Objective: Using a triage algorithm for primary cytoreductive surgery (PCS) reduces perioperative mortality, however, nonlethal complications are common. This study identified procedures associated with postoperative complications in triage-appropriate women, with the aim of guiding the next steps to foster surgical quality improvement. Materials and Methods: Consecutive triage-appropriate women with stage IIIC/IV ovarian cancer undergoing PCS, from January 2012 to April 2018, were included. The expanded Accordion scale was used to grade complications. Adjusted risk ratios (RRs) were calculated to quantify the association between concomitant procedures and risk of 30-day grade 3+ (G3+) complications by fitting Poisson regression models adjusted for performance status and age. Population-attributable risk (PAR) was calculated based on the adjusted RRs and prevalence of each procedure. Results: Of 214 women, 82.7% had intermediate- or high-complexity surgery, 68.7% had complete gross resection, 3.7% had residual disease >1 cm, and 18.7% experienced G3+ complications. In univariate analysis, operative time, surgical complexity, splenectomy, and bowel resection (any and extent of) were associated with G3+ complications. Operative time, bowel resection (any, extent of, and large) were associated with G4+ complications. In the adjusted analysis for G4+ complications, bowel resection (any, extent of, and large) had statistically significant PAR values of 60.7%, 54.7%, and 50.8%, respectively. PAR values associated with G3+ complications were 27.4% and 26.8% for any and multiple bowel resections, respectively. Conclusions: Bowel resection, upper abdominal procedures, and longer operative times are essential for PCS, but each contributes to the relatively constant rates of postoperative morbidity despite triage to prevent frail patients from undergoing PCS. Surgical-improvement research should focus on improving the safety of these procedures. (J GYNECOL SURG 20XX:000)

Journal of Gynecologic Surgery

Journal of Gynecologic Surgery

Journal of Gynecologic Surgery

Journal of Gynecologic Surgery

Journal of Gynecologic Surgery

Objective: The goal of this research was to investigate the feasibility, safety, and short-term clinical outcome of pure extraperitoneal sacrocolpopexy with transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for treating central pelvic defects. Material and Methods: A total of 9 patients with central pelvic prolapse underwent extraperitoneal sacrocolpopexy with V-NOTES, at the Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China, between December 2020 and June 2022. The patients' demographic characteristics, perioperative parameters, and clinical outcomes were analyzed retrospectively. Each patient had the following major surgical procedures: (1) Establishing a platform for an extraperitoneal approach with V-NOTES; (2) separating the extraperitoneal path to the sacral promontory region; (3) suturing the long arm of the mesh to the anterior longitudinal ligament S1; and (4) suturing and fixating the short arm of the mesh at the top of the vagina. Results: The median patient age was 55, the median operative time was 145 minutes, and the median intraoperative blood loss was 150 mL. The operations were successful for all 9 cases, with a median preoperative Pelvic Organ Prolapse–Quantification score of C: +4, and a 3-months postoperative score of C: −6. There were no recurrences during a follow-up of 3–11 months, and no complications occurred, such as mesh erosion, exposure, and infection. Conclusion: As a new surgical approach, extraperitoneal sacrocolpopexy with V-NOTES is safe and feasible. (J GYNECOL SURG 20XX:000)

Pelvic organ prolapse is a highly prevalent condition that can have a large impact on a patient's quality of life. Multiple approaches to surgical repair exist, each with a unique set of risks and benefits. For patients with apical prolapse, repair of the apex is the cornerstone of any surgical procedure. Since adaptation of robotic techniques to sacrocolpopexy were introduced in the early 2000s, the minimally invasive approach to sacrocolpopexy has surpassed open case volumes. Compared to native-tissue transvaginal procedures, minimally invasive sacrocolpopexy offers potential advantages in durability. This article reviews surgical techniques, troubleshooting, outcomes, and ongoing areas of development regarding the use of a robotic approach to prolapse surgery. (J GYNECOLOGIC SURG 2023:000)

Objective: This article describes the incidence, presentation, management, and outcome of posthysterectomy vaginal cuff evisceration over a 2-year timeperiod at a major cancer center. Materials and Methods: This was a retrospective chart review of patients who developed vaginal cuff evisceration after prior hysterectomy. The denominator of hysterectomies performed by the department between May 1, 2020 and April 30, 2022, was included in the analysis. The cases of vaginal evisceration were well-known to the practice. Results: Three women who had undergone hysterectomy during the 2-year timeperiod developed vaginal cuff evisceration. This incidence was 0.3%. All 3 women underwent surgical repair (1 with bowel resection) without subsequent complications. Conclusions: Vaginal evisceration is a rare complication of hysterectomy at a major cancer center. This report adds to the body of knowledge regarding diagnosis and management of this dramatic and life-threatening event. (J GYNECOLO SURG 20XX:000)

Objective: The aim of this research was to learn if 900 mg of vaginal isonicotinic acid hydrazide (INH) reduced pain and improved insertion ease during diagnostic outpatient hysteroscopy (DOH) in nulliparous infertile patients, when administered 12 hours before DOH. Materials and Methods: A double-blinded, randomized, controlled study was carried out at a university teaching hospital. Primary infertile women (150) were allocated randomly to receive 900 mg of INH vaginally or a placebo 12 hours before DOH for infertility assessment. Patients were requested to assess the intensity of their pain on a visual analogue scale ranging from 1 to 10 during the DOH, which was the study's primary objective. Secondary outcomes were the time it took to insert the hysteroscope via the external cervical os and to view the uterus, patient satisfaction, postprocedural analgesic needs, and the ease with which DOH was performed. Results: Both groups shared baseline features. The INH group had a reduced mean pain score during DOH (3.9 ± 0.8 versus 5.8 ± 0.8; p < 0.001). DOH was easier in the INH group; ease of insertion score in the INH group was lower than in the placebo group (5.3 ± 0.1 versus 7.3 ± 1.1; p < 0.001). The INH group had greater satisfaction (7.6 ± 1.3 versus 5.1 ± 0.9; p < 0.001) and needed less analgesia (p = 0.02) than the placebo group. Both groups had comparable adverse effects. Conclusions: In nulliparous infertile women, 900 mg of vaginal INH 12 hours before DOH reduces perceived pain more effectively than a placebo, facilitating easier hysteroscope insertion and improving patient satisfaction. (J GYNECOL SURG 20XX:000)

Objective: Dysmorphic uterus, a rare uterine malformation characterized by an abnormal uterine cavity, may lead to reproductive failures, such as infertility and adverse pregnancy outcomes. Results of hysteroscopic correction of this uterine malformation on reproductive outcomes are poorly reported. This study evaluated reproductive outcomes of frozen-thawed electives single-blastocyst transfers (eSBTs) in patients who underwent hysteroscopic metroplasty for dysmorphic uteri, and compared these results with those of a control group. Materials and Methods: This study included 78 patients with primary infertility who had dysmorphic uterine anomalies and 379 age- and body mass index–matched infertile patients with normal uterine cavities (controls). All patients were enrolled in an in-vitro fertilization program. Selected top/good-quality blastocysts were frozen and then transferred in another cycle after hysteroscopic metroplasty. Reproductive and obstetric outcomes of all cases and characteristics of frozen embryo transfer (FET) cycles were analyzed retrospectively. Results: Demographic characteristics of both groups were similar. There were no statistically significant differences between the study and control groups for implantation rates, clinical pregnancy rates, and live birth rates (LBRs): 63.2% versus 64.8%, 57% versus 55%, and 39.8% versus 40.3%, respectively; all p > 0.05. Rates of clinical pregnancy losses were higher in the study group, but this difference was not statistically significant (27.1% versus 19.5%; p > 0.05). Preterm deliveries were significantly higher in the study group than in the control group (23.5% versus 10.9%; p = 0.03). Type of endometrial preparation, day of embryo transfer, and grade of transferred embryos were similar in both groups, except endometrial thickness was significantly lower in the study group (8.9 ± 1.4 mm versus 10.1 ± 1.7 mm; p < 0.001). Conclusions: Patients who underwent hysteroscopic metroplasty of the uterine cavity, reproductive outcomes of FET cycles as were successful as in patients with normal uterine cavities. eSBTs with top/good quality embryos after hysteroscopic metroplasty in patients with dysmorphic uteri improves LBRs but preterm births are higher, compared to patients with normal uterine cavities. (J GYNECOL SURG 20XX:000)

Pelvic organ prolapse (POP) is a common pelvic floor disorder (PFD) that affects quality of life (QoL) in millions of women in the United States and around the world. The normal position of pelvic organs relies on both the pelvic floor muscles/levator ani muscle and the connective tissue support for the uterus and vagina. Known risk factors for POP include age, parity, family history, genetic predisposition, and chronic straining. The diagnosis of POP depends mainly on history and clinical examination. After diagnosis, progression is slow, and regression is more common than expected. Treatment starts with patient education about the disorder and available treatments. It is important to note that “doing nothing” is always an option. If patient has troublesome symptoms, there are nonsurgical and surgical options. Nonsurgical options include pelvic floor muscle training and pessary therapy. Surgery is an option for patients with POP who decline nonsurgical options or for whom those options fail. Management of women with POP and other PFDs requires a multidisciplinary team to evaluate and formulate individualized plans to address the specific health and QoL issues facing each patient. (J GYNECOL SURG 20XX:000)

Journal of Gynecologic Surgery

Correction of apical descent is an essential component of a durable prolapse surgery and can be achieved by multiple different techniques and surgical approaches. Laparoscopic prolapse surgery produces excellent outcomes and lower costs, compared to robotic surgery, without compromising success and remains a valuable surgical approach to prolapse repair. This review summarizes the evidence for conventional laparoscopic apical prolapse repair, compared to alternative surgical approaches, and provides recommended techniques with tips and tricks to optimize this approach.

Objectives: The effects of an algorithm for postoperative prescriptions on opioid-prescribing practices, pain-related postdischarge clinical encounters, and patient satisfaction were studied. Materials and Methods: A quality-improvement initiative was implemented at a single, tertiary-care, comprehensive cancer center. Perioperative patient education was restructured with detailed verbal and written components. An algorithm for postoperative discharge medications included prescribing nonopioid analgesics to all patients without contraindications. Opioid prescriptions were based on patients' length of stay and inpatient opioids' use. Data on opioids prescribed and postoperative encounters for pain were collected, and surveys at a postoperative visit were taken on patient satisfaction pre- and postintervention. Groups' results were compared. Results: The patients (107 preintervention and 90 postintervention) had similar demographics. The postintervention group had a 25% reduction in median number of opioids prescribed at discharge (p = 0.16), with similar patterns of postoperative encounters for pain and frequency of opioid refills. Patient satisfaction, assessed in 29 preintervention and 40 postintervention participants, had significant improvement; 95% postintervention participants answered that they were satisfied with their pain control, compared with 75% preintervention participants (p = 0.03). Conclusions: Perioperative education plus an algorithm for postoperative discharge medications in gynecologic oncology patients results in improved patient satisfaction, a trend toward fewer opioid prescriptions, and a similar pattern of postoperative pain encounters. Comprehensive perioperative education is effective for improving patient satisfaction and pairs well with an algorithmic approach to decreasing opioid prescriptions. (J GYNECOL SURG 20XX:000)

Laparoscopic suturing is an important component of advanced gynecologic procedures. A needle may be inadvertently lost, and searching for it can be especially challenging. The goal of this review is to present useful strategies when this problem occurs. This article reviews current literature and suggests a structured approach for retrieving a lost needle. Preventive measures that reduce the risk of the needle being lost are also highlighted. A systematic search of a lost needle should cover all areas of the gynecologic surgical field, including the abdominal cavity, abdominal wall, laparoscopic cannulas, and the surrounding area. Intraoperative imaging, such as plain film X-ray or C-arm fluoroscopy, has been shown to be useful for localizing lost needles. The benefits and risks of conversion to laparotomy should be carefully evaluated if the needle remains missing after a prolonged search. The 7-step approach described in this article can be followed by laparoscopic surgeons faced with lost-needle occurrences. (J GYNECOL SURG 20XX:000)

Objectives: Centering is a unique form of counseling that unifies education and supporting patients with similar conditions to facilitate learning and develop a mutual support network. This study's primary objective was to evaluate the effect of centering preoperative counseling on anxiety scores in patients with newly diagnosed gynecologic malignancies. Secondary outcomes included the effect of this form of counseling on depression, compliance with preoperative instructions, hospital length of stay, and use of unscheduled health care resources. Materials and Methods: In this prospective cohort study, women with known or suspected gynecologic malignancies were assigned to standard-of-care counseling or centering. The centering cohort participated in a 1–1.5 hour online group-counseling session before surgery. All participants completed Patient-Reported Outcomes Measurement Information System® (PROMIS®) anxiety and depression patient-reported outcome (PRO) surveys at baseline, preoperatively, and 4 weeks postoperatively. Paired and unpaired t-tests were used to evaluate differences in PROs between timepoints and between the cohorts. χ², Fisher's exact, and Wilcoxon rank-sum tests were used to evaluate secondary outcomes. Results: There were 17 patients in the standard-of-care cohort and 52 patients in the intervention cohort evaluated. The centering group had a reduction of 4.8 points in anxiety scores after the intervention. There was no difference in Enhanced Recovery After Surgery compliance or utilization of unscheduled health care resources between the 2 cohorts. Conclusions: Centering preoperative counseling meaningfully reduces anxiety scores in patients undergoing surgery for suspected gynecologic malignancy. (J GYNECOL SURG 20XX:000)

Background: An interstitial ectopic pregnancy implants within the proximal and intramural portion of the fallopian tube that is enveloped by the myometrium. The high mortality rate in this type of pregnancy is due, in part, to delay in diagnosis, as well as from massive intraperitoneal hemorrhage. Excessive blood loss can occur after a rupture or during surgical treatment of an interstitial pregnancy. Several ways to reduce surgical blood loss have been reported. Our team's experiences and management tools are described in this article and in a video (Supplementary Video S1; supplementary data are available online at www.liebertonline.com/GYN) Both show a laparoscopic approach for managing an interstitial ectopic pregnancy to reduce the risk of uterine rupture and to preserve future fertility. To minimize surgical blood loss, both uterine arteries are temporarily occluded with surgical clips. Technique: Laparoscopic cornual resection of a left interstitial ectopic pregnancy involves: (1) successfully identifying the ureters and uterine arteries, and occluding the latter by surgical clipping; (2) making a circular incision in the left horn up to the gestational sac; (3) removing the cornual capsule and ipsilateral fallopian tube; (4) enucleating the entire gestational sac; and (5) suturing the myometrial bed and repairing the incision. Conclusions: Laparoscopic cornual resection is appropriate for interstitial pregnancy in patients wishing to preserve fertility. Temporary occlusion of bilateral uterine arteries using surgical clips is a safe, effective, blood-sparing intraoperative technique. (J GYNECOL SURG 20XX:000)

Objective: Vulvar extramammary Paget's disease (EMPD) is a rare intraepithelial adenocarcinoma of the vulvar skin. This study evaluated the clinical characteristics, treatment modalities, and oncologic outcomes in patients with vulvar EMPD. Materials and Methods: Cases of patients who were treated for vulvar EMPD between 1994 and 2022 were identified. Patient demographics, associated malignancies, treatments, histopathologic features, need for re-operations, and long-term outcomes were documented. Results: The study involved 10 patients with vulvar noninvasive EMPD, with a median age of 57 (31–86) years. None of the patients had prior malignancies. The index operations performed were wide local excision with reconstructive surgery (5 patients) and vulvectomy with reconstructive surgery (3 patients). Seven patients were positive for margin involvement. Five patients developed recurrences. The mean time of the first recurrence was 32.6 (4–88) months. All recurrences were treated with reoperations. Only 1 associated malignancy was found: cervical cancer. There was no disease progression in any of the patients who were followed; of the 10 patients, 2 were lost to follow-up. Conclusions: EMPD is characterized by a high tendency to recur after surgical resection. Surgical management can be a challenge due to the high rate of residual tumors in the surgical margins. (J GYNECOL SURG 20XX:000)

Objective: Left adnexectomy and/or pelvic lymphadenectomy often require mobilization of the sigmoid colon to gain adequate exposure, which involves division of peritoneal attachments of the sigmoid colon. Variations in native sigmoid attachments and techniques needed to achieve adequate mobilization have not been well-described. Materials and Methods: This was a prospective cohort study of patients undergoing laparotomy, laparoscopy, or robotic surgery by a gynecologic oncologist. Exclusions were patients who had pelvic surgery (other than tubal ligation), pelvic radiation therapy, concurrent pelvic inflammatory processes, or extensive pelvic peritoneal disease (e.g., ovarian cancer, severe endometriosis). Detailed patient and clinical data were collected, along with anatomical findings in the sigmoid colon, such as diverticula; length; and sigmoid colon attachments relative to the infundibulopelvic ligament (IPL), broad ligament, and posterior cul-de-sac. Results: Of the 92 patients in the study, 75 had peritoneal attachments of the sigmoid colon or its mesentery. The most-common attachment location was lateral to the IPL only (n = 27; 36%), followed by lateral to the IPL and to the IPL (n = 15; 20%). The most-common type of attachment was congenital (n = 60; 45.5%), followed by adhesive (n = 58; 45%). Congenital attachment lateral to the IPL was the most-common at 24% of all documented attachments. Conclusions: Peritoneal attachments of the sigmoid colon are a common finding of natural anatomy and may be complex and/or multifocal, even in patients without risk factors. Knowledge of the peritoneal lines of attachment is important for having adequate exposure when performing left adnexectomy and/or pelvic lymphadenectomy. (J GYNECOL SURG 20XX:000)

Objective: Many uterine procedures cause intrauterine adhesions (IUAs). The standard of care (SOC) for detecting IUAs includes initiating a work-up after a patient reports such symptoms as menstrual irregularity, pelvic pain, or infertility. Routine hysteroscopy (RHSC) is not currently performed after an event that may cause an IUA. This study objective was to determine if routine diagnostic HSC following procedures that are high risk for causing IUAs could be a cost-saving alternative to the current SOC from both medical-system and patient perspectives. Materials and Methods: This nonclinical economic-modeling exercise involved a hypothetical cohort of women who received office RHSC after an inciting event, compared to women who received SOC. The model had 4 scenarios for a range of diagnostic work-up costs and costs of HSC lysis of adhesions of varying severity. Each scenario was run with a proportion of IUA formation after an inciting event varying from 1% to 99%. Results: Costs of RHSC became equivalent to the SOC with an IUA incidence rate from 5% to 22%, depending on the cost of the work-ups. For less expensive work-ups, RHSC yielded cost savings of 18%–22%, with an IUA rate depending on the HSC treatment costs. For more expensive work-ups, including full infertility work-ups, RHSC provided cost savings for only 5% of IUAs in a given cohort of patients. Conclusions: The model demonstrated that RHSC after a procedure known to cause IUAs can be cost-saving in many clinical scenarios. Accounting for various infertility work-up cost estimates and gradients of adhesion severity, RHSC costs were equivalent to SOC with an IUA formation rate of 5%–22%. This suggests that RHSC could be considered in reproductive-age women who desire fertility after procedures known to cause IUAs, without expected increased costs to the medical system. Additionally, RHSC may confer health benefits and increase patient satisfaction due to earlier diagnosis and less loss of reproductive years. (J GYNECOL SURG 20XX:000)

A decline in surgical training and skill acquisition in gynecology has been widely recognized and has been receiving much attention during the past 5 years. Potential solutions have been discussed in a number of publications and forums. A system of tracking is 1 such proposal, with the idea being to provide residents opportunities to direct their training into more-specialized areas after basic training. Gynecologic surgical training, as it relates to obstetrical practice has received little attention. This article discusses the importance of gynecologic surgical training for the practicing obstetrician. (J GYNECOL SURG 2022:000)

The discipline of gynecology has grown immensely in the last decades. Recognition of the complexity of gynecologic pathology, the evolving patient population, and advancements in imaging technology have required the gynecologic surgeon to function at an increasingly rigorous technical level. While minimally invasive routes of surgery remain paramount within the specialty to optimize patient outcomes, the ability to offer open surgery continues to be of the utmost relevance to any practicing surgeon. We assert that fundamental surgical principles of anatomical relationships, expert medical knowledge, and preoperative planning comprise the true skill set acquired through surgical training and that these principles apply regardless of the planned approach to any given case. This article discusses these key tenets of pelvic surgery, explores their relevance to laparotomy cases encountered in complex gynecology, and discusses how they may apply to contemporary training and practice.

Objective: This research compared laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) for operative time, complications, postoperative pain, inflammatory response, hospital stay, and costs. Materials and Methods: A randomized controlled trial compared LH and VH for 80 patients equally allocated to undergo either for benign pathology (Canadian Task Force Classification I). Results: Mean operative time was significantly higher for LH (127.5 ± 25.9 minutes; 95% confidence interval [CI]: 119.2, 135.8) than for VH (104 ± 30.8 minutes; 95% CI: 94.2, 113.9); p = 0.0004. There was no significant difference in median blood loss (LH: 250 mL and VH: 235 mL); p = 0.7983). There was a strong positive correlation between operative time and estimated uterine weight, especially for VH. Adnexal surgery was performed as planned preoperatively in 62.5% of LHs versus 27.5% of VHs; p < 0.0035. Both groups were comparable regarding intra- and postoperative complications (p = 1.0). Median postoperative pain intensity was lower in LH than in VH at 2 hours (51 versus 64.5; p = 0.0038), 6 hours (38.5 versus 46; p = 0.0009), and 24 hours (24.5 versus 36.5; p < 0.0001). Inflammatory response did not differ between the groups, neither as postoperative fever (7.5% of LH versus 2.5% of VH; p = 0.6153) nor as postoperative C-reactive protein rise (median: 57.4 mg/L for LH; 41.6 mg/L for VH; p = 0.1489). There was no difference in hospital stay (LH median: 35.5 hours; VH median: 30 hours; p = 0.6991). Costs for LH were higher (LH median: 5525 Egyptian pounds (EGPs), 335 US dollars (USD); VH median: 3400 EGPs, 207 USD; p < 0.0001). Conclusions: LH has longer operative time, yet better postoperative pain profile, than VH. However, cost considerations make LH fall behind VH as a primary choice for benign hysterectomy, especially in low-resource settings. (J GYNECOL SURG 20XX: 000)

Objective: This Surgical Techniques report demonstrates the efficacy of laparoscopic management for complications of cesarean scar pregnancy (CSP). The study aim was to detail the procedure for treating 2 patients and report on their postsurgical outcomes. Materials and Methods: A study of 2 cases of CSP complications was conducted at a tertiary university hospital. The 2 women had CSP pregnancy terminations performed by evacuations at private clinics. They were susequently admitted to the tertiary university hospital with vaginal bleeding and pelvic pain. Cesarean-scar dehiscence and hematoma were noted in each patient. Both patients underwent laparoscopy. The hematomas were evacuated, and residual placental necrotic tissues were removed. The edges of the cesarean scars were stitched laparoscopically. Results: In both patients, no isthmocele formations were seen at the first-month follow-up. Conclusions: The laparoscopic approach may be an efficient option for patients with particularly complicated cases of CSP. (J GYNECOL SURG 20XX:000)

Female pelvic medicine and reconstructive surgery (FPMRS) relies on a range of surgical approaches to treat pelvic-floor disorders. Concomitant hysterectomy is involved in many of these approaches. In general, due to advances in nonsurgical treatment of benign conditions, the hysterectomy rate has decreased in the United States. Moreover, when hysterectomy is performed, the trend now favors minimally invasive laparoscopy and robotic-assisted techniques, while abdominal and vaginal approaches are less common. Mirroring national trends, studies examining trainee case logs have reported decreased volumes of vaginal hysterectomies. Surveys of trainees and program directors show wide variability in preparedness and case numbers, highlighting the lack of uniformity in training and expectations. To augment vaginal hysterectomy training, many efforts have been developed to enhance trainee education and simulation for vaginal surgery. Fidelity, cost, and validation vary in these simulation models. By simulating different steps of a vaginal hysterectomy, many models have been validated by trainees and expert surgeons to be accurate and helpful, but limited data exist on applications to FPMRS training. For FPMRS, limited studies cover training variability in vaginal, laparoscopic, and robotic approaches to prolapse repair. A 2020 Accreditation Council for Graduate Medical Education update on case minimums for FPMRS detailed the requirements for each procedure even more. As FPMRS adapts to growth of the field, surgeons must continue to educate the next generation of trainees on various routes, such as conventional laparoscopic, robotic-assisted laparoscopic, and vaginal surgery. (J GYNECOL SURG 20XX:000)

Benign gynecologic surgery is vital to health care for women in different age groups. Surgical interventions tend to fall into 1 of 2 categories. The first category comprises surgeries specifically aimed at reestablishing or maintaining female reproductive function; this is more succinctly termed fertility-sparing or reproductive surgery. The second category addresses gynecologic conditions in a definitive fashion without focusing on future fertility. Among gynecologic surgeons, the physicians who are reproductive endocrinology and infertility specialists (REIs) are highly trained to be attentive to women's future fertility needs, specifically focusing on minimizing the negative impact of surgery on female reproductive structures/organs. Optimal results during reproductive surgery can be achieved when these procedures are performed through minimally invasive gynecologic surgery (MIGS) approaches. While REIs were the pioneers of microsurgery and MIGS, significant improvement in assisted reproductive technology (ART) outcomes, inadequate surgery compensation, and cultivation of more gynecologists with special training in MIGS have led most REIs to focus primarily on ART as opposed to reproductive surgeries over the last few decades. Given this change in practice pattern, this article reviews the roles that REI subspecialists played in developing microsurgery/MIGS and where the REI specialty currently fits in the spectrum of gynecologic surgeries. (J GYNECOL SURG 20XX:000)

The existing literature shows that the current obstetrics and gynecology residency training model is not able to produce proficiency in gynecologic surgery. As benign uterine and adnexal disorders become more complex with more treatment options and surgical routes available, new training and professional structures are needed to provide adequate surgical care to gynecologic patients.

Journal of Gynecologic Surgery

Journal of Gynecologic Surgery

Journal of Gynecologic Surgery

With the recent changes in U.S. law governing abortion, the topic of abortion provision is all the more important among health care providers. This commentary, from the perspective of physicians who provide abortions, highlights the key points of what makes abortion provision a net-positive ethical/moral action, utilizing the framework of medical ethical principles. The authors discuss how abortion provision applies the medical ethical principles of autonomy, beneficence, nonmaleficence, and justice to achieve safe, quality, and equitable care that improves the lives and well-being of patients. (J GYNECOL SURG 38:339)

Induced abortion in the United States is safe, and complications are rare. Because of their rarity, many clinicians may not have direct experience with managing complications during surgical abortions. This review details the management of hemorrhage, uterine and cervical injury, and infection after surgical abortions. (J GYNECOL SURG 38:335)

In general, demand for abortion services has been consistent throughout U.S. history; what has varied throughout the centuries is a person's ability to access a safe abortion, free from persecution and prosecution. Recent U.S. history has demonstrated that making abortions illegal does not stop people from obtaining abortions. Furthermore, when discussing abortion access in the United States, a recurring theme in our history is how restriction of abortion and antiabortion legislation primarily affects the poorest and most-underprivileged members of U.S. society. This article examines the history of abortion legislation in the United States to promote better understanding of current antiabortion legislation and what these laws mean for patients and providers. (J GYNECOL SURG 2022:XXX)

Journal of Gynecologic Surgery

Ectopic pregnancy occurs in 1%–2% of pregnancies in the United States and accounts for significant pregnancy-related mortality. Although the rate of ectopic pregnancy among patients seeking abortion is thought to be lower than that of the general population, physicians and clinicians who provide abortion may diagnose rare sites of abnormal implantation due to their frequent use of early ultrasound as a part of abortion care. In addition, complex family planning practitioners can be relied upon for assistance with these cases as these practitioners are typically skilled in the management and termination of pregnancies with abnormal implantations. In the post-Roe landscape, with abortion being outlawed in many states, physicians and clinicians should be able to identify and treat these abnormal pregnancies that present a threat to the life and health of the pregnant woman. (J GYNECOL SURG 20XX:000)

Journal of Gynecologic Surgery

In response to the COVID-19 pandemic, gynecologists have increased their use of telehealth services to expand access to care and minimize the need for in-person office-visits. While abnormal uterine bleeding (AUB) is the most-common complaint for patients presenting to gynecologic office visits, there is little research on the utility of telehealth in its management. A practical guide to managing AUB using telehealth services was developed for each of the common causes of AUB according to PALM-COEIN [polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified] nomenclature. Examples of applications in assessment include comprehensive history intake, electronic scheduling of transvaginal ultrasounds, laboratory work orders, patient counseling, and referrals to specialists. Telemedicine can also be incorporated into treatment of AUB. Preoperative consultations, prescribing medications (such as non–long-acting reversible hormonal contraceptives), and uncomplicated postoperative management can all be done via telehealth services. Telehealth can improve the efficiency of evaluation and treatment of AUB, including appropriate triage of patients and completing necessary workups needed prior to an in-person visit. Integration of telemedicine services may help overcome challenges with access to care such as geographical or resource limitations. (J GYNECOL SURG 20XX:000)

Abortion procedures are associated with some degree of pain, and managing pain is an essential goal in caring for patients who undergo this procedure. Patients seeking abortion should be counseled on all pain-management options, which include nonpharmacologic methods, local cervical anesthetic injection, oral medication, intravenous sedation, and general anesthesia. Organizations, including the American Society of Anesthesiologists, the National Abortion Federation, and the Planned Parenthood Federation of America have published evidence-based guidelines for anesthesia administration to patients receiving abortion care. Abortion-care practices should have pertinent anesthesia and procedural policies consistent with the care setting, whether they are hospital-based or freestanding sites. These policies should follow guidelines set by national medical institutions and not include additional targeted regulation of clinics or providers of abortion care. (J GYNECOL SURG 20XX:000)

Objective: This study compared rates of postoperative complications in patients, with early stage gynecologic malignancies, who had drains or no drains used after bilateral pelvic lymph node dissections (PLNDs), with or without para-aortic lymph-node dissections (LNDs). Materials and Methods: All willing patients, ages 18–70, with histologically proven gynecologic malignancies, who had PLNDs, with or without para-aortic LNDs, as a part of their primary surgeries, were randomized to have drains inserted or no drains inserted post surgery. Intraoperative details as well as postoperative length of drainage, hospital stays, and morbidity (wound complications, fluid accumulation needing intervention, hematomas, seromas, and lymphocysts) were noted. Patients were followed in 30 days post surgery, clinically and radiologically, to evaluate and compare morbidity in both groups. Results: A total of 144 cases were studied (73 in a drain group and 71 in a no-drain group). The average visual analogue score for pain was 6.7 in the drain group and 6.6 in the no-drain group (p = 0.44). The average postoperative hospital stay was 7 days in the drain group and 6 days in the no-drain, group (p = 0.014). There was no significant difference in other parameters (wound-infections, fluid accumulation needing intervention, seromas, lymphocysts, and paralytic ileus). Conclusions: Placing pelvic drains following surgeries routinely for early-stage gynecologic malignancies needs to be revisited as it confers no advantage, and by avoiding drains, patients can be discharged to go home earlier. (J GYNECOL SURG 20XX:000)

Objective: The primary outcome of this study was to note the rate of delayed-diagnosis urinary tract injury posthysterectomy if ureteral catheters (UCs) were used to prevent such injuries. Materials and Methods: This cohort study, using the American College of Surgeons National Safety and Quality Improvement Project database, included women undergoing hysterectomy with or without UC placement. Demographic and outcome data were collected and compared. Results: The study involved 189,727 patients undergoing hysterectomies. The mean age of the entire cohort was 50.6 ± 12.9 (standard deviation [SD]) years and the mean body mass index was 31.4 ± 8.2 (SD). The rate of prophylactic UC placement was 0.58%. Women who underwent UC placement were more likely to have postoperative progressive renal insufficiency (0.54% versus 0.09%; p < 0.001) and postoperative urinary-tract infection (7.0% versus 2.5%; p < 0.001). There were 420 (0.22%) delayed-diagnosis urinary-tract injuries. The rate of any type of delayed-diagnosis urinary-tract injury was significantly higher in women who underwent UC placement (28, 2.5% versus 392; 0.21%; p < 0.001). Women with delayed-diagnosis urinary-tract injury had significantly more unplanned reoperations and readmissions. Multivariable logistic regression showed that the odds of having delayed-diagnosis urinary-tract injury were 9.54 times higher among patients who received UCs (confidence interval: 6.30–14.45; p < 0.001). Conclusions: UCs are rarely used during hysterectomy, tend to be utilized in cases when more difficulty is expected, and appear to increase, rather than decrease, the risk of urinary-tract injury. Routine use of prophylactic UCs during hysterectomies are not recommended. (J GYNECOL SURG 20XX:000)

Objective: The goal of this research was to determine if dye can be omitted without affecting the accuracy of urinary-tract injury assessment during cystoscopy at the time of hysterectomy. Materials and Methods: This prospective randomized study was performed at a gynecologic oncology service in a tertiary-care center from July 2018 to June 2019. All patients undergoing hysterectomy for either benign and malignant indications were included. The study focused on the routine cystoscopy given to each patient per protocol. Patients were randomized into 2 main groups: (1) dye versus (2) no-dye, and then into 4 subgroups based on the distending media that was used (water or saline). A linear, continuous visual scale was used to grade ureteral jet strength. The time to visualization of ureteral jets was documented. The primary outcome measure was the degree of agreement between 2 observers' ratings of ureteral jet strengths when urinary dye was used or when it was not used. Results: According to Cronbach's α, the correlation between 2 observers was 85.3% agreement for the strength of the right-side ureteral jets and 85.8% for the left side ureteral jets. The difference in jet strength between the dye and no-dye groups was statistically significant for evaluation of the right-side ureter but not clinically significant. No statistical significance for assessment of ureteral jet strength was noted between water and saline distension media nor was there a difference between the groups for time until first jet visualization. Conclusions: Cystoscopy can be performed without using dye for ureter and bladder assessment during gynecologic surgeries. (J GYNECOL SURG 20XX:000)

This article discusses mesh biology and known issues with mesh kits. The current mesh recommendations of national and international societies, as well as the impact of hysterectomy on mesh exposure during sacrocolpopexy are also discussed.

Objective: This study was conducted to evaluate the feasibility and ease of vaginal hysterectomy (VH) after performing an office examination and an examination under anesthesia (EUA). Materials and Methods: This was a prospective observational study of women who required simple hysterectomy. If the vaginal route was potentially feasible after office examination, EUA was performed, and the route proceeded accordingly. The data were analyzed to determine which preoperative factors were the best predictors of difficult VH. Results: There were 155 patients enrolled into this study. Office and EUA findings of a larger pelvis correlated with a “non-difficult” VH. Office and EUA findings of a platypelloid pelvis and large uterine size correlated with a “difficult” VH. Poor uterine mobility and global assessment at the time of EUA had the strongest correlation with a “difficult” VH. Position of the cervix above the ischial spines, both at rest and with traction, also correlated with a “difficult” VH. Multivariate analyses showed larger pelvic size found on office examination to be a significant predictor of a non-difficult VH; pelvic shape, uterine size, and mobility on EUA remained significant predictors of a “difficult” VH. Conclusions: EUA is more accurate than office examination for predicting the difficulty of VH and should be considered before deciding against the vaginal route. (J GYNECOL SURG 38:294)