Grace Liu

The laparoscopic myomectomy: a survey of Canadian gynaecologists.

OBJECTIVE To survey all gynaecologists in Canada to determine the number who perform or offer the laparoscopic myomectomy (LM) procedure, the barriers that deter gynaecologists from performing or offering LM, and to understand the perceptions and attitudes of Canadian gynaecologists with respect to LM. METHODS A survey was developed, pre-tested, and distributed to all 1279 obstetrician-gynaecologists on the SOGC mailing list in April 2007. RESULTS A total of 529 obstetrician-gynaecologists participated in the survey a response rate of 41.4%. Of the 485 respondents who practised gynaecology, 119 (24.5%) performed LM, but only 15 (3.1%) stated that more than 50% of their myomectomies were performed laparoscopically. Two hundred twelve gynaecologists (44.3%) admitted to having referred a patient to another gynaecologist for LM. Laparoscopic surgeons felt the principal barrier to performing LM was lack of training in the procedure (70.7%). Gynaecologists felt the principal barrier to referring to another gynaecologist for LM was their uncertainty about who offered the procedure (33%). The majority of gynaecologists believed that LM has faster recovery time. The majority of respondents, however, were unsure which procedure is superior with respect to blood loss, adhesion formation, fertility rate post-procedure, uterine rupture rate in subsequent pregnancy, and cost-effectiveness. CONCLUSION Despite existing evidence that indicates that LM is comparable to abdominal myomectomy with respect to complication rates and fertility, only one quarter of Canadian gynaecologists who responded to this survey performed the procedure. Barriers to performing LM included lack of training and barriers to referral included uncertainty about who offered the procedure.

Preterm Labour and Birth: A Survey of Clinical Practice Regarding Use of Tocolytics, Antenatal Corticosteroids, and Progesterone

OBJECTIVES We wished to determine prescribing practices of obstetricians in Canada regarding tocolytics, antenatal corticosteroids, and progesterone for women at increased risk of preterm labour and birth, and to determine whether these practices changed between 1997-98 and 2004. METHODS Two cross-sectional surveys of Canadian obstetricians were conducted. The initial survey was in 1997-98 (N = 1313); the follow-up survey was in 2004 (N = 1508). RESULTS Response rates were 46.4% in 1997-98 and 43.3% in 2004. Most respondents reported that they prescribed tocolytics to women with signs and symptoms of preterm labour (97.4% in 1997-98; 92.2% in 2004; P < 0.001) but use had decreased. In 1997-98, 20.0% of respondents used tocolytics for > 48 hours during one course of treatment, whereas in 2004, only 9.6% did this (P = 0.06). The tocolytic prescribed most frequently was magnesium sulphate in 1997-98 (40.6% of respondents), whereas in 2004, it was indomethacin (47.5% of respondents). The use of repeat courses of antenatal corticosteroids decreased from 72.9% in 1997-98 to 18.7% in 2004 (P < 0.001). In 2004, only a few respondents (7.0%) prescribed progesterone for women at increased risk of preterm birth. CONCLUSIONS Most Canadian obstetricians continue to use tocolytics for women in preterm labour, although use has decreased over time, and the most frequently prescribed tocolytic has changed from magnesium sulphate to indomethacin. The use of repeat courses of antenatal corticosteroids decreased substantially during this time, and in 2004, progesterone was not in frequent use.

First- Versus Second-Generation Endometrial Ablation Devices for Treatment of Menorrhagia: A Systematic Review, Meta-Analysis and Appraisal of Economic Evaluations

OBJECTIVE To estimate the clinical and economic effect of using second-generation endometrial ablation devices compared to first-generation devices for treatment of menorrhagia in pre-menopausal women. The secondary objective was to compare the second-generation devices with one another. DATA SOURCES We searched Medline and EMBASE, and other sources of unpublished literature, and screened references from relevant articles. STUDY SELECTION We included only randomized controlled trials or full economic evaluations of premenopausal women with menorrhagia undergoing endometrial ablation using first-generation compared with second-generation devices. DATA EXTRACTION AND DATA SYNTHESIS Data extraction and risk of bias assessment was carried out for all clinical studies, and data were pooled using the random effects model. A qualitative narrative synthesis was used to combine results from the economic review. Eleven studies met eligibility criteria (n = 1679). There was no difference in the rate of amenorrhea between first- and second-generation ablation (5 studies with 998 patients, rate ratio 1.15, 95% CI 0.96 to 1.38; P = 0.14), but second-generation devices had a lower complication rate (7 studies with 1272 patients, rate ratio 0.52, 95% CI 0.35 to 0.76; P < 0.001), decreased operating time by 16.6 minutes (3 studies with 486 patients, 95% CI 12.1 to 21.2 minutes; P < 0.001), and could more commonly be used with local anaesthesia (3 studies with 558 patients, rate ratio 1.87, 95% CI 1.04 to 3.37; P = 0.04). There was a higher rate of amenorrhea in patients treated with Novasure than with other second-generation devices (4 studies with 407 patients, rate ratio 2.60, 95% CI 1.63 to 4.14; P < 0.001). Three European studies were included in the economic synthesis, which found that second-generation devices were more cost-effective than first-generation devices. CONCLUSION Second-generation endometrial ablation devices seem to be as effective as first-generation devices but likely reduce operating time, can be used more often with local anaesthesia, and have fewer complications. They also seem to be more cost-effective than first-generation devices, but further economic evaluations need to be carried out in Canada.

Occurrence of and Risk Factors for Urological Intervention During Benign Hysterectomy: Analysis of the National Surgical Quality Improvement Program Database

OBJECTIVE To determine the occurrence of lower genitourinary tract (LGUT) injury during hysterectomy for benign disease and identify risk factors for LGUT injury, with a specific focus on the effect of hysterectomy modality. METHODS We performed a retrospective cohort study of patients undergoing hysterectomy for benign disease from 2010 t o 2014 using the American College of Surgeons National Surgical Quality Improvement Program, a multi-institutional prospective registry that captures perioperative surgical outcomes. We identified the occurrence of concomitant cystoscopy and therapeutic urologic interventions including endoscopic ureteric stenting, ureteric repair, bladder repair, cystectomy, and urinary diversion as a proxy for LGUT injuries. Adjusted odds ratios and 95% confidence intervals were calculated using multivariate logistic regression. RESULTS We identified 101,021 patients treated with hysterectomy for benign disease: 18,610 (18.4%), 27,427 (27.2%), and 54,984 (54.4%) underwent vaginal, open, and laparoscopic hysterectomy, respectively. Cystoscopy was performed in 16,493 cases (16.3%). There were 2427 patients (2.4%) who underwent concomitant urologic intervention. Patients undergoing laparoscopic hysterectomy had increased occurrence of urologic intervention, excluding cystoscopy (adjusted odds ratio 1.47, 95% confidence interval 1.29-1.69), compared to vaginal hysterectomy; no differences were found between open and vaginal hysterectomy or laparoscopic and open hysterectomy. Larger uteri, a postoperative diagnosis of endometriosis, increasing comorbidity, and African American race were associated with an increased odd of urologic intervention whereas concomitant cystoscopy was associated with a decreased chance. CONCLUSION The incidence of lower genitourinary tract intervention in benign hysterectomy is significant and may be higher than previously reported. Predisposing patient factors and operative technique are key risk factors.

A Multicenter Study Evaluating the Effect of Ulipristal Acetate during Myomectomy

STUDY OBJECTIVE To compare surgical experience at myomectomy between patients with myomas pretreated with ulipristal acetate versus no pretreatment. DESIGN A prospective, observational, multicenter study of myomectomy procedures by any route (hysteroscopic, laparoscopic, or laparotomy) (Canadian Task Force classification II-2). SETTING Five university-affiliated hospitals including tertiary care and community sites. PATIENTS Any patient who underwent hysteroscopic, laparotomic, or laparoscopic myomectomy regardless of medical pretreatment. INTERVENTIONS Surgeons completed a Web-based questionnaire after each myomectomy procedure. Surgeons evaluated visualization, the myoma-myometrium relationship, extrusion, fluid deficit, blood loss, and overall ease of hysteroscopic myomectomies. For laparotomic/laparoscopic myomectomies, plane delineation, myoma separation, blood loss, and overall ease were assessed. The total surgical experience score was calculated by summing the values for each subscale. MEASUREMENTS AND MAIN RESULTS A total of 309 myomectomies were evaluated by 52 surgeons (response rate = 83%) at 5 institutions. Of 140 hysteroscopic myomectomies, 84 (60%) were performed without pretreatment, 29 (21%) after ulipristal acetate pretreatment, and 27 (19%) after pretreatment with gonadotropin-releasing hormone agonist/other. Of 169 laparotomic/laparoscopic myomectomies, 104 (62%) were performed without pretreatment, 46 (27%) after ulipristal acetate, and 19 (11%) after gonadotropin-releasing hormone agonist/other. The mean surgical experience score (±standard deviation) was comparable between the no pretreatment and ulipristal acetate groups for hysteroscopic myomectomies (13.8 ± 2.2 vs 13.3 ± 2.2, p = .35) and laparotomic/laparoscopic myomectomies (12.9 ± 4.1 vs 12.1 ± 4.2, p = .30). Compared with no pretreatment, more laparotomic/laparoscopic myomectomies after ulipristal acetate pretreatment were associated with difficult delineation of surgical planes (22 [47.8%] vs 23 [22.1%], p = .002) and difficult myoma separation (20 [43.5%] vs 21 [20.2%], p = .003). More myomas were described as soft with ulipristal acetate pretreatment (14 [30.4%] vs 17 [16.4%], p = .049). The rates of profuse/abundant endometrium during hysteroscopy were similar between the no pretreatment (21 [25.0%]) and ulipristal acetate (7 [24.1%], p = .93) groups. CONCLUSION Despite differences in surgical nuances, the overall myomectomy experience was not negatively affected by ulipristal acetate pretreatment.

The Cervical Fibroid

A 37-year-old G0P0 patient with a cervical fibroid presents with dysfunctional uterine bleeding and anemia. She notes that over the course of the past one and a half years, her periods, while still regular, have slowly increased in amount. Her cycles are 33 days in length, and last for a total of 5 days. Days one to three are heavy, and she will change both a super tampon and overnight pad every 2 h on these days. She is otherwise completely healthy. She has no preexisting conditions and has not had any previous surgeries. She is on no medications and has no known drug allergies. Her last pap smear was 2 years ago and was normal. She has never had any history of abnormal pap smears or sexually transmitted infections. There is no family history of breast, ovarian, or colon cancer.

Impact of Resident Overnight Duty Hour Changes on Obstetrical Outcomes: A Population-Based Cohort Study

OBJECTIVE To determine whether obstetrical patient outcomes have changed following the introduction of restricted resident work hours. METHODS A population-based retrospective cohort study of the effects of restricted duty hours for residents in July 2013 at three academic hospitals in Toronto, ON using linked health care databases. The study included 6763 deliveries in the 2 years pre-exposure and 5548 deliveries in the 2 years post-exposure. RESULTS The primary outcome, planned prior to data collection, was a composite index of 29 maternal/fetal outcomes including maternal transfusion/postpartum hemorrhage, maternal infection, fetal mortality, NICU admissions, and surgical/obstetrical complications. There were seven secondary outcomes analysed: NICU admissions; neonatal death; maternal transfusion or postpartum hemorrhage; maternal infection; and three composite measures. A generalized estimating equation model, clustered by institution, was utilized to assess for differences post-intervention. We found no significant differences in baseline demographics between groups. After the implementation of duty hour restrictions, no significant difference was seen in the primary outcome. However, an increased incidence of composite maternal surgical/obstetrical outcomes (OR 1.191; 95% CI 1.037-1.367, P = 0.013) and transfusion/postpartum hemorrhage (OR 1.232; 95% CI 1.074-1.413, P = 0.003) was found. There were no significant differences in other secondary outcomes. CONCLUSION Since the implementation of resident duty hour restrictions, there was no overall change in patient outcomes. However, there was an increase in surgical/obstetrical complications and transfusion/postpartum hemorrhage. This suggests that duty hour restrictions may not be beneficial to patient outcomes. It highlights the need to further investigate the clinical impact of a change in resident duty hours.