Nichole Mahnert

Unexpected gynecologic malignancy diagnosed after hysterectomy performed for benign indications

OBJECTIVE: To define the incidence of unexpected gynecologic malignancies among women who underwent hysterectomy for benign indications. METHODS: We conducted a data analysis of hysterectomy cases from a quality and safety database maintained by the Michigan Surgical Quality Collaborative, a statewide group of hospitals that voluntarily reports perioperative outcomes. Cases were abstracted from January 1, 2013, through December 8, 2013. Benign preoperative surgical indications included pelvic mass, family history of cancer, hyperplasia without atypia, prolapse, endometriosis, pelvic pain, abnormal uterine bleeding, or leiomyomas. Women with a surgical indication of cancer, cervical dysplasia, or hyperplasia with atypia were excluded. RESULTS: During the study period, 7,499 women underwent a hysterectomy and 85.24% (n=6,360) were performed for benign indications. The incidence of unexpected gynecologic malignancy among hysterectomies performed for benign indications was 2.7% (n=172) and included ovarian, peritoneal, and fallopian tube cancer (n=69 [1.08%]), endometrial cancer (n=65 [1.02%]), uterine sarcoma (n=14 [0.22%]), metastatic cancer (n=13 [0.20%]), and cervical cancer (n=11 [0.17%]). The most common indications for hysterectomy were leiomyomas and abnormal uterine bleeding. There was no difference in the mean age (46.86±10.57 compared with 47.0±10.76 years, P=.96) of women with unexpected sarcoma compared with benign disease. Women with unexpected sarcoma were more likely to have a history of venous thromboembolism and preoperative blood transfusion, but this did not reach statistical significance. CONCLUSION: The 2.7% incidence of unexpected gynecologic malignancy includes a 0.22% incidence of uterine sarcoma and 1.02% incidence of endometrial cancer. No reliable predictors of uterine sarcoma exist and caution is warranted in preoperative planning for hysterectomy. LEVEL OF EVIDENCE: II

Prevalence of Endometriosis During Abdominal or Laparoscopic Hysterectomy for Chronic Pelvic Pain.

OBJECTIVE: To estimate the prevalence of surgically confirmed endometriosis in women undergoing laparoscopic or abdominal hysterectomy, including those with and without preoperative indications of chronic pelvic pain or endometriosis, and to describe characteristics and operative findings associated with surgically confirmed endometriosis in women undergoing hysterectomy for chronic pelvic pain. METHODS: A retrospective cohort study was performed with 9,622 women who underwent laparoscopic or abdominal hysterectomy for benign indications in the Michigan Surgical Quality Collaborative from January 1, 2013, to July 2, 2014. The prevalence of surgically confirmed endometriosis, determined by review of the operative report and surgical pathology, was calculated for the entire cohort and for subgroups of women with and without chronic pelvic pain or endometriosis. Multivariate logistic regression models were used to identify characteristics associated with surgically confirmed endometriosis at the time of hysterectomy among women with chronic pelvic pain. RESULTS: Of the 9,622 hysterectomies available for analysis during the study period, 15.2% (n=1,465) had endometriosis at the time of hysterectomy. Among the 3,768 women with a preoperative indication of chronic pelvic pain, fewer than one in four had endometriosis (806/3,768 [21.4%]). Even among those with preoperative indication of endometriosis, many women did not actually have endometriosis at the time of hysterectomy (527/1,232 [42.8%]). The rate of unexpected endometriosis in women without a preoperative indication of chronic pelvic pain or endometriosis was 8.0% (434/5,457). Among women with a preoperative indication of chronic pelvic pain (n=3,786), multivariate analysis showed endometriosis was more common in women of younger age, white race, lower body mass index, and those who failed another treatment previously. Among those with pelvic pain, oophorectomy was more commonly performed in women with surgically confirmed endometriosis than those without (47.4% compared with 33.3%, P<.001). CONCLUSION: Fewer than 25% of women undergoing laparoscopic or abdominal hysterectomy for chronic pelvic pain have endometriosis at the time of surgery.

Risk Factors and Outcomes for Conversion to Laparotomy of Laparoscopic Hysterectomy in Benign Gynecology.

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

Fibromyalgia Phenotype in Chronic Pelvic Pain Patients Presenting to a Tertiary Care Pain Clinic [3Q]

INTRODUCTION: To describe a chronic pelvic pain population and assess for centralized pain using a validated fibromyalgia scale, and further to evaluate how the fibromyalgia phenotype correlates with patient clinical characteristics. METHODS: A retrospective chart review was performed of new patients who presented to the University of Michigan Chronic Pelvic Pain Clinic in the department of Obstetrics and Gynecology from January to November 2013. We collected patient demographics, pain characteristics and treatments, medical history, fibromyalgia survey score, Brief Pain Inventory (BPI), and standardized depression, anxiety and sleep surveys. Fibromyalgia survey scores were categorized into low (0–4), medium (5–7), and high (8–16) based on previous data and descriptive statistics were applied. RESULTS: During the study period 312 women presented to the Chronic Pelvic Pain clinic. The majority were White and employed, and the mean age was 35.5±11.7 years. Women with higher fibromyalgia survey scores were younger (33.8±10.6, P=.006), had more days of pain per month and missed days of work, higher pain intensity and interference scores, and significantly more pain with a full bladder (P=.01) and bowel movements (P=.001). Furthermore, women with a fibromyalgia phenotype were more likely to have depression, anxiety, and sleep problems. CONCLUSION: Higher Fibromyalgia survey scores in a chronic pelvic pain population were significantly associated with higher pain severity and pain interference scores. Similar to other chronic pain conditions, the fibromyalgia phenotype among women with chronic pelvic pain is associated with greater pain morbidity.

Comparison of Intrauterine Device Expulsion Rates After Aspiration Abortion or Interval Insertion

INTRODUCTION: Twenty-two percent of all pregnancies in the United States result in termination, reflecting the need for more robust contraception. The intrauterine device (IUD) is highly effective and reversible although underused in the United States compared with other countries. Several institutions in the United States insert IUDs immediately after abortions with success despite international research that suggests a higher rate of expulsion. OBJECTIVE: To compare the rate of IUD expulsion in immediate postabortion insertion compared with interval insertion. METHODS: A retrospective cohort study was performed to ascertain complications after immediate compared with interval IUD placement after first-trimester aspiration abortions between April 1, 2006, and September 30, 2011, at all Kaiser Permanente Northern California facilities. The primary outcome was the rate of expulsion within 90 days of IUD insertion. Secondary outcomes included rates of uterine perforation, upper genital tract infection, and early removal of IUD. Statistical analysis used &khgr;2 and t test comparisons. Logistic regression was performed for multiple variable analysis. RESULTS: Four hundred forty-seven women with same-day insertions were compared with 316 women with interval insertions. The overall rate of expulsion was low with no statistically significant differences seen between cohorts at 4.1% and 1.7%, respectively (P<.073). Secondary outcome rates were all low. In multivariate analysis, African American race was noted to be an independent risk factor for expulsion with an odds ratio of 3.95. CONCLUSION: In a diverse, American population, levonorgestrel or Cu-T IUD insertion immediately after first-trimester abortion appears to be safe with no significant increase in rates of expulsion or other complications when compared with interval insertion.