Gynecologic Oncology Surgery Research Articles

La certification de compétence en chirurgie cancérologique gynécologique au vu d’un parcours de formation

ObjectiveIn France, we are lacking an identified pathway for training in gynaecological cancer surgery. The four competent French learned societies, the SFOG, the CNGOF, the SFCO and the SCGP, supported by the CNU of Obstetrics &Gynaecology- and UNICANCER, agreed to materialize this course and attest it by a certification awarded by a national jury. Material and methodsThe national committee of certification in gynaecological oncology made up of 10 members, representing the 6 concerned organizations, set itself 5 objectives: the definition of the eligibility criteria for training centres; the determination of a check-list to be filled by the candidate; the determination of a targeted curriculum for the training in gynecological oncological surgery; the determination of the assets necessary for the certification of a candidate already in practice; and the practical organization of the certification. ResultsCriteria for approval of centres for training included 150 gynaecological cancer cases per year, among which 100 excisional surgeries, including 20 advanced-stage ovarian cancers. For certification of candidate who followed the curriculum established by the committee or by validation of prior experience for an actual practitioner, a candidate must validate a logbook and fill out a checklist including 4 parts: theoretical and practical training; research and publications; teaching and subscription to a continuing education program. The accomplished elements of the logbook and the checklist will be evaluated by a score. The first certification session is planned for the end of 2021. ConclusionThe optimisation of the surgical management of patients treated for gynaecological cancer is achieved through the identification of a training course and the certification, by a national jury, of the skills of surgeons who have completed it.

PROPER—PRehabilitatiOn Plus Enhanced Recovery after surgery versus enhanced recovery after surgery in gynecologic oncology: a randomized clinical trial

BackgroundPrehabilitation is a process that occurs before surgery and aims to improve patient functional capacity and enhance surgical recovery. This process includes medical, nutritional, physical, and psychological interventions that may...

Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery

ObjectivesOpioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate the impact of a...

Mandate to evaluate robotic surgery implementation: a 12-year retrospective analysis of impact and future implications.

The introduction of robotic surgery in hospitals has raised much debate given the various effects on care, costs, education and medical advancement. Purchasing discussions are often approached with more questions than answers and there is a need for reports that provide a case for whether or not such technologies are advantageous from multiple perspectives, and offer insights into ways such devices can be introduced into a hospital setting. This report provides an evidence-based review of a university-affiliated tertiary care hospital's 12-year experience with robotic surgery in gynecologic oncology and delves into the various takeaways and challenges of implementing robotic surgery. Key findings were that robotic surgery significantly reduced complication rates, lengths of hospital stays for patients and overall hospital costs. Key obstacles were large upfront costs and the need for significant leadership and collaboration. Ongoing challenges to evaluating robotics include assessing long-term survival data, making comparisons with concurrently changing hospital conditions and determining how data can be generalized to other departments and institutions.

A New Insight of the Fascia in Gynecologic Surgery, “the Dissectable Layer”

<h3>Study Objective</h3> With recent development of the surgical visual system, laparoscopic surgeons have become more conscious of the fascial structures. It has been found that the three-dimensional fascial structure is heterogenous and variable, composed of extracellular matrix such as collagen fibers. A Japanese surgeon Prof. Shinohara advocated surgical meaning of these fascia and named it "the dissectable layer". The object of the video is to clarify this layer and apply the concept to gynecologic oncology or nerve sparing surgery. <h3>Design</h3> Video demonstration with narrated video. <h3>Setting</h3> A Japanese tertiary care hospital. <h3>Patients or Participants</h3> Patients who undertaken gynecologic surgery in our institution with informed consent were included in the study. <h3>Interventions</h3> We verified the detailed fascial structure in hysterectomy and pelvic/para-aortic lymphadenectomy by using 4K video system or robotic scope. <h3>Measurements and Main Results</h3> According to the fascial concept, the target organs were isolated without bleeding by consciously dissecting loose connective tissue, the dissectable layer, between the organs. Certainly, we can create the layer around any blood vessels or muscles or organs by pulling surrounding structure also in gynecologic surgery. Especially, en-bloc lymphadenectomy and nerve sparing radical hysterectomy were possible accurately by following the concept. <h3>Conclusion</h3> By being of aware of the "dissectable layers," bleeding may be minimized, and surgical accuracy may be improved. For malignancy, en-bloc removal is possible, and the margin can be adjusted as per tumor progression. For nerve sparing radical hysterectomy, autonomic nerves can be preserved by gathered thin nerve fibers with attached facia. The use of this concept may have the potential to improve oncologic outcomes.

Wound Complications in Obese Patients after Gynecologic Oncology Surgeries, an Intervention Study

Background: Obesity is one of the comorbid conditions which can affect the operative and postoperative outcome of patients undergoing surgery. Objective: The aim of the current work was to assess the impact of using specific protocol suggested by author included (saline wash, suture material, subcutaneous drain and binder) on wound complications after major gynecologic Oncology surgeries in obese patients. Patients and Methods: This study was an intervention prospective study which included 86 women undergoing surgical gynecologic procedures via a vertical abdominal incision performed at Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University Hospital during the period from April 2020 to October 2020. All patients were subjected to detailed history taking, Clinical examination including general, abdominal and pelvic examination. Surgical Protocol for skin closure was applied. Results: There was a significant difference between study group and control group regarding wound complications (P=0.001). Fever was found in 23.2% in study group and 34.8% in control group, seroma was found in 100% in study group and 80% in control group and wound dehiscence, wound infection and wound hematoma respectively were found in 100% in study group and 60% in control group. Conclusion: It could be concluded that using this specific protocol (saline wash, suture material (Polydioxanone Suture), subcutaneous drain and binder) may decrease the incidence of wound complications in obese women undergoing a gynecologic procedure via a vertical abdominal incision.

Myocardial injury after gynecologic oncology surgery in septuagenarians and octogenarians: Is there a role for routine postoperative cardiac biomarker monitoring?

220 Background: Accumulating evidence correlates myocardial injury after noncardiac surgery (MINS), even when asymptomatic, with increased cardiac and non-cardiac morbidity and mortality. There is no literature on MINS specific to Gynecologic Oncology. We sought to evaluate the incidence and risk factors of MINS in patients aged ≥70. Methods: Elective laparotomies between 01/2016-09/2020 for patients aged≥70 at a tertiary hospital in ON, Canada, were reviewed using prospectively-collected National Surgical Quality Improvement Program (NSQIP) data. MINS was defined as peak serum high-sensitivity troponin-T concentration ≥0.04ng/mL within 30 days postoperatively. Logistic regression analysis was performed. Results: In this cohort of 258 patients, of 242 (93.8%) who underwent postoperative troponin screening, 40 (16.5%) experienced MINS without exhibiting ischemic symptoms or ECG changes. The diagnosis of MINS led to a prescription or optimization of cardiovascular medications for 35 patients (87.5%). On univariate analysis, Revised Cardiac Risk Index (RCRI) of 3-5(p = 0.002), history of coronary artery disease (p = 0.003) or insulin-dependent diabetes (p = 0.006), preoperative use of antiplatelets (p = 0.009), beta-blockers (p = 0.02), ACE-inhibitors (ACEI) or angiotensin-receptor blockers (ARB)(p = 0.002) and frailty as defined by the NSQIP modified frailty index-5 (p = 0.02), were associated with greater risk of MINS. Factors reflecting surgical complexity including surgical complexity score, operative duration, blood loss and advanced oncologic stage were not predictive. Multivariable analysis using backward selection procedure identified elevated RCRI and preoperative ACE/ARB as significant risk factors (OR 5.93, 95% CI 1.52-24.31, p = 0.01 and OR 2.4, 95% CI 1.18-5.06, p = 0.02). Conclusions: One in 6 patients in our cohort experienced asymptomatic MINS irrespective of surgical complexity. Our analysis highlights a possible opportunity to optimize cardiac risk factors and to potentially improve perioperative patient safety by reducing morbidity. Routine preoperative cardiac risk-stratification and postoperative cardiac biomarkers monitoring should be considered in elderly patients with gynecologic malignancies.[Table: see text]

Intrathecal morphine in planned gynecologic surgery: Recovery and postoperative pain control

BackgroundTo compare post-operative pain control and side effects of intrathecal morphine (ITM) given in two different doses in patients undergoing gynecological surgery. MethodsThis was a retrospective data base cohort study conducted between 2015 and 2017 at the Shaare Zedek Medical Center. Surgeries were divided into subgroups: vaginal, abdominal and oncological. A comparison was made between 2 distinct doses of ITM (standard – 150 mcg and high - 200 mcg) in terms of post-operative pain as reflected by visual analog scale (VAS) scores and side effects. Additional subgroup of the three surgical groups was made regardless of the ITM dose used. Multivariate analysis was carried out using appropriate tests. ResultsThe study included 156 patients. Forty five patients received a standard dose ITM and 111 received the high dose. Sixty three patients had vaginal surgery, 80 had benign abdominal surgery and 13 had a gynecologic oncology surgery. No difference was noted in VAS scores during the first 24 h of hospitalization. However, average and maximal VAS scores were higher among those who received high dose ITM. This difference did not remain significant in the multivariate analysis controlling for patient age and surgery type. Patients treated with high dose ITM had a higher incidence of pruritus. No difference was noted in respiratory depression as reflected by medically indicated oxygen consumption between those treated with high vs. standard dose ITM. ConclusionsITM dose higher than 150 mcg is associated with a higher rate of pruritus without any additional benefit on the analgesic effect as reflected by post-operative VAS scores.

Determining post-operative morbidity and mortality following gynecological oncology surgery: protocol for a multicenter, international, prospective cohort study (Global Gynaecological Oncology Surgical Outcomes Collaborative—GO SOAR)

BackgroundThe Global Gynaecological Oncology Surgical Outcomes Collaborative (GO SOAR) aims to develop a network of gynecological oncology surgeons, surgical departments, and other interested parties that will have the long-term ability...

Reconstruction of Vulva and Perineal Defects After Gynecological Oncological Surgery and Effectiveness of Local Flaps

Aim: Although most defects can close by primary suturing after radical surgery of gynecological malignancies, different reconstruction options are available when large defects that require reconstruction occur. In this study, we present the treatment strategy and results for patients who underwent reconstruction after resection for gynecological cancer in the vulva and perineum. Material and Methods: A total of 18 patients who underwent reconstruction between May 2018 and July 2020 were included in this retrospective study. Demographics and clinical data, the resection operation, characteristics of the defect, and the reconstruction methods applied were evaluated. Postoperative treatment strategy and complication rates were evaluated. Results: The mean age was 62.3±13.2 (42-83) years. 88.9% of the patients had additional diseases. Pelvic exentration was performed in 5 (27.8%) patients, anterior resection in 2 (11.1%) patients and vulvectomy in 11 (61.1%) patients. The most common malignancy was squamous cell carcinoma, and mean defect size was 106±97 (12-476) cm2. Reconstruction was performed with a local fasciocutaneous flap in 16 (88.9%) patients, pedicled rectus myocutaneous flap in one (5.6%) patient, and skin graft in one (5.6%) patient. Wound complications occurred in 5 (27.8%) patients, partial flap necrosis in one (5.6%) patient, and recurrence in one (5.6%) patient in the long term. Conclusion: It is possible to reconstruction most of the vulva and perineal defects with local flaps after oncological resections, Considering the characteristics of the area and patient comorbidities, it should be kept in mind that prolonged wound problems may be seen, especially in vulvectomy patients.

P–348 Laparoscopic radiofrequency thermal ablation for diffuse adenomyosis: symptomatology after a long-term follow-up

Abstract Study question Is conservative laparoscopic treatment with RFA (radiofrequency thermal ablation) related to a good outcome on a long-term follow-up? Summary answer RFA for diffuse adenomyosis was related to a good outcome on a long-term follow-up in terms of pain and ultrasonographic reduction. What is known already Uterine adenomyosis may cause symptoms refractory to medical treatment. New, uterine-sparing treatments have been introduced for patients who desire avoiding hysterectomy. Among surgical techniques used for this purpose, radiofrequency thermal ablation (RFA) has been introduced, first for the treatment of uterine fibroids and then for focal adenomyosis. Diffuse adenomyosis is characterized by an extensive involvement of uterus, as on ultrasound less than 25% of the lesion is surrounded by healthy myometrium. It often leads to enhanced uterine volume, which presents soft consistence and globular aspect. Conservative treatment of diffuse adenomyosis is a real challenge. Study design, size, duration All consecutive patients who underwent RFA for diffuse adenomyosis in our institution between July 2011 and August 2017. Patients with focal adenomyosis were not included in the study. The treatment was reserved to selected patients who wanted to conserve the uterus and presented symptoms such as pain or abnormal uterine bleeding refractory to medical treatment. In all cases the treatment was performed by laparoscopy, which allowed for complete removal of extrauterine endometriosis, if associated. Participants/materials, setting, methods Nineteen patients (aged 33–49, mean 40) underwent radiofrequency thermal ablation for diffuse adenomyosis, and all of them completed the follow-up. Setting: referral center for endometriosis (Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Negrar). Follow-up consisted on ambulatory clinical evaluation with pelvic ultrasound and assessment of pain using the visual analog scale (VAS) ranging from 0 to 10 points for all pain components. Main results and the role of chance: Endometriosis was associated in12 cases, (63%) and in all cases was removed completely during surgery. The mean follow-up was 64 months (range 29–105). Abnormal uterine bleeding was present in 11 (60%) patients before the treatment and only in four of them (21%) during the follow-up. Preoperative and postoperative mean VAS score for dysmenorrea, dyspareunia, dyschezia and chronic pelvic pain was 6.95 vs 3.7, 4.1 vs 1.4, 3.7 vs 0.9 and 3.9 vs 1.5 respectively (p &amp;lt; 0.05 for all pain components). The reduction of adenomyosis on ultrasound was observed in 75% of cases. After surgery, two of four patients who desired pregnancy conceived, one of them delivered at term by caesarian section and one had an extrauterine pregnancy. Hysterectomy was performed in two cases during follow-up, at 35 and at 84 months after RFA. Limitations, reasons for caution The present study reports outcome in a limited population as the treatment was reserved to selected cases. The results, particularly regarding fertility and pregnancy outcome should be taken with caution because of small numbers. In our opinion for the moment the treatment should be performed in selected cases. Wider implications of the findings: The present treatment could be performed to avoid hysterectomy, as it was necessary only in two cases in our study. No cases of hysterectomy were reported within the first two years from surgery, so we can consider that RFA allows at least a temporary benefit on symptoms. Trial registration number Not applicable

Implementation of a standardized voiding protocol after minimally invasive surgery in gynecologic oncology: a quality improvement initiative

<h3>Objectives:</h3> Urinary retention after pelvic surgery is common and contributes to postoperative catheter-associated urinary tract infection (UTI). The aim of our quality improvement study was to reduce the rate of UTI by 50% during the study period. <h3>Methods:</h3> A standardized voiding protocol was designed and implemented in patients undergoing minimally invasive hysterectomy for gynecologic malignancy between January to September 2020. The protocol included: 1) aseptic indwelling catheter insertion technique, 2) use of a new catheter for every insertion attempt, 3) proper positioning of the catheter bag below the patient's bladder on the side of the table during surgery, 4) catheter removal immediately after surgery prior to transfer to recovery room, 5) bladder scan after void, 6) and limiting repeat catheterizations for retention (Figure 1). We compared the demographics, time to first void, rate of urinary retention, and UTI rates between the pre- and post-protocol cohorts. Data for the historical cohort was obtained using the National Surgical Quality Improvement Program (NSQIP) database. Chi-square and Fisher's exact tests were used for comparison of categorical variables and Wilcoxon Rank-Sum tests for continuous variables. <h3>Results:</h3> A total of 79 post-protocol patients were compared to 124 patients in a historical cohort. The post-implementation cohort was younger (59 vs 65; p=0.04) but clinical and surgical characteristics were not statistically different between the two cohorts. The voiding protocol led to a significant decrease in the interval to first void (289 vs 526 minutes; p<0.001). The rate of postoperative UTI was reduced from 6% (8 of 124) to 3% (2 of 79) during the study period (p<0.001). <h3>Conclusions:</h3> Implementation of a standardized voiding protocol was associated with a significant reduction in time to first void, and 50% decreased catheter-associated UTI.

Implementation of a broader pre-operative antibiotic coverage and chlorhexidine irrigation associated with a lower postoperative surgical site infection

<h3>Objectives:</h3> Post-operative surgical site infections (SSI) cause major health and economic burden on the patients and the healthcare systems. Multiple risk factors such as obesity and medical comorbidities are known to increase the risk of SSI in gynecologic oncology patients. Commonly used preoperative antibiotic regimens focus on targeting the skin flora as described by the enhanced recovery protocols adopted by many hospitals. We sought to investigate the effect of the addition of metronidazole to the preoperative antibiotic regimen and the intraoperative pelvic irrigation with 0.05 % chlorhexidine gluconate (CHG) on the rate of SSI after a minimally invasive surgery in gynecologic oncology. <h3>Methods:</h3> After IRB approval, we collected data from June 2018 to January 2020 for patients who underwent minimally invasive gynecologic oncology surgery at Marshall University School of Medicine. Implementation of the infection control model (pre-operative Metronidazole + intraoperative CGH pelvic irrigation) started in July 2019. Demographic and medical data, as well as intraoperative and postoperative data, were collected. The rate of SSI was analyzed before and after adoption of the model. <h3>Results:</h3> A total of 508 patients underwent a minimally invasive gynecologic oncology procedure: 262 before the implementation of the infection control model and 318 afterward. The median age of the patients was 59 years old and the rate of comorbidities was equal between the groups. The rate of SSI before the implementation of the model (Group 1) was 2.29% (6/262) and the rate of SSI afterward (Group 2- post infection control model) was 0.94% (3/318). The most common bacteria isolated from the first group were gram-negative bacilli (Klebsiella and E. Coli) and anaerobes, while Group 2 had a single patient with Klebsiella infection, one Bacteroides species infection, and one MRSA infection. All of these infected patients required pelvic abscess drainage and hospital readmission for intravenous antibiotics, with an average of 2-day hospital stay. <h3>Conclusions:</h3> The addition of metronidazole to the preoperative antibiotics regimen and the intraoperative pelvic irrigation with 0.05 % CHG appears to decrease the rate of SSI after a minimally invasive gynecologic oncology surgery. This model merits further studying in order to validate these results.

Impact of steroid use and glucose control on surgical outcomes in diabetic gynecologic oncology patients

<h3>Objectives:</h3> The objective of this study was to assess the impact of preoperative steroid use and glucose control on postoperative outcomes for diabetes mellitus (DM) gynecologic oncology patients undergoing surgery. <h3>Methods:</h3> This retrospective cohort study included all gynecologic oncology patients admitted for inpatient surgery on an enhanced recovery protocol (ERP) between 10/2016 and 12/2018 with the addition of further patients with DM until 9/2019. The utilization of preoperative steroids has largely been adopted in most ERP patients. At our institution, 8mg intravenous dexamethasone is frequently used. Individual chart review was completed to identify the primary outcome of postoperative complications including: DKA, surgical site infection, ileus, DVT/PE, CVA, MI, AKI, unplanned ICU admission, pulmonary complications, and blood transfusions. Secondary outcomes included length of hospital stay (LOS) and readmission rate. SPSS v. 25 was used for statistical analysis. <h3>Results:</h3> 684 patients were identified and 184 (26.9%) had coexisting type I or II DM. Demographics including CCI, race, diagnosis, and surgical complexity were similar between groups. Patients with DM tended to be older, have a larger body mass index (BMI), and longer operative times. The overall complication rate was 32.5%. Patients with DM were more likely to have postoperative complications (77.5% vs. 15.9%, P=0.0001), increased LOS (4.0±4.6 vs. 3.1±1.9 days, P=0.001), though no difference in readmission rate was observed (10.3% vs. 7.6%, P=0.25). Patients were more likely to have postoperative complications if they had at least one documented serum glucose greater than 300 (74.1% vs 26.8%, P=0.0001) or an average serum glucose greater than 180mg/dL in the first 24 hours (80.0% vs 24.8%, P=0.0001). 54.3% of DM patients got preoperative steroids with no difference in complication or readmission rates seen (p=0.1; p=0.7). <h3>Conclusions:</h3> Diabetic patients are at a much higher risk for postoperative complications after gynecologic oncology surgery. There was no increased risk for postoperative complications in DM patients who received steroids as part of the ERP. However, poorly controlled glucose levels in the immediate postoperative period were associated with a higher rate of complications. Adequate blood glucose control perioperatively for these high-risk patients undergoing surgery is vital given the increased risk of postoperative complications and length of stay.

Opioid analgesics following surgery for gynecologic cancer patients at a university health center: have we altered our prescribing patterns in this patient population?

Objectives: Our objective was to analyze the effect of increased opioid prescribing regulations, implemented as an updated state law in July 2016, on the number of opioid tablets prescribed to postoperative gynecologic oncology patients at a state-funded university health center. Methods: This Institutional Review Board (IRB)-approved, retrospective review utilized several electronic health records systems and our referral list to identify patients who qualified. Patients were included in the study if they received surgery performed by a gynecologic oncologist for suspicious masses, premalignant or malignant conditions of the uterus, tubes, ovaries or cervix. The charts were divided into Before July 2016 and After July 2016. The number of opioids prescribed to patients at time of discharge was recorded when available. Qualitative data was collected including the prescription or recommendation for non-opioid analgesics within the discharge summary, and type of procedure conducted (open versus minimally invasive). Demographic information including age, ethnicity and insurance coverage was also recorded. The study was designed to detect a 25% decrease in opioid tablets prescribed after the regulation was implemented (alpha = 0.05, power 0.8). Comparisons were made between groups after a Kolmogorov-Smirnov and Shapiro-Wilk test determined that the data was not normally distributed. Therefore, we utilized Mann-Whitney U tests to compare number of opioid tabs prescribed and to compare median age between the Before and After July 2016 groups. We used Chi-Square and Fischer Exact tests to compare differences in ethnicity and non-opioid analgesic (NSAID) use between the Before and After July 2016 groups. Finally, we utilized a multivariate linear regression model to determine if ethnicity and NSAID use significantly impacted the number of opioid tablets prescribed. Statistical analyses were performed utilizing SPSS software version 25. Results: We identified a statistically significant, 50% decrease in the number of opioid tablets prescribed after gynecologic oncology surgeries after July 2016. As anticipated, we also saw fewer opioid tablets prescribed following minimally invasive procedures compared to open cases (p=0.007). When examining non-opioid analgesic data, we identified significantly more patients received a prescription for non-opioid analgesics in the After July 2016 group compared to the Before July 2016 group (p Conclusions: This study confirms there was a significant decrease in the number of opioid tablets prescribed to postoperative gynecologic oncology patients at discharge since July 2016 in our state-funded university hospital. The difference cannot be attributed to the change in the regulatory guidelines alone, but is temporally related to the updated provider requirements. These results reemphasize that minimally invasive surgery has a reduced number of prescribed opioids, inferring a decreased amount of postoperative analgesic requirements. Multi-institutional study is required with more patients to detail the factors involved in further decreasing opioid prescribing and use. It appears from these results that increasing regulatory oversight is an important variable in harnessing the opioid epidemic.

Comprehensive perioperative care program to improve same-day discharge after minimally invasive gynecologic oncology surgery (MIGOS)

<h3>Objectives:</h3> Same-day discharge (SDD) after minimally invasive hysterectomy for benign or malignant gynecologic conditions has been shown to be safe and feasible, but remains challenging to implement. We designed and implemented a quality improvement perioperative program for minimally invasive gynecologic oncology surgery (MIGOS). Our aim was to improve SDD rate from 30% to 75% over the study period, while maintaining acceptable 30-day perioperative outcomes and patient experience. <h3>Methods:</h3> Consecutive patients undergoing minimally invasive hysterectomy at a single cancer centre were included during the 9-month project period and a historical cohort of 100 consecutive patients was identified for comparison. A team of gynecologic oncologists, anesthesiologists, and nurses developed a comprehensive perioperative care program and met bi-weekly to revise interventions through plan-do-study-act (PDSA) cycles. Patients were followed for 30 days after discharge. We conducted a descriptive analysis of the characteristics of pre-MIGOS and MIGOS patient cohorts using Wilcoxon rank-sum or Fisher exact tests. We used a run chart to monitor effects of interventions on outcomes and a pre-post analysis to evaluate for statistical significance of change in SDD and perioperative outcomes. <h3>Results:</h3> We assessed 100 consecutive pre-MIGOS and 79 consecutive MIGOS patients. Overall SDD rates increased from 31% (31/100) to 71% (56/79) after implementation (p<0.001) (Figure 1). There was a consistent increase in SDD rate after implementation, although more pronounced following the start of the COVID pandemic. The MIGOS cohort was significantly younger (59 vs. 65; p=0.04) and had shorter operative times (168 vs. 202 minutes; p<0.001) but the two groups were not different with respect to BMI, comorbidity, stage distribution, type of procedure performed, and intraoperative blood loss. We found no difference in 30-day perioperative complication rates, readmission, reoperation, clinic visits, emergency department visits, mortality or morbidity. The most common reason for overnight admission was nausea and vomiting (35%), complications related to pre-existing comorbidities (15%) and urinary retention (10%). Overall, 89% of MIGOS patients rated their experience as ‘very good' or ‘excellent', and 87% felt that their post-operative length of stay was adequate. <h3>Conclusions:</h3> Following implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, a multidisciplinary team significantly improved SDD rates while maintaining low 30-day perioperative complications and excellent patient experience.

Postoperative pain management in gynecologic oncology: regional anesthesia effects on time to pain control and achieving postoperative milestones

<h3>Objectives:</h3> We investigated the time to achieve postoperative milestones in patients who underwent exploratory laparotomy for suspected gynecologic malignancy and received either patient-controlled analgesia alone (PCA), PCA with transversus abdominus plane block (TAP), or PCA with continuous epidural infusion (CEI). <h3>Methods:</h3> A retrospective cohort study of patients who underwent open gynecologic oncology surgery in a university was conducted over 18 months. Our primary outcomes included time to achieve the following postoperative milestones: pain control (mean pain score ≤ 5), foley catheter removal, ambulation, flatus, tolerating a regular diet, and control of nausea and emesis. All milestones, except for foley catheter removal, were measured using postoperative day (POD). Foley catheter removal was measured in hours after insertion and analyzed as a categorical variable using quartiles. All postoperative milestones were compared using Fisher's Exact Test. <h3>Results:</h3> Of 214 eligible patients, 127 received PCA alone, 76 received additional TAP block, and 11 received additional CEI. 19 patients without PCA or regional, and 13 patients without PCA, were excluded. Pain control took longer in the CEI group as over half of those who received PCA alone (54%) or TAP (57%) achieved pain control on POD 0 compared to 30% in CEI (p=0.02). Similarly, by POD 3, only 80% of the CEI group had pain controlled compared to 96% in PCA and 85% in TAP (p=0.02). CEI also lagged in time to foley removal as none (0%) of the CEI group had foley removal within the first quartile, 0-15 hours, whereas 23% of the PCA group and 27% of the TAP group had achieved successful removal by that time (p=0.02). This trend continued with 73%, 28%, and 20% of the CEI, PCA, and TAP groups, respectively had foley removal within the last quartile, 41-503 hours (p=0.02). The CEI group also took longer to ambulate with 18% ambulating by POD 1 compared to 59% in PCA and 64% in TAP (p=0.01). Similarly, by POD 2, only 54% of the CEI patients were ambulating compared to 89% in PCA and 90% in TAP (p=0.01). The CEI group lagged in time to regular diet, as only 9% were eating by POD 1 vs 35% in PCA and 29% in TAP, although this finding was not statistically significant (p=0.07). The CEI group also experienced increased time to flatus with 9% on POD 1 compared to 17% in PCA and 7% in TAP (p=0.02). Only 9% of the CEI patients had nausea controlled by POD 1, whereas 48% in PCA and 49% in TAP groups met that milestone by then (p=0.02). It took 3 or more postoperative days for 82% of the CEI group to have controlled nausea. When reviewing these results in the combined regional group (TAP and CEI) vs PCA alone, there were no statistically significant differences except in time to flatus, with 17% of the PCA group passing flatus by POD 1 compared to 7% in the regional group (p=0.03). <h3>Conclusions:</h3> Our study showed that regional anesthesia increased time to flatus in patients who underwent open gynecologic surgery. Although limited by small sample size, CEI was an outlier in time to postoperative milestones, including pain control, ambulation, control of nausea and emesis, and foley removal. Benefits and drawbacks of CEI anesthesia should be considered using full assessment of the effect on postoperative milestones. Further study of costs of CEI vs TAP anesthesia, while not in the scope of this study, can provide further context for decision making. Our results merit future investigation into the effects of regional anesthesia, especially epidural, on time to postoperative milestones.

Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery

<h3>Objectives:</h3> Opioids are routinely prescribed for patients after surgery, with minimal data to inform the ideal dose. The aim of the study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents (MME) prescribed and to assess pain control in patients undergoing minimally invasive gynecologic oncology surgery. <h3>Methods:</h3> A restrictive opioid prescription protocol was implemented from January through September 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for malignancy were included. As part of the protocol, we implemented use of multimodal analgesia (acetaminophen and non-steroidal anti-inflammatory drugs (NSAID)), patient and provider education, pre-printed standardized opioid prescriptions and tracking of opioid prescriptions. Total opioid tablets prescribed and refill requests were compared to a historical cohort of 100 consecutive patients (2018-2019). Post-intervention, patients were surveyed regarding postoperative opioid use, pain control and overall experience. We performed a descriptive analysis of the characteristics of pre-post intervention cohorts. Chi-square and Fisher's exact tests were used for categorical variables and Wilcoxon Rank-Sum tests for continuous variables. <h3>Results:</h3> A total of 79 women in the post-intervention cohort were compared with 100 historical controls. The post-intervention cohort was younger (59 vs 65; p=0.04) however clinical and surgical characteristics were not statistically different between the groups. Following protocol implementation, MME prescribed decreased from 50 (range 9-100) to 25 (range 7.5-75) (p<0.001). Overall, 74% (59/79) used 10 MME or less and 41 patients (52%) used 0 MME. Multimodal analgesia including acetaminophen and NSAIDs was used in 85% of patients post-intervention compared to 73% in the historical cohort (p=0.069). There was no additional increase in opioid refill requests after implementation of our strategy. Overall, post-intervention, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery. <h3>Conclusions:</h3> Implementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery with over 50% of patients not requiring opioids postoperatively. This initiative was not met with added adverse consequences.

Gynecologic oncology and surgical oncology treatment modifications, cancellations or delays in response to the COVID-19 pandemic in public versus private cancer centers in North America

Objectives:The major shift in health-care resource utilization during the COVID-19 pandemic to support patients requiring mechanical ventilation and intensive care monitoring has led to unprecedented cancellations of elective surgeries and reductions of ambulatory clinic visits worldwide. The primary objective of this study is to determine whether the response to the pandemic resulted in modifications, cancellations or delays to the standard therapeutic algorithms for patients with gynecologic malignancies at tertiary, large-volume publicly funded Canadian cancer centers as compared to a privately funded American cancer center.Methods:This is a retrospective cohort study of all surgical oncology and gynecologic oncology cases performed in the province of Ontario and at the University Health Network/Princess Margaret Cancer Center (UHN/PMH) as a surrogate for treatment delays, compared to all gynecologic oncology patients treated at the Dana Farber Cancer Institute, Boston, MA, USA, between March 3, 2020-June 30, 2020. Descriptive statistics and treatment times were analysed using SPSS 25.0Results:In the province of Ontario, between March 15, 2020-October 25, 2020, there was a 19% overall decrease in surgical oncology volumes compared to the same time period the previous year (March 17, 2019-Oct 17, 2019). There was an increase of 96% in high priority surgical oncology cases and a 43% decrease in low priority cancer cases. Surgeries for gynecologic malignancies decreased by 8% in the province of Ontario as compared to the previous year. At UHN/PMH, a publicly funded tertiary cancer center in Ontario, there was a 59.8% reduction in surgical oncology volumes between March 09, 2020-May 04 2020, as compared to the previous year (March 04, 2019-April 29 2019). In comparison, at the Dana Farber Cancer Institute, a privately funded tertiary cancer center, there were 202 new gynecologic oncology patient referrals and 66 returning patients between March 3, 2020-June 30, 2020. The median time from referral to first consultation for new patients was 11 days (range 1-21) and the time to primary treatment was 31 days (range 5-157). New patients with ovarian malignancies had the shortest time to treatment of 22 days (range 5-157). There were no modifications made to the standard of care treatment plans for any patients and 5.7% of the patients had treatment delays.Conclusions:During the COVID-19 pandemic, the public Canadian healthcare system in the province of Ontario was subjected to a 19% reduction in surgical oncology volumes and 8% specifically for gynecologic oncology surgeries, while there was a 5.7% treatment delay for gynecologic oncology surgeries for a similar patient cohort treated at a tertiary cancer center in a privately funded health care system in the United States.

Acute kidney injury in Enhanced Recovery After Surgery (ERAS) protocols in open gynecologic oncology surgery

<h3>Objectives:</h3> To estimate the incidence of and factors associated with acute kidney injury (AKI) in women undergoing elective open gynecologic oncology surgery using an Enhanced Recovery After Surgery (ERAS) protocol. <h3>Methods:</h3> A retrospective cohort study was performed. All women who underwent open gynecologic surgery for suspected or confirmed malignancy using an ERAS protocol between March 2018 to December 2019 were identified. Incidence and degree of AKI were classified by the Kidney Disease Improving Global Outcomes (KDIGO) staging system. Descriptive statistics and univariate analysis for associated factors were performed using Fisher's exact test. <h3>Results:</h3> A total of 114 patients met inclusion criteria. The majority underwent abdominal hysterectomy (102/114, 89%) with anesthesia time ≥240 minutes in 73% of patients. Median age and body mass index (BMI) were 54 years and 28.1 kg/m², respectively. A total of 9 patients (9/114, 7.9%) developed KDIGO class 1 (7/114, 6.1%) or class 2 (2/114, 1.8%) AKI. All but one case of AKI (8/9, 88.8%) resolved by day of discharge. Factors associated with AKI included: obesity (OR 13.8, p=0.003), ASA 3+ (OR 11.8, p=0.01), complication other than AKI (OR 9.3, p=0.02), cardiovascular disease (OR 8.3, p=0.03) diabetes mellitus (OR 4.7, p=0.04), and baseline creatinine of ≥1.0 (OR 9.3, p=0.04). Procedural blood loss, age >65, ECOG performance status, receipt of neoadjuvant chemotherapy, intraoperative time, intraoperative albumin infusion, and postoperative transfusion were not significantly associated with AKI. <h3>Conclusions:</h3> AKI is uncommon in women undergoing open gynecology oncology surgery using an ERAS protocol. Nearly all cases resolved prior to discharge and were associated with patient-specific factors. While care should be taken during protocol implementation to monitor for and to prevent AKI, fluid restriction principles used in ERAS protocols are safe in this study population.