Prostaglandin Injection for Myoma Expulsion (PRIME): Case Series of a Novel Approach to Hysteroscopic Resection of FIGO Type 2 Myomas

STUDY OBJECTIVE

To evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure.

DESIGN

Case series.

SETTING

Single high-volume academic medical center.

PATIENTS

Seven patients aged 32 to 51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 to July 2023.

INTERVENTION

Dilute injection of carboprost tromethamine (10 µg/mL) at time of hysteroscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and postoperative pharmacologic side effects and/or surgical complications. Among our 7 patients, all had successful single procedure complete resections of myomas ranging from 0.9 to 4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30 to 180 µg. One patient experienced prolonged postoperative nausea and vomiting that resolved with antiemetics. One patient experienced postoperative endometritis that improved with antibiotics.

CONCLUSION

In this pilot study, injection of dilute carboprost intraoperatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

Attitudes and Beliefs about Hysterectomy in Patients with Uterine Fibroids

STUDY OBJECTIVE

To investigate the attitudes toward and beliefs about hysterectomy that influence the decision of women with symptomatic uterine fibroids regarding hysterectomy.

DESIGN

A prospective survey study.

SETTING

An outpatient clinic.

PATIENTS

Patients in an urban, academic complex gynecology outpatient clinic at the age of 35 years or older with uterine fibroids and without previous hysterectomy were invited to participate. A total of 67 participants were surveyed between December 2020 and February 2022.

INTERVENTIONS

Data were collected on demographics, Uterine Fibroid Symptom Health-Related Quality of Life (UFS-QOL) Questionnaire scores, and beliefs regarding hysterectomy via a web-based survey. Participants were posed with clinical scenarios and asked to indicate a preference for hysterectomy or myomectomy and stratified into groups by acceptability of hysterectomy as a treatment option for fibroids.

MEASUREMENTS AND MAIN RESULTS

Data were analyzed using chi-square or Fisher exact tests, t tests, or Wilcoxon tests as appropriate. The mean age of participants was 46.2 (SD 7.5) years, and 57% of participants self-identified as White/Caucasian. The mean UFS-QOL symptoms score was 50 (SD 26) and the mean overall health-related quality of life score was 52 (SD 28). Notably, 34% of participants preferred hysterectomy whereas 54% preferred myomectomy assuming equivalent efficacy; 44% of those who preferred myomectomy did not desire future fertility. There were no differences observed in UFS-QOL scores. Participants opting for a hysterectomy believed that it would improve their mood/emptions, relationship with partner, general quality of life, sense of femininity, feeling whole, identity/body image, sexuality, and relationships. Those who opted for a myomectomy believed all those factors would worsen with a hysterectomy, and in addition, it would worsen their vaginal moisture and their partner's experience.

CONCLUSION

Many factors affect a patient's decisions regarding hysterectomy for uterine fibroids beyond those related to fertility, including factors related to body image, sexuality, and relationships. Physicians should consider these factors when counseling patients and recognize their importance to facilitate improved shared decision making.

Energy Device Preferences Among Gynecologic Surgeons

Background and Objectives

Multiple vessel-sealing devices are available for use during laparoscopy. The objective of this study is to determine what surgeon-level and device characteristics influence the choice of advanced energy device during gynecologic laparoscopy.

Methods

This is a national cross-sectional study of gynecologic surgeons conducted via social media, utilizing an online, publicly-available, anonymous survey. Gynecologic surgeons who had completed residency training were approached for participation in the survey. Survey completion was voluntary and involved no further follow-ups. The web-based survey consisted of six questions with the option to answer three additional questions if time permitted. The institutional review board determined that this study qualified for exemption.

Results

There were 92 respondents who participated in the survey. Of these, 81 completed the survey and were included in the analysis. Female respondents were younger and more frequently reported a glove size of 6.5 or less. Surgeon-level characteristics, including gender, age, glove size, case volume, region, and practice setting, were not significantly associated with preferred energy devices. Device availability in the operating room was the only characteristic associated with preferred energy devices (P-value = .0076). Other device-level characteristics such as optimal thermal spread, reduced plume, ease of use, device reliability, and teachability had no statistically significant association with preferred energy devices.

Conclusion

Multiple advanced energy devices are available for use during gynecologic laparoscopy. These devices have varying energy profiles, thermal spread, and device size. Despite this diversity, only device availability in the operating room influenced the surgeon's preferred device selection.

Informational Preferences of Women Seeking Treatment for Symptomatic Uterine Fibroids: A Qualitative Study

STUDY OBJECTIVE

To establish the informational needs and preferences of women navigating treatment options for symptomatic uterine fibroids.

DESIGN

Qualitative study using semistructured interviews.

SETTING

Academic institution.

PATIENTS

Participants had a diagnosis of symptomatic uterine fibroids with an active treatment plan.

INTERVENTIONS

Semistructured video interviews were conducted with female patients undergoing treatment for symptomatic uterine fibroids (n = 20). Women were recruited from the outpatient Center for Complex Gynecology in Chicago, IL. Interviews were recorded and transcribed verbatim. A codebook was developed based on the interview transcripts, and the finalized coding was used to conduct a thematic analysis.

MEASUREMENTS AND MAIN RESULTS

Four distinct themes emerged from the interviews: (1) Social supports-including social media-play an important role in informing patients' treatment choices; (2) Patients spend significant energy seeking additional information beyond their obstetrician-gynecologist; (3) Patients prioritize receiving full and complete information from their provider; and (4) Patients experience information-related delays in receiving care.

CONCLUSION

Patients seeking care for symptomatic uterine fibroids have strong preferences about both the quality and extent of information they receive from their gynecologists. Physicians treating these conditions must adapt to changing informational desires and consider expanding physician engagement with patients' social media needs.

Female sterilization reversal in the era of in-vitro fertilization

PURPOSE OF REVIEW

Regret after female sterilization is not uncommon in the United States. Prior to the development of assisted reproductive technology (ART), surgical reversal of sterilization was the only option for patients interested in fertility. First performed in 1972, this procedure has since been refined over the years by gynaecologic surgeons. With in-vitro fertilization (IVF) gaining popularity, interest in sterilization reversal has waned. However, sterilization reversal should remain an important option in patients seeking pregnancy after tubal ligation.

RECENT FINDINGS

A direct comparison between IVF and sterilization reversal is challenging due to inherent differences in reporting fertility outcomes. However, sterilization reversal may optimize fertility in younger women, whereas IVF may be more effective in older women. The surgical approach to sterilization reversal can be laparotomic, laparoscopic or robotic. Clinical decision making should include consideration of the risk of ectopic pregnancy, interval from sterilization to reversal, type of sterilization procedure, planned anastomotic site and projected remaining tubal length.

SUMMARY

In the era of IVF, sterilization reversal still has a place in the management in restoring fertility. Creating awareness of the role of sterilization reversal is the first step in improving access to adequate training in this procedure for the next generation of reproductive surgeons.

The power of proximity: Effects of a multidisciplinary fibroid clinic on inter-specialty perceptions and practice patterns

Background

Multidisciplinary collaboration has generally been shown to have positive effects on healthcare but can be difficult to facilitate. This study assessed the effects of a multidisciplinary fibroid clinic on practice patterns and clinician perceptions to better understand drivers of interspecialty collaboration.

Materials and methods

Annual rates of hysterectomies, myomectomies, and uterine fibroid embolizations (UFEs) performed in an urban healthcare system were collected from 2012–2019. Rates of each procedure were compared over time before and after launching a multidisciplinary fibroid clinic at the academic medical center. Referral rates were also compared. The gynecologists and interventional radiologists (IRs) involved in the clinic were interviewed 2 years prior to and after the clinic launch about their approaches to fibroids and perceptions of others who treat this condition. A phenomenological approach was used to identify and compare themes within the interviews by two researchers with excellent inter-rater agreement (κ = 0.80).

Results and discussion

Annual rates of fibroid procedures increased over time (p<0.01) but the relative number of UFEs decreased (p = 0.01). UFE referrals by the clinic gynecologists significantly increased as did the number of combined fibroid procedures (p<0.01). However, the rates of one fibroid procedure relative to others were not different between the clinic and rest of the healthcare system (p = 0.55). Specialty-specific perceptions of fibroid treatments and inter-specialty dynamics did not change. Despite this, clinicians unanimously perceived the clinic and post-clinic practice patterns as positive and distinct from their previous work and relationships between gynecology and IR elsewhere. Limitations of this study included its single clinic design and potential confounder of differences in advertising pre- versus post-clinic.

Conclusion

Creating the right practice environment may be more important for fostering inter-specialty collaboration and work satisfaction than shared mental models or procedural volumes in certain practice settings.

Body Image and Sexual Function Improve after Both Myomectomy and Hysterectomy for Symptomatic Fibroids

OBJECTIVES

To determine the factors that influence the choice of myomectomy, uterine fibroid embolization (UFE), or hysterectomy in women with symptomatic uterine fibroids and to assess women's perception of body image and sexual functioning before and after treatment.

METHODS

In this prospective observational cohort pilot study, women scheduled to undergo hysterectomy, myomectomy, or UFE were surveyed before surgery and again at 3 to 6 months after their procedure to assess body image and sexual function using the validated 10-item Body Image Scale and 19-item Female Sexual Function Index. Logistic regression was used to determine predictive factors for surgery choice and paired t tests were used to determine changes in perceived sexual function and body image.

RESULTS

Of the 71 women surveyed, 69 underwent their scheduled procedure and 68 participants completed the preoperative questionnaire completely (98%). A total of 33 participants completed the postoperative questionnaire (49%). The predictive factor for hysterectomy versus myomectomy/UFE was older age (odds ratio 1.13, P = 0.017, 95% confidence interval [CI] 1.02-1.24). Regardless of surgery type, there were significant improvements in perceived body image and sexual function, including an increase in the overall sexual satisfaction of the participant (mean difference 0.50, P = 0.021, 95% CI 0.92-0.08) and less likely to feel less sexually attractive because of their menstrual bleeding problem (P < 0.0001, 95% CI 0.637-1.675).

CONCLUSIONS

Women of older age are more likely to choose hysterectomy over myomectomy or UFE for the treatment of symptomatic uterine fibroids. In addition, women who underwent any treatment for fibroids have increases in perception of body image and sexual functioning after their procedure.

Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review

OBJECTIVE

To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications.

DATA SOURCES

A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted.

METHODS OF STUDY SELECTION

One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts.

TABULATION, INTEGRATION, AND RESULTS

Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08-0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03-0.05), comprising 48% (95% CI 40-55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76-89), and the remainder occurred during surgical dissection (18%, 95% CI 11-24). Most injuries were recognized intraoperatively (93%, 95% CI 87-100), and approximately half (55%, 95% CI 46-63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000-0.004).

CONCLUSION

The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.

A Game Show-Based Curriculum for Teaching Principles of Reproductive Infectious Disease (GBS PRIDE Trial)

OBJECTIVES

The purpose of this study was to evaluate whether a game show-based curriculum improves obstetrics and gynecology (OBGYN) residents' confidence in and understanding of the principles of reproductive infectious disease (RID), clinical manifestations and sequelae of sexually transmitted infection (STI), and management of serious long-term consequences of STIs.

METHODS

A game show-based curriculum was developed from the basic principles of RID, which include the following: (1) distinguishing between clinical manifestations of STIs and management of long-term sequelae of STIs; (2) evaluation and management of common gynecologic infectious diseases, including chronic vaginitis, pelvic inflammatory disease, and other pelvic infections; (3) diagnosis and management of perinatal infectious diseases, such as parvovirus, varicella-zoster virus, cytomegalovirus, human immunodeficiency virus, toxoplasmosis, and infection-mediated prematurity; (4) evaluation and management of obstetric and gynecologic postoperative infections; and (5) diagnosis and management of acute and chronic human immunodeficiency virus and hepatitis C virus infections in pregnancy. OBGYN residents at a large urban academic training program were randomized to either a Jeopardy-style educational game show intervention plus a traditional didactic-based curriculum or traditional didactic-based curriculum alone. The study team recruited participants by sending out an e-mail to all of the residents, detailing the study and consent process. Participants from both the intervention and control groups completed confidence and knowledge-based pretests. Posttests were administered 4 weeks after completion of the pretests. Statistical methods were applied to analyze the data.

RESULTS

Thirty-eight residents were randomized to a Jeopardy-style game show-based educational intervention (n = 19) or to a traditional didactic-based curriculum (n = 19). All of the participants (100%) completed the pre- and posttests. Pretest median scores were similar between both groups, in which the Jeopardy group had a median score of 48.5 and the traditional group had a median score of 51.4 (P = 0.091). The Jeopardy group median test scores improved between the pretest and posttest (48.5 vs 62.8, P ≤ 0.001). The traditional didactic-based curriculum had a minimal increase in its median posttest scores (51.4 compared with 54.2, P = 0.773). The Jeopardy group had significantly higher posttest median scores and confidence scores than the traditional didactic-based curriculum (Jeopardy = 62.8, traditional = 54.2, P = 0.002).

CONCLUSIONS

A game show-based curriculum improves OBGYN residents' confidence and retention of knowledge regarding RIDs, clinical manifestations and sequelae of STIs, and management of serious long-term consequences of STIs. Additional studies that include longer posttest time intervals are needed to assess the longer-term impact of game show-based curriculum on knowledge retention among OBGYN residents.

Magnetic Resonance Imaging in the Evaluation of Female Infertility

Pelvic MRI plays an important adjunctive role in the clinical workup of female infertility. Hysterosalpingography is the first line imaging modality in evaluation of female infertility, and hysterosalpingo-contrast sonography can also be used to evaluate both the uterine cavity and fallopian tubes. Pelvic MRI can be helpful in the workup of female infertility, particularly in cases of Mullerian duct anomalies, fibroids, adenomyosis, endometriosis, and tubal disease. These conditions and their appearance on imaging will be reviewed in this article.

Instructional Video and Medical Student Surgical Knot-Tying Proficiency: Randomized Controlled Trial

BACKGROUND

Many senior medical students lack simple surgical and procedural skills such as knot tying.

OBJECTIVE

The aim of this study was to determine whether viewing a Web-based expert knot-tying training video, in addition to the standard third-year medical student curriculum, will result in more proficient surgical knot tying.

METHODS

At the start of their obstetrics and gynecology clerkship, 45 students were videotaped tying surgical knots for 2 minutes using a board model. Two blinded female pelvic medicine and reconstructive surgery physicians evaluated proficiency with a standard checklist (score range 0-16) and anchored scoring scale (range 0-20); higher numbers represent better skill. Students were then randomized to either (1) expert video (n=26) or (2) nonvideo (n=24) groups. The video group was provided unlimited access to an expert knot-tying instructional video. At the completion of the clerkship, students were again videotaped and evaluated.

RESULTS

At initial evaluation, preclerkship cumulative scores (range 0-36) on the standard checklist and anchored scale were not significantly different between the nonvideo and video groups (mean 20.3, SD 7.1 vs mean 20.2, SD 9.2, P=.90, respectively). Postclerkship scores improved in both the nonvideo and video groups (mean 28.4, SD 5.4, P<.001 and mean 28.7, SD 6.5, P=.004, respectively). Increased knot board practice was significantly correlated with higher postclerkship scores on the knot-tying task, but only in the video group (r=.47, P<.05).

CONCLUSIONS

The addition of a Web-based expert instructional video to a standard curriculum, coupled with knot board practice, appears to have a positive impact on medical student knot-tying proficiency.

Trends in malpractice claims for obstetric and gynecologic procedures, 2005 through 2014

BACKGROUND

Interest in medical malpractice and areas of medicolegal vulnerability for practicing obstetricians and gynecologists has grown substantially, and many providers report changing surgical practice out of fear of litigation. Furthermore, education on medical malpractice and risk management is lacking for obstetrics and gynecology trainees. Recent obstetric and gynecologic malpractice claims data are lacking. We report on recent trends in malpractice claims for obstetrics and gynecology procedures, and compare these trends to those of other medical specialties.

OBJECTIVE

We sought to evaluate recent trends in malpractice claims for obstetrics and gynecology procedures and compare these to other medical specialties.

STUDY DESIGN

A search was performed on all medicolegal claims data for obstetrics and gynecology procedures from Jan. 1, 2005, through Dec. 31, 2014, using the Physician Insurers' Association of America data-sharing project, which was created to identify medical professional liability trends. Data from 20 insurance carriers were reviewed based on a search using International Classification of Diseases, Ninth Revision codes and unique database-specific codes.

RESULTS

Of the 10,915 total claims closed from 2005 through 2014, the majority (59.5%) were dropped, withdrawn, or dismissed. The average indemnity of the remaining paid claims (31.1%) was $423,250. The most frequently litigated procedure was operative procedures on the uterus; 27.8% of cases were paid with an average indemnity of $279,384. The procedure associated with the highest proportion of paid claims was vacuum extraction. The average indemnity for paid obstetrics and gynecology procedural claims was 27% higher than that for all medical specialties combined. Obstetrics and gynecology procedural claims had the second highest average indemnity payment and the fifth highest paid-to-closed ratio of all medical specialties.

CONCLUSION

Litigation claims for obstetrics and gynecology procedures have higher average indemnity payments and higher paid-to-closed ratios than most other medical specialties. Claims most frequently relate to gynecologic surgery, but obstetric procedures are more expensive. Possible factors may include procedural experience and unique perioperative complications. We encourage efforts addressing procedures, litigation, and quality interventions to improve outcomes, mitigate risk, and potentially lower indemnity payments.

Fostering better policy adoption and inter-disciplinary communication in healthcare: A qualitative analysis of practicing physicians' common interests

Purpose

In response to limited physician adoption of various healthcare initiatives, we sought to propose and assess a novel approach to policy development where one first characterizes diverse physician groups’ common interests, using a medical student and constructivist grounded theory.

Methods

In 6 months, a medical student completed 36 semi-structured interviews with interventional radiologists, gynecologists, and vascular surgeons that were systematically analyzed according to constructivist grounded theory to identifying common themes. Common drivers of clinical decision making and professional values across 3 distinct specialty groups were derived from physicians’ descriptions of their clinical decision making, stories, and concerns.

Results

Common drivers of clinical decision making included patient preference/benefit, experience, reimbursement, busyness/volume, and referral networks. Common values included honesty, trustworthiness, loyalty, humble service, compassion and perseverance, and practical wisdom. Although personal gains were perceived as important interests, such values were easily sacrificed for the good of patients or other non-financial interests. This balance was largely dependent on the incentives and security provided by physicians’ environments.

Conclusions

Using a medical student interviewer and constructivist grounded theory is a feasible means of collecting rich qualitative data to guide policy development. Healthcare administrators and medical educators should consider incorporating this methodology early in policy development to anticipate how value differences between physician groups will influence their acceptance of policies and other broad healthcare initiatives.

Specialty-Specific Values Affecting the Management of Symptomatic Uterine Fibroids

PURPOSE

To better understand why interventional radiologists and gynecologists differ in their approaches to symptomatic uterine fibroids.

METHODS

Conversational interviews were conducted with 26 interventional radiologists and gynecologists about their professional roles, clinical reasoning, and practice variation within and outside their specialty. Interview transcripts were systematically analyzed using NVivo 10 software (QSR International, Burlington, Massachusetts) according to grounded theory and content analysis to identify key themes and compare themes across specialties and practice environments. Data were supplemented with retrospective analysis of 7,659 patients with symptomatic uterine fibroids treated at a large academic center over 11 years.

RESULTS

Interventional radiologists' shares of symptomatic uterine fibroid treatment and endovascular stent treatments have remained constant (P > .05) for 11 y at a large medical center, whereas minimally invasive gynecologic fibroid treatments and the percentage of interventional radiology (IR) procedures reimbursed by Medicaid/Medicare have increased significantly (r > .90, P < .001 and r = .93, P < .001). Interventional radiologists and gynecologists shared a commitment to do "the right thing" for patients, but each group possessed distinct professional values affecting how they viewed medical evidence, outcomes, and their colleagues. When differences were apparent and concerning, physicians tended to suspect ulterior motives not in patients' best interests.

CONCLUSIONS

Interventional radiologists and gynecologists demonstrated wide-ranging perspectives regarding their role in caring for patients with symptomatic uterine fibroids. To promote genuine collaboration and adoption of shared goals, stakeholders should seek and promote a deeper understanding of specialty-specific values and culture.

Risk Factors for Unscheduled 30-day Readmission after Benign Hysterectomy

OBJECTIVES

Readmission rates after hysterectomy have been reported, but specific risk factors for readmission have not been fully delineated. We aimed to determine risk factors for and implications of 30-day unscheduled readmission after benign hysterectomy using data from the American College of Surgeons National Surgical Quality Improvement Program.

METHODS

We identified benign hysterectomy procedures recorded at all participating National Surgical Quality Improvement Program institutions between 2011 and 2012. Outcomes of interest were 30-day unscheduled readmission rates, variables associated with readmission, and complication and mortality rates associated with readmission. Bivariate analyses were performed using Pearson χ(2) and independent t tests for categorical and continuous variables, respectively. Multivariable regression analysis was performed to identify factors independently associated with readmission.

RESULTS

In total, 21,228 hysterectomies were identified during the study period. Thirty-day readmission rates were 3.8% for abdominal hysterectomy, 2.7% for laparoscopic hysterectomy, 2.9% for laparoscopic-assisted vaginal hysterectomy, and 3.0% for vaginal hysterectomy. Readmission was associated with increased perioperative complications (49.2% vs 6.1%, P < 0.001), return to the operating room (26.3% vs 0.6%, P < 0.001), and mortality (0.3% vs 0.01%, P < 0.001). The most common complications in patients requiring readmission were surgical site infections (28.4%), sepsis (12.8%), urinary tract infection (9.7%), and blood transfusion (6.7%). Variables that were independently associated with 30-day readmission after multivariable regression analysis included younger age (odds ratio [OR] 0.98/year, P < 0.001), smoking (OR 1.28, P = 0.01), diabetes mellitus (OR 1.47, P = 0.008), dyspnea (OR 1.48, P = 0.04), bleeding disorders (OR 1.82, P = 0.04), American Society of Anesthesiologists class ≥ 3 (OR 1.32, P = 0.009), prior surgery within 30 days (OR 3.60, P = 0.04), longer operative time (OR 1.20 per hour of operative time, P < 0.001), inpatient status (OR 1.36, P = 0.001), and longer length of hospital stay (OR 1.04/day, P < 0.001).

CONCLUSIONS

Using a large national database, we identified several patient-related and procedural risk factors for unscheduled 30-day readmission after hysterectomy. Readmission was associated with significantly higher rates of complications, a return to the operating room, and a 30-fold increase in mortality. Our findings reinforce the importance of patient selection and optimization of comorbidities before hysterectomy. Future research should aim to further delineate differential risks of readmission by surgical route as well as modifiable risk factors for readmission.

Pregnancy outcomes after myomectomy with polytetrafluoroethylene placement

BACKGROUND AND OBJECTIVES

The aim of this study was to report preliminary data on pregnancy outcomes after myomectomy with placement of an expanded polytetrafluoroethylene adhesion barrier membrane.

METHODS

In this retrospective case series, 68 women who underwent myomectomy with expanded polytetrafluoroethylene membrane placement between January 1, 2003, and December 31, 2009, were identified. Of these women, 15 subsequently had documented pregnancies and were included in the final dataset.

RESULTS

Eighteen pregnancies were documented among 15 women. There were no reported cases of preterm labor, preterm premature rupture of membranes, or uterine rupture.

CONCLUSION

In this case series, there were no documented cases of preterm labor, preterm premature rupture of membranes, or uterine rupture after myomectomy with expanded polytetrafluoroethylene membrane placement.

Fertility-preserving management of a uterine arteriovenous malformation: a case report of uterine artery embolization (UAE) followed by laparoscopic resection

Herein is presented a fertility-preserving approach in the management of a uterine arteriovenous malformation (AVM) resistant to endovascular management. The patient had a documented AVM and underwent 2 uterine artery embolization procedures, with subsequent recurrence of symptoms. Doppler ultrasound demonstrated recanalization of the AVM. Ultimately, laparoscopic resection of the AVM was performed after laparoscopic ligation of the uterine arteries. Postoperatively, the patient has remained asymptomatic. Laparoscopic resection of a uterine AVM may offer a fertility-preserving alternative to hysterectomy in patients in whom endovascular management has failed.

Comparison of short-term outcomes between transvaginal hybrid NOTES cholecystectomy and laparoscopic cholecystectomy

INTRODUCTION

A natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC).

METHODS

Patients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18 years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.).

RESULTS

Seven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68 min; p < 0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8 mg morphine equivalents; p = 0.02). Visual Analog Scale pain scores (scale 0-10) were less in the TVC group at 30 min (1 vs. 5; p = 0.02) and 60 min (2 vs. 5; p = 0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p = 0.01). SF-36 scores were similar at 1 and 3 months postoperatively.

CONCLUSIONS

This series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.

Uterine artery embolization immediately preceding laparoscopic myomectomy

OBJECTIVE

To determine whether performing uterine artery embolization (UAE) immediately before laparoscopic myomectomy can facilitate a minimally invasive surgical approach for larger uterine fibroids.

METHODS

In a retrospective case-control study, laparoscopic myomectomy with and without preoperative UAE was examined. Data were analyzed from 26 laparoscopic myomectomies performed by a single surgeon at Northwestern University Feinberg School of Medicine between 2004 and 2010. Controls were matched for age, calendar year, surgeon, and number of fibroids removed. Surgical outcomes included preoperative clinical uterine size, operative time, operative blood loss, and postoperative myoma specimen weight. Data were analyzed via 2-tailed Student t test.

RESULTS

Twelve women underwent laparoscopic myomectomy within 169 ± 16minutes (mean ± SEM) of preoperative UAE. Fourteen control patients underwent laparoscopic myomectomy alone. The UAE group had a greater mean preoperative clinical uterine size (19.7 versus 12.4 weeks, P<0.001) and a greater mean myoma specimen weight measured postoperatively (595.3 versus 153.6 grams, P<0.05). There were no significant differences in operative time or blood loss, and there were no intra-operative complications.

CONCLUSION

UAE performed immediately before laparoscopic myomectomy facilitated minimally invasive surgery for larger uteri and larger uterine myomas, with no differences in operative time or blood loss.

Uterine leiomyoma causing menometrorrhagia with a concomitant mature teratoma in a 15-year-old child: a case report and review of the literature

Uterine leiomyoma is the most common uterine tumor in adult females but is rare in the pediatric population with only 10 previous cases reported. We describe the unique case of a 15-year-old girl who presented with abdominal pain and menometrorrhagia and was found to have a uterine leiomyoma as well as a mature ovarian teratoma that required surgical resection. We review diagnostic imaging and optimal management for the 2 gynecologic masses in this teenage girl.

A unique pathology associated with pelvic pain and adnexal mass

OBJECTIVE

To present a unique case of pelvic pain.

DESIGN

Case report.

SETTING

Academic institution.

PATIENT(S)

Thirty-nine year-old with history of endometriosis presented with pelvic pain and possible adnexal mass.

INTERVENTION(S)

Imaging results were not consistent and suggested possible adnexal mass and hydrosalpinx in different studies. Physical exam was concerning for a vaginal mass that was felt not to be contiguous with the adnexa. At laparoscopy, a 3 cm pararectal mass was identified immediately lateral to the uterosacral ligament and medial to the ureter. This mass was completely resected laparoscopically.

MAIN OUTCOME MEASURE(S)

Resolution of pelvic pain.

RESULT(S)

Pathologic diagnosis was ganglioneuroma. Postoperatively, the patient had resolution of her pelvic pain.

CONCLUSION(S)

Pelvic ganglioneuromas are a very rare entity but emphasize the importance of a broad differential for pelvic pain.

Randomized controlled trial: effects of acupuncture on pregnancy rates in women undergoing in vitro fertilization

OBJECTIVE

To evaluate the influence of "true" versus "sham" acupuncture on pregnancy rates (PRs) in women undergoing IVF.

DESIGN

Randomized controlled trial, double-blinded with independent observer.

SETTING

Academic infertility clinic.

PATIENT(S)

One hundred sixty patients <38 years old undergoing IVF with or without intracytoplasmic sperm injection.

INTERVENTION(S)

Subjects were randomly allocated to the true or sham group and underwent acupuncture 25 minutes before and after ET. Subjects completed a McGill Pain Questionnaire regarding their clinical symptoms during ET.

MAIN OUTCOME MEASURE(S)

Clinical PR and clinical symptoms during ET.

RESULT(S)

While the overall clinical PR was 51.25%, there was no significant difference between the arms of the study (true = 45.3% vs. sham = 52.7%); 33.1% of the patients had ultrasound-documented singleton pregnancy, and 15% of patients had twin gestations, while one patient in the true arm had a triplet gestation. There were significant differences in the subjective, affective, and total pain experience between both arms. The subjects in the true arm described their acupuncture session as being more "tiring" and "fearful" and experienced more "achiness" compared with their sham counterparts.

CONCLUSION(S)

There was no statistically significant difference in the clinical or chemical PRs between both groups. Patients undergoing true acupuncture had differing sensory experiences compared with patients in the sham arm. There were no significant adverse effects observed during the study, suggesting that acupuncture is safe for women undergoing ET.

Steroidogenic factor-1 and endometriosis

Endometriosis is a common and chronic disease characterized by persistent pelvic pain and infertility. Estradiol is essential for growth and inflammation in endometriotic tissue. The complete cascade of steroidogenic proteins/enzymes including aromatase is present in endometriosis leading to de novo estradiol synthesis. PGE(2) induces the expression of the genes that encode these enzymes. Upon PGE(2) treatment, coordinate recruitment of the nuclear receptor SF-1 to the promoters of these steroidogenic genes is the key event for estradiol synthesis. SF-1 is the key factor determining that an endometriotic cell will respond to PGE(2) by increased estradiol formation. The presence of SF-1 in endometriosis and its absence in endometrium is determined primarily by the methylation of its promoter. The key steroidogenic enzyme in endometriosis is aromatase encoded by a single gene because its inhibition blocks all estradiol biosynthesis. Aromatase inhibitors diminish endometriotic implants and associated pain refractory to existing treatments in affected women.