Benign Gynecologic Indications Research Articles

Early surgical outcomes of 550 consecutive patients treated for benign gynecological conditions by transvaginal natural orifice transluminal endoscopic surgery.

Evidence about intra- and postoperative complication rates related to transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynecological conditions is still limited. We report and analyze data from a large cohort of patients operated in a single institution during 3.5 years. To evaluate the safety and feasibility of vNOTES for benign gynecological indications, we performed a single-center observational study reporting and analyzing perioperative outcomes of 550 consecutive patients operated between 2020 and 2024. Of the 550 included patients, 365 (66.4%) underwent a vNOTES hysterectomy, 167 (30.4%) a procedure limited to the adnexa, and 18 (3.3%) other interventions, including myomectomy, pelvic adhesiolysis, post-hysterectomy pelvic hematoma drainage, pelvic organ prolapse repair, and appendectomy. The mean age was 49.4 ± 12.2 years, and the mean BMI was 26.2 ± 5.8 kg/m2. The total complication rate was 6.5% (36 cases), of which 2.7% (15 cases) were intraoperative complications and 4.0% (22 cases) were postoperative complications. Patients presented postoperative complications classified as Clavien-Dindo (CD) grade I in 4 cases (0.7%), grade II in 10 cases (1.8%), and grade III in 8 cases (1.5%). We observed no CD grade IV and V complications. Three patients (0.5%) were rehospitalized for postoperative complications management. The conversion rate was 1.6%, with nine cases of conversion to conventional laparoscopy and none to laparotomy. The application of vNOTES appears safe and feasible for most benign gynecological surgeries. Our study focused on surgical complications and demonstrated a profile similar to those reported in previous studies.

Evaluating for Racial Disparities in the Utilization of Minimally Invasive Hysterectomy for the Treatment of Uterine Leiomyoma

Introduction: Minimally invasive hysterectomy (MIH) for benign gynecologic indications has many patient advantages over traditional abdominal hysterectomy (AH) including decreased hospital stay, decreased mortality, and faster recovery. Although MIH has been shown to improve outcomes as compared with abdominal hysterectomy, racial and socioeconomic disparities can impact patient access to the minimally invasive procedure. Previous studies have demonstrated that Black and Hispanic-identifying patients are significantly less likely to receive a MIH when compared to White patients. One proposed contributor to this finding is the higher rate and delayed diagnosis of uterine leiomyoma in Black patients compared to White patients. This disparity could delay diagnosis, and cause a larger leiomyoma necessitating use of abdominal hysterectomy. Another explanation in disparity is the physician training at hospitals in underserved areas. This study aims to investigate if race impacts access to MIH for leiomyoma at Carle Foundation Hospital in Urbana, Illinois. Methods: This retrospective analysis studied patients from 2011-2020 who received a hysterectomy at Carle Foundation Hospital for a primary diagnosis of leiomyoma. MIH included laparoscopic, vaginal, and robotic-assisted. Hysterectomies for malignancy were excluded. The demographic data included age, race, body mass index (BMI), type of hysterectomy, insurance, history of previous obstetric and abdominal surgeries, and uterine weight. The race categories included White, Black, and Others. Hispanic and Asian patients were placed into the other category due to the limited sample size. Descriptive statistics were used to evaluate the demographic data. Odd ratios were calculated to determine if a patient received a MIH over an AH based on race. An adjusted odds ratio was calculated to account for BMI, uterine weight, history of cesarean section, and previous abdominal surgery. Results: A total of 324 hysterectomies from 2011-2020 were performed for leiomyoma. Abdominal hysterectomies accounted for 32.1% and MIH accounted for 68.9%, with 7.4% being laparoscopic, 5.6% being vaginal, and 55.9% being robotic-assisted. The average age of White patients was 46.7 years old, and was higher than Black patients, 43.6 years old (p<.01). The average BMI of Black patients was 34.6 kg/m2, and was higher than White patients, 30.3 34.6 kg/m2 (p<.01). More White patients had commercial insurance at 83.5% compared to Black patients at 48.1% (p<.01). More Black patients had Medicaid or Medicare at 50.6% compared to White patients at 14.8% (p<.01). Black patients had an average uterine weight at 579.8g compared to White patients at 438.6g (p<.05). The majority (73.7%) of White patients received a MIH, with 26.3% receiving an AH. Forty five percent of Black patients received an AH while 54.5% received a MIH. Conclusion: At Carle Foundation Hospital during the years 2011-2020, a lower percentage of African American patients, compared to white patients, received a minimally invasive hysterectomy in the treatment of uterine leiomyoma. Further analysis will investigate for the odds ratios of each group receiving a MIH and will adjust for BMI, uterine weight, obstetric and abdominal surgical history.

Occult endometrial cancer in women undergoing hysterectomy for benign indications: a retrospective cohort study in a tertiary hospital in China.

To evaluate the feasibility of further reducing the incidence of occult endometrial cancer in women undergoing hysterectomy for benign gynecological indications. Patients who underwent hysterectomies for presumed benign gynecologic conditions at Peking Union Medical College Hospital were retrospectively identified. Patients with occult endometrial cancer, which was defined as endometrial cancer diagnosed on postoperative histopathology with no preoperative confirmed malignancy, were selected. 24/7558 (0.32%; 95% CI 0.20-0.47%) patients undergoing hysterectomy for benign indications had occult endometrial cancer. Asymptomatic patients with normal endometrial imaging all tended to have favorable pathology. Heavy menstrual bleeding was the most overlooked AUB pattern in the premenopausal group. In the postmenopausal group, all the patients with serous adenocarcinoma or G3 endometrioid adenocarcinoma histology/stage T1b disease/LVSI space invasion had a history of persistent or recurrent PMB ≥ 6months and/or an intracavitary lesion > 20mm in diameter. 3/4 of the samples of the postmenopausal patients did not have adequate endometrium for evaluation. To further reduce the incidence of occult endometrial cancer, physicians should focus on the patient's bleeding pattern and actively implement endometrial sampling whenever indicated. Transvaginal ultrasonography is a valuable preoperative evaluation. Hysteroscopy with directed biopsy is the preferred procedure in postmenopausal patients.

Health-related quality of life following hysterectomy by vNOTES versus conventional laparoscopy

Objective To evaluate safety, efficacy, pre- and postoperative outcomes of vNOTES hysterectomy compared to conventional laparoscopic (CL) hysterectomy. Material and methods This prospective study was conducted on patients who underwent CL or vNOTES hysterectomy for benign gynecological indications between January and July 2021. Sociodemographic, clinical, and surgical data were collected. Health-related quality of life (HRQoL) outcomes were evaluated using the EQ-5D-5L questionnaire. Results A total of 228 patients (CL vs. vNOTES: 147 vs. 81) were included. No significant differences were observed between the two groups in terms of blood loss, uterine weight, complications, length of hospital stay, and readmission rate. Patients in the vNOTES group experienced significantly less postoperative pain and required less analgesia compared to those who underwent CL hysterectomy (p < 0.001). The CL group had a shorter operative time (p < 0.001). There was a significant difference between the two groups in the EQ-5D-5L pain/discomfort dimension (p = 0.047). Conclusion This research showed that vNOTES has various advantages, such as less postoperative pain, reduced analgesic usage, and better HRQoL outcomes three months after surgery.

Association between Endometriosis and Surgical Complications among Benign Hysterectomies

Toinvestigate the effect of endometriosis on perioperative outcomes in patients undergoing hysterectomy for benign disease. A retrospective cohort study. The American College of Surgeons National Surgical Quality Improvement Program database. A total of 127556 hysterectomies performed for benign gynecologic indications INTERVENTIONS: Differences in the primary outcomeswere compared betweenpatients with and without endometriosis after adjustment for group differences in covariates using inverse probability of treatment weighting approach. Of the 127556 hysterectomies identified, 19618 (15.4%) had a diagnosis of endometriosis. Patients with endometriosis were younger with a lower prevalence of chronic comorbidities but had higher rates of concurrent pelvic inflammatory diseaseand previous abdominal operations. The incidence of postoperative complications was higher in patients with endometriosis (9.9% vs 8.1%; odds ratio [OR],1.25; 95% confidence interval [CI], 1.17-1.34). The incidence of 30-day mortality (0.1% vs 0.03%; OR, 1.98; 95% CI, 0.69-5.65) and reoperations (1.50% vs 1.36%; OR, 1.18; 95% CI, 0.98-1.42) were not different in patients with and without endometriosis. Postoperative complications are more likely in hysterectomies involving endometriosis than those without endometriosis, likely owing to anatomic distortion incurring increased surgical complexity. Patients and surgeons should be aware of the increased risk of complications and plan for mitigating these increased risks before and during surgery for suspected endometriosis.

Bilateral salpingo-oophorectomy at the time of benign hysterectomy among females with disabilities: a population-based cross-sectional study

Up to 40% of patients aged ≤55 years undergo concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy, with practice variation in bilateral salpingo-oophorectomy occurring along the lines of patient health and social factors. Disability is common in premenopausal women and is an important determinant of reproductive health more broadly; however, studies on bilateral salpingo-oophorectomy rates among women with disabilities are lacking. This study aimed to examine whether the use of concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy differs by preexisting disability status in adult females aged ≤55 years. This population-based cross-sectional study used data from the 2016-2019 US National Inpatient Sample. Females undergoing inpatient hysterectomy for a benign gynecologic indication (n=74,315) were classified as having physical (6.1%), sensory (0.1%), intellectual or developmental (0.2%), or multiple (0.2%) disabilities and compared with those without a disability. Logistic regression was used to estimate risk ratios for differences in bilateral salpingo-oophorectomy rates by disability status, adjusted for patient and clinical factors. Models were stratified by potentially avoidable or potentially appropriate bilateral salpingo-oophorectomy based on the presence of clinical indications for ovarian removal and by age group. Bilateral salpingo-oophorectomy at the time of benign hysterectomy occurred in 26.0% of females without a disability, with rates clearly elevated in those with a physical (33.2%; adjusted risk ratio, 1.10; 95% confidence interval, 1.05-1.14) or intellectual or developmental (31.1%; adjusted risk ratio, 1.32; 95% confidence interval, 1.02-1.64) disability, possibly elevated in those with multiple disabilities (38.2%; adjusted risk ratio, 1.20; 95% confidence interval, 0.94-1.45), and similar in those with a sensory disability (31.2%; adjusted risk ratio, 0.98; 95% confidence interval, 0.83-1.13). The results were similar but with lower statistical precision for potentially avoidable and potentially appropriate bilateral salpingo-oophorectomy, which occurred in 9.1% and 17.0% of females without a disability, respectively. The largest differences in bilateral salpingo-oophorectomy rates among women with any disability were observed in the perimenopausal 45- to 49-year age group. Females with disabilities experienced elevated concomitant bilateral salpingo-oophorectomy rates at the time of benign hysterectomy, particularly those with an intellectual or developmental disability and those of perimenopausal age, although some estimates were imprecise. Equity-focused physician training in surgical counseling and research into the epidemiology and experiences of gynecologic conditions among females with a disability may be beneficial.

Variations in sexual function after laparoendoscopic single-site hysterectomy in women with benign gynecologic diseases.

Laparoendoscopic single-site surgery (LESS) has become a novel minimally invasive approach applied as an option to perform hysterectomy. The aim of the study was to evaluate the influence of LESS hysterectomy on the sexual function in women with benign gynecologic indications. From October 2016 to May 2021, a total of 486 premenopausal, sexually active women were eligible. Female sexual function index (FSFI) was used to assess sexual function preoperatively and 6, 12 months postoperatively. Total FSFI score ≤26.55 indicated female sexual dysfunction (FSD). Compared with pre-operation, each subdomain and total FSFI scores increased at 6 (all p < 0.05) and 12 months (all p < 0.001). Prevalence of FSD decreased at 6 (30 vs 39.9%, p = 0.002) and 12 months (27 vs 39.9%, p < 0.001). In patients with preoperative FSD, each subdomain and total FSFI scores improved at 6 and 12 months (all p < 0.001), while decreased at 6 months (p < 0.001) and had no significant difference at 12 months (p = 0.54) in patients without preoperative FSD. These results suggest that LESS hysterectomy has a significant positive effect on the sexual function in women with benign gynecologic diseases, especially those with preoperative FSD.

Constipation After Elective Laparoscopy for Benign Gynecological Indications–A Prospective Observational Study

Discover the rate of post-operative constipation in participants undergoing elective laparoscopy for benign gynecological indications DESIGN: Prospective observational study SETTING: Single site, tertiary level gynecology unit with a focus on pelvic pain and endometriosis. Recruited participants were patients of the institution over the age of 18 who had planned to undergo an elective laparoscopy for benign gynecological indications prior to enrolment in the study. Participants were excluded if they were not English speaking, had a chronic bowel condition (with the exception of irritable bowel syndrome), were planned to have bowel surgery, hysterectomy, or converted to laparotomy. In this prospective study, participants completed 3 consecutive surveys. One prior to surgery, one a week post-surgery, and a third 3 months post-surgery. The surveys collected data regarding the participant's bowel habits, pain relief used, laxatives used, and the distress or bother caused by their bowels. Constipation was defined by a modified ROME IV criteria. Opiate use and laxative use were defined by patient-reported tablet counts. The level of distress was measured as a continuously variable scale from 0 to 100. Variables adjusted for included subject's demographics, pre-operative constipation, indication for surgery, duration of surgery, estimated blood loss, opiate use (preoperative, peri-operative, and post-operative), laxative use, and length of stay. A total of 153 participants were recruited, of which 103 completed both the pre-operative and post-operative survey. Post-operative constipation was present in 70% of participants. The mean length of time to first bowel motion was 3 days, with 32% of participants having their first bowel motion after the third post-operative day. The level of bother caused by their bowel habit was higher in the constipation group compared to those without constipation. Post-operatively opiates were used in 84.9% of participants, and laxatives were used in 47.1%. Visits to the general practitioner for constipation occurred in 5.8% of participants. Post-operative constipation is common and bothersome in participants who undergo elective laparoscopy for benign gynecological indications. Analysis of individual variables failed to identify any factors that influenced the rate of constipation.

Severe pelvic pain is associated with sexual abuse experienced during childhood and/or adolescence irrespective of the presence of endometriosis.

Is endometriosis associated with childhood and/or adolescent sexual abuse? Endometriosis is not associated with a history of sexual abuse, unlike the presence of severe pelvic pain. Several studies have highlighted a link between pelvic pain and sexual abuse during childhood/adolescence. Moreover, an inflammatory state has been described in patients with a history of childhood maltreatment. Given that inflammation and pelvic pain are two entities often encountered with endometriosis, several teams have investigated whether endometriosis is associated with abuse during childhood/adolescence. However, the results are conflicting, and the link between sexual abuse and the presence of endometriosis and/or pain is hard to disentangle. A survey nested in a cohort study of women surgically explored for benign gynecological indications at our institution between January 2013 and January 2017. For each patient, a standardized questionnaire was completed during a face-to-face interview with the surgeon in the month preceding the surgery. Pelvic pain symptoms (dysmenorrhea, deep dyspareunia, non-cyclic chronic pelvic pain, and gastrointestinal or lower urinary tract symptoms) and their intensities were assessed with a 10 cm visual analog scale (VAS). Pain was considered to be severe when the VAS score was ≥7. A 52-question survey was sent in September of 2017 to evaluate abuses, especially sexual abuse during childhood and/or adolescence, and the psychological state during childhood and adolescence. The survey was structured to cover the following sections: (i) abuses and other life events during childhood and adolescence; (ii) puberty and body changes; (iii) onset of sexuality; and (iv) family relationships during childhood and adolescence. The patients were divided into groups according to whether or not they exhibited histologically proven endometriosis. Statistical analyses were conducted using univariate and multivariate logistic regression models. Two hundred and seventy-one patients answered all the questions of the survey: 168 with (endometriosis group) and 103 without endometriosis (control group). The mean ± SD overall population age was 32.2 ± 5.1 years. There were 136 (80.9%) and 48 (46.6%) women who experienced at least one severe pelvic pain symptom in the endometriosis and the control groups, respectively (P < 0.001). No differences were found between the two study groups regarding the following characteristics: (i) a history of sexual, physical, or emotional abuse; (ii) a history of abandonment or bereavement; (iii) the psychological state regarding puberty; and (iv) the family relationships. After multivariable analysis, we found no significant association between endometriosis and a history of sexual abuse during childhood and/or adolescence (P = 0.550). However, the presence of at least one severe pelvic pain symptom was independently associated with a history of sexual abuse (odds ratio = 3.6, 95% CI (1.2-10.4)). Evaluation of the psychological state during childhood and/or adolescence can be subject to recall bias. In addition, selection bias is also a possibility given that some of the patients surveyed did not return the questionnaire. Severe gynecological painful symptoms in women with or without histologically proven endometriosis may be linked to sexual abuse experienced during childhood and/or adolescence. Patient questioning about painful symptoms and abuses is important to provide comprehensive care to the patients, from a psychological to a somatic point of view. No funding or competing interests. N/A.

Postoperative Complications of Appendectomy in Gynecologic Laparoscopic Surgery for Benign Indications.

To assess whether concomitant appendectomy in patients who undergo laparoscopic surgery for benign gynecologic indications is associated with increased rates of complications in the 30-day postoperative period. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent laparoscopic surgery by a gynecologist. Patients were excluded if they underwent open abdominal surgeries, bowel resections, urogynecologic surgeries, or if diagnoses of cancer or appendicitis were present. There were 246,987 patients included in the population cohort from 2010 to 2020. Demographic information and postoperative outcomes of patients who underwent concomitant appendectomy were compared with patients who did not undergo appendectomy. A matched cohort was created by computing propensity scores, and outcomes were again compared between groups. All patients undergoing appendectomy were 1:1 matched to a unique patient who did not undergo appendectomy using a greedy matching based on the propensity score calculated from demographic and surgical characteristics. A total of 1,760 patients (0.7%) underwent concomitant appendectomy. There was an 8.0% complication rate in the appendectomy group, compared with 5.5% in the group of those without appendectomy (P<.001), and this was similar to the results in the propensity-matched sample. Patients who underwent appendectomy had significantly higher rates of readmission (4.3% vs 2.3%), which remained significant in the propensity-matched sample. There were no differences in the rates of postoperative thromboembolic events, blood transfusion, or reoperation. Patients who are undergoing concomitant appendectomy have an increased risk of any complication and hospital readmission. Additional studies may be conducted to identify patients with optimal risk benefit profiles when considering performing concomitant appendectomy at time of gynecologic surgery.

Association between Surgical Fibroid Removal and Blood Pressure: A Retrospective Case-Control and Prospective Cohort Study

<h3>Study Objective</h3> Fibroids, monoclonal proliferations of uterine smooth muscle cells, are common in women and have recently been associated with cardiometabolic risk factors including hypertension. The objective of this study is to determine whether fibroids are biomarker of systemic hypertension, and whether they may contribute to elevation in blood pressure. <h3>Design</h3> IRB-approved retrospective case-control study and prospective cohort study. <h3>Setting</h3> Single academic institution. <h3>Patients or Participants</h3> Retrospective chart review of 313 patients undergoing hysterectomy or myomectomy for fibroids and patients undergoing other surgical procedures for benign gynecological indications with similar demographic characteristics (control). Prospective cohort of 9 women undergoing myomectomy or hysterectomy for fibroids. <h3>Interventions</h3> Hysteroscopy, laparoscopy, open myomectomy or hysterectomy for fibroids (or non-fibroid indications as control). <h3>Measurements and Main Results</h3> In our retrospective cohort (n=294; mean age 41.9±10.6, 43.5% Black, 50% with fibroids), we found consistently that compared to patients without fibroids, patients with fibroids had significantly elevated systolic BP (pre-op 128 vs 122mmHg, p=0.0005; post-op 126 vs 122mmHg, p=0.02) but not diastolic BP (pre-op 77.6 vs 75.9mmHg, p=0.17; post-op 76.7 vs 75.0, p=0.19). Among patients with fibroids, surgical fibroid removal was associated with a small but not statistically or clinically significant drop in systolic (Δ=-2.21mmHg, p=0.062) but not diastolic BP (Δ=-0.93mmHg, p=0.39). The direction and magnitude of effect for change in systolic BP remained consistent after adjustment for age, race, and presence of diagnosed hypertension (β=-2.45, p=0.17). In our prospective cohort, there was a significant decrease in SBP of 9.9mmHg (pre- versus post-operatively), but no change in DBP following fibroid removal (p=0.03, p=0.14, respectively). Serum levels of Ang-II and ACE were not significantly altered following surgical fibroid removal (p=0.39, p=0.80, respectively). <h3>Conclusion</h3> Altogether, these findings demonstrate that fibroids are associated with hypertension and suggest that fibroid removal may lead to a clinically significant decrease in systolic blood pressure. These changes may occur by a mechanism independent of the renin-angiotensin-aldosterone system.

7754 The Impact of Physician Remuneration Incentive on Laparoscopic Hysterectomy Practice in Canada: An Interrupted Time Series Analysis

<h3>Study Objective</h3> To determine whether the introduction of a physician remuneration incentive within certain Canadian provinces resulted in increased practice of laparoscopic hysterectomy over time. <h3>Design</h3> Retrospective population-based study with interrupted time series analysis of federal health administrative data from the Canadian Institute for Health Information <h3>Setting</h3> Hospitals in all the provinces of Canada, excluding territories <h3>Patients or Participants</h3> 81,507 patients aged ≥18 years undergoing hysterectomy for benign gynecologic indication in Canada from 2006/07 to 2016/17 <h3>Interventions</h3> Hysterectomy <h3>Measurements and Main Results</h3> Reviewof physician remuneration fee schedules for each province in Canada identified three provinces where a physician incentive (additional 25-50% remuneration) was introduced: British Columbia (BC) (2013), Saskatchewan (SK) (2012), and Prince Edward Island (PEI) (2011). During the 10-year period, the rates of laparoscopic hysterectomy increased rapidly in BC (6.0%-54.7%), SK (13.5%-66.7%), and PEI (<1.0%-36.9%) (<i>p</i><0.05 for all trends). In SK (n=7,857 hysterectomies), there was a significant additional increase in the rate of laparoscopic hysterectomy from 40.6% to 49.4% in the quarter following the incentive (<i>p</i><0.0001). In BC (n=16,332), there was no significant additional increase in the rate of laparoscopic surgeries after the introduction of a financial incentive. Though PEI appeared to demonstrate an increase in the rate of laparoscopic hysterectomy following the incentive, ITS analyses were not performed due to the small sample size (n=2,583). <h3>Conclusion</h3> The introduction of physician remuneration incentive appears to be associated with an increase in practice of laparoscopic hysterectomy in some provinces but not others. While physician incentive may help encourage minimally invasive surgical practice, the effects are likely modified by other important factors, such as operating room resources and training opportunities.

7542 Post-Operative Complications of Appendectomy in Benign Gynecologic Surgery: National Surgical Quality Improvement Program Analysis

<h3>Study Objective</h3> This study was conducted to assess if concomitant appendectomy in women undergoing laparoscopic surgery for benign gynecologic indications is associated with increased rates of post-operative complications in the 30-day post-operative period. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> National database study. <h3>Patients or Participants</h3> American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to identify women who underwent laparoscopic surgery by a gynecologist. Patients were excluded if they underwent open abdominal surgeries, bowel resections, urogynecologic surgeries, or if cancer or appendicitis was present. There were 247,700 patients included in population cohort between 2010 and 2020. <h3>Interventions</h3> Patients were identified using Current Procedural Terminology codes. Patients who underwent concomitant appendectomy were compared to patients who did not undergo appendectomy. Demographic variables included age, body mass index, and medical co-morbidities. Post-operative complications included superficial, deep, or organ space infection, sepsis, thromboembolic events, blood transfusion, hospital re-admission, and re-operation. A matched cohort was created by computing propensity scores. Outcomes were compared between groups using Fisher and Mann-Whitney tests. <h3>Measurements and Main Results</h3> 1,815 patients (0.7%) underwent concomitant appendectomy. In the propensity matched sample, there were comparable rates of post-operative surgical site infections at 2.8% in the appendectomy group and 2.4% in the no appendectomy group (p-value 0.469). There were higher rates of sepsis in the appendectomy group with 1.3% of patients being diagnosed with sepsis compared to 0.3% in the no appendectomy group (p-value 0.003). There were higher rates of hospital re-admission in the appendectomy group at 4% compared to 3% in the no appendectomy group (p-value 0.006). There were no differences in the rates of post-operative thromboembolic events, blood transfusion, or re-operation. <h3>Conclusion</h3> Patients undergoing concomitant appendectomy at the time of benign gynecologic laparoscopic surgery have increased risk of post-operative sepsis and hospital re-admission. Additional studies may be conducted to identify patients with optimal risk-benefit profiles when considering concomitant appendectomy.

The effect of pre-analytical variables on downstream application and data analysis of human endometrial biopsies.

STUDY QUESTIONWhat are the effects of pre-analytical variables on the downstream analysis of patient-derived endometrial biopsies?SUMMARY ANSWERThere are distinct differences in the protein levels of the master regulator of oxygen homeostasis, hypoxia-inducible factor-1-alpha (HIF1α), and the protein and mRNA levels of three related genes, carbonic anhydrase 9 (CA9), vascular endothelial growth factor A (VEGFA) and progesterone receptor (PR) in human endometrial biopsies, depending on the pre-analytical variables: disease status (cancer vs benign), timing of biopsy (pre- vs post-hysterectomy) and type of biopsy (pipelle vs full-thickness).WHAT IS KNOWN ALREADYPatient-derived biopsies are vital to endometrial research, but pre-analytical variables relating to their collection may affect downstream analysis, as is evident in other tissues.STUDY DESIGN, SIZE, DURATIONA prospective observational study including patients undergoing hysterectomy for endometrial cancer (EC) or benign indications was conducted at a large tertiary gynaecological unit in the UK. Endometrial biopsies were obtained at different time points (pre- or post-hysterectomy) using either a pipelle endometrial sampler or as a full-thickness wedge biopsy.PARTICIPANTS/MATERIALS, SETTING, METHODSThe changes in HIF1α, CA9, VEGFA and PR protein levels were measured by semi-quantitative analysis of immunostaining, and the expression levels of three genes (CA9, VEGFA and PR) were investigated by quantitative real-time PCR, in endometrial biopsies from 43 patients undergoing hysterectomy for EC (n = 22) or benign gynaecological indications (n = 21).MAIN RESULTS AND THE ROLE OF CHANCEAn increase in HIF1α immunostaining was observed in EC versus benign endometrium (functionalis glands) obtained pre-hysterectomy (P < 0.001). An increase in CA9 immunostaining was observed in EC versus benign endometrial functionalis glands at both pre- and post-hysterectomy time points (P = 0.03 and P = 0.003, respectively). Compared with benign endometrial pipelle samples, EC samples demonstrated increased mRNA expression of CA9 (pre-hysterectomy P < 0.001, post-hysterectomy P = 0.008) and VEGFA (pre-hysterectomy P = 0.004, post-hysterectomy P = 0.002). In benign uteri, HIF1α immunoscores (functionalis glands, P = 0.03 and stroma, P = 0.009), VEGFA immunoscores (functionalis glands, P = 0.03 and stroma, P = 0.01) and VEGFA mRNA levels (P = 0.008) were increased in matched post-hysterectomy versus pre-hysterectomy samples. Similarly, in EC, an increase in VEGFA immunoscores (epithelial and stromal) and VEGFA mRNA expression was observed in the matched post-hysterectomy versus pre-hysterectomy biopsies (P = 0.008, P = 0.004 and P = 0.018, respectively). Full-thickness benign post-hysterectomy endometrial biopsies displayed increased VEGFA (P = 0.011) and PR (P = 0.006) mRNA expression compared with time-matched pipelle biopsies.LARGE SCALE DATAN/A.LIMITATIONS, REASONS FOR CAUTIONThis descriptive study explores the effect of pre-analytical variables on the expression of four proteins and three hypoxia-related genes in a limited number of endometrial biopsies from patients with EC and benign controls. Due to the small number, it was not possible to investigate other potential variables such as menstrual cycle phase, region-specific differences within the endometrium, grade and stage of cancer, and surgical technicalities.WIDER IMPLICATIONS OF THE FINDINGSCareful consideration of the effects of these pre-analytical variables is essential when interpreting data relating to human endometrial biopsies. A standardized approach to endometrial tissue collection is essential to ensure accurate and clinically transferrable data.STUDY FUNDING/COMPETING INTEREST(S)The authors have no conflicts of interest to declare. The work included in this manuscript was funded by Wellbeing of Women project grants RG1073 and RG2137 (D.K.H.), Wellbeing of Women Entry-Level Scholarship ELS706 and Medical Research Council MR/V007238/1 (A.M./D.K.H.), Liverpool Women’s Hospital Cancer Charity (M.A.) and University of Liverpool (L.B., L.R. and E.N.).

Predictors of same-day discharge following benign minimally invasive hysterectomy

Same-day discharge following minimally invasive hysterectomy has been shown to be safe and feasible in select populations, but many nonclinical factors influencing same-day discharge remain unexplored. To develop prediction models for same-day discharge following minimally invasive hysterectomy using both clinical and nonclinical attributes and to compare model concordance of individual attribute groups. We performed a retrospective study of patients who underwent elective minimally invasive hysterectomy for benign gynecologic indications at 69 hospitals in a statewide quality improvement collaborative between 2012 and 2019. Potential predictors of same-day discharge were determined a priori and placed into 1 of 7 attribute groupings: intraoperative, surgeon, hospital, surgical timing, patient clinical, patient socioeconomic, and patient geographic attributes. To account for clustering of same-day discharge practices among surgeons and within hospitals, hierarchical multivariable logistic regression models were fitted using predictors from each attribute group individually and all predictors in a composite model. Receiver operator characteristic curves were generated for each model. The Hanley-McNeil test was used for comparisons, 95% confidence intervals for the areas under the receiver operator characteristic curve were calculated, and a P value of <.05 was considered significant. Of the 23,513 patients in our study, 5062 (21.5%) had same-day discharge. The composite model had an area under the receiver operator characteristic curve of 0.770 (95% confidence interval, 0.763-0.777). Among models using factors from individual attribute groups, the model using intraoperative attributes had the highest concordance for same-day discharge (area under the receiver operator characteristic curve, 0.720; 95% confidence interval, 0.712-0.727). The models using surgeon and hospital attributes were the second and third most concordant, respectively (area under the receiver operator characteristic curve, 0.678; 95% confidence interval, 0.670-0.685; area under the receiver operator characteristic curve, 0.655; 95% confidence interval, 0.656-0.664). Models using surgical timing and patient clinical, socioeconomic, and geographic attributes had poor predictive ability (all areas under the receiver operator characteristic curve <0.6). Clinical and nonclinical attributes contributed to a composite prediction model with good discrimination in predicting same-day discharge following minimally invasive hysterectomy. Factors related to intraoperative, hospital, and surgeon attributes produced models with the strongest predictive ability. Focusing on these attributes may aid efforts to improve utilization of same-day discharge following minimally invasive hysterectomy.

Individualized Assessment of Risk of Complications after Benign Hysterectomy

The primary objective of this study is to identify patient characteristics associated with postoperative complications or readmissions after hysterectomy for a benign indication. Retrospective cohort. The Surgical Gynecologic Scorecard Database includes performance metrics and patient outcomes for hysterectomies across 7 sites in Ontario, Canada. Individuals who underwent hysterectomy for benign gynecologic indication and were recorded in the Surgical Gynecologic Scorecard Database between July 2016 and June 2019 were included in this study. Two outcomes of interest were considered: (1) complications grade II or greater on the Clavien-Dindo classification scale and (2) emergency room visits or hospital readmissions within 6 weeks after operation. Logistic models were generated to determine the associations between outcome of interest and potential predictors using a mixed-step AIC selection algorithm. A total of 2792 patients underwent hysterectomy for a benign indication during the study period, with a mean age of 52.6 ± 11.7 years and mean body mass index of 29.0 ± 0.7 kg/m2. The most common indications for surgery were abnormal uterine bleeding (33.3%) and myomas (33.6%). Previous cesarean delivery (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42), American Society of Anesthesiologists class ≥3 (aOR, 2.31; 95% CI, 1.42-3.99), preoperative anemia (aOR, 1.51; 95% CI, 1.12-2.02), and laparotomic approach (aOR, 1.73; 95% CI, 1.30-2.29) were associated with increased odds of complication. Perioperative complications (aOR, 2.95; 95% CI, 2.12-4.08), preoperative anemia (aOR, 1.43; 95% CI, 1.03-1.98), and vaginal (aOR, 1.94; 95% CI, 1.26-2.96) or laparotomic (aOR, 1.64; 95% CI, 1.10-2.43) approach were associated with increased odds of emergency room visit or readmission to hospital. This study identified several important risk factors for complications after hysterectomy. The utility of these data is important to help improve counseling for patients undergoing a hysterectomy and potentially optimize modifiable risk factors when identified preoperatively.

Prediction models for same-day discharge following benign minimally invasive hysterectomy

To develop prediction models for same-day discharge (SDD) following minimally invasive hysterectomy (MIH) using both clinical and nonclinical attributes and to compare model concordance of individual attribute groups. We performed a retrospective study of patients who underwent elective MIH for benign gynecologic indications at 69 hospitals in a statewide quality improvement collaborative between 2012 and 2019. Potential predictors of SDD were determined a priori and placed into attribute groups (Figure 1). To account for clustering of SDD practices among surgeons and within hospitals, hierarchical multivariable logistic regression models were fitted using predictors from each attribute group individually and all attribute groups in a composite model. Receiver operating characteristic (ROC) curves were generated for each model. To compare the concordance of each attribute group within the composite model, the area under the ROC curve (AUC) of the composite model was compared to that of a model from which a single attribute group was removed. The Hanley-McNeil test was used for comparisons, 95% confidence intervals (CI) for the AUCs were calculated, and a p-value of <0.05 was considered significant. Of the 25,770 patients in our study, 5,411 (21.0%) underwent same-day discharge. ROC curves are presented in Figure 2. The composite model had an AUC of 0.777 (95% CI 0.770-0.784). Among models using factors from individual attribute groups, the model using intraoperative attributes had the highest concordance for SDD (AUC 0.715, 95% CI 0.707-0.722). Removal of intraoperative attributes from the composite model was associated with the largest decrease in the composite model AUC (Table 1). Models using surgeon and hospital attributes were second and third most concordant, respectively (AUC 0.678, 95% CI 0.670-0.685; AUC 0.659, 95% CI 0.650-0.667). Models using surgical timing and patient clinical, socioeconomic, and geographic attributes groups were poor (all AUCs <0.6). Even so, factors from each attribute group contributed incrementally to the concordance of the composite model, with the exception of patient geographic attributes. Clinical and nonclinical attributes contributed to a composite prediction model with good discrimination in predicting SDD following MIH. Factors related to intraoperative, hospital, and surgeon attributes produced models with the strongest concordance. Attention to these attributes may aid efforts to improve utilization of SDD following MIH.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

English

BACKGROUND We wanted to assess the feasibility of natural orifice non-descent hysterectomy (NONH) for various benign gynaecological indications. METHODS This retrospective study was conducted at a tertiary care centre including patients requiring hysterectomy for various gynaecological indications over 12 months. Outcomes including time of surgery, blood loss, intraoperative surgical technique, complications, and conversion to the abdominal route were noted. RESULTS A total of 68 cases of natural orifice non-descent hysterectomy were performed. The uterine fibroid was the most common (50 %) indication for surgery followed by adenomyosis. Uteri with previous multiple surgeries were also successfully operated vaginally. The average surgical time was 60 min, with minimal blood loss. Post-operative recovery was good and patients were discharged after 48 hours. CONCLUSIONS This article concludes that natural orifice is a safe route of non-descent hysterectomy even for larger and scarred uteri using various debulking and surgical techniques but requiring good anatomical knowledge, surgical expertise and teamwork. KEY WORDS Natural Orifice Non-Descent Hysterectomy (NONH); Surgical Variations; Debulking Technique; Post-Operative Recovery

Left Upper Quadrant Entry: Tips and Tricks for Success

Study Objective The objectives of this video are to: (1) define when left upper quadrant (LUQ) entry is indicated, (2) describe identification of Palmer's point and (3) demonstrate optimal technique for optical entry at the LUQ, (4) troubleshoot commonly encountered difficulties and (5) discuss alternatives if initial attempt at LUQ entry is unsuccessful. Design N/A. Setting Academic medical center. Patients or Participants Patients undergoing minimally invasive surgery for benign gynecologic indications. Patients agreed to use of photos and videos via informed consent process. Interventions This video reviews when LUQ entry should be considered due to conditions such as past surgical history, size of pelvic pathology, and failed umbilical entry. We demonstrate how to locate Palmer's point and options for the entry technique. We primarily focus on optical entry and correct technique is demonstrated. Recommendations for approaching commonly encountered issues are reviewed including failed entry, poor visibility, and skiving. Lastly, alternative entry techniques and locations are described and Veress needle entry is shown. Measurements and Main Results N/A. Conclusion This video is a comprehensive review regarding the LUQ entry approach. Knowledge of the indications and anatomy, location of Palmer's point and best practices for optical entry are reviewed and demonstrated. Additionally, alternatives are offered and exemplified. The objectives of this video are to: (1) define when left upper quadrant (LUQ) entry is indicated, (2) describe identification of Palmer's point and (3) demonstrate optimal technique for optical entry at the LUQ, (4) troubleshoot commonly encountered difficulties and (5) discuss alternatives if initial attempt at LUQ entry is unsuccessful. N/A. Academic medical center. Patients undergoing minimally invasive surgery for benign gynecologic indications. Patients agreed to use of photos and videos via informed consent process. This video reviews when LUQ entry should be considered due to conditions such as past surgical history, size of pelvic pathology, and failed umbilical entry. We demonstrate how to locate Palmer's point and options for the entry technique. We primarily focus on optical entry and correct technique is demonstrated. Recommendations for approaching commonly encountered issues are reviewed including failed entry, poor visibility, and skiving. Lastly, alternative entry techniques and locations are described and Veress needle entry is shown. N/A. This video is a comprehensive review regarding the LUQ entry approach. Knowledge of the indications and anatomy, location of Palmer's point and best practices for optical entry are reviewed and demonstrated. Additionally, alternatives are offered and exemplified.

Surgical Outcomes of Hysterectomy Via Robotic Assisted Versus Traditional Transvaginal Natural Orifice Transluminal Endoscopic Surgery

<h3>Study Objective</h3> To evaluate the safety and feasibility of robotic assisted transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) hysterectomy when compared to traditional vNOTES (T-vNOTES) hysterectomy. <h3>Design</h3> A retrospective chart review. <h3>Setting</h3> An academic tertiary setting. <h3>Patients or Participants</h3> 114 patients with benign gynecologic indication for hysterectomy. <h3>Interventions</h3> T-vNOTES or R-vNOTES hysterectomy performed by a single minimally invasive gynecologic surgeon in the study period. <h3>Measurements and Main Results</h3> The primary outcome of this study was surgical equivalence, measured principally by total operative time between T-vNOTES and R-vNOTES hysterectomy. Secondary operative outcomes measured included estimated blood loss, length of hospital stay, reported postoperative pain levels, and number of conversions. 79 women underwent T-vNOTES hysterectomy and 35 women underwent R-vNOTES hysterectomy without differences in operative time (p = .37), estimated blood loss (p = .27), length of hospital stay (p = .06), or reported postoperative pain levels at weeks 1, 2, and 3 after surgery (p = .78, p = .36, p = .38, respectively). 6 patients underwent conversion in the T-vNOTES hysterectomy group compared to 0 in the R-vNOTES hysterectomy group; however, this was not statistically significantly different, and there were no conversions to laparotomy. <h3>Conclusion</h3> Robotic vNOTES hysterectomy is a feasible approach to surgery when compared to traditional vNOTES hysterectomy and warrants further consideration as a skillset in a gynecologic surgeon's toolbox. Wristed instruments may allow surgeons unexperienced in single site laparoscopy to more quickly adopt vNOTES as a new technique when performing hysterectomy through a comparable minimally invasive approach.