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We aimed to study whether separating the vaginal and abdominal surgical fields during total laparoscopic hysterectomy (TLH) is associated with surgical site infection rates. This was a retrospective cohort study of all patients who underwent TLH and any concomitant procedures with two minimally invasive gynecologic surgery subspecialists between January 2016 and May 2023. Among 680 included patients, the rate of infection was 0.8% with surgical field separation and 1.3% without (3/377 vs 4/303; odds ratio 0.60, 95% CI, 0.13-2.70). There was no statistical difference between groups; however, the difference in infection rates between groups was extremely small, which led to inadequate power. Our findings suggest that rates of infection after TLH are low, with or without surgical field separation. Treating the vagina, perineum, and abdomen as a single, continuous operative field during TLH may be an acceptable practice., Competing Interests: Financial Disclosure Rebecca Schneyer reports money was paid to her institution by Ethicon for her efforts in this study. Matthew Siedhoff reports receiving payment from Applied Medical. The other authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To study racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States., Design: A cohort study., Setting: Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2012-2020., Patients: Patients with an adenomyosis diagnosis., Intervention: Hysterectomy for adenomyosis., Main Outcome Measures: Patients were identified using the International Classification of Diseases 9th and 10th editions codes 617.0 and N80.0 (endometriosis of the uterus). Hysterectomies were classified on the basis of the Current Procedural Terminology codes. We compared baseline and surgical characteristics and 30-day postoperative complications across the different racial and ethnic groups. Postoperative complications were classified into minor and major complications according to the Clavien-Dindo classification system., Results: A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) non-Hispanic White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) non-Hispanic Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander, and 91 (0.7%) American Indian or Alaska Native. Postoperative complications occurred in 8.8% of cases (n = 1,104), including major complications in 3.1% (n = 385). After adjusting for confounders, non-Hispanic Black race and ethnicity were independently associated with an increased risk of major complications (adjusted odds ratio 1.54, 95% confidence interval [CI] {1.16-2.04}). Laparotomy was performed in 13.7% (n = 1,725) of cases. Compared with non-Hispanic White race and ethnicity, the adjusted odd ratios for undergoing laparoscopy were 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for non-Hispanic Black or African American, 0.33 (95% CI 0.27-0.40) for Asian, and 0.26 (95% CI 0.17-0.41) for Native Hawaiian or Pacific Islander race and ethnicity., Conclusion: Among women undergoing hysterectomy for postoperatively diagnosed adenomyosis, non-Hispanic Black or African American race and ethnicity were associated with an increased risk of major postoperative complications. Compared with non-Hispanic White race and ethnicity, Hispanic ethnicity, non-Hispanic Black or African American, Asian, Native Hawaiian, or Pacific Islander race and ethnicity were less likely to undergo minimally invasive surgery., Competing Interests: Declaration of Interests R.M. has nothing to disclose. C.M. has nothing to disclose. K.H. has nothing to disclose. Y.N. has nothing to disclose. M.B. has nothing to disclose. G.L. has nothing to disclose. M.D.T. has reported serving as a consultant for Ethicon, Medtronic, Heracure Medical, and Cooper Surgical; K.N.W. has reported serving as a consultant for Aqua Therapeutics, Hologic, Ethicon, and Karl Storz. M.T.S. has reported serving as a consultant for Applied Medical and Intuitive Surgical., (Copyright © 2024 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Objective: Compare odds of postoperative urinary symptoms in women who had cystoscopy after benign laparoscopic hysterectomy with 50% dextrose and with normal saline solution with intravenous indigo carmine., Design: Retrospective cohort study., Setting: Two tertiary care centers., Patients: All women who underwent benign laparoscopic hysterectomy and intraoperative cystoscopy carried out by a single surgeon., Interventions: We compared postoperative urinary symptoms in patients who received 50% dextrose cystoscopy fluid (January 2016-June 2017) with those who received saline cystoscopy with intravenous indigo carmine (November 2013-April 2014)., Measurements and Main Results: A total of 96 patients had cystoscopy with 50% dextrose and 104 with normal saline with intravenous indigo carmine. Differences in baseline characteristics of the two groups of participants mainly reflected institutional population diversity: age (45.2 vs 41.9, p = .01), body mass index (26.9 vs 33.4, p <.01), race, current smoking status (1% vs 7.8%, p = .04), diabetes (2.1% vs 11.5%, p = .01), history of abdominal surgery (53.1% vs 74%, p <.01), hysterectomy type, receipt of intraoperative antibiotics (92.7% vs 100%, p <.01), recatheterization (10.4% vs 0%, p <.01), and removal of catheter on postoperative day 0 (66.7% vs 12.5%, p <.01). Urinary symptoms were similar for 50% dextrose and saline (12.5% vs 7.7%, p = .19). After adjusting for age, body mass index, race, diabetes, and day of catheter removal, there remained no significant differences in urinary symptoms between the groups (odds ratio 3.19 [95% confidence interval, 0.82-12.35], p = .09). One immediate bladder injury was detected in the saline group and 1 delayed lower urinary tract injury in the 50% dextrose group., Conclusion: Overall, most women experienced no urinary symptoms after benign laparoscopic hysterectomy. There were no significant differences in postoperative urinary symptoms or empiric treatment of urinary tract infection after the use of 50% dextrose cystoscopy fluid as compared with normal saline. The previous finding of increased odds of urinary tract infection after dextrose cystoscopy may be due to use in a high-risk population., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate techniques for addressing the unique challenges for a minimally invasive approach to hysterectomy presented by a massive myomatous uterus., Design: Technical video of an operation demonstrating the methods used to perform hysterectomy in this setting, highlighting such aspects as port placement (Fig. 1), uterine manipulation (Fig. 2), exposure, and vascular control (Figs. 3 and 4) (Canadian Task Force classification III)., Setting: Academic tertiary care hospital., Intervention: A 49-year-old woman elected to proceed with laparoscopic hysterectomy after years of suffering from bleeding and bulk symptoms from a massively enlarged myomatous uterus. A computed tomography scan estimated uterine dimensions of 32 × 27 × 24 cm, for a volume of >7000 mL (Fig. 5). Her surgical history included a ventral herniorrhaphy with mesh, and her body mass index was 43 kg/m 2 . She was a Jehovah's Witness, and thus blood transfusion was not an acceptable option for her due to a religious prohibition. Intraoperatively, the uterus extended deep into the pararectal and paravesical spaces on the right, from the caudad below the cervix (Fig. 6) to superiorly near the liver edge (Fig. 7)., Measurements and Main Results: Laparoscopic hysterectomy was successfully completed (Table), and the patient was discharged on the day after surgery. Final pathology revealed a 6095-g uterus with benign leiomyomata. She presented 9 days after surgery with nausea and vomiting, suspicious for an incarcerated hernia at the tissue extraction site. Her symptoms were ultimately determined to be due to either ileus or small bowel obstruction, which likely could have been managed nonoperatively with bowel rest and fluids. She stayed an additional 2 days after readmission and was then discharged, with no further complications., Conclusions: The size of the uterus was once considered a barrier to the use of laparoscopy for hysterectomy, but experience has shown that the benefits of minimally invasive surgery are particularly relevant for large myomas [1-4], given that a vaginal approach is not feasible and that other risks, such as wound complications and venous thromboembolism, would be greater with the large incision required to perform the procedure by laparotomy. This video uses a particularly challenging case to demonstrate a roadmap for addressing myomas in laparoscopic hysterectomy through exposure and vascular control. Although the presentation focused on the initial steps of the procedure and not on uterine extraction, this patient's readmission highlights potential complications associated with various methods of tissue removal for very large specimens., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Fragmented tissue extraction (morcellation) of uterine and leiomyoma tissue in gynecologic surgery has been performed for decades, but recent years have seen a vast expansion of techniques to address risks associated with tissue dispersion. Use of power, or electromechanical, morcellation has largely been replaced by manual morcellation with a scalpel. Morcellation can take place through a laparoscopic incision, a minilaparotomy incision, or through a colpotomy. Containment systems are now available for both power and manual morcellation, allowing tissue fragmentation to take place within an enclosed specimen bag. These products require additional training and skill and may add operating time, but have the potential to mitigate risks associated with tissue dissemination.

Background: Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown., Objective: The objective of the study was to evaluate the relative cost-effectiveness of 4 treatment options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation, nonresectoscopic endometrial ablation, and the levonorgestrel-releasing intrauterine system., Study Design: We formulated a decision tree evaluating private payer costs and quality-adjusted life years over a 5 year time horizon for premenopausal women with heavy menstrual bleeding and no suspected malignancy. For each treatment option, we used probabilities derived from literature review to estimate frequencies of minor complications, major complications, and treatment failure resulting in the need for additional treatments. Treatments were compared in terms of total average costs, quality-adjusted life years, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was conducted to understand the range of possible outcomes if model inputs were varied., Results: The levonorgestrel-releasing intrauterine system had superior quality-of-life outcomes to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel-releasing intrauterine system was cost-effective compared with hysterectomy in the majority of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were associated with reduced costs compared with hysterectomy but resulted in a lower average quality of life. According to standard willingness-to-pay thresholds, resectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 44% of scenarios, and nonresectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 53% of scenarios., Conclusion: Comparing all trade-offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel-releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel-releasing intrauterine system as a first-course treatment for heavy menstrual bleeding, consideration of cost, procedure-specific complications, and patient preferences can guide the decision between hysterectomy and ablation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Previous decision analyses demonstrate the safety of minimally invasive hysterectomy for presumed benign fibroids, accounting for the risk of occult leiomyosarcoma and the differential mortality risk associated with laparotomy. Studies published since the 2014 Food and Drug Administration safety communications offer updated leiomyosarcoma incidence estimates. Incorporating these studies suggests that mortality rates are low following hysterectomy for presumed benign fibroids overall, and a minimally invasive approach remains a safe option. Risk associated with morcellation, however, increases in women age >50 years due to increased leiomyosarcoma rates, an important finding for patient-centered discussions of treatment options for fibroids., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose of Review: Safety concerns regarding morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in surgical technique., Recent Findings: The prevalence of occult leiomyosarcoma is debated; however, estimates from a robust meta-analysis suggest it may be in the range of 1 case per 1960-8300 fibroid surgeries. Advancing age is an important clinical risk factor for occult malignancy. The impact of tumor morcellation may vary by mode of tissue removal, though tissue fragmentation is consistently associated with poorer outcomes. Decision and cost analyses continue to support laparoscopic hysterectomy as a low-morbidity and cost-effective approach. The increased scrutiny on fibroid procedures in the past few years may lead to changes in surgical approach; however, alternative tissue extraction options are evolving, including incorporation of contained morcellation., Summary: Although the incidence of occult leiomyosarcoma is low, outcomes are poor and may be worsened by morcellation. By addressing risk factors for malignancy and incorporating evolving surgical techniques into practice, gynecologists can continue to offer patients a minimally invasive approach for fibroid management.

Study Objective: Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH., Design: Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III)., Setting: U.S. hospitals., Patients: Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata., Interventions: We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature., Measurements and Main Results: Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of $2193 ($24 181 vs $26 374). Over 5 years, women in the LH group experienced 4.99 QALY versus women in the AH group with 4.91 QALY (incremental gain of .085 QALYs). LH dominated AH in base-case estimates: LH was both less expensive and yielded greater QALY gains. The ICER was sensitive to operative costs for LH and AH. Varying operative costs of AH yielded an ICER of $87 651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time; 17.4% of simulations fell above the willingness-to-pay threshold of $50 000/QALY gained., Conclusion: When considering total direct hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. Driven by the rarity of occult LMS and the reduced incidence of intra- and postoperative complications, LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to model outcomes in laparoscopic hysterectomy with morcellation compared with abdominal hysterectomy for the presumed fibroid uterus and to examine short- and long-term complications and death., Study Design: A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women who underwent hysterectomy for presumed fibroid tumors over a 5-year time horizon. Parameter and quality-of-life utility estimates were determined from published literature for postoperative complications, leiomyosarcoma incidence, death related to leiomyosarcoma, and procedure-related death., Results: The decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy compared with abdominal hysterectomy (98 vs 103 per 100,000). Although there were more deaths from leiomyosarcoma after laparoscopic hysterectomy (86 vs 71 per 100,000), there were more hysterectomy-related deaths with abdominal hysterectomy (32 vs 12 per 100,000). The laparoscopic group had lower rates of transfusion (2400 vs 4700 per 100,000), wound infection (1500 vs 6300 per 100,000), venous thromboembolism (690 vs 840 per 100,000) and incisional hernia (710 vs 8800 per 100,000), but a higher rate of vaginal cuff dehiscence (640 vs 290 per 100,000). Laparoscopic hysterectomy resulted in more quality-adjusted life years (499,171 vs 490,711 over 5 years)., Conclusion: The risk of leiomyosarcoma morcellation is balanced by procedure-related complications that are associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit on which patient-centered decisions can be made., (Copyright © 2015 Elsevier Inc. All rights reserved.)

When appropriately performed, hysterectomy most often contributes substantially to quality of life. Postoperative morbidity is minimal, in particular after minimally invasive surgery. In a minority of women, pain during intercourse is one of the more long-lasting sequelae of the procedure. Complete evaluation and treatment of this complication requires a thorough understanding of the status and function of neighboring organ systems and structures (urinary system, gastrointestinal tract, and pelvic and hip muscle groups). Successful resolution of dyspareunia often may be facilitated with review of the patient's previous degree of comfort during sex and the nature of her relationship with her partner. Repeat surgery is needed in a small minority of patients., (Copyright © 2014. Published by Elsevier Inc.)

Objective: To examine the influence of mechanical bowel preparation on surgical field visualization during laparoscopic hysterectomy., Methods: The study's primary outcome was the percentage of operations rated "good" or "excellent" in terms of surgical field visualization at the outset of the case by the primary surgeon. Additional measures included assessment of visualization during the case and patient perioperative comfort. The study was powered to detect a 20% absolute difference in the proportion of cases rated as "good" or "excellent.", Results: Seventy-three patients were assigned to mechanical bowel preparation and 73 to no mechanical bowel preparation. The groups were comparable regarding patient and surgery characteristics. No differences were found for this rating between groups (mechanical bowel preparation, 64 of 73 patients [87.7%], compared with no mechanical bowel preparation, 60 of 73 patients [82.2%], P=.36). Surgeons guessed patient assignment correctly 59% of the time (42 of 71 patients) with mechanical bowel preparation and 55% of the time (41 of 75 patients) with no mechanical bowel preparation., Conclusion: Mechanical bowel preparation is well-tolerated but does not influence surgical field visualization for laparoscopic hysterectomy., Clinical Trial Registration: ClinialTrials.gov, www.clinicaltrials.gov, NCT01576965.

The patient presented here delivered at 32 weeks' gestation after expectant management of spontaneous preterm membrane rupture. She had an unusually located placenta accreta at the left cornu that required a hysterectomy for treatment. The type of abnormal placentation and the laparoscopic approach to her surgery were unique features of her care., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve when ovarian preservation is planned in view of determining the feasibility of conducting the study on a larger scale., Design: Pilot randomized controlled trial., Setting: Tertiary care, academic medical center., Patient(s): Thirty premenopausal women aged 18 to 45 years undergoing laparoscopic hysterectomy with ovarian preservation for benign indications from April 2012 to September 2012., Intervention(s): Bilateral salpingectomy (n = 15) versus no salpingectomy (n = 15) at the time of laparoscopic hysterectomy with ovarian preservation., Main Outcome Measure(s): Antimüllerian hormone (AMH) measured preoperatively, at 4 to 6 weeks postoperatively, and at 3 months postoperatively, with operative time and estimated blood loss abstracted from the medical records., Result(s): The mean AMH levels were not statistically significantly different at baseline (2.26 vs. 2.25 ng/ml), 4 to 6 weeks postoperatively (1.03 vs. 1.25 ng/ml), or 3 months postoperatively (1.86 vs. 1.82 ng/ml) among women with salpingectomy versus no salpingectomy, respectively. There was also no statistically significant temporal change in the mean AMH level from baseline to 3 months postoperatively (-0.07 vs. -0.08 ng/ml) between the two groups. No difference in operative time (116 vs. 115 minutes) or estimated blood loss (70 vs. 91 mL) was observed., Conclusion(s): Salpingectomy at the time of laparoscopic hysterectomy with ovarian preservation is a safe procedure that does not appear to have any short-term deleterious effects on ovarian reserve, as measured by AMH level. Conducting a trial of this nature that is adequately powered with long-term follow-up evaluation would be feasible and is required to definitively confirm these results., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Objective: To estimate the effect of body mass index (BMI) on several outcomes in laparoscopic hysterectomy, in particular in the extremes of obesity., Design: Retrospective cohort study (Canadian Task Force classification II-3)., Setting: Tertiary-care university-based teaching hospital., Patients: Eight hundred thirty-four patients who underwent laparoscopic hysterectomy from January 2007 to October 2011., Intervention: Laparoscopic hysterectomy for benign indications., Measurements and Main Results: Demographic, operative, and postoperative data were abstracted from medical records. The primary outcome was a composite index score that took into account operative time, nonsurgical operating room time, estimated blood loss, length of hospital stay, number of complications, and severity of complications according to the Dindo-Clavien classification. We individually examined elements of the composite index as a secondary outcome. Models were developed to assess the association of BMI with the composite index score and the components of the index, controlling for age, presence of diabetes, tobacco use, surgeon, type of hysterectomy (total vs supracervical), use of robotics, uterine weight, number of additional procedures performed, presence of adhesions requiring lysis, and deeply infiltrating endometriosis as potential confounders. Mean (SD) BMI was 31.4 (8.1). Mean (SD) uterine weight was 345 (388) g. Mean operative time was 150 (61) minutes. Increasing BMI was associated with a worse composite score (p < .01); longer operative time (p = .03), nonsurgical operating room time (p = .02), and total operating room time (p < .01); greater estimated blood loss (p < .01); and complication severity (p = .01)., Conclusion: These data suggest that there is a significant association of BMI with surgical outcomes in laparoscopic hysterectomy, and the effect is most pronounced in the morbidly obese. These patients may stand to gain the greatest differential benefit from a laparoscopic approach to surgery. However, they should be properly counseled about the challenge that obesity poses to the operation., (Copyright © 2012 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To estimate whether a new surgical technique is associated with lower incidence of postoperative breakdown of the vaginal cuff after laparoscopic hysterectomy or trachelectomy, compared with previous methods of closure., Design: Retrospective cohort study, Canadian Task Force Classification II-3., Setting: Tertiary-care university-based teaching hospital., Patients: Patients who underwent laparoscopic vaginal closure after removal of the uterus and/or cervix by members of a subspecialty gynecologic laparoscopy division from January 2007 to January 2010 (n = 387)., Interventions: Use of bidirectional barbed suture for laparoscopic vaginal cuff closure., Measurements and Main Results: A total of 387 patient records were reviewed. The incidence of vaginal cuff dehiscence among those with other methods of closure was 4.2%, while there were no cases of dehiscence among those who had closure with bidirectional barbed suture (p = .008). Postoperative bleeding (OR 2.3, 95% C.I. 1.3-3.9), presence of granulation tissue (OR 1.9, 95% C.I. 0.92-3.9), and cellulitis (OR 4.6, 95% C.I. 1.0-21.1) all occurred more frequently in patients without barbed suture closure., Conclusion: Dehiscence of the vaginal cuff after laparoscopic closure is a rare but important complication in gynecologic surgery. Use of bidirectional barbed suture eliminated the problem in our first year of experience with the technique. We also observed a decreased incidence of other common problems of the vaginal cuff. This method is easy to learn and inexpensive and does not require advanced skills such as laparoscopic knot-tying., (Published by Elsevier Inc.)

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

Objective: The objective of this study was to evaluate the effect of an Enhanced Recovery After Surgery (ERAS) protocol on patient experience after discharge from laparoscopic hysterectomy. Materials and Methods: Patients having laparoscopic hysterectomies by high-volume surgeons (>10 hysterectomies per year) at an urban tertiary-care hospital were divided into 2 cohorts: (1) a perioperative ERAS protocol adopted by the institution or (2) standard perioperative care according to the patient's surgeon. At the postoperative visit, each patient completed a validated questionnaire of self-reported recovery scores in domains of daily functional activities Results: There were 40 patients in the ERAS group and 44 in the standard perioperative care group, and 100% follow-up through the 2-week postoperative visits. Patients in both groups had similar rates of same-day discharges (88% versus 73%; p = 0.09). Both groups reported similar physical activity scores (1.38 versus 1.33; p = 0.79), days of first bowel movements (2.69 versus 2.71; p = 0.94), and days of opioid use after surgery (3.13 versus 2.64; p = 0.48). ERAS patients had fewer unplanned patient contacts than the standard care group (15% versus 50%; p < 0.01). There were no readmissions. Patients took few opioids, with 90% of all patients using <10 opioid tablets post surgery (5-mg oxycodone equivalents). Conclusions: Same-day discharge, patient-reported recovery experience, and opioid requirements did not differ between the ERAS protocol versus standard perioperative care. The ERAS protocol decreased unplanned patient contacts. [ABSTRACT FROM AUTHOR]

Study Objective: Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void before discharge). The primary objective of this study was to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol with more strict voiding protocols. Secondary outcomes included length of hospital stay (LOS) and urinary tract infection (UTI).Design: Retrospective cohort study.Setting: Quaternary-care academic hospital in the United States.Patients: Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n = 652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded.Interventions: Hysterectomy, myomectomy.Measurements and Main Results: POUR, defined as the need for recatheterization within 24 hours of catheter removal, along with UTI and LOS were compared between liberal and strict voiding protocols. A subgroup analysis was performed for those undergoing minimally invasive surgery (MIS). A total of 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) women with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different between the groups (2.6% liberal vs. 4.9% strict, p = .14). UTIs also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p = .86). Similar results were seen specifically among those who underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p = .17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p = .28). The median LOS (interquartile range) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall [interquartile range 15 hours], 9 [4] hours liberal vs. 36 [34] hours strict, p <.01). Among those discharged the same day (72.6% of the MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean [standard deviation] 9.4 [2.5] hours vs. 10.6 [35] hours, p <.01). Postoperative complications occurred less frequently in those with MIS procedures (11.8% in MIS vs. 20.2% in laparotomies, p <.01) and those with liberal voiding protocols (11.2% liberal vs. 16.9% strict p = .04).Conclusion: Overall, POUR occurs infrequently after major benign gynecologic surgery and does not differ between those with liberal and strict voiding protocols. Our data suggest that same-day discharge after MIS hysterectomy and myomectomy without a requirement to void does not increase the risk of POUR and shortens LOS. Eliminating voiding protocols after these procedures may facilitate greater efficiency in the postanesthesia recovery unit and may contribute to enhanced recovery after surgery protocols. [ABSTRACT FROM AUTHOR]

Objective: The goal of this research was to explore physicians' perceptions of uterine morcellation and minimally invasive hysterectomy in the setting of new hospital regulations, comparing gynecologists and internal medicine providers, geographic locations, and levels of training. Design: This was a multicenter cross-sectional study. Materials and Methods: A 17-question, anonymous, electronic survey was administered to resident, fellow, and attending gynecologists, and internal medicine physicians at three institutions. Results: Two hundred and twenty-two gynecologists responded for a response rate of 46%. Most gynecologists believe morcellation is safe and acceptable, and the benefits of minimally invasive surgery outweigh the potential risk of cancer dissemination as a result of morcellation. The majority reported that the incidence of occult leiomyosarcoma is rarer than 1 in 350. Physicians from Boston, MA, responded less favorably toward morcellation than providers in Pittsburgh, PA, and Chapel Hill, NC ( p < 0.001). Trainees were not significantly different from attending gynecologists. One hundred and forty-seven internal medicine physicians responded for a response rate of 40%. Compared to internal medicine providers, significantly more gynecologists believe minimally invasive approaches, as opposed to laparotomy, yield the best overall outcome ( p < 0.001), and the benefits of morcellation outweigh its potential risks ( p < 0.001). Compared to gynecologists, more internal medicine physicians felt morcellation should be banned ( p < 0.001). Conclusions: Most gynecologists highly value morcellation as a means of tissue extraction to facilitate minimally invasive approaches in order to provide the most optimal patient outcomes. Gynecologists' opinions regarding morcellation differ by geographical location but not by level of training. Gynecologists responded more favorably toward minimally invasive hysterectomy and morcellation, compared to internal medicine physicians. (J GYNECOL SURG 33:12) [ABSTRACT FROM AUTHOR]

Objective: To compare the rate of delayed 30-day lower genitourinary tract injury in women who underwent cystoscopy at the time of hysterectomy for benign indications to those who did not.Methods: This was a retrospective cohort study of patients who underwent hysterectomy without a concomitant procedure for prolapse or incontinence for benign pathology with a general obstetrician-gynecologist (ob-gyn) recorded in the National Surgical Quality Improvement Program targeted hysterectomy file between 2015 and 2017. The primary outcome was a delayed lower genitourinary tract injury in the 30 days after hysterectomy. Secondary outcomes included urinary tract infection and operative time. The exposure of interest was cystoscopy at the time of hysterectomy. Stratified analysis was performed by route of surgery. Bivariable tests were used to examine associations.Results: We identified 39,529 women who underwent hysterectomy for benign indications with a general ob-gyn. Surgical approach was open (26%), laparoscopic or robotic assisted laparoscopic (46%), and vaginal or vaginally assisted (28%). Overall, 25% of women underwent cystoscopy at the time of hysterectomy; cystoscopy was more commonly performed in laparoscopic or robotic (32%) and vaginal hysterectomy (25%) as compared with open hysterectomy (11%) (P<.001). There was no difference in delayed lower genitourinary tract injury between patients who underwent cystoscopy at time of hysterectomy compared with those who did not undergo cystoscopy (0.27% vs 0.24%, P=.64). Patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (2.6% vs 2.0%, RR 1.27 95% CI 1.09-1.47). Median operative time was increased by 17 minutes in cases where cystoscopy was performed (132 vs 115 minutes, P<.001).Conclusion: Cystoscopy at the time of hysterectomy for benign indications does not result in a lower rate of 30-day delayed lower genitourinary tract injury compared with no cystoscopy. [ABSTRACT FROM AUTHOR]

A 38-year-old gravida 6 para 2042 woman presented in consultation regarding management of a uterine defect, or “niche,” following resolution of a cesarean scar ectopic pregnancy. She had 3 prior losses, followed by in vitro fertilization that resulted in 2 healthy births, both delivered by cesarean. A third in vitro embryo transfer resulted in the cesarean scar ectopic. After consideration of treatment options, she underwent multiple-dose parenteral methotrexate with eventual termination of the ectopic. Magnetic resonance imaging demonstrated a uterine defect, suspected to contain residual pregnancy tissue. Questions considered in her consultation included whether the defect should be repaired and, if so, from a hysteroscopic or laparoscopic approach, as well as her risk of intrauterine scarring, when, or if, it would be safe to pursue another pregnancy, and her subsequent risk of uterine rupture. Literature review regarding cesarean niche was helpful, but did not seem to completely inform this particular clinical scenario. She elected to proceed with robotic-assisted laparoscopic repair. The vesicovaginal space was opened to expose the defect. Dilute vasopressin was injected circumferentially around the defect to help minimize the use of electrosurgery in opening the hysterotomy. Scar overlying the defect was resected and pregnancy tissue removed. The hysterotomy was closed with delayed-absorbable barbed suture, extrapolating technique from laparoscopic myomectomy. The first layer was imbricated with a second, similar to a 2-layer closure in cesarean delivery. Follow-up magnetic resonance imaging revealed resolution of the defect. After several failed attempts at repeat in vitro fertilization, spontaneous pregnancy was achieved 18 months postoperatively. The pregnancy was uncomplicated and she underwent scheduled cesarean delivery of a healthy neonate at 37 weeks’ gestation. The lower uterine segment was thick and developed, with no evidence of a dehiscence. [ABSTRACT FROM AUTHOR]

Background: A better understanding of the relative risks and benefits of common treatment options for abnormal uterine bleeding (AUB) can help providers and patients to make balanced, evidence-based decisions.Objectives: To provide comparative estimates of clinical outcomes after placement of levonorgestrel-releasing intrauterine system (LNG-IUS), ablation, or hysterectomy for AUB.Search Strategy: A PubMED search was done using combinations of search terms related to abnormal uterine bleeding, LNG-IUS, hysterectomy, endometrial ablation, cost-benefit analysis, cost-effectiveness, and quality-adjusted life years.Selection Criteria: Full articles published in 2006-2016 available in English comparing at least two treatment modalities of interest among women of reproductive age with AUB were included.Data Collection and Analysis: A decision tree was generated to compare clinical outcomes in a hypothetical cohort of 100 000 premenopausal women with nonmalignant AUB. We evaluated complications, mortality, and treatment outcomes over a 5-year period, calculated cumulative quality-adjusted life years (QALYs), and conducted probabilistic sensitivity analysis.Main Results: Levonorgestrel-releasing intrauterine system had the highest number of QALYs (406 920), followed by hysterectomy (403 466), non-resectoscopic ablation (399 244), and resectoscopic ablation (395 827). Ablation had more treatment failures and complications than LNG-IUS and hysterectomy. Findings were robust in probabilistic sensitivity analysis.Conclusions: Levonorgestrel-releasing intrauterine system and hysterectomy outperformed endometrial ablation for treatment of AUB. [ABSTRACT FROM AUTHOR]