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To determine whether minimally invasive surgery (MIS) for uterine myomas is used differentially based on race and ethnicity.Retrospective cohort study.Quaternary care academic hospital in the United States.Patients undergoing hysterectomy or myomectomy for uterine myomas between March 15, 2015, and March 14, 2020 (N = 1311). Cases involving correction of pelvic organ prolapse, malignancy, peripartum hysterectomy, or combined procedures with nongynecologic specialties were excluded. Racial/ethnic composition of the study population was 40.0% non-Hispanic white (white), 27.9% non-Hispanic black (black), 14.0% Hispanic, 13.7% non-Hispanic Asian (Asian), and 4.3% non-Hispanic American Indian/Alaska Native/Pacific Islander/Other.Hysterectomy, myomectomy.Of the 1311 cases, 35.9% were minimally invasive hysterectomy, 16.4% abdominal hysterectomy, 35.6% minimally invasive myomectomy, and 12.1% abdominal myomectomy. MIS rates were 94.7% among fellowship-trained minimally invasive gynecologic surgery subspecialists, 44.2% among obstetrics and gynecology specialists, and 46.8% among gynecologic oncologists. There were disparities in surgeon type based on race/ethnicity, with 59.8% of white patients having undergone surgery with a minimally invasive gynecologic surgery subspecialist vs 44.0% of black patients and 45.7% of Hispanic patients. Black and Hispanic patients were less likely to undergo MIS overall vs white patients (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.22-0.48 and aOR 0.44, 95% CI 0.28-0.72, respectively). Black and Hispanic patients undergoing hysterectomy were less likely than white patients to undergo MIS (aOR 0.33, 95% CI 0.21-0.51 and aOR 0.35, 95% CI 0.20-0.60, respectively). There were no significant differences in rates of MIS based on race/ethnicity for myomectomies nor differences in major or minor complications by race/ethnicity overall.At a quaternary care institution, black and Hispanic patients were significantly less likely than white patients to undergo MIS for uterine myomas, particularly for hysterectomy.

STUDY OBJECTIVE: Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void prior to discharge). The primary objective of this study is to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol to more strict voiding protocols. Secondary outcomes include length of hospital stay and urinary tract infection (UTI). DESIGN: Retrospective cohort study. SETTING: Quaternary-care academic hospital in the United States. PATIENTS: Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n=652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded. INTERVENTIONS: Hysterectomy, myomectomy MEASUREMENTS AND MAIN RESULTS: POUR, defined as the need for re-catheterization within 24 hours of catheter removal, along with UTI and length of stay, were compared between liberal and strict voiding protocols. Sub-group analysis was performed for those undergoing minimally invasive surgery (MIS). 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different among groups (2.6% liberal vs. 4.9% strict, p = 0.14). UTI also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p= 0.86). Similar results were seen specifically among those that underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p= 0.17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p= 0.28). Median length of stay (IQR) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall (IQR 15 hours), 9 (4) liberal vs. 36 (34) strict, p

Compare odds of postoperative urinary symptoms in women who had cystoscopy after benign laparoscopic hysterectomy with 50% dextrose and with normal saline solution with intravenous indigo carmine.Retrospective cohort study.Two tertiary care centers.All women who underwent benign laparoscopic hysterectomy and intraoperative cystoscopy carried out by a single surgeon.We compared postoperative urinary symptoms in patients who received 50% dextrose cystoscopy fluid (January 2016-June 2017) with those who received saline cystoscopy with intravenous indigo carmine (November 2013-April 2014).A total of 96 patients had cystoscopy with 50% dextrose and 104 with normal saline with intravenous indigo carmine. Differences in baseline characteristics of the two groups of participants mainly reflected institutional population diversity: age (45.2 vs 41.9, p = .01), body mass index (26.9 vs 33.4, p.01), race, current smoking status (1% vs 7.8%, p = .04), diabetes (2.1% vs 11.5%, p = .01), history of abdominal surgery (53.1% vs 74%, p.01), hysterectomy type, receipt of intraoperative antibiotics (92.7% vs 100%, p.01), recatheterization (10.4% vs 0%, p.01), and removal of catheter on postoperative day 0 (66.7% vs 12.5%, p.01). Urinary symptoms were similar for 50% dextrose and saline (12.5% vs 7.7%, p = .19). After adjusting for age, body mass index, race, diabetes, and day of catheter removal, there remained no significant differences in urinary symptoms between the groups (odds ratio 3.19 [95% confidence interval, 0.82-12.35], p = .09). One immediate bladder injury was detected in the saline group and 1 delayed lower urinary tract injury in the 50% dextrose group.Overall, most women experienced no urinary symptoms after benign laparoscopic hysterectomy. There were no significant differences in postoperative urinary symptoms or empiric treatment of urinary tract infection after the use of 50% dextrose cystoscopy fluid as compared with normal saline. The previous finding of increased odds of urinary tract infection after dextrose cystoscopy may be due to use in a high-risk population.

To assess rates of and factors associated with complications and reoperation after myomectomy.Population-based cohort study.All non-Veterans Affairs facilities in the state of California from January 1, 2005, to December 31, 2018.Women undergoing abdominal or laparoscopic myomectomy for myoma disease were identified from the Office of Statewide Health Planning and Development datasets using appropriate International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes.Demographics, surgery facility type, facility surgical volume, and surgical approach were identified. Primary outcomes included complications occurring within 60 days of surgery and reoperations for myomas. Patients were followed up for over an average of 7.3 years. Univariate and multivariable associations were explored between the above factors and rates of complications and reoperation. All odds ratios (ORs) are adjusted ORs.Of the 66 012 patients undergoing myomectomy, 5265 had at least one complication (8.0%). Advanced age, black, Asian race, MediCal and Medicare payor status, academic facility, and medical comorbidities were associated with increased odds of a complication. Minimally invasive myomectomy (MIM) was associated with decreased complications compared with abdominal myomectomy (AM) (OR, 0.29; 95% confidence interval [CI], 0.25-0.33; p.001). Overall, 17 377 patients (26.3%) underwent reoperation. Medicare and MediCal payor status and medical comorbidities were associated with increased odds of a repeat surgery. Reoperation rates were higher in the MIM group over the entire study period (OR, 2.33; 95% CI, 1.95-2.79; p.001). However, the odds of reoperation after MIM decreased each year (OR, 0.93; 95% CI 0.92-0.95; p.001), with the odds of reoperation after AM surpassing MIM in 2015.This study identifies outcome disparities in the surgical management of myomas and describes important differences in the rates of complications and reoperations, which can be used to counsel patients on surgical approach. These findings suggest that MIM can be considered a lasting and safe approach in properly selected patients.

Study Objective To evaluate if there is a difference in hospital readmission when patients are required to void versus not required to void before discharge after a same-day gynecologic procedure. Design A retrospective cohort study. Setting An urban tertiary care hospital. Patients A total of 4743 patients undergoing same-day gynecologic surgery. Interventions The readmission rates of patients discharged home without an order to void were compared with those with an order to void. Chart review was performed for readmission within 30 days and time to discharge from the postanesthesia recovery unit. Measurements and Main Results There was no statistically significant difference in the readmission rate between patients with or without an order to void before discharge (0.4% vs 0.9%, p = .08). Only 3 patients were readmitted for urinary retention, all with an order to void before discharge. Compared with gynecologic surgeons treating benign conditions, gynecologic oncologists were 23% more likely to place an order to void before discharge. Patients without an order to void spent approximately 59 minutes more in the postanesthesia care unit compared with those required to void (p Conclusion Discharge without an order to void is a safe practice in patients undergoing same-day gynecologic procedures. The risk of postdischarge urinary retention is low, consistent with previously reported rates in the literature.

Evaluate inter-rater and intrarater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy.Validation study.Academic medical center.Total of 11 academic obstetrician-gynecologists with varying years of postresidency training, clinical practice, and surgical volumes.Application of a novel scoring tool to evaluate surgical complexity of 150 sets of images taken in a standardized fashion before surgical intervention (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Using only these images, raters were asked to assess uterine size, number, and location of myomas, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions in relevant locations. Surgical complexity was staged on a scale of 1 to 4 (low to high complexity).Number of postresidency years in practice for participating surgeons ranged from 2 to 15, with an average of 8 years. A total of 8 obstetrician-gynecologists (72.7%) had completed a fellowship in minimally invasive gynecologic surgery. Six (54.6%) reported an annual volume of50 hysterectomies. Raters reported that 95.4% of the images were satisfactory for assessment. Of the 150 sets of images, most were found to be stage 1 to 2 complexity (stage 1: 23.8%, stage 2: 41.6%, stage 3: 32.8%, stage 4: 1.8%). The level of inter-rater agreement regarding stage 1 to 2 vs 3 to 4 complexity was moderate (κ = 0.49; 95% confidence interval [CI], 0.42-0.56). Moderate inter-rater agreement was also found between surgeon raters with an annual hysterectomy volume50 (κ = 0.49; 95% CI, 0.40-0.57) as well as between surgeon raters with fellowship experience (κ = 0.50; 95% CI, 0.42-0.58). Intrarater agreement averaged 80.2% among all raters and also achieved moderate agreement (mean weighted κ = 0.53; range, 0.38-0.72).This novel scoring tool uses clinical assessment of preintervention anatomic images to stratify the surgical complexity of endoscopic hysterectomy. It has rich and comprehensive evaluation capabilities and achieved moderate inter-rater and intrarater agreement. The tool can be used in conjunction with or instead of traditional markers of surgical complexity such as uterine weight, estimated blood loss, and operative time.

Study Objective We aim to describe the clinical and laparoscopic features of suspected endometriosis lacking histologic confirmation. Design Retrospective cohort study. Setting Quaternary community medical center. Patients or Participants All consecutive pathology reports from patients who underwent surgery for clinically suspected endometriosis by three surgeons from the Division of Minimally Invasive Gynecologic Surgery between 01/01/2016 and 12/31/2019 were reviewed and categorized in two groups: endometriosis histologically confirmed, and endometriosis not histologically confirmed. A retrospective analysis of the patients without confirmed endometriosis was performed by evaluating clinical, surgical, and histologic characteristics. Interventions Laparoscopic surgery. Measurements and Main Results Of 487 patients, endometriosis was histologically confirmed in 419 (86.0%) and not confirmed in 68 (14.0%). Study group age range was 16 to 48 (median 30.5). Patients clinically presented with a variety of symptoms suspicious for endometriosis. 23 (33.8%) of the 68 patients without confirmed endometriosis had other gynecologic abnormalities, including leiomyomata, endometrial polyps or adenomyosis. 39 cases (57.3%) without confirmed endometriosis had non-specific histopathologic findings such chronic inflammation, fibrosis, adhesions, reactive changes, and hemosiderin deposits, while the remaining 29 (42.6%) had no histologic abnormalities. On laparoscopic evaluation, lesions appeared heterogeneous and suspicion of endometriosis was high in 10 (15%), low in 36 (53%), and absent in 22 (32%) patients. Laparoscopically, there were 14 cases without any abnormality visualized in the group with no histologic abnormalities (48%) compared to only 5 cases in the group with histologic findings (13%). Conclusion Despite the absence of histologically confirmed endometriosis, patients with clinically suspected disease still experience significant symptoms and management decisions remain challenging for both patientsand clinicians. Over half of the patients without confirmed endometriosis had non-specific histopathologic findings. Further research should analyze how these findings correlate to the clinical symptoms of patients with suspected endometriosis and role in management in such patients.

Study Objective To evaluate if smooth muscle cells can be detected in pelvic washings at time of intact hysterectomy. Design A multi-centered pilot cohort study. Setting Two academically affiliated tertiary referral centers. Patients or Participants Patients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. Interventions Pelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, slides were stained using hematoxylin and eosin (HE three subjects were excluded due to unplanned morcellation. Smooth muscle uterine cells were detected in 1 pre-wash specimen and 2 post-wash cases. The group with positive washings was noted to have longer procedure time (136 minutes versus 114 minutes), lower blood loss (25 mL versus 86 mL) and higher uterine weight compared to negative washings group (242 grams versus 234 grams). Conclusion Tissue dissemination of uterine cells may be possible at time of hysterectomy. Larger prospective studies are needed in order to better describe the incidence of and risk factors for tissue dissemination.

Study Objective Enhanced Recovery after Surgery (ERAS) pathways have led to improved perioperative outcomes in hospital quality of care and cost parameters in gynecologic surgery. There is less data on the impact of ERAS on patient-reported recovery experience after laparoscopic hysterectomy in the outpatient setting. Design An IRB-approved single-blinded non-randomized prospective cohort study compared two cohorts of patients who underwent laparoscopic hysterectomy: perioperative ERAS protocol or standard perioperative care at a single institution. Surveys were distributed to patients at their initial postoperative appointment. Setting Urban academic-affiliated community tertiary care center. Patients or Participants Women undergoing laparoscopic hysterectomy by high volume surgeons (>10 hysterectomies per year). Interventions Perioperative ERAS protocol; postoperative self-administered survey 2 weeks after surgery. Measurements and Main Results Between 8/1/18 and 4/9/19, 73 patients undergoing laparoscopic hysterectomy were surveyed: 37 (ERAS) cases and 44 under standard perioperative care (controls). 8 surveys from the control group were excluded due to predefined criteria. The patients responded to Likert scaled questions regarding ability to perform daily activities (ascending difficulty from 1 to 5). Conclusion Implementation of ERAS does not adversely affect self-reported patient recovery. At two weeks following laparoscopic hysterectomy, the majority of patients returned to baseline physical activity, bowel function, appetite & diet, and required no additional narcotic medications.

Study Objective The objective of this video is to provide an example of how to teach laparoscopic skills, specifically FLS (fundamentals of Laparoscopic Surgery) virtually and remotely. Design This is an educational video. Institutional review board approval was not required for this video article as the video does not describe a clinical case but rather laparoscopic simulation. Setting Academic teaching hospital. Patients or Participants Gynecologic surgery trainees. Interventions The video demonstrates how to set up a portable laparoscopic trainer box for mobile devices and provides tips and tricks to optimize a virtual platform for teaching FLS (Fundamentals of Laparoscopic Surgery). Measurements and Main Results The key elements for successful implementation of virtual laparoscopic skills training include accessibility to low-cost portable laparoscopic trainers, a mobile device and a virtual platform. Conclusion Tele-simulation for laparoscopic skills training is feasible and cost-effective.

Study Objective To evaluate if smooth muscle cells can be detected in pelvic washings at the time of intact hysterectomy. Design A multicentered pilot cohort study (Canadian Task Force classification II-2). Setting Two academically affiliated tertiary referral centers. Patients Patients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. Interventions Pelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, and slides were stained using hematoxylin and eosin, smooth muscle actin, and desmin and interpreted by 1 expert pathologist at each institution. Measurements and Main Results Thirty-eight subjects were recruited; 3 subjects were excluded because of unplanned morcellation. Smooth muscle uterine cells were detected in 1 prewash specimen and 2 postwash specimens. The group with positive washings was noted to have longer procedure times (136 vs 114 minutes), lower blood loss (25 vs 86 mL), and higher uterine weight (242 vs 234 g) compared with negative washings group. Conclusion Tissue dissemination of uterine cells may be possible at the time of hysterectomy. Larger prospective studies are needed to better describe the incidence of and risk factors for tissue dissemination.

Video Objective Vessel ligation, typically the uterine artery, has been described as a preventative measure for bleeding in laparoscopic myomectomy. The internal iliac, or hypogastric artery, a vessel that obstetricians are familiar with ligating in the setting of postpartum hemorrhage, can also be used in laparoscopic myomectomy. In this video, we will review existing literature on vessel ligation in laparoscopic myomectomy, and then demonstrate internal iliac artery ligation as a prophylactic measure, as well as one to treat acute intraoperative hemorrhage. Setting Tertiary care academic hospital. Interventions Laparoscopic myomectomy. Conclusion Internal iliac artery ligation can be used to prevent and treat bleeding during difficult laparoscopic myomectomy.

To describe opioid distribution and patient use after gynecologic procedures.Survey study (Canadian Task Force classification III).An urban academic tertiary care hospital.Ninety-six gynecologists in the Boston area, and 147 patients who underwent a benign hysterectomy between January 2015 and April 2016.Survey study of physicians and patients composed of 2 parts: (1) a physician survey on opioid prescribing practices after gynecologic procedures and (2) a patient survey on opioid consumption after hysterectomy. Physicians were contacted via e-mail to participate in an online survey. Eligible patients were contacted via telephone and asked to participate in a telephone survey.Fifty-one physicians responded to an online survey and prescribed a mean of 27.1 tablets (range, 5-30) of oxycodone (5 mg) or hydromorphone (2 mg) after abdominal hysterectomy (AH), a mean of 22.6 tablets (range, 5-30) after laparoscopic hysterectomy (LH), and a mean of 16.8 tablets (range 5-30) after vaginal hysterectomy (VH). Physicians prescribed more opioids for AH compared with LH, with a mean difference of 4.5 tablets (standard deviation, 4.7; p .01), and AH compared with VH, with a mean difference of 6.8 tablets (standard deviation, 5.8; p .01), which were both statistically significant. In addition, 40.0% of physicians prescribe opioids after a hysteroscopy and 19.2% after a dilation and curettage. Fifty-six patients participated in the telephone survey: 64.6% of patients used less than half of the opioids prescribed and 16.1% used none. For AH, patients reported being prescribed a mean of 25.7 tablets and using a mean of 8.7 tablets (range, 0-60; 33.9% used). For LH or VH, patients reported being prescribed a mean of 24.2 tablets and using a mean of 10.0 tablets (range, 0-30; 41.4% used). Opioid consumption was not significantly different for AH compared with LH or VH (p = .613 for AH to LH, p = .279 for AH to VH).With respect to the physician survey, we conclude there is a wide range of opioid prescription practices and patient opioid consumption after gynecologic surgery. The patient survey revealed that physicians prescribe fewer opioid tablets after a minimally invasive approach to hysterectomy versus open hysterectomy. However, most patients use less than half of prescribed opioids, and a fraction did not use any opioids at all.

Background Safe tissue removal is a challenge for minimally invasive procedures such as myomectomy, supracervical hysterectomy, or total hysterectomy of a large uterine specimen. There is concern regarding disruption or dissemination of tissue during this process, which may be of particular significance in cases of undetected malignancy. Contained tissue extraction techniques have been developed in an effort to mitigate morcellation-related risks. Objective The objective of the study was to quantify perioperative outcomes of contained tissue extraction using power morcellation, specifically evaluating parameters of tissue or fluid leakage from within the containment system. Study Design This was a study including a multicenter prospective cohort of adult women who underwent minimally invasive hysterectomy or myomectomy using a contained power morcellation technique. Blue dye was applied to the tissue specimen prior to removal to help identify cases of fluid or tissue leakage from within the containment system. Results A total of 76 patients successfully underwent the contained power morcellation protocol. Mean time for the contained morcellation procedure was 30.2 minutes (±22.4). The mean hysterectomy specimen weight was 480.1 g (±359.1), and mean myomectomy specimen weight was 239.1 g (±229.7). The vast majority of patients (73.7%) were discharged home the same day of surgery. Final pathological diagnosis was benign in all cases. Spillage of dye or tissue was noted in 7 cases (9.2%), although containment bags were intact in each of these instances. Conclusion Findings are consistent with prior work demonstrating the feasibility of contained tissue extraction; however, further refinement of this technique is warranted.

To compare the operative time of contained hand tissue extraction with power morcellation and to quantify the learning curve required to develop this skill.A retrospective cohort study (Canadian Task Force classification II-3).Lahey Hospital and Medical Center, a suburban academic tertiary care center serving a broad base of patients.Eighty-eight women undergoing laparoscopic hysterectomy requiring morcellation or tissue extraction from 2012 through 2015.Power morcellation before the institution's ban on power morcellation and contained hand tissue extraction instituted in a response to the ban.Data were collected to compare the operative time and perioperative outcomes of morcellation before discontinuation of the power morcellator and after adaptation of a contained hand tissue extraction protocol. The data were then used to determine a learning curve for the new procedure. Eighty-eight consecutive cases of laparoscopic hysterectomy requiring morcellation were identified during the study duration, with 46 patients undergoing power morcellation and 42 undergoing hand tissue extraction. The 2 groups were similar overall in body mass index (28.9 vs 29.5, p = .70), prior laparoscopy (28% vs 21%, p = .46) or laparotomy (39% vs 21%, p = .07), removal of the cervix (56% vs 86%, p .01), and uterine weight (581 vs 628 g, p = .56). The hand tissue extraction group had an average operating room time of 170 minutes compared with 154 minutes (p = .08) for the power morcellation group. The 2 surgeons performed 32 and 10 hand tissue extractions, respectively, with a decrease in 0.7 and 3 minutes per case, respectively, over the course of 7 months (p = .3 and .6, respectively).Contained hand tissue extraction was similar to power morcellation in the total operative time. The learning curve of surgeons performing contained hand tissue extraction showed a nonsignificant trend toward improvement in the operative time with an increasing number of cases.

OBJECTIVE:In a 3-year period, the main mode of access for hysterectomy at Brigham and Women's Hospital changed from abdominal to laparoscopic. We estimated potential effects of this shift on perioperative outcomes and costs.METHODS:We compared the perioperative outcomes and the cost of care for all