Search

Objective: The goal of this research was to characterize the discrepancy in access to care between publicly and privately insured patients when seeking subspecialty minimally invasive gynecologic s...

STUDY OBJECTIVE: Scientifically evaluate the validity and reproducibility of 2 novel surgical triaging systems, as well as offer modifications to the Medically-Necessary, Time-Sensitive (MeNTS) criteria for improved application in gynecologic surgeries. DESIGN: Retrospective cohort study. SETTING: Academic university hospital. PATIENTS: Ninety-seven patients with delayed benign gynecologic procedures owing to the coronavirus disease 2019 pandemic. INTERVENTION(S): Surgical prioritization was assessed using 2 novel scoring systems, the Gynecologic Medically-Necessary Time-Sensitive (Gyn-MeNTS) and modified Elective Surgery Acuity Scale (mESAS) systems for all 93 patients included. MEASUREMENTS AND MAIN RESULTS: The interrater reliability and validity of 2 novel surgical prioritization systems (Gyn-MeNTS and mESAS) were assessed. The Gyn-MeNTS scores were calculated by 3 raters and analyzed as continuous variables, with a lower score indicating more urgency/priority. The mESAS score was calculated by 2 raters and analyzed as a 3-level ordinal variable with a higher score indicating more urgency/priority. All 5 raters were blinded to reduce bias. The Gyn-MeNTS interrater reliability was tested using Spearman r and paired t tests were used to detect systematic differences between raters. Weighted κ indicated mESAS reliability. Concurrent validity with mESAS and surgeon self-prioritization (SSP) was examined with Spearman r and logistic regression. Spearman r's for all Gyn-MeNTS rater pairs were above 0.80 (0.84 for 1 vs 2; 0.82 for 1 vs 3; and 0.82 for 2 vs 3, all p

The preoperative work-up and optimal surgical approach to colorectal endometriosis is a highly studied topic lacking definitive recommendations. Synthesis of the available data can be extremely challenging for surgeons due to the heterogeneity of existing comparisons, a variety of studied surgical outcomes, and a predominant focus on operative complications. While these considerations are extremely important for surgeons performing such complex gynecologic surgery there is still much to be desired with regards to evidence based guidelines for the preoperative assessment and surgical technique for colorectal endometriosis. Having an established guideline stating in which clinical situations endometriosis surgeons should performing rectovaginal shaving, versus discoid excision, versus segmental resection would be extremely important for all pelvic surgeons, even those operating in high-volume centers dedicated to the surgical management of complex endometriosis. This perspective highlights the shortcomings of the available data and attempts to create an algorithm surgeons can follow when performing surgery for colorectal endometriosis. This algorithm is based on our expert opinion after synthesising available data.

PURPOSE: Platelet-rich plasma (PRP) has become a novel treatment in various aspects of medicine including orthopedics, cardiothoracic surgery, plastic surgery, dermatology, dentistry, and diabetic wound healing. PRP is now starting to become an area of interest in reproductive medicine more specifically focusing on infertility. Poor ovarian reserve, menopause, premature ovarian failure, and thin endometrium have been the main areas of research. The aim of this article is to review the existing literature on the effects of autologous PRP in reproductive medicine providing a summation of the current studies and assessing the need for additional research. METHODS: A literature search is performed using PubMed, MEDLINE, and CINAHL Plus to identify studies focusing on the use of PRP therapy in reproductive medicine. Articles were divided into 3 categories: PRP in thin lining, PRP in poor ovarian reserve, and PRP in recurrent implantation failure. RESULTS: In women with thin endometrium, the literature shows an increase in endometrial thickness and increase in chemical and clinical pregnancy rates following autologous PRP therapy. In women with poor ovarian reserve, autologous intraovarian PRP therapy increased anti-Mullerian hormone (AMH) levels and decreased follicle-stimulating hormone (FSH), with a trend toward increasing clinical and live birth rates. This trend was also noted in women with recurrent implantation failure. CONCLUSIONS: Limited literature shows promise in increasing endometrial thickness, increasing AMH, and decreasing FSH levels, as well as increasing chemical and clinical pregnancy rates. The lack of standardization of PRP preparation along with the lack of large randomized controlled trials needs to be addressed in future studies. Until definitive large RCTs are available, PRP use should be considered experimental.

Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve the quality of life for women with either previously confirmed or suspected endometriosis often a decision must be made whether or not to proceed with surgery. When deeply infiltrating disease is diagnosed either clinically or by imaging studies often medical management alone will not suffice without excisional surgery. Surgery for endometriosis, especially deeply infiltrating disease, is not without risks. Aside from common risks of surgery endometriosis may also involve pelvic nerves, which can be hard to recognize to the untrained eye. Identification of pelvic nerves commonly encountered during endometriosis surgery is paramount to avoid inadvertent injury to optimize function outcomes. Injury to pelvic nerves can lead to urinary retention, constipation, sexual dysfunction, and refractory pain. However, nerve-sparing surgery for endometriosis has been proven to mitigate these complications and enhance recovery following surgery. Here we review the benefits of nerve-sparing surgery for deeply infiltrating disease.

Endometriosis of the diaphragm has been gaining more attention in the practice of gynecologists and thoracic surgeons in recent years. Understanding related symptoms and developing imaging methods have improved their approach. A review of the literature was performed with the aim to report on incidence, diagnosis, treatment and prognosis of diaphragmatic endometriosis. We also cover the issue of the Thoracic Endometriosis Syndrome (TES). Complaints of cyclic chest pain in patients of childbearing age should have as differential diagnosis the presence of thoracic endometriosis. Catamenial pneumothorax is the main manifestation of diaphragmatic endometriosis and Thoracic Endometriosis Syndrome. Other possible manifestations are hemothorax, pulmonary nodules, and diaphragmatic hernia. Despite the possibility of drug treatment, many patients will be submitted to surgical treatment. The minimally invasive approach should be the one of choice. The robotic pathway allows for an easier approach due to its ability to articulate robotic arms, allowing the treatment of lesions in hard-to-reach locations, such as the posterior part of the diaphragm. Multidisciplinary treatment should be used in most cases, as only abdominal approach is not sufficient for the diagnosis and treatment of lesions in the thoracic cavity. The approach of endometriosis of the diaphragm and Thoracic Endometriosis Syndrome should be multidisciplinary, allowing the improvement of quality of life in most patients.

Health care has changed in unprecedented ways since the first reported cases of COVID-19. With global case rates continuing to rise and government restrictions beginning to loosen, many worry that a second wave in our future. In many hospitals around the world, non-emergent surgeries were put on hold as hospitals were transformed into COVID centers. As surgeons and administrators do their best to reinstate non-emergent procedures, guidance is sought from any and all reliable sources. Robotic surgery has many known and demonstrated benefits over open surgery and often over conventional laparoscopy. In this commentary, we aim to highlight some of the advantages robotic surgery may offer during this uniquely challenging time in health care.

One strategy thought to reduce direct costs associated with robotic surgery is minimizing the number of robotic arms used for a surgery. We aim to demonstrate the safety and feasibility of the three-port robot-assisted hysterectomy across uterine weights. Retrospective cohort study in a tertiary care university hospital of consecutive patients undergoing a three-port robot-assisted hysterectomy for benign indications. All surgeries were performed between 2012 and 2018 by fellowship-trained minimally invasive gynecologic surgeons. Data from 232 patients were collected. Eighty-eight (37.9%) patients had a uterine weight

PURPOSE: Adenomyosis is a poorly understood entity with no unified treatment protocol. It has been thought to only affect the quality of life of older women, but growing evidence is highlighting the increased frequency of adenomyosis in younger patients and its possible effects on fertility outcomes. This can have a great impact on how clinicians screen, diagnose, and treat this condition. The aim of this review is to explore the relationship between adenomyosis and infertility. METHODS: A literature search of the keywords “adenomyosis”, “infertility”, “pregnancy” and “fertility” was conducted using the PubMed and Medline search engines. The articles selected were observational, systematic reviews, meta-analyses, and randomized controlled trials. The search was limited to English, abstracts were screened, and articles were selected. RESULTS: The literature reports lower clinical pregnancy rates, lower live birth rates, higher miscarriage rates, and higher odds of adverse obstetric outcomes in patients with adenomyosis. Treatment seems to be associated with higher pregnancy rates and live births rates. CONCLUSION: An association between adenomyosis and infertility seems to exist, and treatment could lead to improved fertility outcomes.

Common benign gynecologic procedures include hysterectomies and myomectomies, with hysterectomy being the most common gynecologic procedure in the United States [1]. While historically performed via laparotomy, the field of gynecologic surgery was revolutionized with the advent of laparoscopic techniques, with the most recent advancement being the introduction of robotic-assisted surgery in 2005. Robotic surgery has all the benefits of laparoscopic surgery such as decreased blood loss, quicker return to activities, and shorter length of hospital stay. Additional robotic-specific advantages include but are not limited to improved ergonomics, 3D visualization, and intuitive surgical movements. Despite these advantages, one of the most commonly cited drawbacks of robotic surgery is the associated cost. While the initial cost to purchase the robotic console and its associated maintenance costs are relatively high, robotic surgery can be cost-effective when utilized correctly.This article reviews application strategies and factors that can offset traditional costs and maximize the benefits of robotic surgery.

Study Objective We sought to identify the variables independently associated with intra/postoperative blood transfusion at the time of myomectomy. We further hoped to develop an accurate prediction model using preoperative variables to categorize an individual's risk of blood transfusion during myomectomy. Design Case-control study. Setting Not applicable to this study, which used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients Women who underwent an open/abdominal or laparoscopic (robotic or conventional) myomectomy between 2014 and 2017 at participating ACS-NSQIP sites. Intervention The primary dependent variable was occurrence of intra/postoperative bleeding requiring blood transfusion. Patient demographics, clinical characteristics, preoperative comorbidities, intraoperative variables, and additional 30-day postoperative outcomes were compared at the bivariable level. For the prediction-model development, only variables that can be reasonably known before surgery were included. Variables associated with intra/postoperative bleeding were entered into 2 separate multivariable logistic regression models. Validation of our prediction model was performed internally using 250 bootstrapped iterations of 50% subsamples drawn from the overall population of myomectomy cases from the ACS-NSQIP database. Measurements and Main Results We identified 6387 myomectomies performed during the defined study period. The most common race in our population was black/African American (45.7%), and most of the patients (57.5%) received an open/abdominal route of myomectomy. A total of 623 patients who underwent myomectomy (9.8%) experienced intraoperative/postoperative bleeding with a need for blood transfusion. At the bivariable level, we identified several variables independently associated with the need for blood transfusion at the time of myomectomy. In using only those variables that can be reasonably known before surgery to develop our prediction model, additional multivariable logistic regression elucidated black race, need for preoperative blood transfusion, planned abdominal/open route of surgery, and preoperative hematocrit value as independently associated with blood transfusion. Conclusion We identified a number of perioperative variables associated with intraoperative or postoperative bleeding requiring blood transfusion at the time of myomectomy. We subsequently created a model that accurately predicts individual bleeding risk from myomectomy, using variables that are reasonably apparent preoperatively. Making this prediction model clinically available to gynecologic surgeons will serve to improve the care of women undergoing myomectomy.

With the advent of new technologies, surgical specialties have witnessed impressive changes in operative techniques, shifting toward minimally invasive procedures, including laparoscopic and robotic approaches. The benefits of minimally invasive surgery are abundant—improved postoperative pain control, decreased postoperative hospitalization, and less estimated blood loss, among others. Within the realm of gynecology, there has been widespread use of laparoscopic approaches for common procedures, including hysterectomy and myomectomy, and current evidence supports improved clinical outcomes for laparoscopic technique compared to conventional laparotomy for such procedures. Introduction of robotic platforms has further revolutionized the field of minimally invasive gynecologic surgery. Robotic hysterectomy has shown promise, with comparable clinical outcomes, decreased hospitalization, shift toward outpatient procedure, and improved postoperative pain profile compared with laparoscopic approach. Similar benefits are seen for robotic myomectomy, with a significant reduction in intraoperative blood loss and postoperative pain. Resection of endometriosis is a complex procedure that requires impeccable visualization and surgical dexterity, which are components of laparoscopy that require further refinement; robotic platforms have the ability to improve upon laparoscopy and aid in endometrial resection, particularly in complex cases. With most robotic gynecologic operations, operative times are cited to be longer than with laparoscopic approaches, which can be mitigated by increased surgeon experience. Cost remains a barrier to implementation of robotic surgical systems, with the largest contributor to overall cost being the initial acquisition of the platform; however, largest predictor of cost-effectiveness of robotics in gynecology remains physician expertise, supporting the continued commitment to minimally invasive technology.

Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve quality of life often women are left making a decision whether or not to proceed with surgery. With endometriomas, patient’s surgical options include complete surgical removal or drainage via laparoscopy. Here, we review the literature to discuss both techniques, excision and drainage of endometriomas, and what the research supports for endometrioma management.

International audience; (1) Background: Adenomyosis is a poorly understood entity which makes it difficult to standardize treatment. In this paper we review and compare the currently approved medical and surgical treatments of adenomyosis and present the evidence behind them. (2) Methods: A PubMed search was conducted to identify papers related to the different treatments of adenomyosis. The search was limited to the English language. Articles were divided into medical and surgical treatments. (3) Results: Several treatment options have been studied and were found to be effective in the treatment of adenomyosis. (4) Conclusions: Further randomized controlled trials are needed to compare treatment modalities and establish a uniform treatment algorithm for adenomyosis.

Endometriosis is a complex chronic inflammatory condition that can create a multitude of bothersome painful symptoms for women. Bowel endometriosis is often misdiagnosed or overlooked leading to years of suffering for many women. The surgical management of bowel endometriosis varies based on extent of disease as well as surgeon experience. Surgical treatment for bowel endometriosis is complex and a variety of intraoperative and postoperative complications must be considered. Two significant postoperative complications for bowel endometriosis include anastomotic leak and fistula formation. There is continued debate regarding the appropriate surgical treatment for bowel endometriosis. Aggressive surgery with segmental bowel resection is being utilized more cautiously, with an increase in less aggressive shaving or disc excision techniques. Historic beliefs regarding the limitations of shaving and disc excision are being challenged, and with a reduction in morbidity these less aggressive techniques are winning favor among gynecologic surgeons. Shaving, discoid excision, and segmental bowel resection are all feasible surgical management options for bowel endometriosis. Segmental resection is associated with the highest rates of both anastomotic leak and fistula formation, while shaving is associated with the lowest.

Study Objective Scientifically evaluate the validity and reproducibility of two novel surgical triaging systems, as well as offer modifications to the MeNTS criteria for improved application in gynecologic surgeries Design Retrospective cohort study Setting Academic university hospital Patients or Participants 97 patients with delayed benign gynecologic procedures due to the COVID pandemic Interventions Surgical prioritization was assessed using two novel scoring systems, the Gyn-MenTS and mESAS systems for all 93 patients included Measurements and Main Results The inter-rater reliability and validity of 2 novel surgical prioritization systems (Gyn-MeNTS and mESAS) were assessed Gyn-MeNTS scores were calculated by 3 raters and analyzed as continuous variables, with a lower score indicating more urgency/priority The mESAS score was calculated by 2 raters and analyzed as a 3-level ordinal variable with a higher score indicating more urgency/priority All 5 raters were blinded to reduce bias Gyn-MeNTS inter-rater reliability was tested using Spearman r and paired t-tests were used to detect systematic differences between raters Weighted kappa indicated mESAS reliability Concurrent validity with mESAS and surgeon self-prioritization (SSP) was examined with Spearman r and logistic regression Spearman r's for all Gyn-MeNTS rater pairs were above 0 80 (0 84 for 1 vs 2, 0 82 for 1 vs 3, 0 82 for 2 vs 3, all p< 0001) indicating strong agreement The weighted kappa for the 2 mESAS raters was 0 57 (95% CI 0 40-0 73) indicating moderate agreement When used together, both scores were significantly independently associated with SSP, with strong discrimination (AUC 0 89) Conclusion Inter-rater reliability is acceptable for both scoring systems, and concurrent validity of each is moderate for predicting SSP, but discrimination improves to a high level when they are used together

Technology has been integrated into every facet of human life, and whether it is completely advantageous remains unknown, but one thing is for sure; we are dependent on technology. Medical advances from the integration of artificial intelligence, machine learning, and augmented realities are widespread and have helped countless patients. Much of the advanced technology utilized by medical providers today has been borrowed and extrapolated from other industries. There remains no great collaboration between providers and engineers, which may be why medicine is only in its infancy of innovation with regards to advanced technologic integration. The purpose of this narrative review is to highlight the different technologies currently being utilized in a variety of medical specialties. Furthermore, we hope that by bringing attention to one shortcoming of the medical community, we may inspire future innovators to seek collaboration outside of the purely medical community for the betterment of all patients seeking care.

To determine whether perioperative narcotic utilization at the time of hysterectomy has decreased since 2012.Retrospective cohort study.Academic university hospital.Patients who underwent a laparoscopic hysterectomy for benign indications between January 2012 and December 2018.Perioperative narcotics administration.We identified 651 patients who underwent a hysterectomy for benign indications from 2012 to 2018. Of these, 377 surgeries were performed using robotic-assistance (58%) and the remainder (42%) were performed by conventional laparoscopy. Narcotic utilization declined significantly by year for both intra-operative and post-operative periods (both p.001). The largest decline for intraoperative morphine milligram equivalents (MME) was between 2016 and 2017, while for post-operative MME, it was between 2012 and 2013. The pattern remained significant after adjusting for covariates. Intraoperative MME administration was correlated with postoperative MME use (Spearman r = 0.23, p.001). Of the demographic variables only Body Mass Index was significantly associated with perioperative narcotic administration.Administration of opioids for intraoperative and postoperative pain after minimally invasive hysterectomy substantially decreased from 2012 to 2018. Intraoperative narcotic utilization was correlated with immediate postoperative narcotic consumption. Heightened awareness of opioid administration practices during and immediately following surgery is critically important to decreasing risk of chronic opioid dependence and providing the best possible care for the patients we serve.

BACKGROUND Previous studies have demonstrated increased rates of poor obstetrical outcomes including preterm delivery, placental abruption, and intrauterine growth restriction in women with uterine leiomyomas. Currently, preconception myomectomy has not been reported to improve pregnancy rates or pregnancy outcomes in women with subserosal leiomyomas, and the data remain inconclusive for intramural fibroids. Pregnancy rates have been found to improve after the removal of submucosal fibroids. However, the effect of preconception myomectomy for submucosal fibroids on birth outcomes has yet to be examined. OBJECTIVE This study aimed to determine whether hysteroscopic excision of submucosal leiomyomas affects the rate of preterm delivery, among other obstetrical outcomes. STUDY DESIGN We performed a retrospective case-control study of women who underwent hysteroscopic resection of leiomyomas (cases) and controls of women who had submucosal fibroids at the time of their first-trimester ultrasounds. Women were included if they delivered a nonanomalous fetus beyond 20 weeks' gestation. A total of 73 cases were identified and matched with 219 controls (case-to-control ratio, 1:3). Subsequently, owing to multiple-gestation pregnancy, 11 patients were excluded from the case population and 4 patients from the control group. The final analysis included 277 women-62 cases and 215 controls. Our primary outcome was preterm delivery before 37 weeks' gestation. Prespecified secondary outcomes of interest were preterm delivery before 34 weeks' gestation, placental abruption, fetal malpresentation, intrauterine growth restriction, and rate of cesarean delivery. Data analysis was performed using univariate and multivariate statistics. RESULTS Cases and controls were similar with respect to age, race, body mass index, and mode of delivery. Cases were more likely to be primiparous (66% cases [42 of 62] vs 37% controls [80 of 215]; P=.00) and use assisted reproductive technology to conceive (22.6% cases [14 of 62] vs 7.0% controls [15 of 215]; P

Objective This video tutorial identifies key anatomic landmarks useful in identifying the path of the most commonly encountered pelvic nerves in benign gynecologic surgery. Design This is a narrated overview of commonly encountered pelvic nerves during benign gynecology, their origin, sensory, and motor function, as well as sequelae related to injury. Setting The unintended injury of pelvic neural connections can be a complication of any pelvic surgery, however, surgery for malignancy or endometriosis may increase the likelihood of encountering these nerves. The majority of focus surrounding surgical nerve injury, however, relates to patient positioning [1] . Injury to the pelvic nerves can lead to lifelong sexual, bladder, and defecatory dysfunction [2] . Interventions We review the Genitofemoral, Lateral Femoral Cutaneous, Ilioinguinal, Obturator, Superior and Inferior Hypogastric nerves, Pelvic Splanchnic nerves, and the Sacral nerves. Surgical illustrations are used (Fig. 1) alongside real-time narrated video to help viewers recognize the normal course of commonly encountered pelvic nerves at the time of gynecologic surgery (Figs2–3). Conclusion The surgical management of complex pelvic disease can unfortunately carry significant patient morbidity [3] . The neural pathways traveling through the pelvis via the hypogastric nerves are responsible for proprioception, vaginal lubrication, and proper functioning or the urethral and anal sphincters [4] . Sparing these nerves during pelvic surgery, and especially when anatomic planes are distorted by pelvic disease, requires surgical expertise and an immense understanding of pelvic neuroanatomy [ 4 , 5 ]. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications. This video tutorial also highlights the origin of these nerves, their anatomic location, procedures in which these nerves may be encountered, and what sequelae occur from their unintended injury.

The long-term management of deeply infiltrative endometriosis (DIE) remains debatable. Surgical excision improves pain and fertility in patients with endometriosis, however recurrence is common. In this article, we present an evidence-based approach of recurrence and postoperative hormonal suppression in DIE. A clear understanding of recurrence patterns and methods for prevention of DIE are lacking. Repeat surgery in DIE patients is associated with increased morbidity. Older data has suggested the limited utility of short-term postoperative hormonal suppression for the prevention of pain or disease recurrence for patients with endometriosis (Yap et al., Cochrane Database Syst Rev. (3):CD003678, 2004). More recent studies suggest that long-term medical therapy with oral contraceptive pills (OCPs) or progesterone only pills (POPs) reduces recurrence of superficial disease and endometriomas. Limited data, however, exists for DIE. This article reviews the literature of hormonal suppression for the prevention of postoperative recurrence of DIE. Despite the dearth of data, the current evidence suggests the utility of long-term postoperative hormonal suppression after surgery especially in those who underwent incomplete excision of DIE. Longer follow-up studies are greatly needed.

Induction of labor is a common obstetrical intervention; much research focuses on medical indications, clinical outcomes, and induction agents. Little research has been conducted evaluating the patients' understanding of and satisfaction with induction of labor. Video-based educational tools have been validated as a practical and efficient counseling method by previous studies.This study aimed to evaluate whether an educational video enhances the patients' knowledge about induction of labor and improves satisfaction with the induction of labor process.This was a single-center study in which women undergoing a scheduled induction of labor were randomized to either the control or intervention group. The control group was given a knowledge questionnaire about induction of labor before meeting their provider (midwife or obstetrician) on the day of scheduled induction of labor. The intervention group was shown a 3-minute educational video about induction of labor before administration of the knowledge questionnaire. Both groups, 24 to 48 hours after delivery, were asked to fill out a second questionnaire about satisfaction with the induction of labor process. Moreover, the video intervention group was asked to evaluate the video in the second questionnaire. Both knowledge and satisfaction questionnaires were compared between the control and intervention groups.From October 2019 to February 2020, 145 women scheduled for induction of labor were eligible and approached for the study. Of the 145 participants, 129 consented and 119 completed the entire study. Moreover, 64 participants were randomized into the control group and 55 into the intervention group. Compared with patients in the control group, the patients who watched the educational video in the intervention group had significantly improved baseline knowledge about induction of labor (P.001). Knowledge scores remained significantly higher in the intervention group when considering participants who had a previous induction of labor (parity, P.001; nulliparity, P.001; multiparity, P.001). In addition, satisfaction with the induction of labor process among participants in the intervention group was significantly higher than those in the control group (P.001). Moreover, this held true in those who had a cesarean delivery or had a history of a previous induction of labor (P.003 and P.001, respectively).A brief educational video about induction of labor improved the patients' knowledge about the induction of labor process and their overall satisfaction with their delivery experience. Video-based education can play an innovative and important role in patient knowledge and satisfaction with the induction of labor process.

Objective Clarify the normal patterns of voiding after minimally invasive hysterectomy. We also aim to identify perioperative factors associated with delayed time to void immediately following hysterectomy. Design Retrospective cohort study Selection Women undergoing laparoscopic hysterectomy between September 2012 to October 2018 at a single academic university hospital. Results 450 minimally invasive hysterectomies were included in the final analysis, 274 (60.9%) robotically-assisted, and 176 (39.1%) conventional laparoscopy. The overall median postoperative time-to-void following a retrograde bladder filling of 150 mL normal saline was 179 min. Based on the 50th percentile of the distribution of the time-to-void, two groups were created. Demographic characteristics between the groups were similar, except those who were above the 50th percentile were more likely to be older, have a reported history of previous myomectomy, and had a longer postoperative PACU stay compared to those below or equal to the 50th percentile. The mean time-to-void following conventional laparoscopic hysterectomy was less than that of robotic surgery (187.3 vs 200.5 min) however the difference was not statistically significant (p=.22). The use of hydromorphone intraoperatively and the combination of oxycodone-acetaminophen postoperatively were more likely to be associated with the group of patients above the 50th percentile but there was no significant difference in perioperative utilization of median morphine milliequivalents (MME) between the two groups. Conclusions Following laparoscopic hysterectomy (either conventional or with robotic-assistance) with a retrograde bladder fill of 150 mL normal saline most patients will void within 4 h after surgery. This is consistent with historic data on normal voiding patterns facilitating safe same day discharge without prolonged time in the PACU.

Health-care costs are affected by obesity with both the direct and indirect costs of health care increasing as body mass index (BMI) increases. However, one important aspect of obesity that lacks rigorous study is what impact BMI has on direct surgical cost. We performed a retrospective cohort study of women undergoing a laparoscopic hysterectomy at our single academic university center between January 2012 and December 2017. Women were excluded if their surgery was performed by anyone other than those surgeons with subspecialty training in minimally invasive gynecologic surgery (MIGS), if their hysterectomy was performed by a modality other than conventional laparoscopy or with robotic assistance, or if the indication for hysterectomy was related to any gynecologic malignancy. We identified 600 patients who underwent laparoscopic hysterectomy during the study period. Women who underwent robotic hysterectomy, compared to laparoscopic, had a shorter operative time, lower estimated blood loss, and shorter length of stay. Mean direct cost (± standard deviation) for the cohort was $6398.53 ± $2304.67, age was 44.5 ± 7.5 years, and BMI was 32.2 ± 7.6. Direct cost for all laparoscopic hysterectomies was evaluated across the five different BMI quintiles and no significant difference between groups was found. There was no significant difference in direct cost across procedures between obese and non-obese patients (p = 0.62) and this remained true when separated out by surgical modality. However, when evaluating morbidly obese patients, there appears to be a trend toward cost reduction with robotic hysterectomy compared to conventional laparoscopy. It does not appear that BMI has a statistically significant impact on direct cost between robotic-assisted and conventional laparoscopic hysterectomy. However, these findings may be due to surgical proficiency and warrant further investigation among surgeons with lesser volume.

Background: The COVID-19 pandemic necessitated cancellation of non-emergent surgeries worldwide. As local resources and infection rates allow, systems face an unprecedented backlog of patients, some of whom have incurred suffering and morbidity as a consequence of their delay. Clinically and ethically appropriate triaging is paramount to maximize patient outcomes, allocate resources, and minimize COVID-19 exposure risk. Methods: We performed a retrospective cohort study at a single academic tertiary care center in the US. The inter-rater reliability and validity of 2 novel surgical prioritization systems (Gyn-MeNTS and mESAS) were assessed. For benign gynecologic procedures postponed between 3/16/2020 and 4/30/2020, surgeons self-prioritized patients per institutional guidelines to minimize patient morbidity. Gyn-MeNTS scores were calculated by 3 raters and analyzed as continuous variables, with a lower score indicating more urgency/priority. The mESAS score was calculated by 2 raters and analyzed as a 3-level ordinal variable with a higher score indicating more urgency/priority. All 5 raters were blinded to reduce bias. Gyn-MeNTS inter-rater reliability was tested using Spearman r and paired t-tests were used to detect systematic differences between raters. Weighted kappa indicated mESAS reliability. Concurrent validity with mESAS and surgeon self-prioritization (SSP) was examined with Spearman r and logistic regression. Findings: 93 patients were included. Spearman r’s for all Gyn-MeNTS rater pairs were above 0·80 (0·84 for 1 vs. 2, 0·82 for 1 vs. 3, 0·82 for 2 vs. 3, all p

Evaluate the perioperative narcotic utilization patterns at the time of myomectomy, specifically as they relate to the opioid epidemic. We also aim to evaluate the differences between conventional laparoscopy and robotic surgery in terms of narcotic utilization.Retrospective cohort study.Single academic university hospital.Women undergoing minimally invasive myomectomy.Laparoscopic or robot-assisted myomectomy.We identified 312 minimally invasive myomectomies to be included in the final analysis. For the entire cohort, the mean age (± standard deviation) was 35.7 ± 5.1 years, and the mean body mass index was 28.3 ± 6.3. Of the 312 myomectomies included, 239 (76.6%) were performed using robotic assistance, and the remainder (23.4%) were performed by conventional laparoscopy. A statistically significant inverse relationship was found between year of myomectomy and perioperative narcotic administration (p.001). Yearly morphine milligram equivalent (MME) administration decreased significantly for both intraoperative and postoperative administration (p.001). The largest decline for intraoperative MME use was between 2016 and 2017, and for postoperative MME use, it was between 2012 and 2013. There was no statistically significant difference in perioperative narcotic administration between conventional laparoscopy and robot-assisted myomectomy. The time effect for intraoperative (p.001) and postoperative (p.001) narcotic administration remained significant after adjusting for covariates, including mode of surgery, race, insurance, age, and body mass index. None of the background variables assessed were associated with perioperative narcotic administration.Perioperative narcotic administration for minimally invasive myomectomy has decreased following widespread awareness of the national opioid crisis.

Bleeding at the time of benign gynecologic surgery, as well as from benign gynecologic conditions, is a major source of morbidity for many women. Few nonhormonal medical options exist for the treatment of heavy menstrual bleeding, and to reduce surgical bleeding during major gynecologic surgery. Interest in Tranexamic acid (TXA) as a means to reduce surgical blood loss has been growing across many surgical specialties. This review focuses on applications for TXA as a means to reduce heavy menstrual bleeding (HMB) as well as to reduce surgical bleeding during benign gynecologic surgery.Tranexamic acid is an effective treatment to reduce the volume of bleeding during menstruation. Tranexamic acid was found to be superior to both placebo and oral progestins, and as good as combined oral contraceptives at reducing menstrual blood volume. Tranexamic acid has also been show to reduce the volume of bleeding during abdominal myomectomy as well as hysterectomy. There is a major need for prospective studies evaluating the utility of TXA for reducing blood loss during benign gynecologic surgery.Tranexamic acid has been found to be an excellent affordable nonhormonal treatment option for women with HMB and should be considered during major gynecologic surgery.

Study Objective To demonstrate the safe laparoscopic management of a tubal ectopic pregnancy presenting at an advanced gestational age. Design Narrated video tutorial for safe laparoscopic management of this rare presentation. Setting Ectopic pregnancy most often occurs within the fallopian tube commonly presenting as vaginal bleeding and abdominal or pelvic pain during the first trimester. Second-trimester tubal ectopic pregnancies are extremely rare and carry a significantly higher level of maternal morbidity and mortality compared to first-trimester presentation. Second-trimester tubal ectopic pregnancies are challenging to diagnose by ultrasound alone and may appear as peritoneal or ovarian ectopics. A high degree of suspicion must be maintained to ensure the best maternal outcomes. Patients or Participants We present a case of a bleeding tubal ectopic pregnancy diagnosed at 13 weeks and 4 days at an academic tertiary care hospital. Interventions A laparoscopic approach to manage a tubal ectopic pregnancy at 13 weeks and 4 days gestational age. Measurements and Main Results Laparoscopic approach was utilized with several key steps: 1. Confirmation of the tubal location of the ectopic pregnancy 2. Sequential cuts through the mesosalpinx minimizing injury to the adjacent ovary while limiting intraoperative blood loss 3. Specimen containment and umbilical extraction Conclusion Advanced gestational age tubal ectopic pregnancy represents an extremely rare clinical situation that requires the surgeons appreciation for the potential for massive maternal bleeding. Ultrasound diagnosis alone can be very challenging and thus high clinical suspicion should be maintained and appropriate preoperative planning is crucial.

Introduction To date, there are few reports describing the management of traumatic gynecologic injuries leaving physicians with little guidance. Objective Describe the injury patterns and the preferred management of these injuries. Methods A retrospective cohort study was performed using the National Trauma Data Bank (NTDB) from years 2011 to 2013. Female patients age 16 years and older with internal gynecologic injuries were identified based on diagnosis codes. Demographics, associated diagnoses and procedure codes were compiled for the cohort. Results 313 patients met inclusion criteria. The mechanism of injury was blunt in 236 (75%) patients, penetrating in 68 (21%), and other in 9 (4%). The mean Injury Severity Score was 16.6 ± 14.6. Mean age was 34 ± 21 years old. 226 (74.8%) patients had an ovarian and/or fallopian tube injury, 71 (25.2%) had a uterine injury, 8 (3%) had both, and 8 (3%) had injury to the ovarian or uterine vessels only. Of the 226 patients with ovarian and/or fallopian tube injury, 11(5%) underwent repair and 10 (4%) underwent salpingo-oophorectomy. Of the 71 uterine injuries, 15 (21%) underwent repair and 5 (7%) required a hysterectomy. Conclusions Most traumatic internal gynecologic injuries result from blunt mechanism. Currently, these injuries are largely managed non-operatively. When surgery was performed, ovarian and uterine repair was more common than salpingo-oophorectomy and hysterectomy. Prospective large-scale studies are needed to establish a standard of treatment for the management of gynecologic trauma and to assess both short and long term outcomes and fertility rates.

To analyze the interaction between the route of hysterectomy for benign disease and postoperative morbidity among patients stratified by body mass index (BMI) and to test for a dose-dependent relationship between obesity severity and postoperative morbidity.A retrospective cohort study.Benign hysterectomy cases were abstracted from the American College of Surgeons National Safety and Quality Improvement Program from 2005 to 2016. Cancer and prolapse surgeries were excluded by corresponding International Classification of Diseases and Current Procedural Terminology codes.Laparoscopic hysterectomy.Associations between BMI, route of surgery, and categoric patient variables were examined using the chi-square test. Associations of BMI, route of surgery, and continuous patient variables were examined using 1-way analysis of variance. Associations of the route of surgery with binary outcomes were examined within BMI categories using the chi-square or Fisher exact test. Logistic regression and interaction tests were used for final outcomes of interest. There were 159 025 patients in the collected sample. Patients who underwent an abdominal hysterectomy had higher odds of composite morbidity if they were obese; the adjusted odds were 17% higher for class 1 obesity, 55% higher for class 2 obesity, and 163% higher for class 3 obesity. An abdominal hysterectomy was associated with worse postoperative outcomes when compared with a laparoscopic hysterectomy (p.001). The risk of increased composite postoperative morbidity for patients undergoing a laparoscopic hysterectomy was not significantly different from the reference group until women had class 3 obesity; the odds of composite morbidity for class 3 obesity women become 31% higher than for nonobese patients.BMI directly impacts postoperative morbidity for both abdominal and laparoscopic hysterectomies although the effect is more pronounced after an abdominal hysterectomy. Roughly 40% of women undergoing a hysterectomy in the United States are obese. These data should motivate surgeons to consider ways to medically and surgically optimize patients, including weight reduction before hysterectomy and choosing a laparoscopic approach whenever possible to lower the risk of postoperative morbidity.

We present the case of a 28-year-old nulliparous female with malignant transformation of an ectopic focus of endometriosis in the right ischioanal fossa. A 28-year-old nulliparous patient with a past medical history of polycystic ovarian syndrome (PCOS) was diagnosed with endometrioid adenocarcinoma in her right ischioanal fossa. Initially, patient presented to an emergency department and underwent a CT scan of the appendix to rule out appendicitis. A multiloculated cystic lesion adjacent to the right obturator internus muscle was found. She underwent surgical resection of the mass, which confirmed FIGO grade 2 endometrioid adenocarcinoma, followed by localized radiation therapy. Malignancy arising in endometriosis is rare, and the influence of PCOS on the rate of malignant transformation is not well established.

Study Objective Evaluate the readiness of senior U.S. Ob/Gyn residents to perform minimally invasive surgery. Furthermore, we specifically hope to evaluate their readiness to perform complex minimally invasive gynecologic surgery as well as their perceptions of the minimally invasive gynecologic surgery subspecialty Design Nationwide survey study Setting U.S. accredited Obstetrics and Gynecology residency programs Patients or Participants United States senior (3rd and 4th year) Ob/Gyn residents Interventions Voluntary participation in a 58-item survey Measurements and Main Results We received 158 survey responses with 84 (53.2%) responses coming from 4th year residents and 74 (46.8%) responses from 3rd year residents. The majority of resident respondents graduated from an allopathic medical school (139; 88%), identify as female (129, 81.6%), and are attending an Academic-University based program (96, 60.8%). The majority of respondents (67.7%) have not and do not plan on applying for a surgical fellowship in Ob/Gyn. Overall, the majority of residents (71.5%) feel their residency training adequately prepared them to be a competent minimally invasive surgeon. However, only 50% feel prepared to perform a laparoscopic hysterectomy on a uterus greater than 12 weeks size, and 12% feel prepared to offer a laparoscopic hysterectomy for a uterus above the umbilicus. Less than one-third of residents (29%) feel prepared to offer a vaginal hysterectomy on a uterus 12-week size or greater, and only 17% of residents feel comfortable performing a laparoscopic myomectomy. For endometriosis surgery 76% of senior residents do not feel prepared to offer excisional surgery. Of the residents not interested in a surgical fellowship 45% do not plan on referring complex gynecologic cases to a fellowship trained minimally invasive surgeon. Conclusion The overwhelming majority of senior U.S. Ob/Gyn residents do not feel prepared to provide minimally invasive surgery for complex gynecologic cases. Despite this discomfort nearly half of these residents do not plan on referring their patients to a competent minimally invasive surgeon.

Study Objective Demonstrate the safety, feasibility, and outcomes associated with the reduced port robotic-assisted hysterectomy (RPRH). Design We performed a retrospective cohort study of women undergoing a reduced-port robotic-assisted hysterectomy between 2012 and 2018 for benign indications. Setting A single academic university hospital. Patients or Participants Women who underwent a reduced port robotic-assisted hysterectomy for benign indications by a fellowship trained minimally invasive surgeon. Interventions A reduced port robotic-assisted hysterectomy for benign indications. Measurements and Main Results Women included were stratified into one of four groups based on uterine weight: Conclusion Reduced port robotic-assisted hysterectomy is a safe, effective, and efficient surgery for appropriately selected women. Outcomes appear similar across uterine weights with increased operative time, estimated blood loss, and odds of ureterolysis increasing as specimen weight increases.

STUDY OBJECTIVE To determine whether pain, as part of an indication for global endometrial ablation, is an independent risk factor for failure. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Academic-affiliated community hospital. PATIENTS Women undergoing global endometrial ablation with radiofrequency ablation (RFA), hydrothermablation (HTA), or uterine balloon ablation (UBA) between January 2003 and December 2015. INTERVENTIONS Procedure failure was defined as subsequent hysterectomy after the index ablation. MEASUREMENTS AND MAIN RESULTS A total of 5818 women who underwent an endometrial ablation were identified, including 3706 with RFA (63.7%), 1786 with HTA (30.7%), and 326 with UBA (5.6%). Of the 5818 ablations, 437 (7.5%) involved pain (i.e., pelvic pain, dysmenorrhea, dyspareunia, lower abdominal pain, endometriosis, or adenomyosis) before ablation, along with abnormal uterine bleeding. Pain as part of the preoperative diagnoses before endometrial ablation was a significant risk factor for subsequent hysterectomy compared with all other diagnoses (19.2% vs 13.5%; p = .001). Consistent with previous studies, women who underwent ablation at an older age were less likely to fail, which held true even when one of the indications for ablation was related to pain (odds ratio, 0.96/year; 95% confidence interval, 0.95-0.97). When the pathology reports of women who underwent a hysterectomy were examined, women in the pain group had lower rates of adenomyosis than women without pain (38.1% vs 50.1%; p = .04). However, there was a trend toward a higher rate of endometriosis on pathology reports (14.3% vs 8.7%; p = .09) and even higher rates of visualized endometriosis identified by operative reports in women who had pain before their ablation (42.9% vs 15.8%; p

Background The need for any treatment following an endometrial ablation is frequently cited as “failed therapy,” with the two most common secondary interventions being repeat ablation and hysterectomy. Since second-generation devices have become standard of care, no large cohort study has assessed treatment outcomes with regard to only these newer devices. We sought to determine the incidence and predictors of failed second-generation endometrial ablation, defined as the need for surgical re-intervention. We performed a retrospective cohort study at a single academic-affiliated community hospital. Subjects included women undergoing second-generation endometrial ablation for benign indications between October 2003 and March 2016. Second-generation devices utilized during the study period included the radiofrequency ablation device (RFA), hydrothermal ablation device (HTA), and the uterine balloon ablation system (UBA). Results Five thousand nine hundred thirty-six women underwent endometrial ablation at a single institution (3757 RFA (63.3%), 1848 HTA (31.1%), and 331 UBA (5.6%)). The primary outcome assessed was surgical re-intervention, defined as hysterectomy or repeat endometrial ablation. Of the total 927 (15.6%) women who required re-intervention, 822 (13.9%) underwent hysterectomy and 105 (1.8%) underwent repeat endometrial ablation. Women who underwent re-intervention were younger (41.6 versus 42.9 years, p p p Conclusion Surgical re-intervention was required in 15.6% of women who underwent second-generation endometrial ablation. Age, ethnicity, and radiofrequency ablation were significant risk factors for failed endometrial ablation, and menorrhagia was the leading indication for re-intervention.

Background Second-generation endometrial ablation has been demonstrated safe for abnormal uterine bleeding treatment, in premenopausal women who have completed childbearing, in short-stay surgical centers and in physicians’ offices. However, no standard regarding anesthesia exists, and practice varies depending on physician or patient preference and hospital policy and setting. Objective The aim of this study was to evaluate whether local anesthetic, in combination with general anesthesia, affects postoperative pain and associated narcotic use following endometrial ablation. Materials and Methods This was a single-center single-blind randomized controlled trial conducted in an academic-affiliated community hospital. A total of 84 English-speaking premenopausal women, aged 30 to 55 years, who were undergoing outpatient endometrial ablation for benign disease were randomized to receive standardized paracervical injection of 20 mL 0.25% bupivacaine (treatment group) or 20 mL normal saline solution (control group) upon completion of ablation. The study was designed to test a 40% 1-hour mean visual analog scale (VAS) pain score difference with an average standard deviation of 75% of both groups’ mean VAS scores, using a 2-tailed test, a type I error of 5%, and statistical power of 80%. A sample of 36 patients per study group was required. Assuming a 15% attrition rate, the study enrolled 42 patients per study arm randomized in blocks of 2 (84 total). Two-tailed cross-tabulations with Fisher exact significance values where appropriate and Student t tests were used to compare patient characteristics. Backward stepwise regressions were conducted to control for confounding. Results Between April 2016 and February 2017, a total of 108 women scheduled for endometrial ablation were screened (refusals, n = 21; ineligible, n = 3) to determine whether there were meaningful differences in postoperative VAS pain scores and postoperative narcotic use. Of the 84 randomized women, 2 age-ineligible women were excluded. Intent-to-treat analyses included 1 incorrect randomization (in which the provider consciously decided to provide analgesia regardless of the protocol, after which the provider was excluded from further study participation) and 3 women having no ablation because of operative difficulties. Three were lost to second-day follow-up. Treatment group patients (n = 41) experienced 1.3 points lower 1-hour postoperative VAS pain scores than the control group (n = 41, P = .02). The difference diminished by 4 hours (P = .31) and was negligible by 8 hours (P = .62). Treatment group patients used 3.6 less morphine equivalents of postoperative pain medication (P = .05). Regression analyses controlled for confounding reduced the 1-hour postoperative treatment group pain score difference to 0.8 (confidence interval [CI], −0.6 to 0.1) but slightly increased the average postoperative morphine equivalents to 3.7 (CI, −6.8 to −0.7). Conclusion This randomized controlled trial found that local anesthetic with low risk for complications, used in conjunction with general anesthesia, decreased postoperative pain at 1 hour and significantly reduced postoperative narcotic use following endometrial ablation. Further research is needed to determine whether the study results are generalizable and whether post procedure is the best time to administer the paracervical block to decrease endometrial ablation pain.

Video Objective A thorough understanding of the natural course and functions of the nerves in the pelvis is critical in complex benign gynecological surgery to avoid injury and morbidity to the patient. This video reviews how to locate and safely dissect common nerves found in the pelvis that may be encountered in complex gynecological cases. Setting Multiple patients at a large academic center with a robust team of minimally invasive gynecologic surgeons. Many patients have extensive adhesions or severe endometriosis. Interventions Multiple nerves, such as the superior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves, sacral nerve roots, and the genitofemoral nerves, are dissected out during the course of the surgery. Simple surgical techniques, such as traction-countertraction and blunt dissection are employed. Conclusion In complex gynecologic surgeries, the disease process may require extensive dissections in to the retroperitoneal spaces, where critical pelvic nerves are at risk for injury. With increased knowledge of the natural course of the nerves as well as having an array of dissection techniques, the surgeon can decrease the risk of inadvertent nerve injury and patient morbidity. If the disease is severely involved in areas where fragile nerves are, consideration needs to be given for a nerve preservation.

Provoked vestibulodynia is an often underdiagnosed and mismanaged medical condition that impacts the lives of many women. When symptoms are due to a dramatically increased density of pain fibers in the vestibular endoderm, the condition is referred to as neuroproliferative-associated vestibulodynia. Unfortunately, assessment of pain fiber density can only be performed after surgery during histologic examination. First-line therapies for this condition often include topical or oral medications targeting hyperalgesia and allodynia at the vulvar vestibule. However, in the setting of refractory disease, surgical treatment should be considered. The surgical video (Video 1) highlights anatomical landmarks as well as key surgical steps when performing a vulvar vestibulectomy with a vaginal advancement flap for the treatment of neuroproliferative-associated vestibulodynia. Surgeons should have a thorough understanding of pertinent vulvar anatomical landmarks before performing this procedure (Figure 1). The goal of vulvar vestibulectomy, as described in this video, is to excise the entirety of the vestibule containing the pathologic density of afferent pain fibers. This tutorial serves to identify key anatomical landmarks including Hart's line as well as outline the meticulous dissection required for successful completion of this procedure. We describe our surgical instrumentation as well as provide insight into steps that can be taken to minimize postoperative morbidity.

Study Objective Evaluate the utilization patterns for narcotic medication both intraoperatively and postoperatively at the time of benign minimally invasive hysterectomy, specifically as they relate to the opioid epidemic. Design Retrospective cohort study. Setting A single academic university hospital. Patients or Participants Women undergoing minimally invasive hysterectomy for benign indications. Interventions Laparoscopic or Robotic-Assisted hysterectomy. Measurements and Main Results 651 hysterectomies were included in the analysis between 2012 and 2018. For consistency all narcotics administered intraoperatively and in immediate postoperative period were converted to mean morphine equivalents (MME). For the entire cohort the mean age was 44.5 ± 7.4 years and the mean Body Mass Index (BMI; Kg/m2) was 32.1 ± 7.6. Of these, 377 hysterectomies (57.9%) were performed with robotic assistance and the remainder (42.1%) were performed using conventional laparoscopy. A statistically significant inverse relationship was found between the year of surgery and perioperative narcotic usage (p=.007). In all hysterectomies analyzed yearly MME use decreased over time (p Conclusion Perioperative narcotic use has down trended over time for patients undergoing minimally invasive hysterectomy. Hysterectomy performed with robotic assistance was associated with lower postoperative narcotic use compared to conventional laparoscopy.

Video Objective To demonstrate the surgical technique and steps of a vulvar vestibulectomy procedure used for management of neuroproliferative vulvodynia. Setting A patient with lifelong vulvar pain and dyspareunia diagnosed with neuroproliferative vulvodynia seeking surgical management at a large academic center. Interventions Vulvodynia is a common, but under recognized, cause of pain in women. In neuroproliferative vulvodynia, there is a higher density of nociceptors in the vestibule that cause both allodynia and hyperalgesia. Though medical management options are available, surgical management through vestibulectomy removes the affected mucosa with the associated nociceptors, and can more effectively alleviate pain for these women. Conclusion For patients with neuroproliferative vulvodynia, surgical management with removal of the vulvar vestibule is a safe and effective treatment method.

Background Second-generation endometrial ablation has been demonstrated safe for abnormal uterine bleeding treatment, in premenopausal women who have completed childbearing, in short-stay surgical centers and in physicians’ offices. However, no standard regarding anesthesia exists, and practice varies depending on physician or patient preference and hospital policy and setting. Objective The aim of this study was to evaluate whether local anesthetic, in combination with general anesthesia, affects postoperative pain and associated narcotic use following endometrial ablation. Materials and Methods This was a single-center single-blind randomized controlled trial conducted in an academic-affiliated community hospital. A total of 84 English-speaking premenopausal women, aged 30 to 55 years, who were undergoing outpatient endometrial ablation for benign disease were randomized to receive standardized paracervical injection of 20 mL 0.25% bupivacaine (treatment group) or 20 mL normal saline solution (control group) upon completion of ablation. The study was designed to test a 40% 1-hour mean visual analog scale (VAS) pain score difference with an average standard deviation of 75% of both groups’ mean VAS scores, using a 2-tailed test, a type I error of 5%, and statistical power of 80%. A sample of 36 patients per study group was required. Assuming a 15% attrition rate, the study enrolled 42 patients per study arm randomized in blocks of 2 (84 total). Two-tailed cross-tabulations with Fisher exact significance values where appropriate and Student t tests were used to compare patient characteristics. Backward stepwise regressions were conducted to control for confounding. Results Between April 2016 and February 2017, a total of 108 women scheduled for endometrial ablation were screened (refusals, n = 21; ineligible, n = 3) to determine whether there were meaningful differences in postoperative VAS pain scores and postoperative narcotic use. Of the 84 randomized women, 2 age-ineligible women were excluded. Intent-to-treat analyses included 1 incorrect randomization (in which the provider consciously decided to provide analgesia regardless of the protocol, after which the provider was excluded from further study participation) and 3 women having no ablation because of operative difficulties. Three were lost to second-day follow-up. Treatment group patients (n = 41) experienced 1.3 points lower 1-hour postoperative VAS pain scores than the control group (n = 41, P = .02). The difference diminished by 4 hours (P = .31) and was negligible by 8 hours (P = .62). Treatment group patients used 3.6 less morphine equivalents of postoperative pain medication (P = .05). Regression analyses controlled for confounding reduced the 1-hour postoperative treatment group pain score difference to 0.8 (confidence interval [CI], −0.6 to 0.1) but slightly increased the average postoperative morphine equivalents to 3.7 (CI, −6.8 to −0.7). Conclusion This randomized controlled trial found that local anesthetic with low risk for complications, used in conjunction with general anesthesia, decreased postoperative pain at 1 hour and significantly reduced postoperative narcotic use following endometrial ablation. Further research is needed to determine whether the study results are generalizable and whether post procedure is the best time to administer the paracervical block to decrease endometrial ablation pain.