Janelle K. Moulder

Mechanical bowel preparation before laparoscopic hysterectomy: A randomized controlled trial

OBJECTIVE: To examine the influence of mechanical bowel preparation on surgical field visualization during laparoscopic hysterectomy. METHODS: The studys 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. LEVEL OF EVIDENCE: I

Post-hysterectomy Dyspareunia

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 patients 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.

The role of simulation and warm-up in minimally invasive gynecologic surgery

Purpose of review The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills. Recent findings Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes. Summary Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeons career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.

Endometrial Sampling After Ablation Therapy

Study Objective: To compare pathology results from endometrial biopsy and curette biopsy to hysterectomy specimen in women with a history of endometrial ablation. Design: Institutional review board approved cross-sectional study. Setting: Surgical setting at single academic institution between July 2014 and March 2015. Patients: Women with a history of endometrial ablation undergoing indicated hysterectomy. Patients with malignancy were excluded. 21 met inclusion criteria; 16 were successfully enrolled. Intervention: An endometrial biopsy (EMB) and curette biopsy were collected in each patient prior to hysterectomy. Measurements and Main Results: Success of the sampling test was defined by agreement with final histopathology from hysterectomy specimens. Primary indication for hysterectomy included abnormal bleeding (n=8, 50%), pelvic pain (n=7, 43.8%), and fibroids (n=1, 6.2%). 10 subjects (63%) had inactive endometrium or scarring on hysterectomy pathology, and 6 subjects (37%) had active endometrium (n=5) or hyperplasia (n=1). From this cohort, 31 biopsies were collected and pathologically evaluated (16 EMB and 15 curette). The frequency of obtaining any endometrial tissue for EMB was 73% (11/15) and was 47% (7/15) for curette (p=0.08). Curette specimens were more frequently insufficient when compared to EMB specimens (73% v. 50%; p=0.03). Although overall concordance with hysterectomy pathology was low for both EMB and curette, EMB agreed more frequently (27% v 20%; p=0.01). Conclusion: In patients with a history of endometrial ablation, sampling with EMB or curette is insufficient for pathologic interpretation in most cases. EMB was statistically more successful at obtaining any endometrial tissue and less likely to have insufficient yield when compared to curette biopsies. However, concordance rates with goldstandard hysterectomy histology were notably low for both EMB and curette. Pre-ablation counseling should include discussion of the difficulty of future endometrial assessment as well as the potential risk for delays in diagnosis and treatment of endometrial hyperplasia and carcinoma.

Uterine weight and complications after abdominal, laparoscopic, and vaginal hysterectomy

BACKGROUND: Although uterine size has been a previously cited barrier to minimally invasive hysterectomy, experienced gynecologic surgeons have been able to demonstrate that laparoscopic and vaginal hysterectomy is feasible with increasingly large uteri. By demonstrating that minimally invasive hysterectomy continues to have superior outcomes even with increased uterine weights, opportunity exists to meaningfully decrease morbidity, mortality, and cost associated with abdominal hysterectomy. OBJECTIVE: We sought to determine if there is an association between uterine weight and posthysterectomy complications and if differences in that association exist across vaginal, laparoscopic, and abdominal approaches. STUDY DESIGN: We conducted a cohort study of prospectively collected quality improvement data from the American College of Surgeons National Surgical Quality Improvement Program database, composed of patient information and 30‐day postoperative outcomes from >500 hospitals across the United States and targeted data files, which includes additional data on procedure‐specific risk factors and outcomes in >100 of those participating hospitals. We analyzed patients undergoing hysterectomy for benign conditions from 2014 through 2015, identified by Current Procedural Terminology code. We excluded patients who had cancer, surgery by a nongynecology specialty, or missing uterine weight. Patients were compared with respect to 30‐day postoperative complications and uterine weight, stratified by surgical approach. Bivariable tests and multivariable logistic regression were used for analysis. RESULTS: In all, 27,167 patients were analyzed. After adjusting for potential confounders, including medical and surgical variables, women with 500‐g uteri were >30% more likely to have complications compared to women with uteri ≤100 g (adjusted odds ratio, 1.34; 95% confidence interval, 1.17–1.54; P < .0001), women with 750‐g uteri were nearly 60% as likely (adjusted odds ratio, 1.58; 95% confidence interval, 1.37–1.82; P < .0001), and women with uteri ≥1000 g were >80% more likely (adjusted odds ratio, 1.85; 95% confidence interval, 1.55–2.21; P < .0001). The incidence of 30‐day postsurgical complications was nearly double in the abdominal hysterectomy group (15%) compared to the laparoscopic group (8%). Additionally, for each stratum of uterine weight, abdominal hysterectomy had significantly higher odds of any complication compared to laparoscopic hysterectomy, even after adjusting for potential demographic, medical, and surgical confounders. For uteri <250 g, abdominal hysterectomy had twice the odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.80–2.33), and among women with uteri between 250–500 g, abdominal hysterectomy was associated with an almost 80% increase in odds of any complication (adjusted odds ratio, 1.76; 95% confidence interval, 1.41–2.19). Even among women with uteri >500 g, abdominal hysterectomy was still associated with a >30% increased odds of any complication, compared to laparoscopic hysterectomy (adjusted odds ratio, 1.35; 95% confidence interval, 1.07–1.71). CONCLUSION: We found that while uterine weight was an independent risk factor for posthysterectomy complications, abdominal hysterectomy had higher odds of any complication, compared to laparoscopic hysterectomy, even for markedly enlarged uteri. Our study suggests that uterine weight alone is not an appropriate indication for abdominal hysterectomy. We also identified that it is safe to perform larger hysterectomies laparoscopically. Patients may benefit from referral to experienced surgeons who are able to offer laparoscopic hysterectomy even for markedly enlarged uteri.

McCall Culdoplasty during Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial

STUDY OBJECTIVE To assess the feasibility and safety of a McCall culdoplasty at the time of total laparoscopic hysterectomy and to evaluate the differences in the total vaginal length, vaginal apex during Valsalva, and sexual function 12 months after McCall culdoplasty compared with standard cuff closure. DESIGN A pilot randomized controlled, single-masked trial (Canadian Task Force classification I). SETTING An academic tertiary care hospital. PATIENTS Women undergoing total laparoscopic hysterectomy for benign indications from June 2013 to December 2013. INTERVENTIONS Women were randomized (1:1) to McCall culdoplasty followed by standard cuff closure versus standard cuff closure. Patients underwent Pelvic Organ Prolapse Quantification examination and completed the Female Sexual Function Index immediately before surgery and at 6 months and 12 months postoperatively. The primary outcome was the operative time. Secondary outcomes included estimated blood loss, complications, total vaginal length, vaginal apex during Valsalva, and sexual function. MEASUREMENTS AND MAIN RESULTS This study included 50 patients. The groups were similar in terms of preoperative and surgical characteristics. The operative time did not differ between the groups. The estimated blood loss and complications were also similar. The loss to follow-up was similar in both groups. Changes in the total vaginal length, vaginal apex during Valsalva, sexual function, and pain with intercourse did not differ between the groups. CONCLUSION In this pilot study, the addition of McCall culdoplasty to standard cuff closure during total laparoscopic hysterectomy was not associated with an increase in operative time, estimated blood loss, or surgical complications. No differences in the total vaginal length or vaginal apex during Valsalva were observed at the 12-month follow-up. There were no differences in sexual dysfunction or dyspareunia. Given the well-established risk reduction for the development of apical prolapse with McCall culdoplasty during vaginal hysterectomy, this procedure may be a feasible and safe addition to total laparoscopic hysterectomy.

Risk of appendiceal endometriosis among women with deep-infiltrating endometriosis

To determine whether deep‐infiltrating endometriosis (DE) carries an increased risk of appendiceal endometriosis (AppE) as compared with superficial endometriosis or no endometriosis.

Comparison of the levonorgestrel‐releasing intrauterine system, hysterectomy, and endometrial ablation for heavy menstrual bleeding in a decision analysis model

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.

Hysterectomy for the Transgender Man

Purpose of ReviewOur objective is to summarize the most recent, high-quality data regarding perioperative recommendations for hysterectomy and salpingo-oophorectomy in transgender and gender nonconforming individuals.Recent FindingsMany transgender men desire hysterectomy and salpingo-oophorectomy for gender affirmation, cancer-risk reduction, pelvic pain, or abnormal uterine bleeding. Gender-confirming hysterectomy is safe, effective, and highly beneficial for well-counseled patients. Preoperative considerations include optimizing the office environment, preoperative testing specific to patients with long-term testosterone use, counseling specific to transgender men, consideration of World Professional Association for Transgender Health criteria, and coordination of a multi-disciplinary team. Minimally invasive approaches, including vaginal, laparoscopic, and robotic-assisted hysterectomy, are the standard of care for cisgender women and transgender men given lower complication rates, better post-operative outcomes, and greater cosmetic satisfaction. Concurrent appendectomy, mastectomy, vaginectomy, and urethral reconstruction may be performed at the time of hysterectomy; phalloplasty and metoidioplasty are generally performed as subsequent procedures. Same-day discharge following hysterectomy is safe and has been shown to improve post-operative outcomes. We recommend follow-up with the patient’s mental health professional and endocrinologist in addition to routine surgical follow-up. Long-term satisfaction after genital surgery appears to be high and regret is low.SummaryMore robust and up to date research is needed to improve guidelines and perioperative care for transgender individuals. Available data suggests that hysterectomy and salpingo-oophorectomy for transgender men is safe, is not associated with any additional risks compared to cisgender women, and is associated with an improved quality of life.

Cost-effectiveness of treatments for heavy menstrual bleeding

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.