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Background: To date, there remains a paucity of present-day literature on the topic of demographics and the biopsy-proven pathological positivity rate of endometriosis. Objective: The goal of this study was to explore the association between patients' demographics and other concomitant gynecological conditions or procedures and the pathological positivity rate of excision of endometriosis. Design: Retrospective cohort study. Methods: All women >18 years old who underwent laparoscopic surgery for endometriosis at a tertiary care hospital from October 2011 to October 2020. Women were classified into two groups: (1) Study group: women with >80% pathological positivity rate of endometriosis and (2) Control group: women with <80% pathological positivity rate. Results: A total of 401 women were included in the analysis. No difference was noted in the 80% pathological positivity rate based on body mass index [BMI; 68.7% in normal BMI versus 80% in underweight, versus 74.5% in overweight, and 74.1% in obese patients (p = 0.72)]. The percentage of patients reaching 80% pathological positivity of endometriosis was lower in women who had undergone previous laparoscopy for endometriosis compared to surgery naïve women (66.5% versus 76.5%, p = 0.03). In addition, a higher percentage of women who underwent concomitant hysterectomy (83.5% versus 68.8% for non-hysterectomy, p = 0.005) or bilateral oophorectomy (92.7% versus 70.0% for non-oophorectomy, p = 0.002) reached 80% pathological positivity. Women with an associated diagnosis of fibroids (79.7% versus 70.5%) or adenomyosis (76.4% versus 71.7%) were more likely to reach 80% pathological positivity compared to women without any other coexisting pathology; however, the observed differences were not statistically significant. After applying a log-binomial regression model, compared to White non-Hispanics, Hispanic patients were 30% less likely to reach 80% positivity (RR: 0.70, 95% CI: 0.49–1.02), although not statistically significant. Conclusion: No significant racial difference was found when comparing the rates of 80% pathological positivity of suspected endometriosis lesions among groups. Endometriosis pathological positivity rate was unaffected by patients' BMI and the presence of concomitant pathologies. In addition, prior laparoscopic surgery for endometriosis might cause tissue changes that result in a decrease in the observed pathological positivity rate of endometriosis lesions during subsequent surgeries. [ABSTRACT FROM AUTHOR]

Objective: History of cesarean section (CS) can affect future hysterectomy; however most studies on this include all routes of hysterectomy. This study aimed to evaluate the effect of history of CS on laparoscopic and robotic hysterectomies by minimally invasive gynecologic surgery (MIGS) fellowship-trained surgeons. Materials and Methods: This retrospective, cross-sectional study was of patients who had laparoscopic hysterectomy at a single tertiary-care center in the southeastern United States. A convenience sample was collected of all patients who underwent laparoscopic hysterectomy with a MIGS-trained surgeon from 2016 to 2019. Primary outcomes were estimated blood loss (EBL), operative time, and intra- and postoperative complication rates, including blood transfusions, conversion to laparotomy, vascular or visceral injury, surgical-site complications, and emergency-room visits. Measures were compared between patients with a history of CS and those without a history of CS, using χ2 and Student's t-tests. Log-linear models with constant coefficient of variation and logistic-regression models adjusted for body mass index (BMI) were used to estimate the association between history of CS and surgical outcomes. Results: A total of 484 hysterectomies were included. 152 patients had at least 1 CS and 332 did not have any CS. There were no significant demographic differences between the groups. In patients with a history of CS, 69 (45%) had 1, 52 (34%) had 2, and 30 (21%) had 3 or more prior CS. When comparing the cohort with a history of CS and the cohort without a history of CS, log-linear and logistic regression models adjusted for BMI did not show any difference between EBL (mean 62 mL versus 57 mL), operative time (mean 152 minutes versus 148 minutes), or total complication rate (27% versus 25%). There was no relationship between number of prior CS and operative outcomes. Conclusions: Neither a history of any CS nor the total number of prior CS affected EBL, operative time, or intraoperative or postoperative complications of laparoscopic hysterectomies performed by MIGS-trained surgeons. This can be helpful for counseling patients and setting expectations of surgical complexity and complication risks. (J GYNECOL SURG 40:156) [ABSTRACT FROM AUTHOR]

Aim: This study aimed to compare introduced robotic‐assisted hysterectomy (RAH) and skilled total laparoscopic hysterectomy (TLH) for the treatment of benign gynecological diseases. Methods: Patients who underwent RAH or TLH by two surgeons at the Tottori University Hospital between January 2018 and May 2022 were included in this retrospective study. Inclusion criteria were patients with 100–300 g of uterine weight. The exclusion criteria were patients with stage IV endometriosis. Mean operative time and learning curve were compared among the first‐half RAH, second‐half RAH, and TLH groups. Results: There were 40 eligible cases (first‐half RAH: 20 cases, second‐half RAH: 20 cases) in the RAH group and 44 cases in the TLH group. The total operative time (TOT) of the second half of RAH was significantly shorter than that of the first half of RAH (p = 0.021) and was comparable to that of the TLH group. The operative time (OT) of the second half of RAH was shorter than that of TLH (p = 0.023). The preparation time of TLH was shorter than that of the RAH group (p < 0.01). The learning curve of the TOT in RAH crossed that of TLH on the 31st case of RAH. In contrast, both curves of the OT crossed on the 11th case of RAH. Conclusion: The TOT of the introduced RAH was equivalent to that of skilled TLH in approximately 30 cases since the first RAH. Furthermore, the OT of RAH was comparable to that of TLH in approximately 10 cases of surgery since the first RAH. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated outcomes following hysterectomies performed for benign indications in surgeries that meet criteria for complexity, compared to those that did not. Materials and Methods: This retrospective study of hysterectomies performed for benign indications compared outcomes in surgeries deemed complex versus noncomplex. Surgery was defined as complex if one or more of the following factors were present: uterine weight >250 g; surgical history of 2 prior cesarean deliveries; or prior laparoscopy or laparotomy for abdominal myomectomy, endometriosis resection, lysis of adhesions, or other surgery on a pelvic organ. Surgeon-level factors were evaluated, including minimally invasive hysterectomy (MIH) use, postoperative length of stay (LOS), and complication rates. Results: From January 2017 to August 2021, 833 women had hysterectomies for benign indications; 603 hysterectomies were complex. These hysterectomies by low-volume surgeons were more likely to have complications than by high-volume surgeons (15.6% versus 5.4%; p < 0.001). These operations by high-volume surgeons were more-frequently MIH (83.4% versus 48.7%; p = 0.009), had fewer blood losses ≥500 mL (1.2% versus 8.0%; p < 0.001), and were less likely to need overnight admissions (74.9% versus 94.5%; p < 0.001). Conclusions: Complex hysterectomies performed for benign indications by high-volume gynecologic surgeons lead to fewer complications and shorter LOS, and are more likely to be performed with a minimally invasive approach. (J GYNECOL SURG 39:229) [ABSTRACT FROM AUTHOR]

Objective: This study quantified the COVID-19 pandemic's impact on same-day discharges for minimally invasive hysterectomy and evaluated the effect on postoperative morbidity and health care use. Materials and Methods: This retrospective cohort study, from March 2018 to October 2021 at a single institution, included women older than age 18 who had laparoscopic, vaginal, or robotic-assisted hysterectomy by any gynecologic surgeon. Primary outcome was rate of same-day hospital discharge. Secondary measures were length of stay and rates of 30-day postoperative morbidity and health care use. Univariate and multivariable logistic regression analyses were conducted to evaluate associations between patients' characteristics and likelihood of same-day discharge. Results: There were 1608 women included, 896 in a prepandemic cohort and 712 in a postpandemic cohort. Surgeon subspecialty rates were similar between groups, but surgical approaches differed, with more laparoscopic procedures in the postpandemic cohort (p = 0.007). Case order and lengths, and concurrent procedures were not different between groups. Postpandemic patients were more likely to be discharged on the same day even after controlling for confounders in a multivariable regression (32% versus 54%, respectively; odds ratio: 2.78; p < 0.001). Rates of 30-day postoperative complications, transfusions, emergency department visits, readmissions, reoperations, and mortality were not significantly different. Conclusions: The COVID-19 pandemic was associated with increased same-day discharges without increases in 30-day postoperative complications. The data confirmed that same-day discharge following minimally invasive hysterectomy was safe for managing hospital constraints caused by the COVID-19 pandemic. (J GYNECOL SURG 39:170) [ABSTRACT FROM AUTHOR]

The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. Key Points The surgical management of PAS requires careful planning and expertise. Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality. Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive hysterectomy is a common gynecologic procedure. Numerous studies have found that a same day discharge (SDD) is safe following this procedure. Research has found that SDDs decrease resource strain, nosocomial infections, and financial burden for both the patient and healthcare system. Due to the recent COVID‐19 pandemic, the safety of hospital admissions and elective surgeries was called into question. Objective: To assess the rates of SDD among patients who underwent a minimally invasive hysterectomy before and during the COVID‐19 pandemic. Study Design: A retrospective chart review was performed from September 2018 to December 2020 on 521 patients, who met inclusion criteria. Descriptive analysis, chi‐square tests of association, and multivariable logistic regression were used for analysis. Results: There was a significant difference between rate of SDDs pre‐COVID‐19 (12.5%) versus during the COVID‐19 period (28.6%) (p < 0.001). Surgical complexity was predictive of not being discharged the same day of surgery (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 2.2–8.8), as was surgical completion time after 4 p.m. (OR = 5.2, 95% CI = 1.1–25.2). There was no difference in readmissions (p = 0.209) and emergency department (ED) visits (p = 0.973) between SDD and overnight stay. Conclusion: Rates of SDD for patients undergoing minimally invasive hysterectomy were significantly increased during the COVID‐19 pandemic. SDDs are safe; the number of readmissions and ED visits did not increase among patients who were discharged on the same day. [ABSTRACT FROM AUTHOR]

Objective: To review of our hospital's experiences in transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and challenges we encountered in performance of the procedure, so as to provide help to medical institutions who are preparing to carry out vNOTES. Methods: We retrospectively analyzed the data of all patients receiving vNOTES in our hospital from April 2018 to May 2021. Data we collected cover the general characteristics, perioperative outcomes, and complications of the patients. Results: A total of 1147 patients underwent vNOTES in the past 3 years at our hospital. The total numbers of adnexal surgery, myomectomy, hysterectomy, pelvic floor reconstruction surgery, and malignant tumor surgery performed via vNOTES were 902, 98, 82, 51, and 14, respectively. Eighteen patients were converted to transabdominal laparoscopic surgery. A total of 38 patients had complications according to Clavien‐Dindo classification, and the total complication rate was 3.31%. Among these cases of complications, 27 were Grade I, 4 were Grade II, and 7 were Grade III. No complications of Grade IV or V were reported. Conclusion: The application of vNOTES is safe and feasible for most gynecological surgeries. Moreover, hospitals with traditional laparoscopic equipment are advised to try this technique as there is no need to purchase additional expensive equipment. However, since vNOTES represents a novel approach, the long‐term complications and efficacy associated with this technique are pending to be verified through large‐scale prospective multicenter randomized controlled studies. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to establish the rate at which routine postoperative renal ultrasonography is able to detect urinary tract injury following gynecological surgery.Methods: A retrospective analysis was carried out for the study period 2015-2019 of all patients who had undergone subtotal or total hysterectomy, or radical hysterectomy or salpingectomy, salpingo-oophorectomy, or oophorectomy, and subsequently had a urinary tract injury.Results: In a total of 2068 patients, 25 urinary tract injuries occurred (1.21%), including 21 urinary bladder lesions (1.02%) and four ureteral injuries (0.19%). The incidence of urinary tract injuries was 3% in oncologic procedures and 0.86% in procedures for benign disease. Nineteen injuries (76%) were diagnosed intraoperatively, and six injuries (24%) were clinically diagnosed after surgery. All of the patients had uneventful postoperative renal ultrasound examinations.Conclusion: Routine postoperative renal ultrasonography was not capable of diagnosing urinary tract injuries after gynecologic surgery. Routine postoperative renal ultrasound examinations should, therefore, not be performed after gynecologic operations. [ABSTRACT FROM AUTHOR]

Objective: This research was conducted to evaluate the incidence and predictors of appropriate antibiotic prophylaxis prior to hysterectomy performed for benign indications in patients with penicillin allergy. Materials and Methods: This was a retrospective cohort study of patients with self-reported penicillin allergy undergoing hysterectomy for benign indications at an academic medical center in 2018. The primary outcome was appropriate preoperative antibiotic administration based on the American College of Obstetricians and Gynecologists guidelines. Secondary outcomes included predictors of receiving appropriate antibiotic prophylaxis and incidence of preoperative allergy testing. Standard analysis for descriptive data was performed, and a multivariable logistic regression was fit to explore predictors for receiving appropriate preoperative antibiotics. Results: For this research, 230 patients met the inclusion criteria. Appropriate antibiotics were administered to 42.6% (n = 98) of patients. There were no significant differences in demographic factors between the groups. Preoperative allergy testing was performed in 3.9% of patients (n = 9). On multivariable logistic regression, the odds of receiving appropriate antibiotics were 0.16 times lower among methicillin-resistant Staphylococcus aureus carriers (confidence interval [CI]: 0.03, 0.91; p = 0.04), 2.50 times higher among those with 3 or more antibiotic allergies (CI: 1.15, 5.42; p = 0.02), 1.97 times higher among those with at least 1 comorbidity (CI: 1.06, 3.67; p = 0.03), 8.94 times higher if anaphylaxis was the reported allergy (CI: 3.53, 22.63; p < 0.001), and 6.24 times higher if the reported allergy was hives (CI: 3.17, 12.29; p < 0.001). Conclusions: More than half of patients with penicillin allergy undergoing hysterectomy received inappropriate prophylactic antibiotics. Patients with more medical comorbidities, greater number of antibiotic allergies, and immunoglobulin E–mediated hypersensitivity reactions to penicillin had higher odds of receiving appropriate prophylaxis. (J GYNECOL SURG 38:287) [ABSTRACT FROM AUTHOR]

Aim: We devised a simplified nerve‐sparing radical hysterectomy that is simpler than commonly used procedures. Methods: We retrospectively examined 16 cases of classical non‐nerve‐sparing radical hysterectomy (non‐nerve‐sparing group) and 16 cases of simplified nerve‐sparing radical hysterectomy (nerve‐sparing group) performed between 2019 and 2020. We examined and compared the duration of surgery, blood loss, perioperative complications, postoperative urinary function (presence or absence of urinary sensation, number of days with residual urine measurement, and frequency and duration of oral sustained release urapidil capsules and self‐catheterization), and short‐term prognosis between the two groups. Results: Compared to conventional non‐nerve‐sparing radical hysterectomy, the duration of surgery for nerve‐sparing radical hysterectomy was significantly shorter (407 [339–555] min vs. 212 [180–356] min; p < 0.001), and blood loss was significantly less. Compared to the nerve‐sparing group, the non‐nerve‐sparing group had more cases of oral urapidil use and a higher frequency of clean intermittent catheterization. Clean intermittent catheterization was required in two cases in the nerve‐sparing group; however, it was withdrawn at 180 and 240 days. Conversely, clean intermittent catheterization was still required in three cases in the non‐nerve‐sparing group. There were no statistically significant differences in progression‐free survival and overall survival between the two groups. Conclusion: The simple nerve‐sparing radical hysterectomy resulted in shorter duration of surgery and less blood loss as well as in a clear improvement in the postoperative urinary status and short‐term prognosis. This technique simplifies nerve‐sparing radical hysterectomy, which is commonly thought to be complicated, making it easier to understand. [ABSTRACT FROM AUTHOR]

Objective: Given the increasing prevalence of obesity, the incidence of endometrial cancer and endometrial intraepithelial neoplasia (EIN) could increase twofold within the next 2 decades. Although hysterectomy is the preferred treatment, increasing body mass indices (BMIs) pose technical challenges to surgeons and are associated with adverse surgical outcomes. This study evaluated perioperative outcomes of superobese (BMI of ≥50 kg/m2) patients who underwent total vaginal hysterectomy (TVH), compared to total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH) for endometrial cancer or EIN. Materials and Methods: This was a retrospective cohort study of 84 patients with BMIs ≥50 kg/m2 who underwent hysterectomy for treatment of endometrial cancer or EIN from July 1, 2007, to May 1, 2017, at a tertiary academic medical center. Demographic data, intraoperative parameters, and postoperative data were collected via a retrospective chart review. The primary outcome was a composite of intraoperative injury, Clavien–Dindo post-operative morbidity score, 30-day readmission rate, estimated blood loss >1000 cc, and transfusion. The secondary outcome was survival. Results: There was no difference in the combined perioperative primary outcome or survival for patients with BMIs ≥50 kg/m2 undergoing TVH for EIN or endometrial cancer, compared to patients undergoing TAH or TLH. Conclusions: TVH is a viable surgical route for superobese patients with endometrial cancer or EIN. Further evaluation of the role of TVH in the setting of EIN and endometrial cancer is needed as the superobese population rapidly increases. (J GYNECOL SURG 37:470) [ABSTRACT FROM AUTHOR]

Objective: This research assessed if attending surgical volume impacted the relationship between resident participation and operative time in robotic surgery for benign gynecologic conditions. Materials and Methods: This retrospective cohort study included 1 academic and 1 community hospital, where a total of 329 patients underwent robotic surgery for benign gynecologic conditions from January 2018 to March 2019. The primary outcome was total operative time. The primary exposure was resident participation versus nonparticipation in robotic cases. The patients were operated on by 3 surgeons from the same group. The lifetime robotic hysterectomy volumes were 1250 (over 11 years), 146 (over 8 years), and 107 (over 8 years), respectively for the 3 surgeons. Results: The unadjusted mean total operative time was longer for cases involving residents (130.3 minutes [95% confidence interval (CI): 122.8–137.7 minutes] versus 109.6 minutes [95% CI: 104.0–115.3 minutes]; p < 0.001). Among hysterectomy cases, the adjusted mean total operative time was 22.3 minutes longer for cases with resident participation versus no participation (95% CI: 11.9–32.7 minutes longer; p < 0.001). Among hysterectomy cases, the mean total operative time for the high-volume surgeon increased by 14.9 minutes with resident participation, compared to an increase of 45.3 minutes for his 2 low-volume partners. Conclusions: This retrospective chart review's results suggest that attending surgeon robotic volume and surgery type appear to mediate the relationship between resident participation in robotic surgery and total operative time. More research is needed to confirm these findings. (J GYNECOL SURG 37:303) [ABSTRACT FROM AUTHOR]

Objective: To compare the quantity in morphine milligram equivalent (MME) of opioids prescribed at hospital discharge after gynecologic surgery before and after passage of comprehensive New Hampshire state legislation (HB 1423) regulating opioid prescribing. Design: A retrospective chart review was performed on all patients undergoing gynecologic surgery between January 1, 2016 and June 30, 2016 (before legislation) and between April 1, 2017 and September 30, 2017 (after legislation) at a single tertiary care center. Materials and Methods: The primary outcome was MME prescribed at hospital discharge. Secondary outcomes included discharge without opioids, prescriptions ≤37.5 and ≥200 MME. Type of gynecologic surgery and benign versus oncologic diagnoses were analyzed. A logistic regression model was conducted to determine variables associated with a prescription of ≥200 MME. Results: Seven hundred seventy-four patients underwent gynecologic procedures during the identified time periods; 349 patients before legislation and 423 patients after legislation. Significantly fewer mean MME were prescribed after legislation (173 MME vs. 78.5 MME, p < 0.001). This was true for laparotomy with hysterectomy (231 MME vs. 111 MME; p < 0.001), laparotomy without hysterectomy (275 MME vs. 141 MME; p = 0.04), laparoscopic hysterectomy (143 MME vs. 62 MME; p < 0.001), other laparoscopy (133 MME vs. 59 MME; p < 0.001), and vaginal hysterectomy (232 MME vs. 89 MME; p = 0.002) and among those with a cancer diagnosis (178.5 vs. 67.9; p < 0.001). The number of patients discharged without a prescription for opioids significantly increased after legislation (4.4% vs. 9.8%; p = 0.005). In multivariate analysis, surgery before legislation (odds ratio [OR] 14.56 [95% confidence interval 8.22–25.82]), having a laparotomy with hysterectomy (OR 5.85 [2.47–13.85]) or laparotomy without hysterectomy (OR 6.35 [2.35–17.13]) were predictive of a prescription ≥200 MME. Conclusion: After opioid prescribing legislation in New Hampshire, significantly fewer opioids were prescribed on hospital discharge after gynecologic surgery. This reduction was seen regardless of type of gynecologic surgery or cancer diagnosis. (J GYNECOL SURG 37:291) [ABSTRACT FROM AUTHOR]

Objective: There are limited studies on laparoscopy for benign hysterectomy in low- and middle-income countries. This article describes national trends in modes of hysterectomy in Brazil and compares outcomes by regions and health sectors. Materials and Methods: This was a cross sectional retrospective analysis of benign hysterectomies from open-access national databases (public sector: 2008–2017; private sector: 2016) in Brazil. Variables examined included the modes (vaginal, abdominal, and laparoscopic) of hysterectomies, geographic regions, mortality rates, and lengths of stay (LOS). Results: Benign hysterectomies decreased by 19.2% over 10 years. The proportion of abdominal surgeries increased from 85% to 88%. Despite an increase in laparoscopic surgeries (0.2–0.9%), minimally invasive surgery (vaginal and laparoscopic) decreased (14.7%–12.6%), largely driven by a drop in vaginal cases (14.5%–11.7%). More laparoscopic hysterectomies were performed in the private sector compared to the public sector (11% versus 1%; p < 0.001). There were significant geographic disparities, with 17% of hysterectomies in the private sector performed laparoscopically in the south compared to 9% in the northeast (p < 0.001). Conclusions: Trends in modes of hysterectomies have changed. There are regional inequities, with wealthier regions accessing more laparoscopic surgery. Understanding the trends and factors affecting access to laparoscopy is essential for ensuring equitable access to high-quality gynecologic care. (J GYNECOL SURG 37:337) [ABSTRACT FROM AUTHOR]

Introduction: Our objective was to compare the short-term outcomes by type of surgical management of endometriosis in Ontario, Canada and to characterize the population of women undergoing surgical management of endometriosis.Material and Methods: We conducted a population-based cohort study including women aged 18-50 years undergoing same-day or inpatient surgery for endometriosis from 1 April 2002 through 31 March 2018. Surgery was classified as minimally invasive hysterectomy (MIH), total abdominal hysterectomy (TAH) or minor or major conservative (uterus-preserving) surgery. Outcomes examined included length of stay, intraoperative complications, postoperative complications, emergency department visits, ambulatory care visits, and readmission. We estimated the relative risk of these outcomes in minor, major conservative surgery and TAH vs MIH adjusted for age, income quintile, parity, and comorbidities.Results: A total of 85 605 patients underwent surgery, 12.9% MIH, 22.1% TAH, 36.3% major conservative, and 28.6% minor conservative. The mean age at index surgery was 37.6 ± 7.7 years. Before surgery, 70.6% of patients had visited a physician for pain at least once (64.7% MIH, 69.5% TAH, 71.1% major conservative and 73.4% minor conservative) and 23.5% of patients had sought infertility consultation (5.7% MIH, 6.6% TAH, 29.3% major conservative and 37.1% minor conservative). The overall risk of intraoperative and postoperative complications was 1.5% and 4.7%, respectively. In adjusted models, compared with those undergoing minor conservative surgery, those having major conservative surgery were 1.77 (95% CI 1.49-2.11) times as likely to experience an intraoperative complication, those having MIH and TAH were 2.55 (95% CI 2.08-3.13) and 2.34 (95% CI 1.93-2.82) times as likely to do so, respectively. Similarly, compared with those undergoing minor conservative surgery, those having major conservative surgery were 2.60 (95% CI 2.30, 2.93) times as likely to experience any postoperative complication, and those having MIH and TAH were 4.69 (95% CI 4.11-5.36) and 5.38 (95% CI 4.76-6.09) times as likely to do so, respectively.Conclusions: Approximately one-third of patients undergoing surgical management for endometriosis in Ontario between 2002 and 2018 had a hysterectomy. Overall, complications following surgery were low, and dependent on extent of surgery. These results should help to inform preoperative counseling for patients and health policy development for providers. [ABSTRACT FROM AUTHOR]

Objectives: The goals of this research were to identify the incidence of, and risk factors for, postoperative urinary retention in patients who underwent outpatient hysterectomy, and to evaluate the incidence of urinary retention among those patients, according to variable requirements for urinary function in the immediate postoperative time period. Materials and Measurements: This retrospective cohort study was conducted in an academic-affiliated community hospital. The subjects were patients who underwent planned outpatient hysterectomies for benign disease from January 2013 to April 2016 at Lahey Hospital and Medical Center, in Burlington, MA. Results: A total of 197 patients who underwent outpatient hysterectomy were identified. The average age of the patients was 45.7 ± 6.8 years, and most patients underwent hysterectomy for leiomyomas. Of these cases, 21 (10.6%) had unplanned hospital admissions. The most-common reasons for admission included nausea (3.1%), pain (1.6%), and dizziness (1.0%). Only 1 patient was admitted for urinary retention (0.5%). Six patients (3.0%) were diagnosed with urinary retention, defined as a bladder scan ≥300cc or a postvoid residual ≥200 cc. All patients with urinary retention were identified either immediately postoperatively or during their admissions. No other patients returned to the clinic or were readmitted to the hospital for urinary retention. Patients identified with urinary retention were more likely to have been admitted overnight for other reasons (83.3%). Of the 197 patients, 8 were required to void prior to same-day discharge, based on provider preference. There was no significant difference in patients' characteristics for patients required to void and those who were not required to do so. No patients in the group required to void were diagnosed with urinary retention. There was no difference between the groups with regard to readmissions or return visits for urinary symptoms. Conclusions: The incidence of urinary retention after outpatient minimally invasive surgery is low, and, when present, can be identified in the immediate postoperative timeperiod regardless of whether or not the patient is required to void prior to discharge. Therefore, it is safe to discharge patients after minimally invasive hysterectomy without a requirement to void postoperatively. (J GYNECOL SURG 37:252) [ABSTRACT FROM AUTHOR]

Aim: We aimed to evaluate regional disparities in the proportion of the three main laparoscopic surgeries for benign gynecological diseases among 47 prefectures in Japan and their correlation with the number of laparoscopy‐qualified gynecologists per population. Methods: In this retrospective ecological study, we collected the data of patients from 47 prefectures in 2017 using "The National Database of Health Insurance Claims and Specific Health Checkups of Japan" Open Data from the Ministry of Health, Labor and Welfare in Japan. The primary outcome of the study was the proportion of laparoscopic surgeries conducted for benign gynecologic diseases (hysterectomy, myomectomy and surgery for the benign ovarian diseases). The main exposure was the number of laparoscopy‐qualified gynecologists per 100 000 females. Results: The average proportion of laparoscopic hysterectomies, myomectomies and surgeries for the benign ovarian disease were 38% (standard deviation (SD) 16, range 12–74), 48% (SD 18, range 9–81) and 60% (SD 11, range 36–79), respectively. Multiple regression analysis showed a significant correlation between the number of laparoscopy‐qualified gynecologists per 100 000 females and the proportion of the three main laparoscopic surgeries. Conclusion: There are obvious regional disparities in the proportion of the three main laparoscopic procedures for benign gynecological diseases among 47 prefectures. The number of laparoscopy‐qualified gynecologists correlated significantly with these regional disparities. The academic society should monitor these regional disparities and make an effort to reduce these regional disparities by increasing laparoscopy‐qualified gynecologists in areas where the widespread use of laparoscopic techniques is lagging. [ABSTRACT FROM AUTHOR]

Objective: To determine the trends of hospitalization (inpatients and outpatients) for uterine leiomyomas in Portugal, over a period of fifteen years.Study Design: We perform a population- and register-based retrospective study of women who were hospitalized with a primary diagnosis of uterine fibroid in public hospitals in continental Portugal, in the period between January 1, 2000 and December 31, 2015. Patient data regarding hospital codes, admission and discharge dates, patient age, diagnosis, procedures and complications were extracted from the national database of Administração Central do Sistema de Saúde (ACSS). All calculations were performed with the STATA software, version 13.1. Categorical data were analysed by the χ2 test and the means of continuous variables were analysed with Student's t-test. Statistical significance was set at p < 0.05.Results: Between 2000 and 2015, 102 476 patients were admitted to public hospitals in Portugal due to uterine leiomyomas. The majority were admitted to hospital for surgery: 73.6 % for hysterectomy and 13.0 % for myomectomy. During this period, the definitive treatment (hysterectomy) decreased from 83.2% to 63.0% (p < 0.001), with a change towards more conservative treatments such as myomectomies (6.4% to 22.6%, p < 0.001). Additionally, in women submitted to hysterectomy, laparoscopic and vaginal routes increased (1.1%-11.5%, p < 0.001 and 2.1%-4.0%, p < 0.001; respectively). Globally, there was a 14.3 % reduction in hospitalizations due to uterine fibroids and an increase in the outpatient rate (from 3.1% to 22.1%). The mean number of hospitalization days for inpatients also decreased (from 6.3 ± 4.1-4.0 ± 3.0, p < 0.001). Regarding urgently hospitalized women, 11.8 % required a blood transfusion. In women submitted to surgical procedures, 0.5 % had an intraoperative complication and 2.3 % a post-operative complication, directly related to the surgical procedure.Conclusion: There was a reduction in hospitalizations due to uterine fibroids and a change towards more conservative treatments. [ABSTRACT FROM AUTHOR]

Objective: Advanced vaginal vault prolapse (VVP) can occur rarely after any type of hysterectomy. Several types of procedures have been applied to correct this defect, but optimal management is still pending. The aim of this study was to describe the surgical technique and results of four-arm transvaginal mesh (FATVM) application for advanced VVP.Study Design: We followed up for 24 months, 160 patients with VVP > II vc (according to the Pelvic Organ Prolapse Quantification Scale (POPQ)), who underwent FAMTVM from 2014 to2017. FAMTVM was inserted with the anterior arms through the obturator foramens and the posterior arms through the ischiorectal fossas and sacrospinal ligaments. Clinical data were prospectively collected in a customized database and retrospectively analyzed. To assess QoL SF 36, KHQ and FSFI questionnaires were used. POPQ was employed to measure degree of VVP. Non-parametric tests (The Wilcoxon signed-rank test) were applied to verify statistical hypotheses.Results: According to SF 36, significant improvement was evident in almost all aspects of general QoL (PCS p = 0.002, MCS p = 0.01). KHQ showed statistically significant improvement in all domains. FSFI scores after surgery indicated significantly improvement in all domains of the questionnaire, apart from lubrication (p = 0.02). Intraoperative bladder injury occurred in 3.75 % (n = 6) of all cases. Five patients (3.1 %) complained of de novo stress urinary incontinence. VVP reoccurred in nine cases (5.6 %). Only two patients (1.25 %) saw mesh exposure after 6 months postoperative recovery.Conclusion: We consider FAMTVM for VVP to be safe and effective. Hence, it applied as an optional treatment, especially in patients with contraindications to laparotomy and laparoscopy. [ABSTRACT FROM AUTHOR]

Objective: To compare surgical outcomes between women undergoing prophylactic internal iliac artery ligation or preoperative placement of balloon-occlusive devices at cesarean hysterectomy for placenta accreta spectrum (PAS) disorders.Methods: A retrospective cohort study was conducted at a tertiary-care referral center for PAS disorders in Ontario, Canada. Eligible electronic records were reviewed of women undergoing cesarean hysterectomy for PAS disorders between November 2012 and June 2018. Outcomes for the ligation and balloon groups were compared primarily on procedure-related complications and secondarily on total procedure time, bleeding and transfusion metrics, and intraoperative and postoperative complications.Results: Of the 79 cases of cesarean hysterectomy, 47 underwent balloon placement and 32 underwent ligation. Baseline characteristics between the groups were similar except for more emergency procedures in the ligation group (37.5% vs 12.8%, P=0.014). The balloon-related complication rate was 5/47 (10.6%), with no reported complications in the ligation group (P=0.077). Procedural time was longer in the balloon group (353 ± 14 vs 227 ± 13 minutes, P<0.001). Estimated blood loss was similar (1874 ± 245 mL vs 1713 ± 181 mL, P=0.590).Conclusion: Women undergoing prophylactic placement of endovascular balloons at caesarean hysterectomy for PAS disorders had a 10.6% procedure-related complication rate and increased total procedure time, with no decrease in blood loss compared to those undergoing surgical ligation. [ABSTRACT FROM AUTHOR]

Objective: To interpret the long-term outcomes of transvaginal round-infundibulopelvic ligament colposuspension after vaginal hysterectomy in patients with stage 3-4 uterovaginal prolapse.Study Design: This retrospective case-control study from 2007 to 2016 analysed patients' medical records and evaluated gynaecological examinations over 11 years of follow-up. One hundred and forty-three patients who underwent transvaginal round-infundibulopelvic ligament colposuspension after vaginal hysterectomy were evaluated. The prespecified primary outcome evaluated at 11-year follow-up was apical prolapse of stage 2 or higher evaluated by the Pelvic Organ Prolapse Quantification System (POP-Q), in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse. The secondary outcome was overall anatomical failure (recurrent prolapse of stage 2 or higher in apical, anterior or posterior compartment). The rate of recurrence of apical prolapse was compared between groups using the McNemar test.Results: The mean (± standard deviation) follow-up period was 88.15 ± 2.519 months (95 % confidence interval 83.17-93.13). The pre-operative diagnoses were stage 3 uterovaginal prolapse in 23 (16.08 %) patients, stage 4 uterovaginal prolapse in 120 (83.91 %) patients, rectocele in 119 (83.21 %) patients, cystocele in 138 (96.50 %) patients and stress urinary incontinence in 53 (37.06 %) patients. Ten (8.33 %) patients with stage 4 uterovaginal prolapse developed postoperative apical prolapse, whereas none of the patients with stage 3 uterovaginal prolapse developed postoperative apical prolapse. Postoperatively, the POP-Q stages of apical prolapse were significantly lower compared with pre-operatively (p < 0.001). Postoperatively, the apical prolapse rate was 7.0 %, the recurrent cystocele rate was 2.07 %, the recurrent rectocele rate was 5.5 %, and the recurrent stress urinary incontinence rate was 18.87 %. Overall, postoperative anatomical failure occurred in 21 of 143 (14.68 %) women. One (0.69 %) patient developed perioperative bladder perforation, two (1.39 %) patients experienced voiding difficulty, and eight (5.59 %) patients experienced vaginal spotting.Conclusion: Transvaginal round-infundibulopelvic ligament colposuspension during vaginal hysterectomy is an effective and useful method that reduces the rate of postoperative apical prolapse in patients with high-grade uterovaginal prolapse. [ABSTRACT FROM AUTHOR]

Aim: The purpose of this study was to report on 626 cases of successful robotic single‐site (RSS) surgeries to address various types of gynecologic disease and to evaluate the outcomes and learning curve inherent to RSS surgery in the gynecology field. Methods: A total of 626 cases of RSS surgeries were performed by 3 gynecologic surgeons at Ewha Womans University Medical Center, Robot Surgery Center from November 2014 to January 2018 were collected retrospectively. All of the patients' charts were reviewed, and the clinical characteristics and surgical variables were analyzed. Results: Among the total of 626 cases, there were 220 cases of RSS myomectomy (RSSM), 182 cases of RSS hysterectomy (RSSH), 195 of RSS adnexectomy, 24 of RSS sacrocolpopexy (RSS SCP) and 5 were classified as other RSS surgeries. The patient's mean age was 38.98 ± 10.07 years. There was 3.99 ± 2.15 min of mean docking time and 117.78 ± 51.18 min of mean operating time. The surgical variables were analyzed annually. The total operating time was seen to decrease significantly according to each period. The docking time declined significantly and gradually after 1 year. We also analyzed each of the surgical types by time. The operating time of RSSH, RSSM, RSS adnexectomy and RSS SCP fell over time. The tendency found was for operating time to decline sharply following the first 10 cases. When we analyzed the data at annual intervals, the operating time was most significantly less and stable following the first year. There were a few intraoperative or perioperative complications in 16 cases (2.6%). Conclusion: Robotic single‐site surgery is a feasible and safe procedure for treating various kinds of gynecologic diseases. The learning curve was approximately 10 cases of RSS surgery in gynecologic disease, having a greater amount of experience at performing RSS surgery was revealed to be key to achieving better surgical outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The widespread misuse of prescription pain medication, including opioids, has serious public health implications. Postoperative pain is a risk factor for persistent or chronic pain unless treated effectively. There are only a few studies that have assessed the use of opioid-containing drugs after gynecological surgery and most of these usually have a short follow-up period. The aim of this study was to identify risk-factors for long-term use of prescription opioid drugs following hysterectomy.Material and Methods: We performed a nationwide cohort study based on prospectively collected data. Information from two population-based registers, the Swedish National Quality Register of Gynecological Surgery and the Swedish National Drug Register, was linked. The study population consisted of women with benign disease undergoing a total hysterectomy from 1 January 2012 until 31 December 2015. To identify long-term changes in prescription of opioids, individual data were collected from 1 year prior to to 3 years after surgery between 2011 and 2018. Data analysis was performed using multivariable logistic regression models.Results: The population included 17 385 women having had hysterectomy for benign disease. Of these women, 4233 (24.4%) were prescribed analgesics continuously for 3 years postoperatively and 1225 (7.1%) used opioids long term. Perioperative predictors of opioid use 3 years after surgery included a diagnosis of adenomyosis (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.2-2.7) and preoperative use of opioids (aOR 29.6, 95% CI 19.7-44.4), psycho- (aOR 3.5, 95% CI 2.4-5.0) and neuroactive drugs (aOR 1.8, 95% CI 1.0-3.1). For women with no opioid prescription preoperatively (n = 260, 1.5%), mild (aOR 2.8, 95% CI 1.1-7.3) and severe (3.0% vs 6.2%: aOR 6.4, 95% CI 1.4-20.0) postoperative complications and preoperative prescription of psychoactive drugs (aOR 4.6, 95% CI 1.9-10.7) were associated with long-term use of drugs containing opioids.Conclusions: Long-term use of prescription opioids after hysterectomy is common and is, among other risk factors, strongly associated with preoperative use of opioids, as well as psychoactive drugs and adenomyosis. To avoid opioid misuse disorders among women at risk for long-term opioid drug prescriptions after hysterectomy, further studies and strategies are needed. [ABSTRACT FROM AUTHOR]

Background: The American College of Obstetricians and Gynecologists recommends that women who have had a prior myomectomy that entered the endometrial cavity undergo cesarean delivery in order to avoid the possible complication of uterine rupture. Women with prior myomectomies may also have intraabdominal adhesions, complicating future surgery and if myomas remain after myomectomy, they may have more bleeding complications during their subsequent pregnancies.Objectives: The purpose of this study was to evaluate maternal and neonatal outcomes after prior myomectomy in women undergoing planned cesarean delivery.Study design: We conducted a retrospective cohort study using the Maternal Fetal Medicine Units Cesarean Registry database comparing women undergoing a cesarean delivery with a history of prior myomectomy to women undergoing a cesarean delivery without a history of a prior myomectomy. Inclusion criteria were singleton gestations at term undergoing planned cesarean delivery. Exclusion criteria were stillbirth, cesarean delivery indication for nonreassuring fetal heart rate, macrosomia, abruption, previa or women undergoing planned trial of labor after cesarean. Primary outcome was incidence of blood transfusion. Maternal and neonatal outcomes were compared secondarily. Logistic regression was used to adjust for confounders.Results: The entire study population included 73,257 deliveries; 34,002 women met inclusion criteria, of which 367 had a prior myomectomy and 33,635 were controls. The demographics, which varied by maternal age, race and number of prior cesareans were adjusted for when calculating maternal outcomes. The rate of intraoperative transfusion in the prior myomectomy group was 1.4% (5/367) compared to 0.4% (131/33,635) in the control group (aOR 2.8; 95% CI 1.15-6.79). The prior myomectomy group had a higher incidence of postpartum transfusion rate (2.5%, 9/367) compared to the control group (1.2%, 416/33,635) (aOR 2.03; 1.06-3.92), uterotonic usage (5.4%, 20/367) compared to the control group (3.5%, 1165/33,635; aOR 1.57; 95% CI 1.01-2.45), bowel injury (0.5%, 2/367) compared to the control group (0.0%, 14/33,635; aOR 8.13; 95% CI 2.05-32.28) and cesarean hysterectomy (1.4%, 5/367) compared to the control group (77/33,635; aOR 3.43; 95% CI 1.32-8.91). Neonatal outcomes were not different between groups.Conclusion: Prior myomectomy in women with term, singleton gestations undergoing planned cesarean delivery was associated with an 180% increased risk of intraoperative transfusion compared to the control group. We also found that women in the myomectomy group are 57% more likely to use uterotonics, 713% more likely to experience a bowel injury, 243% more likely to undergo a cesarean hysterectomy, and 227% more likely to need a classical uterine incision during delivery. Neonatal morbidity was not statistically different between the groups. [ABSTRACT FROM AUTHOR]

Background: Adnexal surgery is believed to be more complex in patients with prior hysterectomy; however, there is little data regarding surgical outcomes. Understanding of individualized risks improves counseling, informed consent, and preoperative planning.Methods: We performed a retrospective cohort study with a control group; we evaluated 744 patients undergoing laparoscopic adnexal surgery at an academic tertiary care center from 2011 to 2015. Comparisons were made using Chi square, Fisher's exact, or Wilcoxon-rank sum tests. We used log-binomial regression to calculate risk ratio and 95% confidence interval.Results: Patients with prior hysterectomy were more likely to have intraoperative or postoperative complications at the time of laparoscopic adnexal surgery when compared to patients without prior hysterectomy [17.7% vs. 10.2%, p = 0.02, risk ratio (RR) 1.7, 95% confidence interval (CI) 1.1-2.7]. Patients with prior hysterectomy were four times more likely to have intraoperative complications (3.2% vs. 0.8%, p = 0.047, RR 4.0, 95% CI 1.1-14.7), and five times more likely to have conversion to laparotomy (5.6% vs. 1.1%, p = 0.004, RR 5.0, 95% CI 1.8-14.0). Patients with prior hysterectomy were more likely to need additional procedures, including lysis of adhesions (69.4% vs. 26.0%, p < 0.001), ureterolysis (15.3% vs. 4.8%, p < 0.001), and cystoscopy (28.2% vs. 8.1%, p < 0.001). They had longer operative time [101.5 min (IQR 59.5-135.0) vs. 78.0 min (IQR 53.0-109.0, p < 0.001)], and were less likely to have outpatient surgery (56.5% vs. 84.8%, p < 0.01). Postoperative complications were also more common (15.3% vs. 9.4%, p = 0.046).Conclusions: Patients with prior hysterectomy were 70% more likely to have a complication at the time of laparoscopic adnexal surgery than patients without hysterectomy. Increased risk of complications in subsequent adnexal surgery may influence the informed consent process or decisions regarding ovarian conservation. Awareness of potential need for additional surgical procedures may guide availability of equipment, choice of operating site, or referral to an advanced pelvic surgeon. [ABSTRACT FROM AUTHOR]

Aim: We aimed to evaluate the urological complications of gynecologic operations in a tertiary academic center and to evaluate the methods of treatment of these complications. Methods: Files of all patients, who underwent gynecological surgery between January 2016 and January 2019, were retrospectively reviewed from the hospital database. The patients with urological complications included in the study. Pediatric (<18 years old) patients, who underwent emergency surgery, and patients with incomplete medical records were excluded from the study. American Anesthesia Society score, menopausal status, body mass index (BMI), preoperative hemoglobin level, postoperative hemoglobin level, length of hospital stay and number of previous surgeries were recorded. In addition, the patients with urological complications were evaluated in terms of the indications for surgery, type of surgery, type of urological complication and the way of treatment of the complication. Results: After 79 patients were excluded according to exclusion criteria, of the 1754 patients who had undergone a gynecological operation, a total of 21 (1.19%) patients had urological complications and the bladder was the most common site of injury (61.9%). The mean age and mean BMI of the patients were 47.8 years and 25.25 kg/m2, respectively. Urological complications occurred most commonly during staging surgeries due to ovarian or cervix cancer and during laparoscopic or abdominal hysterectomy due to large fibroids. When all operations were evaluated, bladder injury was the most common urological complication. Conclusion: Our study showed that urological complications during gynecological operations are rare (1.19%) and the most frequently injured organ is the bladder (61.9%). In addition, the risk of ureteral and renal injury increases in operations performed with the indication of malignancy and visualization of injuries is critical during operation and complication can be managed with variable techniques intraoperatively. [ABSTRACT FROM AUTHOR]

Objective: Complication rates during laparoscopic hysterectomy performed at high-volume surgical centers have not been reviewed recently; rather, reliance is placed on older data when counseling patients. This study reviewed patient demographics and surgical complications occurring during laparoscopic hysterectomy for benign gynecologic disease at a major academic teaching institution. The relationship between surgeon experience and perioperative outcomes were also assessed. Materials and Methods: This was a retrospective chart review of consecutive women who underwent hysterectomy for benign gynecologic disease from September 2014 to August 2016. Clinical, demographic, and surgical characteristics were ascertained. Complications and readmission rates were assessed. Primary outcomes were surgical complications, estimated blood loss (EBL), operative times, and blood transfusions. The patients were treated at a single, high-volume tertiary-care teaching hospital. They were divided into 5 groups. In groups 1–4, surgeries were performed by 4 individual experts. Group 5 had surgeries performed by minimally invasive gynecologic-surgery fellows. Numeric data were expressed as medians and ranges, unless stated otherwise. Statistical analyses were performed with SPSS version 21.0 for Windows. Results: A total of 1095 hysterectomies were included: 1040 (94.98%) were performed laparoscopically; 33 (3.01%) were performed via laparotomy; and 22 (2.01%) via vaginal procedures. Median operative time was 117 minutes (range: 23–499 minutes). Median EBL was 100 mL (range: 10–1000 mL). Only 1 surgery was converted to laparotomy (0.10%). Intraoperative injuries occurred 6 times—3 ureteral (0.29%), 2 bladder (0.19%), and 1 bowel (0.10%). All injuries were noted during the procedures with intraoperative repair performed in each case and subsequent postoperative complications avoided. Blood transfusions were required in 4 patients (0.38%). No ureteral and vesical fistulae occurred. Laparoscopic hysterectomy rates of 100% without conversions were achieved by Surgeons #1 and #3. Compared to other groups, Surgeons #1 and #2 had lower EBLs and shorter mean surgical times. Surgeon #1 had more frequent pelvic adhesions than other groups. Surgeon #4 had the largest uterine weights, while fellows operated on uteri weighing >500 g or >1000 g less frequently. Rates of bowel occlusions were higher for Surgeon #4 and the fellows. Fellows had more-frequent skin infections. Other postoperative complications and readmission rates were similar among the groups. Conclusions: Laparoscopic hysterectomy is a safe, feasible option for benign gynecologic surgery. This procedure is safe even during the initial learning-curves of fellows with low and reasonable complication rates, but with longer associated operative times. An increase in experience is associated with a higher rate of laparoscopic hysterectomies, shorter operating times, less blood loss, and a low incidence of complications. [ABSTRACT FROM AUTHOR]

Objective: To analyze the patterns of presentation and management for urologic complications of obstetrics and gynecology in the form of genitourinary fistulas at a tertiary referral center and highlight the social issues associated with them. Material and methods: We conducted this retrospective study analyzing 311 patients with genitourinary fistulas after obstetric and gynecologic surgeries between January 2005 and January 2018. We recorded the patients' characteristics and area of residence and then analyzed the etiology, surgical management and success rates by grouping the patients into four types of genitourinary fistulas. The primary end point of success was patient being leak free. Results: Majority of patients (90.4%) were from rural areas. The distribution of genitourinary fistulas in descending order was vesicovaginal (79.7%), ureterovaginal (11.8%), urethrovaginal (10.2%) and vesicouterine fistulas (2.6%). The mean time to presentation was 25.80-48.69 days with a wide range of 10 days to 360 months. The most common etiology was obstructed labour (58.5%) followed by abdominal hysterectomy (32.7%). For vesicovaginal fistulas the route to be used for repair depended on surgeon's preference and both transabdominal and transvaginal routes had almost equal success rates. The success rate of laparoscopic vesicovaginal fistula repair was 89.4% and all (100%) laparoscopic ureteroneocystostomies were successful. Conclusion: Genitourinary fistulas especially due to obstructed labour are still common in developing world showcasing the problem of inequitable distribution of healthcare. The surgical treatment approach depends on the surgeon's familiarity with the said procedure although versatility is required. [ABSTRACT FROM AUTHOR]

Objective: To identify patient characteristics and surgical factors predictive of complications requiring mid-urethral sling (MUS) revision/removal.Design: Case-control study.Setting: Tertiary academic centre in Canada.Population: One hundred and seven women undergoing MUS revision/removal between 2005 and 2016 were matched with 214 controls by date of index MUS procedure (2:1 ratio).Methods: Data on patient and surgical factors were obtained via manual electronic and paper chart review. Three sets of pre-specified simple and multivariable logistic regression models were fitted to: (1) examine previously reported risk factors for MUS revision after primary surgical treatment; (2) identify preoperative predictors of MUS complications requiring revision/removal; and (3) identify surgical factors associated with this outcome after adjusting for potential confounding factors.Main Outcome Measures: Crude and adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) for patient and surgical factors.Results: The median time to MUS revision was 153 days (interquartile range, IQR 49-432 days). Active smoking status (OR 2.29, 95% CI 1.13-4.63, P = 0.03), having had a previous hysterectomy (OR 3.88, 95% CI 2.02-7.46, P < 0.01), and undergoing concomitant pelvic organ prolapse surgery at the time of the index MUS procedure (OR 2.63, 95% CI 1.32-5.52, P < 0.01) were independently associated with the need for MUS revision/removal. Sling type (obturator versus retropubic), method of tensioning (to cough versus over instrument), anaesthetic type, and estimated blood loss were not associated with this outcome in the analysis presented here.Conclusions: Active smoking status, having had a previous hysterectomy, and undergoing concomitant surgery for pelvic organ prolapse are risk factors for requiring subsequent MUS revision/removal.Tweetable Abstract: Risk factors for sling revision include smoking, previous hysterectomy, and concomitant prolapse surgery. [ABSTRACT FROM AUTHOR]

Objectives: Our objective is to investigate the prevalence, pathology and prognosis of uterine sarcomas in laparoscopic hysterectomy/myomectomy with electric power morcellation for presumed leiomyomas.Study Design: We retrospectively reviewed patients with laparoscopic power morcellation (LPM) for presumed leiomyomas in a Chinese tertiary institution by chart review from September 1, 2013 to December 31, 2016.Results: Twenty-four in 4478 patients (0.54%) with LPM for presumed leiomyomas had unexpected cancers. The patients showed the highest frequency of occult cancers (10/375, 2.6%) at 51-60 years and lowest (0/255) before 30 years. The pathology included 14 endometrial stromal sarcomas (ESS) (low-grade 12 and high-grade 2), 9 leiomyosarcomas, and 1 malignant mixed mesodermal tumor. The patients underwent abdominal re-exploration including total hysterectomy with bilateral salpingo-oophorectomy and staging surgery. Three patients were at advanced FIGO stage (IIIb-IVb) and 21 at stage I. Seven patients recurred within 1-25 (mean 6.29) months including 5 leiomyosarcomas, 1 high-grade and 1 low-grade ESS. Four recurrent patients with leiomyosarcomas and one with high-grade ESS died of disease in 1-3 months. Seventeen patients had no relapse and were alive for 6-41 (mean 24) months.Conclusions: Our study suggests that patients with LPM for presumed leiomyomas appear to have a considerable risk of unexpected cancers. Moreover, morcellation is potentially associated with adverse prognosis in patients with high-grade sarcomas. Informed consent on unexpected cancers that should be discussed before morcellation. [ABSTRACT FROM AUTHOR]

Objectives: The present study aimed to analyze the clinicopathologic features and treatment of uSTUMP in a single institution. In addition, we described the obstetric outcomes after uterine-preserving surgery for uSTUMP.Methods and Materials: A retrospective chart review was performed of patients diagnosed with uSTUMP between January 2000 and February 2018 at the Comprehensive Gynecologic Cancer Center, CHA Bundang Medical Center. We obtained data on the patients' demographics, treatment, therapeutic results, time to recurrence, disease-free and overall survival, and subsequent obstetric outcomes. The central pathology reviews were carried out by two pathologists specializing in gynecologic oncology.Result: A total of 19 patients diagnosed with uSTUMP were identified and included in the study. The mean age at diagnosis was 41 years (range 28-49 years). Frozen sections were performed in 11 patients including five patients during surgery. Nine of the 19 patients (47.4%) were treated by hysterectomy and 10 patients were initially treated by myomectomy. The mean follow-up period was 47 months (range 6-209 months). Two patients (10.5%; 2/19) experienced recurrence. Although not defined as recurrence in the present study criteria, one patient had a secondary diagnosis of atypical leiomyoma one year after the initial diagnosis of uSTUMP. Seven patients requested uterine-preserving treatment, five of whom wanted to become pregnant. Three of them (3/5; 60%) successfully delivered live birth to full term by Cesarean section without complications such as abortion, preterm delivery or uterine rupture, and tumor recurrence.Conclusions: The present study describes the clinicopathologic data of uSTUMP patients. Our results suggest a uSTUMP recurrence of 10.5%, comparable to previous reports. Although there is a possibility of malignant recurrence, fertility-preserving management is worth attempting because of relatively low affected age with careful close follow-up. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to investigate the incidence of unexpected uterine malignancy (UUM) diagnosed after hysteroscopic surgery for presumed submucosal leiomyomas or endometrial polyps.Study Design: From the Korean national health insurance database between January 1, 2009 and December 31, 2015, we analyzed inpatient sample data that were extracted by a stratified random sampling (gender and age) method. We extracted women with or without UUM that was diagnosed after hysteroscopic surgery using diagnosis codes and procedure codes.Results: A total of 11,866 women who underwent hysteroscopic surgery were extracted from 4,476,495 women. The mean age of the patients who underwent hysteroscopic surgery was 37.8 ± 0.1 years. A hysteroscopic myomectomy or polypectomy was performed in 3498 and 8368 women, respectively. The incidence of UUM diagnosed after hysteroscopic myomectomy or polypectomy was 0.86% and 1.11%, respectively. The logistic regression analysis showed that the risk of UUM increased with age (Odds Ratio (OR), 1.61; 95% Confidence Interval (CI), 1.47-1.77; P < 0.001) and did not indicate hysteroscopic myomectomy or polypectomy (OR, 1.21; 95% CI, 0.93-1.55; P = 0.151).Conclusions: The incidence of UUM diagnosed after hysteroscopic myomectomy (0.86%) or polypectomy (1.11%) was higher than that of UUM diagnosed after hysterectomy (0.19%) or myomectomy (0.12%) for presumed benign leiomyoma. The incidence of UUM increased over the age of 50. [ABSTRACT FROM AUTHOR]

Background: The study objective was to analyze and compare patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) after hysterectomy in women with and without a preoperative complaint of pelvic pain associated with and without a confirmed diagnosis of endometriosis. Methods: Retrospective nationwide register study. Data on 28,776 hysterectomies performed on benign indication between 2004 and 2016 were retrieved from the Swedish National Register for Gynecological Surgery. Multivariable logistic regression models were used to compare the PREMs and PROMs items. The results are presented as adjusted odds ratios (aORs) and 95% confidence intervals (CI). Results: Regardless of the occurrence of pelvic pain preoperatively and a diagnosis of endometriosis, 1 year after surgery, the women were satisfied or very satisfied (>90%) with the hysterectomy, and their medical condition was improved or much improved (>95%). The women with a preoperative complaint of pelvic pain and endometriosis more often reported excessively short hospital stays (aOR 1.45, 95% CI 1.17–1.79), more severe complications after discharge (aOR 2.02, 95% CI 1.59–2.66) at the 8-week follow-up and at the 1-year follow-up (aOR 2.31, 95% CI 1.57–3.39), and more dissatisfaction with the operation (aOR 1.83, 95% CI 1.35–2.48) than preoperative pelvic pain-free women without endometriosis at the 1-year follow-up. Conclusions: The majority of the women were satisfied after their hysterectomy. The women with pelvic pain and endometriosis were at a higher risk of being dissatisfied. Pelvic pain per se seemed to be the main factor affecting the rating in the PREMs and PROMs, and the endometriosis was a significant contributing factor. [ABSTRACT FROM AUTHOR]

The primary objective of this study was to describe surgical treatment patterns among women with newly diagnosed uterine fibroids (UF). A secondary objective was to estimate the medical costs associated with other common surgical interventions for UF. Claims-based commercial and Medicare data (2011-2016) were used to identify women aged ≥30 years with continuous enrollment for at least 12 months before and after a new diagnosis of UF. Receipt of a surgical or radiologic procedure (hysterectomy, myomectomy, endometrial ablation, uterine artery embolization, and curettage) was the primary outcome. Health care resource utilization and costs were calculated for women with at least 12 months of continuous enrollment following a UF surgical procedure. Among women who met selection criteria, 31.7% of patients underwent a surgical procedure; 20.9% of these underwent hysterectomy. An increase was observed over time in the percentage of women undergoing outpatient hysterectomy (from 27.0% to 40.2%) and hysteroscopic myomectomy (from 8.0% to 11.5%). The cost analysis revealed that total health care costs for hysteroscopic myomectomy ($17,324) were significantly lower ( P < 0.001) than those for women who underwent inpatient hysterectomy ($24,027) and those for women undergoing the 3 comparison procedures. Hysterectomy was the most common surgical intervention. Patients undergoing inpatient hysterectomy had the highest health care costs. Although less expensive, minimally invasive approaches are becoming more common; they are performed infrequently in patients with newly diagnosed UF. The results of this study may be useful in guiding decisions regarding the most appropriate and cost-effective surgical treatment for UF. [ABSTRACT FROM AUTHOR]

Objective: To compare outcomes between planned and urgent cesarean hysterectomy for morbidly adherent placenta managed by a multidisciplinary team.Methods: This is a retrospective case-control study of women with singleton pregnancies with antenatally suspected and pathologically confirmed morbidly adherent placenta who underwent cesarean hysterectomy between January 1, 2011, and February 30, 2017. Timing of delivery was classified as either planned (delivery at 34-35 weeks of gestation) or urgent (need for urgent delivery as a result of uterine contractions, bleeding, or both). The primary outcome variable was composite maternal morbidity. Logistic regression analysis was used to evaluate risk factors for urgent delivery.Results: One hundred thirty patients underwent hysterectomy. Sixty (46.2%) required urgent delivery. Composite maternal morbidity was identified in 34 (56.7%) of the urgent and 26 (37.1%) of the planned deliveries (P=.03). Fewer units of red blood cells and fresh frozen plasma were transfused in the planned delivery group (red blood cells, median interquartile range 3 [0-8] versus 1 [0-4], P=.02; fresh frozen plasma, median interquartile range 1 [0-2] versus 0 [0-0], P=.001). Rates of low Apgar score and respiratory distress syndrome were higher in the urgent compared with the planned delivery group (5-minute Apgar score less than 7, 34 [59.6%] versus 14 [23.3%], P<.01; respiratory distress syndrome, 34 [61.8%] versus 16 [27.1%], P<.01). A history of two or more prior cesarean deliveries was an independent predictor of urgent delivery (adjusted odds ratio 11.4, 95% CI 1.8-71.1).Conclusion: Women with morbidly adherent placenta requiring urgent delivery have a worse outcome than women with planned delivery. Women with morbidly adherent placenta and two or more prior cesarean deliveries are at increased risk for urgent delivery. In such women, scheduling delivery before the standard 34- to 35-week timeframe may be reasonable. [ABSTRACT FROM AUTHOR]

Objective: The goal of this research was to evaluate the risk associated with dissemination in laparoscopic procedures with power morcellation for benign gynecologic indications. Materials and Methods: This was a retrospective cohort study. A retrospective analysis was completed for cases of consecutive women who underwent laparoscopic myomectomy or supracervical hysterectomy with morcellation at a single academic institution between 2002 and 2014. The demographics and clinical characteristics of the patients were abstracted from the electronic medical records. Results: There were 456 women who underwent power morcellation during the study period. The majority (78%) was premenopausal with a median body mass index of 26 (range: 19-50). The most common preoperative diagnoses were fibroids, abnormal uterine bleeding, and pelvic organ prolapse. Eighteen percent of patients underwent myomectomy and 82% underwent supracervical hysterectomy. General gynecologists performed 58% of the surgeries, followed by urogynecologists (22%). Sixty-six percent of patients underwent preoperative uterine evaluation with at least an ultrasound or endometrial sampling, with 21% having undergone more than one modality. Patients with a diagnosis of fibroids were more likely to undergo preoperative endometrial sampling than patients with other diagnoses (32% versus 16%; p < 0.05). One uterine specimen (0.2%) had an undiagnosed atypical leiomyoma with moderate-to-severe cytologic atypia. Conclusions: The incidence of occult malignancy discovered on pathology following power morcellation of the uterus and/or fibroids is low in women. These data can be used to counsel patients prior to consideration of power morcellation. Given the limitations in preoperative diagnosis of sarcoma and potential complications of morcellation even of benign pathology, controlled morcellation should be a goal with established guidelines. (J GYNECOL SURG 34:27) [ABSTRACT FROM AUTHOR]

Objective: To quantify the incidence of peripheral neuropathy in gynecologic laparoscopic surgery using a combination of beanbag, eggcrate foam, and shoulder supports; and to assess patient displacement during surgery in a steep Trendelenburg position and determine variables correlated with displacement.Methods: A retrospective study included all gynecologic laparoscopic surgeries performed by one high-volume surgeon at a US center between September 15, 2007, and September 15, 2012. Data included neurologic deficits or extremity pain, any other complications, and-for the final study year-surgical time as well as patient and beanbag displacement.Results: Among 967 patients, no long-term neuropathy was reported, 6 (0.6%) patients had transient shoulder pain beyond the first 24 hours (resolved by initial postoperative visit), and 7 (0.7%) were lost to follow-up. No neurologic complications were reported. Median beanbag and total patient displacement were 0 cm (interquartile range 0-0) and 0 cm (interquartile range 0-2), respectively. Patient displacement relative to the table was correlated with the total surgical time (P=0.025) and patient weight (P=0.023). The median displacement was greater in hysterectomy than non-hysterectomy procedures (P=0.003).Conclusion: Use of beanbags with shoulder supports and convoluted foam armboard pads was associated with minimal patient displacement and risk of arm and leg neurologic injury. [ABSTRACT FROM AUTHOR]

Objective: To compare risk of reintervention, long-term clinical outcomes, and health care utilization among women who have bulk symptoms from leiomyoma and who underwent the following procedures: hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance-guided, focused ultrasound surgery.Methods: This was a retrospective analysis of administrative claims from a large U.S. commercial insurance database. Women aged 18-54 years undergoing any of the previously mentioned leiomyoma procedures between 2000 and 2013 were included. We assessed the following outcome measures: risk of reintervention between uterine-sparing procedures, risk of other surgical procedures or complications of the index procedure, 5-year health care utilization, pregnancy rates, and reproductive outcomes. Propensity score matching along with Cox proportional hazard models were used to adjust for differences in baseline characteristics between study cohorts.Results: Among the 135,522 study-eligible women with mean follow-up of 3.4 years, hysterectomy was the most common first-line procedural therapy (111,324 [82.2%]) followed by myomectomy (19,965 [14.7%]), uterine artery embolization (4,186 [3.1%]) and magnetic resonance-guided focused ultrasound surgery (47 [0.0003%]). Small but statistically significant differences were noted for uterine artery embolization and myomectomy in reintervention rate (17.1% compared with 15.0%, P=.02), subsequent hysterectomy rates (13.2% compared with 11.1%, P<.01) and subsequent complications from index procedures (18.1% compared with 24.6%, P<.001). During follow-up, women undergoing myomectomy had lower leiomyoma-related health care utilization, but had higher all-cause outpatient services. Pregnancy rates were 7.5% and 2.2% among myomectomy and uterine artery embolization cohorts, respectively (P<.001) with both cohorts having similar rates of adverse reproductive outcome (69.4%).Conclusions: Although the overwhelming majority of women having leiomyoma with bulk symptoms underwent hysterectomy as their first treatment procedure, among those undergoing uterine-sparing index procedures, approximately one seventh had a reintervention, and one tenth ended up undergoing hysterectomy during follow-up. Compared with women undergoing myomectomy, women undergoing uterine artery embolization had a higher risk of reintervention, lower risk of subsequent complications, but similar rate of adverse reproductive outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of undiagnosed uterine leiomyosarcoma (LMS) in women undergoing hysterectomy or myomectomy for suspected benign leiomyomas.Study Design: Retrospective, single-centre, cohort study. Information for all gynaecological procedures for suspected benign leiomyomas between 1993 and 2016 was extracted from the hospital database. The prevalence of LMS was calculated by surgery type and age group.Results: The prevalence of LMS was 1.7/1000 [one in 603 women; 95% confidence interval (CI) 0.8-3.4] for all procedures combined. The prevalence of LMS was 1.1/1000 (one in 875 women; 95% CI 0.4-2.9) for all hysterectomies combined and 4.2/1000 (one in 240 women; 95% CI 1.4-12.2) for all myomectomies combined. For women aged <50years, the prevalence of LMS was 5.4/1000 (one in 187 women; 95% CI 1.8-15.6) for abdominal hysterectomies, 1.0/1000 (one in 1040 women; 95% CI 0.2-5.4) for laparoscopic hysterectomies, 5.2/1000 (one in 191 women; 95% CI 0.9-29.1) for abdominal myomectomies, 3.0/1000 (one in 332 women; 95% CI 0.5-16.9) for laparoscopic myomectomies and 8.6/1000 (one in 116 women; 95% CI 1.5-47.2) for hysteroscopic myomectomies.Conclusions: Occult LMS is a rare malignant disease. This study found that the prevalence of LMS was higher in women undergoing myomectomy compared with women undergoing hysterectomy. The highest prevalence of LMS was found in women undergoing hysteroscopic myomectomy. [ABSTRACT FROM AUTHOR]

Controversy regarding psychological or psychiatric outcomes following hysterectomy still exists. The purpose of this study was to investigate the risk of postoperative psychiatric disorders in women with hysterectomy compared to that in women with uterus-conserving surgery for myomas by using population-based data from South Korea. This study was designed as a retrospective cohort study. We analyzed the National Health Insurance Service National Sample Cohort data including all administrative medical claims from 2002 to 2013. The study population, consisting of 9581 women, was defined as those diagnosed with uterine myoma who underwent medical procedures. The association between psychiatric and mood disorders and hysterectomy was assessed using Cox proportional hazard regression. During the study period, 1381 (14.4%) women experienced psychiatric disorders and 374 (3.9%) experienced mood disorders. The hazard ratio (HR) for psychiatric disorder was higher in women after hysterectomy than in women after uterus-conserving procedures (adjusted HR = 1.44; 95% CI = 1.27-1.64, p < 0.0001). In addition, the HR for mood disorders in women after hysterectomy was significantly higher than in women after uterus-conserving procedures (adjusted HR = 1.62; 95% CI = 1.26-2.08, p = 0.0002). Our study suggests that hysterectomy increased the risk of psychiatric disorders compared to uterus-conserving procedures in women with uterine myoma. Considering these findings, more focus on psychological responses in women following hysterectomy is needed, and appropriate psychosocial support or provisioning of information before or after procedures could reduce psychological distress. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of occult pre-malignant or malignant uterine pathology at the time of laparoscopic surgery with open power morcellation for benign gynecologic disease.Methods: The present multicenter, retrospective cohort study included women who underwent open power morcellation for benign indications between January 1, 2007, and February 28, 2014, at three academic medical centers in the USA. The primary outcome was pre-malignant or malignant pathology at the time of open power morcellation, and was determined from the patients' pathology reports.Results: During the study period, 1214 women underwent open power morcellation for benign indications. Similar preoperative characteristics were observed between patients with normal pathology and those with pre-malignant or malignant uterine pathology, including body mass index, parity, hypertension, diabetes, breast cancer, and smoking (all P>0.129). Among patients who underwent open power morcellation, 14 (1.2%) had occult pre-malignant or malignant pathology; 5 (0.4%) women had endometrial adenocarcinoma and 1 (0.1%) had low-grade endometrial stromal sarcoma. There were eight patients with malignant pathology who underwent additional surgical exploration and were disease free at their final clinical visit, with a median follow-up time of 42.0 months (interquartile range 5.0-62.0 months).Conclusion: Endometrial adenocarcinoma and low-grade endometrial stromal sarcoma were rare in the present study and there were no reports of leiomyosarcoma. [ABSTRACT FROM AUTHOR]

Objective: To examine the association between living in a county with gynecologic oncologist provision, the performance of fertility sparing surgery, and survival among young women with early epithelial ovarian cancer.Methods: The present retrospective cohort study was based on the SEER 18 dataset of the US National Cancer Institute. Women younger than 45 years with early stage epithelial ovarian cancer diagnosed between 2000 and 2012 were included. Logistic regression and Cox proportional hazards methods were used to analyze all-cause survival. Adjustment was made for relevant clinical and demographic variables.Results: In total, 1499 women were included. Women living in a county with gynecologic oncologist provision were less likely to undergo hysterectomy (adjusted odds ratio, 0.69; 95% confidence interval, 0.52-0.93) at the time of primary surgery. Women who underwent hysterectomy had a similar risk of mortality as women with uterine preservation (adjusted hazard ratio [HR], 0.73; 95% CI, 0.41-1.30). Living in a county with gynecologic oncologist provision was associated with reduced risk of mortality (adjusted HR, 0.53; 95% CI, 0.31-0.92).Conclusion: Living in a county with gynecologic oncologist provision was independently associated with the use of fertility sparing surgery among young women with early epithelial ovarian cancer. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to assess the effectiveness and safety of vaginal native tissue repair (VNTR) as a surgical treatment for severe pelvic organ prolapse (POP) and, second, to evaluate the impact on the quality-of-life (QoL) and sexual function.Methods: Women with symptomatic POP (≥III stage according to POP Quantification System) with or without stress urinary incontinence (SUI) underwent VNTR. The clinical stage, 3-day voiding diary, and urodynamic testing were evaluated in the preoperative and postoperative times, respectively. The International Consultation on Incontinence Questionnaire-Urinary Incontinence Questionnaire Short Form (ICIQ-UI SF), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12), and the prolapse quality-of-life questionnaire (P-QoL) were administered.Results: One hundred forty-six patients were recruited. The median follow-up was 48 months (36-63). Fifty-two women (36%) had a previous hysterectomy, and 16 (11%) had a previous prolapse/continence surgery. Preoperatively, 135 (92.5%), 109 (74.7%), and 98 (67.1%) patients had anterior, central, and posterior descent ≥III stage, respectively. Thirty-two patients (22%) had concomitant diagnosis of SUI. Median operative time was 85 min (37-154), and median postoperative hospital stay was 2 days (2-4). No intraoperative severe complications occurred. At the long-term follow-up, the subjective cure rate for prolapse was 97.3% and the objective cure rate was 91.1%. A significant improvement of ICIQ-UI SF, the P-QoL, and the PISQ-12 was recorded at the follow-up (p < 0.001).Conclusion: VNTR is effective, safe, and durable and improves POP-related symptoms and sexual function. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to compare surgical outcomes following conventional laparoscopic hysterectomy (LH) (C-LH) versus the combination method of LH plus laparoscopic myomectomy (LM) (LH+LM) for the treatment of large uterine fibroids.Study Design: This study was performed in 56 patients (uterine weights ≥500g) who underwent either C-LH or LH+LM performed by the same surgeon between May 2010 and May 2016. LH+LM was performed when C-LH was problematic because of poor visibility and/or mobility due to uterine fibroids.Results: The C-LH and LH+LM groups consisted of 27 (48%) and 29 (52%) patients, respectively. The clinical characteristics of patients differed significantly only in the median sizes of the dominant fibroid. The sizes of the dominant fibroid in the C-LH and LH+LM groups were 9.5cm and 10.7cm (P=0.04), respectively. Regarding the surgical outcomes for the C-LH and LH+LM groups, the median uterine weights were 558g and 737g (P=0.03), respectively, the median operating times were 156min and 173min (P=0.23), respectively, and the median intraoperative blood losses were 150g and 300g (P=0.0004), respectively. In all patients, LH was performed without conversion to laparotomy and there were no cases of bladder, ureteral, or gastrointestinal tract injury. There were no postoperative complications of Clavien-Dindo scale≥III in either group.Conclusions: When C-LH cannot be performed because of large uterine fibroids that cause poor visibility and/or mobility, LH+LM may allow the procedure to be successfully completed without conversion to laparotomy. However, the latter approach increases the risk for intraoperative blood loss. [ABSTRACT FROM AUTHOR]

Purpose: The high prevalence of Pelvic Organ Prolapse (POP) along with the demographic trend of the ageing population raises the value of sacropexy in the treatment of POP. Thus, efforts to decrease risks associated with this procedure have the potential for public health impact. We examined the perioperative morbidity of laparoscopic sacropexy regarding the surgical access and compared it with the morbidity of one of the most common gynecological procedure, the laparoscopic hysterectomy. Our aim was to prove the safety of laparoscopic sacropexy.Methods: A retrospective evaluation of 80 consecutive laparoscopic sacropexies performed from Sept. 2012 until Oct. 2014 and 126 laparoscopic hysterectomies for a benign indication were undertaken. We assessed the anatomical outcome and the intra- and postoperative complications using the classification system according to Clavien-Dindo (CD).Results: Apical success rate after sacropexy was 100% and global success rate was 95% (POP-Q stage ≤1). The decline in hemoglobin was low in both groups and showed no statistically significant differences. Both operative time (P < 0.001) and the duration of hospitalization (P < 0.001) were longer in case of a sacropexy. Although overall intraoperative complications seemed more frequent during a sacropexy, differences were not statistically significant. Both early and late postoperative complications showed a higher rate of mild complications (CD-I/II) and a lower rate of severe complications (CD-IIIa/IIIb) after a sacropexy. The differences were not statistically significant.Conclusion: The laparoscopic sacropexy represents a safe procedure with good anatomical outcome. Despite higher technical severity, it doesn't seem to bare higher risks for perioperative morbidity than the laparoscopic hysterectomy does. [ABSTRACT FROM AUTHOR]

Objective: To estimate the incidence and factors for conversion to laparotomy in women scheduled for laparoscopic hysterectomy for benign gynecologic indications and to examine the effect of conversion on patient outcomes.Methods: A retrospective cohort study of a Michigan multicenter prospective database was abstracted from January 1, 2013, through July 2, 2014. Participants were collected from an all-payer quality and safety database maintained by the Michigan Surgical Quality Collaborative. Women with a preoperative indication of cancer or obstetric indications were excluded. A logistic regression model was used to calculate odds of conversion using patient preoperative and intraoperative attributes.Results: During the study period, 6,992 women underwent an attempted laparoscopic hysterectomy with 3.93% (n=275) converted to laparotomy. After adjusting for socioeconomic differences, hysterectomy indication, and intraoperative factors, there were decreased odds of conversion to laparotomy with use of robotic-assisted laparoscopy compared with traditional laparoscopy (adjusted odds ratio [OR] 0.14, 95% confidence interval [CI] 0.07-0.25) with a predicted risk of conversion of 0.8% compared with 5.4% (P<.001). High-volume surgeons were less likely to convert to laparotomy compared with low- and medium-volume surgeons (adjusted OR 0.66, 95% CI 0.47-0.92) with a predicted risk of conversion of 1.4% compared with 2.25% (P=.015). Conversion was associated with moderate or severe adhesive disease and increasing specimen weight. Conversion was associated with increased rates of surgical site infection, blood transfusion, severe sepsis, and reoperation.Conclusion: This analysis demonstrates that conversion to laparotomy is associated with increased odds of postoperative morbidity, and robotic assistance and surgeon volume are strongly associated with decreased odds of conversion. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence of, and risk factors for, conversion from robotic gynecologic procedures to other procedure types.Methods: A retrospective cohort study included data from women who underwent any robotic gynecologic procedures between January 1, 2011 and December 31, 2012 at a tertiary care referral center in the USA. Demographic data, perioperative data, and surgeon experience (monthly case volume) data were retrieved; potential risk factors were compared between robotic procedures that were converted to other procedures and those completed as robotic procedures.Results: There were 942 robotic procedures during the study period. Conversion from robotic to any other type of procedure was recorded for 47 (5.0%, 95% confidence interval 3.8-6.6) procedures and robotic-to-open-surgery conversion occurred in 16 (1.7%, 95% confidence interval 1.0-2.7) procedures. Conversion from robotic surgery to another approach was associated with higher body mass index (P<0.001), previous laparotomy (P=0.042), and surgeons having a lower monthly robotic surgical case volume (P=0.011). Asthma (P=0.008), intra-operative bowel injury (P<0.001), intra-operative vascular injury (P=0.003), and single-port robotic surgery (P=0.034) were associated with increased odds of requiring conversion from robotic procedures.Conclusion: The overall incidence of conversion from robotic surgery to laparotomy was low. Higher body mass index, previous laparotomy, history of asthma, using a single-port approach, and surgeon case volume were associated with the risk of conversion. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the feasibility and safety of vaginal morcellation (VM) through the posterior cul-de-sac (PCDS) using an electromechanical morcellator and to compare the perioperative outcomes of VM with those of abdominal morcellation (AM) to remove a single myoma.Methods: The characteristics of 245 consecutive patients who had undergone VM after laparoscopic myomectomy or subtotal hysterectomy were summarized. A retrospective, matched, case-control study was performed; 64 patients had a myoma weighting 100 g or more. Cases were matched with controls (ratio 1:2), who had undergone AM, by age, body mass index, specimen weight, surgical type, and surgeon. Body image questionnaires were used to assess the cosmetic outcome. Medians were analyzed using the Mann-Whitney U test. Differences between means were assessed using Student's t test. Dichotomous groupings were analyzed using either the Chi-squared test or Fisher's exact test, as appropriate.Results: All 245 patients underwent VM without complications. The mean weight of the specimens was 197.2 g (range 78.5-1477 g), and the mean duration of morcellation was 13.0 min (range 2.0-45.0 min). Two hours after surgery, the visual analog scale (VAS) score was significantly lower in the VM group than in the AM group (P = 0.03). Moreover, the morcellator used was significantly larger in the VM group (P < 0.001), and morcellation duration was significantly shorter in the VM group (P < 0.001). Finally, cosmetic outcome was significantly better in the VM group (P < 0.02). The two groups did not differ significantly in terms of hospitalization duration, surgery duration or VAS score 24 and 47 h postoperatively.Conclusion: VM through the PCDS using an electromechanical morcellator is a safe and feasible technique for surgical excision. The benefits of the procedure over AM are reduced immediate postoperative pain, shorter morcellation time, and better cosmesis. [ABSTRACT FROM AUTHOR]

Background: The aims of this study were to evaluate the impact of initial uterus-preserving surgery, such as myomectomy or subtotal hysterectomy, on the recurrence rates of patients with uterine sarcoma found incidentally and to investigate the role of surgical re-exploration in this disease subset.Methods: We performed a retrospective chart review for patients who had previously undergone either total hysterectomy or subtotal hysterectomy or myomectomy at the time of initial surgery for presumed benign uterine leiomyoma and were found to have uterine sarcoma on final pathology. Survival analysis was performed comparing patients according to the type of initial surgery.Results: Between 2006 and 2014, 45 patients with uterine sarcoma were identified. Myomectomy or subtotal hysterectomy was performed in 15 patients, and 30 patients underwent total hysterectomy as the initial surgery. Of the patients who underwent myomectomy or subtotal hysterectomy as the initial surgery (n = 15), 14 were re-explored to complete staging. Of the patients who underwent re-exploration (n = 14), five (35.8 %) had remnant sarcoma on the remaining uterus and no patients had disseminated disease. A Kaplan-Meier curve and log-rank test showed no difference in progression-free survival (P = 0.941) between the two groups.Conclusion: Initial uterus-preserving surgery does not appear to be associated with an adverse impact on survival outcomes for unexpected uterine sarcoma when surgical re-exploration was performed immediately. As such, surgical re-exploration may be useful for removing any remnant sarcoma. [ABSTRACT FROM AUTHOR]