Gynecologic Oncology Procedures Research Articles

Assessment of socioeconomic and racial differences in patients undergoing concurrent gynecologic oncology and urogynecology surgeries: a National Inpatient Sample (NIS) database study

ObjectiveTo assess social determinants of health impacting patients undergoing gynecologic oncology versus combined gynecologic oncology and urogynecology surgeries.MethodsWe identified patients who underwent gynecologic oncology surgeries from 2016 to 2019 in...

Perspectives of gynecologic oncology fellowship training and preparedness for practice

We aimed to examine the preparedness of recent gynecologic oncology fellowship graduates for independent practice.We conducted a web-based survey study using REDCap targeting Society of Gynecologic Oncology (SGO) members who graduated gynecologic oncology fellowship within the last six years. The survey included 52 items assessing fellowship training experiences, level of comfort in performing core gynecologic oncology surgical procedures and administering cancer-directed therapies. Questions also addressed factors driving participants’ selection of fellowship programs, educational experience, research and preparedness for independent practice. A total of 296 participants were invited to complete the survey. Response rate was 42% with n = 124 completed surveys included for analysis. The highest ranked factor for fellowship selection was fit with program 36% (n = 45). Upon completing fellowship, most were uncomfortable performing ureteral conduit formation 84% (n = 103), ureteroneocystostomy 77% (n = 94), exenteration 68% (n = 83), splenectomy 67% (n = 83) and lower anterior resection 41% (n = 51). Most were comfortable managing intraoperative complications 85% (n = 104) and standard cancer staging procedures (range: 61%–99%). Majority were comfortable providing cancer directed therapies with chemotherapy 99% (n = 123), immunotherapy 84% (n = 104), and poly ADP-ribose polymerase (PARP) inhibitors 97% (n = 120). Upon completing fellowship, 77% (n = 95) report having mentorship that met their expectations during fellowship and 94% (n = 116) felt they were ready for independent practice. Majority of fellowship graduates were prepared for independent practice and felt comfortable performing routine surgical procedures and cancer directed treatment. However, most are not comfortable with ultra-radical gynecologic oncology procedures. Maximizing surgical opportunities during fellowship training and acquiring early career mentorship may help.

Postoperative Acute Kidney Injury in Geriatric Gynecologic Oncology Patients After Major Open Abdominal Surgery: A Retrospective Cohort Study

Introduction: This investigation’s purpose was to determine the incidence of acute kidney injury, the associated risk factors, and the 90-day outcomes and kidney function of geriatric patients who underwent major open abdominal gynecologic oncologic surgery. Materials and Method: This retrospective cohort study involved patients aged ≥ 65 years who underwent major open abdominal gynecologic oncologic surgery. Results: The postoperative incidence of acute kidney injury in gynecologic oncologic surgical procedures was 22.1%, with a transient nature observed in 72% of patients. The in-hospital mortality rate was 4 %. Kidney function on the 90th day after acute kidney injury development revealed that estimated glomerular filtration rate regressed by over 25% in 6 patients (24%). Acute kidney injury development was associated with surgical time, intraoperative bleeding volume, bowel procedures, the presence of ascites, intraoperative hypotension, vasopressor use, postoperative diuretic use, postoperative hypoalbuminemia, prolonged post-anesthesia care unit, and hospital stay (p < 0.05). A logistic regression analysis of the risk factors for acute kidney injury revealed that surgery duration was a significant one (p < 0.05). Conclusion: Postoperative acute kidney injury is an important postoperative complication associated with the development or progression of chronic kidney disease. This leads to a prolonged stay in the post-anesthesia care unit and in the hospital. Although acute kidney injury is frequently transient in geriatric patients following major open abdominal gynecologic oncologic surgery, developing preventive measures, encouraging team collaboration, and monitoring serum creatinine concentration in the early postoperative period are critical in complex surgical procedures. Keywords: Postoperative Complications; Acute Kidney Injury; Geriatrics.

Balloon Trocar Is a Suitable Instrument for Retroperitoneal Para-aortic Lymphadenectomy in Gynecologic Malignant Diseases

To demonstrate the surgical technique of retroperitoneal para-aortic lymphadenectomy to prevent peritoneal rupture in gynecologic malignant disease. In this video, the authors describe how to use a balloon trocar to create a safe and efficient working space without peritoneal rupture. A step-by-step video demonstration of a surgical technique. Department of Gynecology and Obstetrics, Mie University, Tsu, Japan. Para-aortic lymphadenectomy is a part of most gynecologic oncology procedures for primary and recurrent gynecologic malignancies. There are 2 approaches to para-aortic lymphadenectomy: transperitoneal and retroperitoneal approaches. Although there are no significant differences between these approaches (such as in terms of the number of isolated lymph nodes or related complications), they are performed based on the operator's preference. The retroperitoneal approach is an unfamiliar surgical technique compared with usual laparotomy and laparoscopic surgery, and its disadvantages include a steeper learning curve for attaining proficiency. It is also difficult to develop the retroperitoneal space without a peritoneal rupture. In this video, we demonstrate the use of balloon trocars to create a retroperitoneal compartment. The patient was placed in the lithotomy position with the pelvis elevated at 5° to 10°. The left internal iliac approach, which is considered the standard approach, was used in this case (Fig 1). After identifying the left psoas muscles and the ureter crossing the common iliac artery, dissection of the left para-aortic lymph node was initiated (Supplemental Video 1, 2). Herein, we demonstrated a successful surgical technique for retroperitoneal para-aortic lymphadenectomy to prevent peritoneal ruptures.

8525 Efficacy and Safety of Single Port Robotic Hysterectomy with Concomitant Urogynecologic and Gynecologic Oncology Procedures

<h3>Study Objective</h3> To assess the feasibility of the DaVinciâ Single Port (SP) robotic platform for urogynecologic and gynecologic oncology surgical procedures. <h3>Design</h3> Retrospective cohort analysis. <h3>Setting</h3> The first SP robotic procedures performed as same day surgeries at an academic tertiary medical center by board certified Female Pelvic Medicine and Reconstructive Surgery and/or Gynecologic Oncology surgeons from December 2021-April 2022. <h3>Patients or Participants</h3> 15 patients underwent SP robotic hysterectomy (RH) and either bilateral salpingectomy (BS) or salpingo-oophorectomy (BSO) with or without concomitant procedures. <h3>Interventions</h3> SP RH and concomitant procedures were performed using a 1.5 cm umbilical incision, the Access Port ä (Intuitive Surgical) and the SP platform robotic camera and instruments. <h3>Measurements and Main Results</h3> Our primary outcome was conversion to a multiport procedure and intraoperative complications. Perioperative details were abstracted from the chart including operative time, estimated blood loss (EBL), and intraoperative complications, PACU length of stay (LOS) and pain scores POD#1 Surgical Pain Scale (SPS) scores. Indications for the 15 SP RH with BS or BSO included prolapse (N=10), risk reduction (N=2,) endometrial cancer (N=1), cervical (N=1), and endometrial (N=1) intraepithelial neoplasia. Concomitant procedures included: 10 (67%) SP sacrocolpopexies, 9 (60%) midurethral slings, 2 (13%) SP sentinel lymph node mapping, and 1 breast reconstruction. There was no conversion to a multiport procedure, intraoperative or immediate postoperative complications with a mean EBL of 66.7 ± 26.1 cc. Mean operative time and PACU LOS were 182 ± 53 and 216 ± 57 min. Median PACU pain scores were low (2, IQR 4) and only one patient required a single dose of postoperative tramadol. Similarly, median POD#1 SPS scores were low for pain at rest and with activity (3 (IQR 4) and 3 (IQR 4.75)) and for the worst pain 5.5 (IQR 4,25). <h3>Conclusion</h3> SP robotic approach for urogynecologic and gynecologic oncology hysterectomy with concomitant procedures performed by sub-specialty surgeons is safe and feasible.

Radiotherapy of an Isolated Port-Site Metastases after Laparoscopic Surgery for Endometrial Cancer: A Case Report

Port-site metastases after gynecologic oncology procedures have a reported incidence of 1-2% and in the 95% of cases had simultaneous carcinomatosis or metastases to other sites at the time of port-site metastasis detection suggesting that the presence of port site implantation is a surrogate for advanced disease. At the moment, only poor cases of isolated port-site metastasis after endometrial cancer have been reported in literature, we reported one of this cases

Surgeon Attitudes Toward Concurrent Urogynecologic and Gynecologic Oncology Procedures: A Cross-sectional Survey.

There is increasing overlap in the urogynecologic and gynecologic oncologic patient populations. To improve patient advocacy and access to care, a collaborative surgical approach may benefit this cohort. The aim of the study was to evaluate surgeon attitudes toward performing concurrent urogynecologic and gynecologic oncology procedures. We hypothesized that most surgeons are amenable to collaboration. We conducted a cross-sectional questionnaire of members of the Society of Gynecologic Oncology and the American Urogynecologic Society from August to November 2020. A 23-item online survey was created to assess surgeon demographics, practice and screening patterns, and attitudes toward surgical collaboration. We also evaluated obstacles to performing joint procedures and assessed whether attitudes could be influenced by new information. A total of 338 surveys were included in the analysis, including 158 urogynecologists and 226 gynecologic oncologists (GOs). Most surgeons (77.8%) will recommend concurrent procedures with another specialty, and 97.8% of urogynecologists and 95.7% of oncologists currently perform joint surgical procedures. Male surgeons, regardless of specialty, were more likely to recommend staged procedures (44% vs 31%, P < 0.001), as were GOs (28% vs 10.1%, P < 0.001). However, oncologists were more likely than urogynecologists to initiate referrals for surgical collaboration (33.3% vs 14.4%, P < 0.001). A total of 22.2% of urogynecologists and oncologists prefer staging surgical procedures. The most common barrier to a combined procedure was logistics. Urogynecologists were more concerned about the effects of cancer treatments on healing, the use of mesh implants, and financial reimbursements as compared with GOs. Treatment delay was a significantly greater concern for the oncologists.

Ten years of live surgical broadcast at Charité-MAYO conferences (2010–2019): a systematic evaluation of the surgical outcome

ObjectiveThe international Charité-MAYO Conference aims to promote international dialog on diagnostics, management, scientific breakthroughs, and state-of-the-art surgical procedures in gynecology and gynecologic oncology and senology. Live surgeries are a fundamental...

Paraaortic Lymphadenectomy in Gynecologic Oncology-Significance of Vessels Variations.

Lymphadenectomy has been an essential part of the surgical treatment in surgical oncology, as the lymphatic channels and nodes are the main dissemination pathway for most of the gynecological cancers. Pelvic and paraaortic lymphadenectomy are frequent surgical procedures in gynecologic oncology. Paraaortic lymph node dissection facilitates staging, prognosis, surgical and postoperative management of patients. It is one of the most challenging retroperitoneal surgeries. A comprehensive knowledge of the paraaortic region is mandatory. Intraoperative bleeding is the most common complication during lymphadenectomy due to direct vascular injury, poor tissue handling, exuberant retraction and possible anatomical variations of the vessels in the paraaortic region. Approximately, one-third of women will have at least one anatomic variation in the paraaortic region. It must be stressed that anomalous vessels may be encountered in every woman who will undergo surgery. Consequently, detailed knowledge of anatomical vessels variations is required in order to prevent iatrogenic vessel injury. The importance of these variations is well described in urology, vascular and general surgery. Conversely, in oncogynecological surgery, there are few articles, which described some of the vessels variations in the paraaortic region. The present article aims to propose a surgical classification and to describe the majority of vessels variation, which could be encountered during paraaortic lymphadenectomy in gynecologic oncology. Moreover, surgical considerations in order to prevent anomalous vessels injury are well described.

Pharmacotherapeutic prophylaxis and post-operative outcomes within an Enhanced Recovery After Surgery (ERAS®) program: A randomized retrospective cohort study

BackgroundPharmacotherapy prophylaxis embedded in Enhanced Recovery After Surgery (ERAS®) protocols is largely unknown because data related to agent choice, dosing, timing, and duration of treatment currently are not collected in the ERAS Interactive Audit System (EIAS®). This exploratory retrospective randomized cohort study characterized pharmacologic regimens pertaining to prophylaxis of surgical site infections (SSI), venous thromboembolism (VTE), and post-operative nausea and vomiting (PONV). Materials and methodsThe records of 250 randomly-selected adult patients that underwent elective colorectal (CR) and gynecologic/oncology procedures (GO) at an ERAS® site in North America were abstracted using REDCap. In addition to descriptive statistics, bivariate associations between categorical variables were compared. ResultsRates of SSI, VTE, & PONV were 3.3%, 1.1%, and 53.6%, respectively. Mean length of stay (LOS) for CR was 6.9 days and for GO, 3.5 days (p < 0.001). The most common antibiotic prophylaxis was one-time combination cefazolin 2 g and metronidazole 500 mg between 16 and 30 min preoperatively after chlorhexidine skin preparation. The most frequent VTE prophylaxis was tinzaparin 4500 units SC daily continued for at least 7 days after hospital discharge in oncology patients. PONV was related to longer LOS in both groups. Total morphine milligram equivalents (MME) was positively related to PONV and LOS in both CR & GO groups. ConclusionGuideline-consistent pharmacologic prophylaxis for SSI and VTE for both CR and GO patients was associated with low complication, LOS, and readmission rates. LOS in both groups was highly influenced by total MME, incidence of PONV and multi-modal anesthesia.

Nerve-sparing surgery in current gynecologic oncology

Nerve-sparing surgery is currently a very important topic in gynecologic oncology. In this review, it is shown that radical hysterectomy is not the only operation where the nerve-sparing technique can be used. Most surgical procedures in modern gynecologic oncology should spare the autonomic nerve structures. The review includes recently published articles precisely describing the nerve-sparing techniques in paraaortic and pelvic lymphadenectomy, and the modern approach to radical nerve-sparing hysterectomy. It has been shown in the literature that the quality of life of patients is directly dependent on the operation technique and its extension. As mentioned above, the nerve-sparing technique needs to be used not only in surgical procedures for cervical cancer, but more extensively also for endometrial and ovarian cancers. Modern techniques demonstrate that such an operation can be suitable both for the radicality and improved quality of life. Results of such operations are comparable to the old – not nerve-sparing techniques – both in terms of progression-free survival and overall survival. Nerve-sparing surgery in gynecologic oncology is our future. Better quality of life and greater patient satisfaction should be our goals. Studies are needed for better examination and comparison of the presented systematic nerve-sparing operations of lymphadenectomy in ovarian and endometrial cancers, and also combined with nerve-sparing radical hysterectomy.

Intraoperative Complications and Conversion to Laparatomy in Gynecologic Robotic Surgery

Introduction In this study our objective was to document complications encountered during our initial experience with the robotic system and also state the cases in which conversion to laparotomy was necessary. Material and Methods This study is a retrospective analysis of robotically performed gynecological and gynecologic oncology procedures at a single center from July 2016 to July 2018. Patient demographics and preoperative indications were obtained from the electronic medical records. Results The patients had a mean age of 53.6 years (range, 25–84 years). The operative time ranged from 1 h and 50 min to 9 h (mean, 5 h and 2 min). Most of the complications were managed within minutes and with robotic assisted suturing when necessary. Five patients out of 83 patients needed a surgical conversion from robotic surgery. Conversion rate was 6.02%. Conclusion During the study period we were able to manage complications uneventfully without requiring conversion to laparotomy most of the time. Vascular complications encountered during robotic surgery can be managed without requiring conversion to laparatomy.

Pelvic Lymphadenectomy in Gynecologic Oncology-Significance of Anatomical Variations.

Pelvic lymphadenectomy is a common surgical procedure in gynecologic oncology. Pelvic lymph node dissection is performed for all types of gynecological malignancies to evaluate the extent of a disease and facilitate further treatment planning. Most studies examine the lymphatic spread, the prognostic, and therapeutic significance of the lymph nodes. However, there are very few studies describing the possible surgical approaches and the anatomical variations. Moreover, a correlation between anatomical variations and lymphadenectomy in the pelvic region has never been discussed in medical literature. The present article aims to expand the limited knowledge of the anatomical variations in the pelvis. Anatomical variations of the ureters, pelvic vessels, and nerves and their significance to pelvic lymphadenectomy are summarized, explained, and illustrated. Surgeons should be familiar with pelvic anatomy and its variations to safely perform a pelvic lymphadenectomy. Learning the proper lymphadenectomy technique relating to anatomical landmarks and variations may decrease morbidity and mortality. Furthermore, accurate description and analysis of the majority of pelvic anatomical variations may impact not only gynecological surgery, but also spinal surgery, urology, and orthopedics.

Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada.

Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.

The Pathogenesis and Prevention of Port-Site Metastasis in Gynecologic Oncology.

Port-site metastasis (PSM) is a specific and challenging complication of laparoscopic gynecologic oncologic procedures. Research has demonstrated that PSM is associated with significant morbidity and poor outcome. The exact pathogenesis of PSM in gynecologic patients is not clear. Several preventive measures of PSM have been addressed in the relevant literature, and novel approaches to prevent this uncommon complication keep emerging. In this review, we summarized the potential mechanisms of PSM and discuss the controversies and merits of proposed preventive measures of PSM in gynecologic oncology. We undertook a literature search using the Medline database to identify studies on the pathogenesis and prevention of laparoscopic PSM. Hypotheses of PSM pathogeneses center on the immune response, pneumoperitoneum, wound contamination, and surgical method. Cogent evidence of effective prevention of PSM after laparoscopic surgery is lacking. Traditional preventive actions such as irrigation and tumor manipulation should be taken individually. Insufflation of hyperthermic CO2 and humidified CO2 leads to a better outcome in patients with a malignant tumor who undergo a laparoscopic procedure compared with normal CO2 pneumoperitoneum. Port-site resection shows no advantage in survival and results in more wound events. PSM prevention plays a crucial part in the overall care of patients with gynecologic malignancies who undergo laparoscopic procedures.

Özellikli çalıştaylar ile jinekolojik onkoloji hemşirelerinin öğrenim düzeyinin arttırılması

Aim: To evaluate the educational level of nurses through a pre and post-test after a gynecologic oncology workshop. Material and method: During the ‘Basic and Advanced Nursing Activities in Gynecologic Oncology’ workshop, pre and post-test were applied to 33 nurses. The lessons consisted of patient care before and after basic surgical procedures in gynecologic oncology; pelvic and paraaortic lymphadenectomy, radical hysterectomy, radical vulvectomy with inguinofemoral lymphadenectomy, with the additional patient care managements for bowel operations, stoma formation, chemotherapy administration, radiotherapy and brachytherapy applications. Additionally, enhanced recovery after surgery and palliative care options were also discussed. Nurses scaled their pre and post-course knowledge ranging between 1-5 points. The post-course evaluation was held at the end of the first month after the workshop. Results: Attending nurses were from all servicing parts of the hospital irrespective of their previous experience, education level or employment in gynecologic oncology. There was a statistically significant improvement of knowledge in all aspects of the course (p&amp;lt;0.05). Conclusion: There is a need for a structured post-graduate educational program specific for nurses, and the dedicated workshops will achieve this.

An analysis of operating time over the years for robotic-assisted surgery in gynecology and gynecologic oncology

Robotic-assisted surgery has a shorter learning curve enabling the surgeons to do complex surgeries in a minimally invasive way. This study analyzed how the time taken for robotic-assisted procedures in gynecology and gynecologic oncology has changed over the years in a university teaching institution. Details were taken from a prospectively maintained electronic database after obtaining permission from the hospital ethics committee. All patients who underwent robotic surgery for gynecologic problems at this center from February 2015 till December 2019 were included. The clinical, perioperative, postoperative and pathologic details were collected from the prospectively maintained database. To analyze quantitative data, student t test was used. Chi-square test was performed to compare categorical variables. 655 patients underwent robotic-assisted surgery during this period. The majority of the patients underwent surgery for uterine cancer (49%). There was a significant improvement in total surgical time (250 vs. 165min), docking time (12.6 vs 8.9min), and console time (130 vs. 95min) between the first and second year (2015-16). The next 2years (2017 and 18) did not show a significant decrease in the total surgery time and console time, but docking times improved in 2017 (5.5 vs 8.5min) compared to 2016. In 2019, there was a significant improvement in all surgical times compared to previous years. This study shows that robotic surgery has a lot of scope for improvement in surgical performance beyond its first and second years. The surgical performance as seen from the improved surgical times keeps on improving even after many years.

How much is too much? Ending excessive opioid prescribing after major gynecologic oncology procedures

How much is too much? Ending excessive opioid prescribing after major gynecologic oncology procedures

The Safety and Feasibility of Gynecologic Cancer Surgery Combined With Surgery for Pelvic Floor Dysfunction.

Women with gynecologic cancer may also present with pelvic floor dysfunction that can have a significant effect on quality of life. Combined surgical intervention for both malignancy and pelvic floor dysfunction may improve quality of life with minimal additional risk. We sought to determine the safety, feasibility, and frequency of combined gynecologic cancer surgery and surgery for pelvic floor dysfunction. This is a retrospective cohort study that utilized the National Surgical Quality Improvement Program database provided through the American College of Surgeons. The National Surgical Quality Improvement Program database was queried for patients with a final diagnosis of gynecologic malignancy from 2011 to 2015. Common Procedural Terminology codes for gynecologic oncology procedures and pelvic floor dysfunction surgery were used to identify the study population. Baseline demographics and postoperative complications were abstracted from the database for these patients and compared for patients with combined surgeries versus gynecologic cancer surgeries alone. One hundred twenty-nine women underwent combined procedures compared with 25,838 women undergoing gynecologic cancer surgery alone. Patients who underwent combined procedures were older, had lower body mass index, had higher preoperative albumin and hematocrit, and lower morbidity estimates (P < 0.05). Mean operative time was longer (226.4 vs 174.4 minutes, P < 0.01). There were no statistically significant differences in race, ethnicity, or medical comorbidities. There were no statistically significant differences in postoperative complications or readmissions between the 2 groups (P > 0.1). Combined gynecologic cancer and pelvic floor dysfunction procedures are feasible and can safely be performed without differences in postoperative complications in appropriately selected patients.

Factors affecting pain during outpatient clinic based surgical procedures in gynecologic oncology.

Colposcopy-directed punch biopsy (punch biopsy) and endocervical curettage (ECC) are accompanied by considerable pain. However, many physicians perform these procedures without adequate pain management. Therefore, identification of factors affecting pain experienced during the procedures may encourage physician effort in selective pain management. This study investigated factors affecting the severity of pain experienced during punch biopsy and ECC in an outpatient clinic of gynecologic oncology department.In this retrospective, exploratory study, a total of 101 Korean patients with abnormal cervical cytology underwent punch biopsy and ECC under a paracervical block performed for pain relief. Residents under training performed these procedures and recorded patient-reporting maximum Numeric Rating Scale (NRS) scores experienced during the procedures. Residents were classified into four outpatient clinic training groups (1st–4th); the group designators correspond to the resident's experience in performing these procedures. A linear mixed model adjusted for physician factors such as either residents or outpatient clinic training groups was used to analyze the association between each variable and maximum NRS score.Among the outpatient clinic training groups, maximum NRS scores significantly decreased in the 4th group, compared with those in the 1st group although those were not different among groups when adjusted for residents. Some of cervical cytology findings and discrepancies between the severity of cervical cytology results and those of punch biopsy or ECC showed significant associations with maximum NRS scores. However, when adjusted for either residents or outpatient clinic training groups, maximum NRS scores were not different by age, body mass index, presence of menopause, cervical cytology findings, discrepancies between the severity of cervical cytology results and those of punch biopsy or ECC, and tissue volume.There are no significant factors affecting the severity of pain experienced during punch biopsy and ECC.