time horizon (Apr. 1, 2014, to Mar. 31, 2017) at a tertiary care hospital in Ontario, Canada. Probabilities, resource use and time to diagnosis and treatment were obtained from a retrospective chart review of 200 randomly selected women who presented with abnormal uterine bleeding. Results were expressed as overall cost and time savings per patient. Costs are reported in 2018 Canadian dollars. RESULTS: Compared with usual care, care in the UATU was associated with a decrease in overall cost ($1332, 95% confidence interval [CI] -$1742 to -$1008) and a decrease in overall time to treatment (-75, 95% CI -89 to -63, d). The point at which the UATU would no longer be cost saving is if the additional cost to operate and maintain the UATU is greater than $1600 per patient. INTERPRETATION: From the perspective of Canada's health care system, an outpatient UATU is more cost effective than usual care and saves time. Future studies should focus on the relative efficacy of a UATU and the total budget required to operate and maintain a UATU.

Type of Pelvic Disease as a Risk Factor for Surgical Site Infectionin Women Undergoing Hysterectomy.

STUDY OBJECTIVE: To quantify the relationship between type of benign pelvic disease and risk of surgical site infection (SSI) after hysterectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). PATIENTS: Women who underwent hysterectomy from 2006-2015 and recorded in NSQIP database. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: SSI risk was compared for type of benign pelvic disease, patient characteristics (i.e., age, race, and selected comorbidities) and process of care variables (i.e., admission status, type of hysterectomy, and operative time). SSI occurred in 2.48% of the 125,337 women who underwent hysterectomy. SSI was most frequent in patients with endometriosis and least frequent in those with genital prolapse (3.13% vs 1.39%; p <.0001). Following adjustment for potential confounders, the odds of SSI were higher in women undergoing hysterectomy for endometriosis (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.43- 2.25), uterine myomas (aOR, 1.28; 95% CI, 1.05-1.55), menstrual disorders (aOR, 1.46; 95% CI, 1.20-1.78), and pelvic pain (aOR, 1.75; 95% CI, 1.34-2.27) compared with women undergoing hysterectomy for genital prolapse. Other patient factors associated with SSI included age, body mass index, smoking, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and American Society of Anesthesiologists classification. Among process-of-care factors, inpatient status, route of hysterectomy, total vs subtotal hysterectomy, and operative time were also associated with SSI. CONCLUSION: In addition to various patient and process-of-care factors known to be associated with SSI, type of underlying pelvic disease is an independent risk factor for SSI in women undergoing hysterectomy for benign indications.

Use of Ulipristal Acetate for the Management of Fibroid-Related Acute Abnormal Uterine Bleeding.

BACKGROUND: Episodes of acute abnormal uterine bleeding related to uterine fibroids can cause significant morbidity. Traditional management with high-dose hormonal regimens may not be as effective when used in women with fibroids. CASE: A 32-year-old woman with a 12 cm uterine fibroid presented with an episode of acute abnormal uterine bleeding requiring blood transfusion. In lieu of using a hormonal maintenance regimen after the bleeding had stabilized, the patient was treated with ulipristal acetate 5 mg daily for three months. Amenorrhea was induced rapidly and the patient had no further episodes of acute excessive uterine bleeding. She subsequently underwent a laparoscopic myomectomy with a satisfactory outcome. CONCLUSION: Ulipristal acetate has been shown to induce amenorrhea rapidly in women with uterine fibroids, and it can be a useful treatment in the emergency management of fibroid-related acute abnormal uterine bleeding.

Hysteroscopic resection in the management of early-stage endometrial cancer: report of 2 cases and review of the literature.

Although endometrial cancer, the most common gynecologic malignancy, is most often diagnosed in postmenopausal women, it affects young women who wish to preserve fertility. The purpose of this article is to describe 2 cases of stage IA endometrial cancer managed conservatively by a combination of hysteroscopic surgery and medical therapy for fertility-sparing purposes, one of which achieved successful pregnancy using assisted reproductive technology, and review the existing literature on the use of hysteroscopic resection in conservative management of endometrial cancer to preserve fertility. The addition of hysteroscopic resection to conservative management of early-stage endometrial carcinoma may be a way to improve response and recurrence rates in women wishing to preserve fertility and can offer other additional benefits, such as a shorter time period to remission and a faster return to fertility. Key factors to success with this approach include an interdisciplinary approach, thorough patient counseling, and the availability of a team experienced in hysteroscopic resection.

Managing expectations of surgical training: a national perspective on gynaecologic endoscopy practice.

OBJECTIVE: To determine if the opinion of obstetrics and gynaecology postgraduate trainees differs from practising gynaecologists with respect to the expected endoscopic surgical skill set of a general gynaecologist upon graduation from residency. METHODS: An electronic survey was designed, validated, and pre-tested. It was sent to 775 Canadian obstetrics and gynaecology residents, fellows, and practising physicians through the Society of Obstetricians and Gynaecologists of Canada's electronic mailing list. Survey respondents were asked their opinion on the level of training (no extra post-residency training vs. fellowship) required to perform various endoscopic procedures. RESULTS: We received 301 responses (39% response rate). Obstetrics and gynaecology trainees and practising physicians agreed on the training and skill level necessary to perform many endoscopic procedures. However, there were significant differences of opinion among trainees and practising physicians regarding advanced endoscopic procedures such as laparoscopic hysterectomy, cystotomy and enterotomy repair, and appendectomy. More trainees felt that a general gynaecologist without additional post-residency surgical training should be competent to perform such procedures, while practising physicians felt fellowship training was necessary. CONCLUSION: Our survey highlights the different expectations of learners versus those in practice with regard to skills required to perform certain endoscopic procedures, particularly laparoscopic hysterectomy. Trainees who responded believed that after graduation from residency any obstetrician-gynaecologist should be able to perform more advanced endoscopic procedures, but practising physicians did not agree. This discordance between learners and practising colleagues highlights an important educational challenge in obstetrics and gynaecology surgical training. Greater clarification of what is expected of our training programs would be beneficial for both residents and training programs.

Objectif : Déterminer si l'opinion des stagiaires postdoctoraux en obstétrique-gynécologie diffère de celle des gynécologues praticiens en ce qui a trait à l'ensemble de compétences en chirurgie endoscopique dont devrait disposer un gynécologue généraliste à la fin de sa résidence. Méthodes : Un sondage électronique a été conçu, validé et prétesté. Nous l'avons fait parvenir, par l'intermédiaire de la liste de diffusion électronique de la Société des obstétriciens et gynécologues du Canada, à 775 résidents, boursiers et praticiens canadiens du domaine de l'obstétrique-gynécologie. Nous avons demandé aux répondants de nous fournir leur opinion quant au niveau de formation requis (aucune formation post-résidence supplémentaire vs fellowship) pour l'exécution de diverses interventions endoscopiques. Résultats : Nous avons reçu 301 réponses (taux de réponse de 39 %). Les stagiaires en obstétrique-gynécologie et les gynécologues prati­ciens étaient du même avis quant au niveau de formation et aux compétences nécessaires pour l'exécution de nombreuses interventions endoscopiques. Toutefois, nous avons constaté des différences d'opinion considérables entre les stagiaires et les praticiens en ce qui concerne les interventions endoscopiques avancées (comme l'hystérectomie laparoscopique, la réparation de cystostomie et d'entérostomie, et l'appendicectomie). Un plus grand nombre de stagiaires étaient d'avis qu'un gynécologue généraliste devrait, sans formation chirurgicale post-résidence supplémentaire, disposer de la compétence requise pour mener de telles interventions, tandis que les praticiens estimaient qu'une formation de type fellowship s'avérait nécessaire. Conclusion : Notre sondage souligne les différences en matière d'attentes, entre les stagiaires et les praticiens, en ce qui concerne les compétences requises pour mener certaines interventions endoscopiques (particulièrement l'hystérectomie laparoscopique). Les stagiaires ayant répondu au sondage estimaient que, à la fin du programme de résidence, tout obstétricien-gynécologue devrait être en mesure de mener des interventions endoscopiques plus avancées, mais les praticiens ne partageaient pas cet avis. Cet écart entre les stagiaires et les praticiens souligne l'existence d'un important défi pédagogique en ce qui concerne la formation chirurgicale en obstétrique-gynécologie. Une meilleure clarification des attentes envers nos programmes de formation s'avérerait bénéfique tant pour les résidents que pour les programmes de formation.

Delayed laparoscopic management of placenta increta.

BACKGROUND: Traditional methods of management of abnormal placentation are often associated with significant maternal morbidity. In an attempt to decrease such morbidity, we present a novel approach: delayed laparoscopic management. CASE: A patient with placenta increta was delivered by Caesarean section, followed by closure of the uterine incision, with the placenta left in situ. The patient underwent total laparoscopic hysterectomy three weeks later. She did not receive any blood product transfusions, either at the time of Caesarean section or at the time of hysterectomy. CONCLUSION: A laparoscopic approach may be considered for delayed surgical management of abnormal placentation. Key factors for success consist of a multi-disciplinary approach, the availability of skilled laparoscopic surgeons and advanced endoscopic equipment, and the availability of resources in the event of complications.

Obesity in pregnancy: pre-conceptional to postpartum consequences.

OBJECTIVE: To review the effects of obesity on reproduction and pregnancy outcome. METHODS: A search of the literature was performed using key word searching and citation snowballing to identify English language articles published between January 1, 2000, and December 31, 2006, on the subject of obesity and its effects on pregnancy. Once the articles were identified, a thorough review of all results was conducted. Results and conclusions were compiled and summarized. RESULTS: Obesity during pregnancy was linked with maternal complications ranging from effects on fertility to effects on delivery and in the postpartum period, as well as many complications affecting the fetus and newborn. The maternal complications associated with obesity included increased risks of infertility, hypertensive disorders, gestational diabetes mellitus, and delivery by Caesarean section. Fetal complications included increased risks of macrosomia, intrauterine fetal death and stillbirth, and admission to the neonatal intensive care unit. CONCLUSION: Obesity causes significant complications for the mother and fetus. Interventions directed towards weight loss and prevention of excessive weight gain must begin in the pre-conception period. Obstetrical care providers must counsel their obese patients regarding the risks and complications conferred by obesity and the importance of weight loss. Maternal and fetal surveillance may need to be heightened during pregnancy; a multidisciplinary approach is useful. Women need to be informed about both maternal and fetal complications and about the measures that are necessary to optimize outcome, but the most important measure is to address the issue of weight prior to pregnancy.