Gynecologic Surgical Subspecialty Training Decreases Surgical Complications in Benign Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: To evaluate the impact of gynecologic subspecialty training on surgical outcomes in benign minimally invasive hysterectomies (MIHs) while accounting for surgeon volume. DESIGN: Retrospective cohort study of patients who underwent an MIH between 2014 and 2017. SETTING: Single community hospital system. PATIENTS: Patients were identified via Current Procedural Terminology codes for MIH: vaginal, laparoscopic, or robotic. Exclusion criteria included a gynecologic cancer diagnosis or concomitant major procedure at the time of hysterectomy. One thousand six hundred thirty-one patients underwent a benign MIH performed by a gynecologic generalist or a subspecialist in minimally invasive gynecologic surgery, urogynecology and pelvic reconstructive surgery, or gynecologic oncology; 125 hysterectomies were vaginal, 539 were conventional laparoscopic, and 967 were robotic. MEASUREMENTS AND MAIN RESULTS: Surgical outcomes, including intraoperative complications, operative outcomes, and postoperative readmissions and reoperations, were compared between generalists and subspecialists and were stratified by surgeon volume status, with high-volume (HV) defined as performing 12 or more hysterectomies annually. Odds ratios for the primary outcome, Clavien-Dindo Grade III complications (which included visceral injuries, conversions, and reoperations within 90 days), were calculated to evaluate the impact of subspecialty training while accounting for surgeon volume status. Of 1631 MIHs, 855 (52.4%) were performed by generalists and 776 (47.6%) by subspecialists. HV generalists performed 618 (37.9%) of MIHs, and 237 (14.5%) were performed by low-volume generalists. All subspecialists were HV surgeons; 38.1% of generalists were HV. The odds ratio of a Clavien-Dindo Grade III complication was 0.39 (0.25-0.62) for hysterectomies performed by subspecialists compared to HV generalists after adjusting for potential confounding variables (p <.001). Subspecialists and HV surgeons had significantly lower incidences of visceral injuries, transfusions, blood loss over 500 mL, and conversions compared with generalists and low-volume surgeons, respectively. CONCLUSION: Both subspecialty training and high surgeon volume status are associated with a lower risk of surgical complications in benign MIH. Subspecialty training is associated with a reduction in surgical complications even after accounting for surgeon volume.

Perioperative visits in minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: Perioperative visits for gynecologic surgery patients have traditionally included in-person examinations and counseling, but the advent of telemedicine has prompted clinicians to consider varying approaches to perioperative care. We aim to educate readers on the optimal setting and context of perioperative visits and provide insight from our experience to optimize care. RECENT FINDINGS: The widespread adoption of telemedicine and a focus on equity and access has prompted gynecologic surgeons to reconsider traditional preoperative and postoperative visits. SUMMARY: This review summarizes evidence for new approaches to perioperative care for minimally invasive gynecologic surgery, including transition to telemedicine for preoperative and postoperative care, adjuvant tools for perioperative counseling, and the value of in-person visits for preoperative planning.

Comparison of Contrast-Enhanced Ultrasound Versus Magnetic Resonance Imaging in the Detection and Characterization of Uterine Leiomyomas.

OBJECTIVES: Uterine fibroids are common findings in women with pelvic pain and abnormal uterine bleeding. The reference standard test in the pretreatment evaluation of fibroids is contrast-enhanced magnetic resonance (MR) imaging. This study compared the number, size, location, and enhancement of uterine fibroids identified by contrast-enhanced ultrasound (CEUS) and MR. The aim of this study was to demonstrate that CEUS performs similarly to MR and could be used as an alternative imaging modality. METHODS: In this prospective observational study, 26 women underwent transabdominal CEUS and MR examinations. Blinded to the original clinical MR interpretations, 2 readers reviewed the MR and CEUS studies for each patient. The number, size, location, and enhancement of each fibroid per patient were reported by MR and CEUS. A Pearson correlation coefficient was calculated for the number of fibroids identified by each modality. RESULTS: In total, 126 fibroids were imaged: 115 (91.3%) were observed on both examinations; 9 (7.1%) were observed by MR only; and 2 (1.6%) were observed by CEUS only. A high correlation was found between the modalities for the number of fibroids identified per patient (r = 0.97; P < .001). There was also no significant difference between the modalities for each patient in the fibroid number, size, location, or enhancement. CONCLUSIONS: These findings suggest that transabdominal CEUS may represent an alternative to MR in pretreatment evaluation of uterine fibroids and could serve as a test of choice in patients with a contraindication to MR.

Preoperative Gabapentin for Minimally Invasive Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate whether a single dose of gabapentin given preoperatively reduces narcotic use 24 hours after minimally invasive hysterectomy (MIH). DESIGN: Randomized controlled trial. SETTING: Single academic-affiliated community hospital. PATIENTS: Women undergoing MIH for benign indications between June 2016 and June 2017. INTERVENTIONS: Subjects were randomized to receive a preoperative regimen of acetaminophen, celecoxib, and gabapentin versus acetaminophen and celecoxib alone. MEASUREMENTS AND MAIN RESULTS: The primary outcome assessed was the total amount of narcotics used at 24 hours after surgery. Secondary outcomes included adverse effects from gabapentin use, total narcotics used, and pain scores at 2 weeks after surgery. A total of 129 women were randomized and eligible for analysis in the gabapentin study arm (n = 68) or the control arm (n = 61). Demographic characteristics and surgical details were similar between groups. Narcotics used at 24 hours after surgery totaling 168 versus 161 oral morphine milligram equivalents in the gabapentin and control groups, respectively, did not significantly differ between groups (p = .60). Total narcotics used and pain scores at 2 weeks after surgery and the rates of adverse effects from gabapentin were also similar between study arms. CONCLUSION: Single-dose, preoperative gabapentin for women undergoing benign MIH does not reduce total opioid use 24 hours after surgery.

Topical hemostatic and tissue-sealing agents in gynecologic surgery.

PURPOSE OF REVIEW: To review current topical hemostatic agent use and how it pertains to gynecologic surgery. RECENT FINDINGS: Recent literature suggests some benefit of topical hemostatic agents (THA). THAs confer reduced bleeding and shorter operating room time in women undergoing hysterectomy for cancer and in abdominal myomectomy. THA use in women undergoing ovarian cystectomy is associated with a decreased reduction in ovarian reserve. Potential complications of THA use include abscess formation, small bowel obstruction, inflammation, allergic reaction, and transmission of blood-borne pathogens. Evidence for use of THA in benign minimally invasive gynecologic surgery (MIGS) procedures is lacking. SUMMARY: Although evidence exists for the efficacy of THA in reducing blood loss and operating times across surgical subspecialties, specific, appropriate, and efficacious use of THAs in gynecologic surgery remains ill-defined. Knowledge of their mechanisms of action and potential complications should enable surgeons to optimize desired effects and minimize harm.

The INSPIRE Comparative Cost Study: 12-Month Health Economic and Clinical Outcomes Associated with Hysterectomy, Myomectomy, and Treatment with the Sonata System.

PURPOSE: The INSPIRE study compared perioperative and 12-month health economic and clinical outcomes associated with hysterectomy, myomectomy, and sonography-guided transcervical fibroid ablation (TFA) using the Sonata® system. PATIENTS AND METHODS: Cost and health care resource utilization (HCRU) data for TFA were obtained from a prospective, multicenter, single-arm clinical trial. Data for hysterectomy and myomectomy arms were derived from the Truven Health MarketScan commercial payer claims database. The Truven data was used to determine health economic outcomes and costs for the hysterectomy and myomectomy arms. For each arm, payer perspective costs were estimated from the available charge and HCRU data. RESULTS: TFA with Sonata had significantly lower mean length of stay (LOS) of 5 hrs versus hysterectomy (73 hrs) or myomectomy (79 hrs; all p< 0.001). The average payer cost for TFA treatment, including the associated postoperative HCRU was $8,941. This was significantly lower compared to hysterectomy ($24,156) and myomectomy ($22,784; all p< 0.001). In the TFA arm, there were no device- or procedure-related costs associated with complications during the peri- or postoperative time frame. TFA subjects had significantly lower costs associated with complications, prescription medications, and radiology. CONCLUSION: Compared to hysterectomy and myomectomy, TFA treatment with the Sonata system was associated with significantly lower index procedure cost, complication cost, and LOS, contributing to a lower total payer cost through 12 months.

A Systematic Review of Perioperative Opioid Management for Minimally Invasive Hysterectomy.

Excessive opioid use and misuse is a pervasive and growing societal problem, and decreasing the surgical contribution to this epidemic represents an opportunity to improve outcomes. Here we describe patterns of opioid prescription, consumption, and persistent use among women undergoing minimally invasive hysterectomy (MIH) for benign indications. We performed a systematic review of English full-text articles addressing opioids and gynecologic surgery using MEDLINE and Cochrane Central Register of Controlled Trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Additional studies were identified by examination of references. Studies were restricted to randomized controlled, cohort, and observational studies reporting primary data on opioid consumption, prescribing patterns, or risk of persistent use surrounding MIH for benign indications. A risk of bias assessment was performed. Twenty-one studies reported on the 3 outcomes of interest. Median opioid consumption after MIH ranged from 14 to 74 oral morphine equivalents (OMEs) in the first 24 hours and from 50 to 100 OMEs over the first 2 postoperative weeks. Physicians prescribed 125 to 300 OMEs after MIH. Persistent opioid use was identified in 1.5% of women undergoing MIH. In a population at risk for persistent opioid use, prescription often exceeds patients' needs. Guidelines for opioid prescribing in the setting of multimodal anesthetic regimens may allow us to lessen our contribution to the opioid epidemic. Further research on patients with chronic pain, patients with chronic opioid use, and the role of patient education is needed.

Fibromyalgia and Irritable Bowel Syndrome in Female Pelvic Pain.

Fibromyalgia and irritable bowel syndrome are common disorders which often coexist in women with chronic pelvic pain. Like pelvic pain, these disorders describe symptoms without pathologic findings. Women with chronic pelvic pain have a higher prevalence of fibromyalgia (4-31%) and irritable bowel syndrome (8-41%) than the general population. Aberrant pain processing and psychosocial stressors are implicated in the co-occurrence of these pain syndromes (chronic overlapping pain conditions), but active epidemiologic, psychosocial, and neurobiologic research is ongoing. Given the higher prevalence of fibromyalgia and irritable bowel syndrome in women with chronic pelvic pain, gynecologists should have more education in diagnosis and treatment of these and other chronic overlapping pain conditions to improve care for women.

Incidence and predictors of failed second-generation endometrial ablation.

BACKGROUND: The need for any treatment following an endometrial ablation is frequently cited as "failed therapy," with the two most common secondary interventions being repeat ablation and hysterectomy. Since second-generation devices have become standard of care, no large cohort study has assessed treatment outcomes with regard to only these newer devices. We sought to determine the incidence and predictors of failed second-generation endometrial ablation, defined as the need for surgical re-intervention.We performed a retrospective cohort study at a single academic-affiliated community hospital. Subjects included women undergoing second-generation endometrial ablation for benign indications between October 2003 and March 2016. Second-generation devices utilized during the study period included the radiofrequency ablation device (RFA), hydrothermal ablation device (HTA), and the uterine balloon ablation system (UBA). RESULTS: Five thousand nine hundred thirty-six women underwent endometrial ablation at a single institution (3757 RFA (63.3%), 1848 HTA (31.1%), and 331 UBA (5.6%)). The primary outcome assessed was surgical re-intervention, defined as hysterectomy or repeat endometrial ablation. Of the total 927 (15.6%) women who required re-intervention, 822 (13.9%) underwent hysterectomy and 105 (1.8%) underwent repeat endometrial ablation. Women who underwent re-intervention were younger (41.6 versus 42.9 years, p < .001), were more often African-American (21.8% versus 16.2%, p < .001), and were more likely to have had a primary radiofrequency ablation procedure (hazard ratio 1.37; 95%CI 1.01 to 1.86). Older age was associated with decreased risk for treatment failure with women older than 45 years of age having the lowest risk for failure (p < .001). Age between 35 and 40 years conferred the highest risk of treatment failure (HR 1.59, 95% CI 1.32-1.92). Indications for re-intervention following ablation included menorrhagia (81.8%), abnormal uterine bleeding (27.8%), polyps/fibroids (18.7%), and pain (9.5%). CONCLUSION: Surgical re-intervention was required in 15.6% of women who underwent second-generation endometrial ablation. Age, ethnicity, and radiofrequency ablation were significant risk factors for failed endometrial ablation, and menorrhagia was the leading indication for re-intervention.

Traditional Versus Simulation Resident Surgical Laparoscopic Salpingectomy Training: A Randomized Controlled Trial.

STUDY OBJECTIVES: To evaluate the effectiveness of the porcine training model for obstetrics-gynecology (OB/GYN) residents in laparoscopic salpingectomy. DESIGN: Randomized, controlled single-blinded trial. CLASSIFICATION: Canadian Task Force Classification I. SETTING: A large community-based teaching hospital. PARTICIPANTS: All postgraduate year 1 through year 4 OB/GYN residents were enrolled (n = 22). INTERVENTION: All participants underwent a preintervention objective skills assessment test (OSAT), in which the participant performed live human laparoscopic salpingectomy. Residents were randomly assigned (using a computer-generated randomization table, in blocks of 2, stratified by ranked baseline OSAT scores) to the intervention or control group. The intervention group consisted of 1 educational session with presession assigned reading, a 40-min didactic lecture, viewing of a procedural video, and simulation and practice of laparoscopic salpingectomy on a porcine cadaver. The control group received traditional training per routine residency rotations. MEASUREMENTS AND MAIN RESULTS: Laparoscopic salpingectomy was performed on live patients by study participants pre- and postintervention. These procedures were video recorded, and then scored by a single blinded evaluator of the OSATs. Nine pre- and postintervention OSAT indicators, reflecting provider knowledge and skill, were the primary outcome measures. Secondary outcomes were the changes in 10 subjective measures of comfort, assessed by a pre- and postintervention survey. The outcomes were assessed using 5-point Likert scales (for OSATs 1 = lowest score; for the subjective survey 1 = highest score). The control group OSAT scores did not change (pre: 26.6 ± 10.8, post: 26.2 ± 10.1; p = .65). There were significant improvements in 2-handed surgery (pre: 2.8 ± 1.6, post: 3.5 ± 1.3; p = .004) and use of energy (pre: 2.9 ± 1.3, post: 3.6 ± 1.0; p = .01) in the intervention group, contributing to an overall score change (pre: 26.7 ± 10.6, post: 29.9 ± 9.8; p ≤ .001). The control group had no change in comfort levels. The intervention group experienced both increases (anatomy, steps of surgery, 2-handed surgery, and use of energy) and decreases (reading and learning in operating room) in reported comfort levels. CONCLUSION: This study demonstrates that simulation can improve surgical technique OSATs. However, of 45 possible points, both groups' average scores were <70% of the optimum. Thus, the improvement, although statistically significant, was relatively small and indicates that further supplementation in training is needed to substantially increase the residents' surgical skills.

Laparoscopic supracervical hysterectomy with transcervical morcellation: initial experience.

STUDY OBJECTIVE: To describe a novel method for morcellation at laparoscopic supracervical hysterectomy and to define its potential benefits. DESIGN: Retrospective observational study (Canadian Task Force classification III). SETTING: Hospital-based urogynecology and general gynecology practice and a single community teaching hospital of a university medical school. PATIENTS: The first 51 women to undergo laparoscopic supracervical hysterectomy with transcervical morcellation at a single institution. INTERVENTION: A novel surgical technique that uses a transcervical approach for morcellation of the uterine fundus after amputation from, and coring of, the cervix. MEASUREMENTS AND MAIN RESULTS: Laparoscopic supracervical hysterectomy with transcervical morcellation was completed successfully in all 51 patients. Mean (SD) operating time for laparoscopic supracervical hysterectomy with transcervical morcellation alone was 64.3 (28.4) minutes, and median hospital stay was 1 day. There were no intraoperative or postoperative complications related to transcervical morcellation at a median (range) follow-up of 4.4 (1.6-11.7) months. CONCLUSION: Laparoscopic supracervical hysterectomy with transcervical morcellation is a feasible procedure that removes the cervical core and does not require enlarging an abdominal port site for introduction of the uterine morcellator.

Complications of gynecologic laparoscopy.

Complications of gynecologic laparoscopy are uncommon, occurring in 3 to 6 per 1000 cases. Complications related to access represent one-third to one-half of these injuries. Major operative complications are more likely to occur in complex procedures. Through the comprehensive understanding of the relevant anatomy, surgical instruments, complex maneuvers, and optimal surgical technique, gynecologic laparoscopists can avoid most of the complications described. Even in the best of hands, however, complications will occur. Most importantly, surgeons should be diligent in recognizing and managing these events.