Risk Factors Associated with Adnexal Torsion after Hysterectomy

Study ObjectiveTo identify preoperative and intraoperative risk factors for adnexal torsion after hysterectomy, and to estimate the incidence of the disease in the modern-day era of laparoscopic surgery.DesignRetrospective nested case-control study.SettingLarge urban medical system.PatientsEighty-nine female patients ages 17 to 51.InterventionsPatients underwent ovarian-sparing hysterectomy.Measurements and Main ResultsThe estimated incidence of ovarian torsion after hysterectomy was 0.5% (46/8538 ovarian-sparing hysterectomies). The following variables were found to be associated with adnexal torsion after hysterectomy in an adjusted logistic regression: laparoscopic or laparoscopic-assisted approach to hysterectomy vs any other approach (odds ratio [OR], 3.36; 95% confidence interval [CI], 0.86–13.23); younger age at the time of hysterectomy (17–40 years) vs older age (41–51 years) (OR, 3.45; 95% CI, 1.33–8.97); and a gynecologic history significant for endometriosis (OR, 4.07; 95% CI, 1.04–15.88).ConclusionThere is an association between laparoscopic approach to hysterectomy, younger age at time of hysterectomy, and a history of endometriosis with subsequent risk of adnexal torsion. Providers should have a heightened index of suspicion for adnexal torsion after hysterectomy in patients presenting with acute-onset abdominal pain who underwent laparoscopic hysterectomy at a younger age.     

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at the Time of Uterosacral Ligament Suspension

Study ObjectiveThe objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension.DesignRetrospective propensity-score matched cohort study.SettingAmerican College of Surgeons National Surgical Quality Improvement Program database.PatientsWe included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy.InterventionsWe compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort.Measurements and Main ResultsThe study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3–2.8; p <.01) and a higher serious complication rate (5.6% vs 3.1%, OR 1.8, 1.1–3.1; p = .02), which excluded urinary tract infection and superficial surgical site infection. The propensity score analysis was performed, and patients were matched in a 1:1 ratio between the TVH-USLS group and the TLH-USLS group. In the matched cohort, patients who underwent TVH-USLS had a higher composite complication rate than those who underwent TLH-USLS (10.3% vs 6.4%, OR 1.7, 95% confidence interval [CI], 1.1–2.7; p = .04), whereas the rate of serious complications did not differ between the groups (4.3% vs 3.1%, OR 1.4, 95% CI, 0.7–2.8; p = .4). On multivariate logistic regression, TVH-USLS remained an independent predictor of composite complications (adjusted OR 1.6, 95% CI, 1.0–2.6; p = .04) but not serious complications (adjusted OR 1.4, 95% CI, 0.7–2.8; p = .3).ConclusionIn this large national cohort, TVH-USLS was associated with a higher composite complication rate than TLH-USLS, largely secondary to an increased rate of urinary tract infection. After matching, the groups had similar rates of serious complications. These data suggest that TLH-USLS should be viewed as a safe alternative to TVH-USLS.     

Identification of Predictive Factors in Endometriosis for Improvement in Patient Quality of Life

Study ObjectiveTo investigate predictive factors for change in quality of life (QOL) between pre- and postoperative periods in patients with endometriosis.DesignA prospective and multicenter cohort study.SettingFive districts including a tertiary referral center and private and general public hospitals.PatientsNine hundred eighty-one patients aged 15 to 50 years underwent laparoscopic treatment (preferred approach) for endometriosis between January 2004 and December 2012.InterventionsLaparoscopic treatment for endometriosis. All revised American Fertility Society stages were included.Measurements and Main ResultsQOL was evaluated using the 36-Item Short Form Survey questionnaire. Factors influencing changes for each 36-Item Shorty Form Survey domain score between t0 (before surgery) and 1 year after surgery were predicted on the basis of univariate and multivariable analyses. The effect size (ES) method was used to measure changes in QOL. Univariate analysis revealed that 47% of stage IV endometriosis patients presented an improvement in the postoperative Physical Component Summary (PCS) score (ES ≥ 0.8) versus 26%, 31.3%, and 27.5% of patients with stage I, II, and III, respectively (p <.001). Forty-four percent and 38% of patients with chronic pelvic pain (CPP) presented an improvement in postoperative PCS and Mental Component Summary scores (ES>0.8) versus 23% and 24% of patients without CPP, respectively (p <.001). Multivariable analysis (ES > 0.8 vs ES < 0) revealed that women with CPP were more likely to experience greater improvement in postoperative PCS and Mental Component Summary scores than women without CPP (relative risk [RR] = 2.7; 95% confidence interval [CI], 1.7–4.4; p <.001 and RR = 1.8; 95% CI, 1.2–2.8; p <.01, respectively). Accordingly, fertile patients were more likely to show higher rates of improvement in the postoperative PCS score than infertile patients (RR = 1.8; 95% CI, 1.1–3.1; p <.05).ConclusionPatients presenting with severe endometriosis and who experience higher levels of pain are more likely to show improvement in QOL after surgery. CPP is the most significant independent predictive factor for changes in QOL scores.     

Feasibility of Oophorectomy at the Time of Vaginal Hysterectomy in Patients with Pelvic Organ Prolapse

Study ObjectiveTo determine the feasibility of oophorectomy at the time of vaginal hysterectomy in patients with pelvic organ prolapse and to define prognostic factors and perioperative morbidity associated with the procedure.DesignA retrospective cohort study (Canadian Task Force classification II-2).SettingAn academic medical center.PatientsAll women who underwent total vaginal hysterectomy for the treatment of pelvic organ prolapse over 5 years were considered for inclusion in the study.InterventionsTotal vaginal hysterectomy and concomitant pelvic organ prolapse repair with or without oophorectomy.Measurements and Main ResultsA total of 289 women underwent total vaginal hysterectomy with pelvic organ prolapse repair. Vaginal oophorectomy was attempted in 179 patients (61.9%). The procedure was successful in 150 patients (83.8%; 95% confidence interval [CI], 77.6%–88.9%). High ovarian location was the most commonly cited reason for the inability to perform a planned unilateral/bilateral oophorectomy (n = 24, 82.7%). Attempting oophorectomy vaginally was associated with an increased duration of surgery by 7.3 minutes (p = .03), an increased change in hemoglobin by 0.2 g/dL (p = .02), and a higher rate of readmission (7.3% vs 1.8%, p = .04). Multiple logistic regression showed that increasing age (odds ratio = 1.12; 95% CI, 1.05–1.20; p <.001) and body mass index (odds ratio = 1.17; 95% CI, 1.07–1.27; p<.001) were associated with an increased risk of vaginal oophorectomy failure. On univariate analysis, race (p = .64), parity (p = .39), uterine weight (p = .91), need for uterine morcellation (p=.21), presence of endometriosis (p=.66), prior cesarean section (p=.63), prior laparoscopy (p=.37), and prior open abdominal/pelvic surgery (p = .28) did not impact the likelihood of successfully performing oophorectomy.ConclusionIn patients with pelvic organ prolapse, a planned oophorectomy at the time of vaginal hysterectomy can be successfully performed in the majority of cases. Greater age and body mass index are associated with an increased likelihood of failure.     

Vesicoureteral Injury during Benign Hysterectomy: Minimally Invasive Laparoscopic Surgery versus Laparotomy

Study ObjectiveThe findings of previous studies have been inconsistent as to whether benign hysterectomy via minimally invasive laparoscopic surgery increases the risk of vesicoureteral injury when compared with laparotomy. The objectives of our study were to (1) examine the rate of vesicoureteral injury on benign hysterectomy by the surgical approach and (2) compare the risk of vesicoureteral injury specifically between minimally invasive laparoscopic and abdominal hysterectomy on a populational level.DesignRetrospective population-based observational study.SettingThe National Inpatient Sample.PatientsA total of 501 110 women who had undergone hysterectomy for benign gynecologic disease between January 2012 and September 2015 were included as follows: total abdominal hysterectomy (TAH, n = 284 365 [56.7%]), total laparoscopic hysterectomy (TLH, n = 60 410 [12.1%]), abdominal supracervical hysterectomy (Abd-SCH, n = 55 655 [11.1%]), laparoscopic-assisted vaginal hysterectomy (LAVH, n = 45 620 [9.1%]), total vaginal hysterectomy (TVH, n = 34 865 [7.0%]), and laparoscopic supracervical hysterectomy (LSC-SCH, n = 20 195 [4.0%]).InterventionsA comprehensive risk assessment for vesicoureteral injury by hysterectomy mode was performed, adjusting for patient demographics and gynecologic disease types. Propensity score inverse probability of treatment weighing was used to compare (1) TLH versus TAH and (2) LSC-SCH versus Abd-SCH with generalized estimating equations. In a sensitivity analysis, gynecologic disease−specific injury risk and vaginal route−specific injury risk (LAVH vs TVH) were assessed.Measurements and Main ResultsVesicoureteral injury was reported in 1045 (0.21%) women overall. LAVH (0.28%) had the highest bladder injury rate, whereas LSC-SCH had the lowest (0.10%) (p <.001). TLH (0.13%) had the highest ureteral injury rate, whereas TAH had the lowest (0.04%) (p <.001). In propensity score inverse probability of treatment weighing models, compared with TAH, TLH was associated with an increased risk of ureteral injury (odds ratio [OR] 3.95, 95% confidence interval [CI] 2.03−7.67, p <.001) but not bladder injury (OR 1.04, 95% CI 0.57−1.90, p = .897). Risk of ureteral injury was particularly high when TLH was performed for endometriosis (OR 6.15, 95% CI 1.18−31.9, p = .031) or for uterine myoma (OR 4.15, 95% CI 2.13−8.11, p <.001). In contrast, for supracervical or vaginal hysterectomy, minimally invasive laparoscopic approaches were not associated with an increased risk of vesicoureteral injury (LSC-SCH vs Abd-SCH: OR 0.62, 95% CI 0.19−1.98, p = .419; LAVH vs TVH: OR 1.21, 95% CI 0.63−2.33, p = .564).ConclusionThe risk of vesicoureteral injury on benign hysterectomy is low overall regardless of hysterotomy modalities but varies widely with the surgical approach. Compared with TAH, TLH may be associated with an increased risk of ureteral injury.     

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

ObjectiveTo assess the impact of type of surgery for colorectal endometriosis—rectal shaving or discoid resection or segmental colorectal resection—on complications and surgical outcomes.Data SourcesWe performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: (“bowel endometriosis” or “colorectal endometriosis”) AND (“surgery for endometriosis” or “conservative management” or “radical management” or “colorectal resection” or “shaving” or “full thickness resection” or “disc excision”) AND (“treatment”, “outcomes”, “long term results” and “complications”).Methods of Study SelectionTwo authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.Tabulation, Integration, and ResultsOf the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10–0.36; p <.001; I² = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15–0.44; p <.001; I² = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70–1.63; p = .76; I² = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06–0.73; p = .01; I² = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10–1.01; p = .05; I² = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30–1.58; p = .38; I² = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05–0.48; p = .001; I² = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40–119.34; p = .02; I² = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55–16.87; p = .20; I² = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54–1.85; p = .99; I² = 71%).ConclusionColorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.     

Rectovaginal Endometriosis–Characteristics of Operative Treatment and Factors Predicting Bowel Resection

Study ObjectiveThe purpose of this study was to characterize operative treatment of patients with rectovaginal endometriosis (RVE), with special emphasis on factors predicting bowel resection.DesignA total of 153 symptomatic cases undergoing radical resection of RVE at our institution between January 2000 and May 2004 were reviewed. Univariable and multivariable association models were used in connection with various factors associated with bowel resection.SettingTertiary referral center.Measurements and Main ResultsIn all, 57 (37%) patients were treated laparoscopically, and 96 (63%) patients via laparotomy. Gastrointestinal and/or urologic surgeon was present in 30% of cases. A total of 54 (35%) patients underwent bowel resection. The median (range) operating times were 145 (75–315) minutes and 100 (20–300) minutes for patients with and without bowel resection, respectively (p <.0001). Four (2.6%) major complications occurred. In the univariable association model, the risk of bowel resection was increased among patients with previous surgery for endometriosis (OR 2.74, 95% CI 1.35–5.54), intestinal symptoms (OR 2.55, 95% CI 1.29–5.02), and revised American Fertility Society score IV (OR 4.71, 95% CI 2.06–10.78). Preoperative use of combined oral contraceptives was associated with a lower risk of bowel resection (OR 0.32, 95% CI 0.15–0.66).ConclusionOperative treatment of RVE is demanding; a multidisciplinary approach is often needed. Patients with intestinal symptoms and those with a history of endometriosis surgery are at increased risk of bowel resection.     

Patient and Hospital Characteristics Associated with Minimally Invasive Hysterectomy: Evidence from 143 Illinois Hospitals, 2016 to 2018

Study ObjectiveTo identify patient and hospital characteristics associated with minimally invasive hysterectomy.DesignRetrospective population-based analysis of administrative data.SettingData from the Illinois Hospital Association Comparative Health Care and Hospital Data Reporting Services Database.PatientsWomen undergoing hysterectomy for benign gynecologic indications in Illinois, 2016 to 2018.InterventionsNone.Measurements and Main ResultsWe determined the significance of the proportion of minimally invasive surgery (MIS) versus abdominal hysterectomies by patient and hospital characteristics. Multivariable logistic regression was used to determine the association between patient and hospital characteristics and the likelihood of MIS versus abdominal hysterectomy controlling for the simultaneous effects of all patient and hospital characteristics and year of surgery. There were 42 945 hysterectomies for benign indications at 143 nonfederal Illinois hospitals from 2016 to 2018. More than three-fourths (32 387, 75.4%) of hysterectomies were MIS. Non-Hispanic black patients had the lowest percentage of MIS (54.7%) compared with 82.1% among whites (p <.001). Being non-Hispanic black (odds ratio [OR] = 0.53, 95% confidence interval [CI], 0.47–0.60), other or unknown race and ethnicity (OR 0.76, 95% CI, 0.52–0.85), or having a diagnosis of myomas (OR 0.54, 95% CI, 0.49–0.60) were associated with a lower likelihood of MIS. Patients treated at hospitals with >80% MIS had almost 6 times the likelihood of MIS (OR 5.89, 95% CI, 4.51–7.68).ConclusionBlack race and a myoma diagnosis were independently associated with decreased odds of undergoing an MIS hysterectomy, whereas the strongest predictor of undergoing an MIS hysterectomy was hospital proportion of minimally invasive procedures.     

Association Between Laparoscopic Appearance of Superficial Endometriosis,Positive Histology,and Systemic Hormone Use

Study ObjectiveTo assess the association between laparoscopic appearance of superficial endometriosis lesions, histopathology, and systemic hormone use.DesignRetrospective study.SettingTertiary care academic medical center.PatientsWe identified 266 women who underwent laparoscopic surgery at an endometriosis center with excision of lesions consistent with possible superficial endometriosis between September 2015 and November 2018.InterventionsAppearance of the peritoneal lesions was confirmed with review of surgical videos and correlated with each pathology specimen. Lesions were dichotomized on positive or negative pathology assessment. All pathology-positive lesions were further dichotomized by hormone use within 1 month of surgery.Measurements and Main ResultsA total of 841 lesions were biopsied from included subjects during the study period. Of those, 251 biopsies were negative, and 590 were positive for endometriosis on pathology assessment. Lesions had significantly higher odds of positive histology when they were red (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.17–2.48), white (OR, 1.99; 95% CI, 1.47–2.70), blue/black (OR, 2.98; 95% CI, 2.00–4.44), or puckering (OR, 9.78; 95% CI, 2.46–38.91) in appearance. The following combined characteristics had significantly higher odds of positive histology: white and blue (OR, 5.98; 95% CI, 2.97–12.02), red and white (OR, 2.22; 95% CI, 1.38–3.56), red and blue (OR, 4.11; 95% CI, 1.83–9.24), and clear and white (OR, 8.77; 95% CI, 1.17–66.02). Among positive biopsies, those with hormone exposure were more likely to have clear lesions than those without hormone use (OR, 3.36; 95% CI, 1.54–7.34) and were 2.89 times more likely to have clear and white lesions (95% CI, 1.07–7.85).ConclusionAlthough lesions suspicious for endometriosis may have differing rates of positive pathology based on appearance, no lesion characteristic was able to exclude the possibility of endometriosis. In addition, hormone use may influence lesion appearance at the time of surgery, with clear lesions more prevalent. These data have implications for appropriate identification of endometriosis at the time of laparoscopy to ensure accurate diagnosis and complete treatment of disease.     

Endometriosis of the Appendix: When to Predict and How to Manage—A Multivariate Analysis of 1935 Endometriosis Cases

Study ObjectiveTo evaluate appendiceal endometriosis (AE) prevalence and risk factors in endometriotic patients submitted to surgery.DesignA retrospective cohort study.SettingA tertiary level referral center, university hospital.PatientsOne thousand nine hundred thirty-five consecutive patients who underwent surgical removal for symptomatic endometriosis.InterventionsElectronic medical records of patients submitted to surgery over a 12-year period were reviewed. We assessed any correlation between demographic, clinical, and surgical variables and AE. In our center, appendectomy was performed using a selective approach. Appendix removal was performed in case of gross abnormalities of the organ, such as enlargement, dilation, tortuosity, or discoloration of the organ or the presence of suspected endometriotic implants.Measurements and Main ResultsAE prevalence was 2.6% (50/1935), with only 1 false-positive case at gross intraoperative evaluation. In multivariate analysis using a stepwise logistic regression model, independent risk factors for AE were adenomyosis (adjusted odds ratio [aOR] = 2.48; 95% confidence interval [CI], 1.32–4.68), right endometrioma (aOR = 8.03; 95% CI, 4.08–15.80), right endometrioma ≥5 cm (aOR = 13.90; 95% CI, 6.63–29.15), bladder endometriosis (aOR = 2.05; 95% CI, 1.05–3.99), deep posterior pelvic endometriosis (aOR = 5.79; 95% CI, 2.82–11.90), left deep lateral pelvic endometriosis (aOR = 2.11; 95% CI, 1.10–4.02), and ileocecal involvement (aOR = 12.51; 95% CI, 2.07–75.75).ConclusionAmong patients with endometriosis submitted to surgery, AE was observed in 2.6%, and it was associated with adenomyosis, large right endometrioma, bladder endometriosis, deep posterior pelvic endometriosis, left deep lateral pelvic endometriosis, and ileocecal involvement.     

Effect of tubal sterilization technique on risk of serous epithelial ovarian and primary peritoneal carcinoma

ObjectiveTo determine the effect of excisional tubal sterilization on subsequent development of serous epithelial ovarian cancer (EOC) or primary peritoneal cancer (PPC).MethodsWe performed a population-based, nested case–control study using the Rochester Epidemiology Project. We identified all patients with a diagnosis of serous EOC or PPC from 1966 through 2009. Each case was age-matched to 2 controls without either diagnosis. Odds ratios (ORs) and corresponding 95% CIs were estimated from conditional logistic regression models. Models were adjusted for prior hysterectomy, prior salpingo-oophorectomy, oral contraceptive use, endometriosis, infertility, gravidity, and parity.ResultsIn total, we identified 194 cases of serous EOC and PPC during the study period and matched them with 388 controls (mean [SD] age, 61.4 [15.2] years). Fourteen cases (7.2%) and 46 controls (11.9%) had undergone tubal sterilization. Adjusted risk of serous EOC or PPC was slightly lower after any tubal sterilization (OR, 0.59 [95% CI, 0.29–1.17]; P = .13). The rate of excisional tubal sterilization was lower in cases than controls (2.6% vs 6.4%). Adjusted risk of serous EOC and PPC was decreased by 64% after excisional tubal sterilization (OR, 0.36 [95% CI, 0.13–1.02]; P = .054) compared with those without sterilization or with nonexcisional tubal sterilization.ConclusionsWe present a population-based investigation of the effects of excisional tubal sterilization on the risk of serous EOC and PPC. Excisional methods may confer greater risk reduction than other sterilization methods.     

Incidence of Complications during Gynecologic Laparoscopic Surgery in Patients after Previous Laparotomy

Study ObjectiveTo estimate the incidence of complications arising during gynecologic laparoscopic surgery in patients who have undergone previous abdominal surgeries and to assess predictable factors associated with complications based on the characteristics of the previous laparotomy.DesignRetrospective study (Canadian Task Force classification II–2).SettingUniversity-affiliated hospital.PatientsWe enrolled 307 patients with a history of laparotomy who underwent laparoscopic surgery at our hospital between January 2002 and June 2009.InterventionsThe closed primary approach via either the ninth intercostal space or the posterior vaginal fornix was used to avert bowel injury. Complications were defined as organ injury that required repair during surgery and immediate conversion to laparotomy because of technical difficulties. Factors influencing complications during laparoscopic surgery were analyzed using logistic regression.Measurements and Main ResultsNo complications developed during primary entry. Adhesiolysis was required in 195 areas of adhesion in 146 patients before laparoscopic surgery could proceed. These areas comprised 45 (14.7%) and 31 (10.1%) abdominal wall adhesions without and within the umbilicus, respectively, and 119 (38.8%) with intrapelvic adhesions. Complications in 41 patients (13.4%) included bowel damage (n = 35), urinary system damage (n = 4), and conversion to laparotomy because of technical difficulties (n = 2). Overall, 38 complications were laparoscopically repaired, and 1 complication was repaired at minilaparotomy. Intrapelvic adhesions were found in all patients with complications, and bowel adherent to the intrapelvis was identified in 38 of these (92.7%). The most significant predictive factors positively associated with development of complications according to logistic regression analysis were a history of abdominal myomectomy (odds ratio, 6.27; 95% confidence interval, 2.95–13.38; p <.001) and excisional endometriosis surgery (odds ratio, 5.80; 95% confidence interval, 2.08–16.13; p = .001). No patients developed severe delayed complications after surgery.ConclusionOur findings suggest that potential predictive factors of complications are a history of abdominal myomectomy and excisional endometriosis surgery performed because of intrapelvic adhesions.     

Endometriosis and Ectopic Pregnancy: A Meta-analysis

ObjectiveTo systematically review and perform a meta-analysis of the risk of ectopic pregnancy in endometriosis.Data SourcesMEDLINE (OVID), Embase (OVID), CINAHL (EBSCO), and Cochrane Library to April 1, 2019. Inclusion criteria were cohort or case-control studies from 1990 onward. Exclusion criteria were cohort studies without controls, case reports or series, or no English full-text.Methods of Study SelectionA total of 1361 titles/abstracts were screened after removal of duplicates, 39 full-texts were requested, and, after 24 studies were excluded, there were 15 studies in the meta-analysis.Tabulation, Integration, and ResultsData were extracted using standardized spreadsheets with 2 independent reviewers, and conflicts were resolved by a third reviewer. We performed random effects calculation of weighted estimated average odds ratio (OR). Heterogeneity and publication bias were assessed with the I² metric and funnel plots/Egger's test, respectively. The Ottawa-Newcastle Quality Assessment Scale was used with a cutoff of ≥7 for higher quality. There were 10 case-control studies (17 972 ectopic pregnancy cases and 485 266 nonectopic pregnancy controls) and 5 cohort studies (30 609 women with endometriosis and 107 321 women without endometriosis). For case-control studies, endometriosis was associated with increased risk of ectopic pregnancy with an OR of 2.66 (95% confidence interval [CI] = 1.14–6.21, p = .02). For cohort studies, the OR was 0.95 (95% CI = 0.29–3.11, p = .94), but after post hoc analysis of the studies with a Ottawa-Newcastle score ≥7, the OR was 2.16 (95% CI = 1.67–2.79, p <.001). For both case-control and cohort studies, there was high heterogeneity among studies (I² = 93.9% and I² = 96.6%, Q test p <.001) but no obvious evidence of systematic bias in the funnel plot, and Egger's test results were not significant (p = .35, p = .70), suggesting no strong publication bias. There were insufficient data to make any conclusions with respect to anatomic characteristics of endometriosis (e.g., stage) or mode of conception (e.g., assisted reproductive technology vs spontaneous).ConclusionPossible evidence of an association between endometriosis and ectopic pregnancy was observed (OR = 2.16–2.66). However, these results should be considered with caution, owing to high heterogeneity among studies. Continued research is needed to delineate the pregnancy implications of endometriosis.     

Is Hysterectomy a Risk Factor for Urinary Retention? A Retrospective Matched Case Control Study

Study objectiveCompare the rates of urinary retention in patients undergoing endoscopic hysterectomy with those of patients undergoing nonhysterectomy endoscopic gynecologic surgery.DesignRetrospective case control study matched by operative time.SettingAcademic medical center.PatientsAll patients undergoing endoscopic gynecologic surgeries between January 2013 and December 2018.InterventionsOutpatient endoscopic gynecologic surgery.Measurements and Main ResultsA total of 200 endoscopic hysterectomy cases were matched to endoscopic nonhysterectomy gynecologic surgery controls in a 1:1 ratio. The differences in baseline and operative characteristics between the 2 groups included age (48.6 years vs 45.7 years, p = .04), perioperative opioid administration (morphine milligram equivalents, 11.6 mg vs 7.6 mg, p = .01), and estimated blood loss (64.1 mL vs 31.8 mL, p = .001). The rate of urinary retention in the hysterectomy group was double that in the nonhysterectomy group (26.5% vs 13%, p = .01). In the hysterectomy group, age, perioperative opioids, operative time, and estimated blood loss did not differ between those who failed and those who passed the void trial. In the nonhysterectomy group, only operative time was significantly longer in those who failed the void trial (108 minutes vs 94.3 minutes, p = .04). After adjusting for perioperative opioid use and operative time, the relative risk of urinary retention in the hysterectomy group was 2.3 (p = .002, 95% confidence interval, 1.38–3.98).ConclusionHysterectomy appears to be an independent and major factor contributing to postoperative urinary retention. When compared with nonhysterectomy gynecologic surgical controls with similar operative times, the rate of urinary retention in patients who underwent hysterectomy was doubled.     

Risk of Upper-body Adverse Events in Robot-assisted Total Laparoscopic Hysterectomy for Benign Gynecologic Disease

Study ObjectiveRecent studies suggest that prolonged Trendelenburg positioning during robot-assisted total laparoscopic hysterectomy (RA-TLH) may lead to fluid shifts and pulmonary, airway, head and neck, and cranial complications in the upper body. This study examined the upper-body complications during RA-TLH for benign gynecologic disease.DesignPopulation-based retrospective study.SettingThe National Inpatient Sample.PatientsA total of 771 412 women who had total hysterectomy for benign gynecologic disease from October 2008 to September 2015, including 661 284 women who had total abdominal hysterectomy (TAH), 51 544 women who had traditional TLH, and 58 584 women who had RA-TLH.InterventionsA multiple-group generalized boosted model to balance the measured baseline covariates across the 3 hysterectomy groups and a generalized estimating equation model to assess the effect size of complication risk (overall and upper-body complications).Measurements and Main ResultsWomen in the RA-TLH group were more likely to be older, white, and have a higher comorbidity index (all, p <.001). The overall rate of upper-body complications was 4.6% across the 3 groups. RA-TLH was not associated with increased risk of upper-body complications compared with traditional TLH (odds ratio [OR] 1.06; 95% confidence interval [CI], 0.90–1.26) or TAH (OR 0.98; 95% CI, 0.87–1.11). In contrast, RA-TLH was associated with decreased risk of overall perioperative complications compared with TAH (12.0% vs 18.6%; OR 0.64; 95% CI, 0.59–0.70; p <.001). RA-TLH and traditional TLH had similar risk of overall perioperative complications (12.0% vs 13.1%; OR 0.91; 95% CI, 0.8–1.02; p = .099). Women who developed upper-body complications had a higher perioperative mortality rate (0.4% vs <0.01%; OR 79.1; 95% CI, 36.0–174). The highest rates of complications (62.5%) were observed in morbidly obese women aged 70–79 with a comorbidity index of ≥4.ConclusionIn hysterectomy for benign gynecologic disease, RA-TLH was not associated with an increased risk of upper-body complications compared with TAH or traditional TLH. However, older age and higher comorbidity are key risk factors that increase the risk of upper-body complications which carry a disproportionally high mortality rate.     

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

ObjectiveSurgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis.Data SourcesWe performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction.Methods of Study SelectionStudy Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted.Tabulation, Integration and ResultsOut of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18–0.63; I² = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09–0.51; I² = 0%; p <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32–1.69; I² = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14–0.66; I² = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4–1.31; I² = 63%; p = .28).ConclusionColorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.     

Comparing Characteristics of and Postoperative Morbidity after Hysterectomy for Endometriosis versus other Benign Indications: A NSQIP Study

Study ObjectiveCompare the difference in postoperative morbidity for benign total hysterectomy by indication.DesignRetrospective cohort.SettingUnited States hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project database from 2018 to 2019.PatientsPatients undergoing total hysterectomy for benign indications age 18 to 55 years old.InterventionsUnivariate comparisons were made between patients with hysterectomies for endometriosis and other benign indications. Unadjusted and adjusted logistic regression models were used to investigate the association between primary outcomes and hysterectomy indication; covariates in the adjusted model include age, race, ethnicity, and route.Measurements and Main ResultsA total of 29 742 women underwent hysterectomies, of which 3596 (12.1%) were performed for endometriosis. Patients undergoing hysterectomy for endometriosis were likely to be younger, were predominately White, and had less comorbidities. They were also more likely to have previous abdominal surgery, have previous pelvic surgery, undergo a laparoscopic approach, and undergo lysis of adhesions (all p <.001). Overall length of stay (≥1 day 73.1% vs 78.6%; p = .983) and operative time (median 118.0 vs 125.0 minutes; p <.001) were similar in both groups. Examining primary outcomes, patients with endometriosis were more likely to experience major morbidity (3.8% vs 3.4%; adjusted odds ratio [OR], 1.25; p = .033), with no difference in minor or overall morbidity (5.8% vs 6.9% [p = .874] and 8.8% vs 9.4% [p = .185], respectively). There were two 30-day mortalities, none in the endometriosis group. Patients with endometriosis were more likely to develop deep surgical site infection (SSI)/organ-space infection (2.3% vs 1.6%; OR, 1.42; p = .024) and less likely to receive blood transfusion (1.8% vs 3.0%; OR, 0.58; p <.001). There was no difference in occurrence of superficial SSI, sepsis, venous thromboembolism, readmission, or reoperation between groups.ConclusionPatients undergoing hysterectomy for endometriosis were more likely to experience major morbidity and deep SSI, although overall major morbidity is rare.     

Ultrasound Prediction of Segmental Bowel Resection in Women with Rectovaginal Endometriosis: A Single-Center Experience

Study ObjectiveTo retrospectively evaluate the ability of routinely collected preoperative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis.Design and SettingPatients at the University College London Hospital who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (British Society for Gynaecological Endoscopy) database. Imaging data were collected and analyzed to determine associations with the requirement for bowel resection.PatientsWe evaluated 228 consecutive women undergoing bowel surgery (shave, disc resection, or segmental resection) for rectovaginal endometriosis.InterventionsThe patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection, and segmental resection of the bowel. All patients underwent a preoperative transvaginal ultrasound to assess the extent of endometriosis.Measurements and Main ResultsThere were 206 rectal shaves (90.4%), 2 disc resections (0.9%), and 20 segmental bowel resections (8.8%). A multivariable analysis demonstrated an association between bowel resection and ≥2 nodules located in the rectovaginal space (odds ratio [OR] 6.85; 95% confidence interval [CI], 1.37–34.2), nodules in the vesicouterine pouch (OR 5.87; 95% CI, 1.03–33.3), and increasing nodule size (OR 2.39 per 1 cm increase per 1 cm diameter increase; 95% CI, 1.56–3.64).ConclusionUltrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counseling and surgical planning in the preoperative setting for women with rectovaginal endometriosis.     

Association of Race/Ethnicity with Surgical Route and Perioperative Outcomes of Hysterectomy for Leiomyomas

Study ObjectiveTo evaluate the associations among race/ethnicity, route of surgery, and perioperative outcomes for women undergoing hysterectomy for uterine leiomyomas.DesignRetrospective cohort study.SettingMultistate.PatientsWomen who underwent hysterectomies for leiomyomas from the American College of Surgeons National Surgical Quality Improvement Program database, 2014 to 2017.InterventionsNone. Exposures of interest were race/ethnicity and route of surgery.Measurements and Main ResultsRacial/ethnic variation in route of surgery and perioperative outcomes. Propensity score matching was employed to control for possible confounders. We identified 20 133 women who underwent nonemergent abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or vaginal hysterectomy (VH) for leiomyomas. We defined minimally invasive hysterectomy (MIH) as LH or VH. Black women were more likely to have open surgery (AH vs MIH adjusted odds ratio [aOR], 2.22; 95% confidence interval [CI], 2.07–2.38; AH vs VH aOR, 1.79; 95% CI, 1.54–2.08; AH vs LH aOR, 2.27; 95% CI, 2.13–2.44) than white women. Likewise, Hispanic women were more likely to have open surgery (AH vs MIH aOR, 1.76; 95% CI, 1.58–1.96; AH vs LH aOR, 1.82; 95% CI, 1.61–2.00) than white women. Black women were more likely to experience any complication after hysterectomy (AH aOR, 1.54; 95% CI, 1.31–1.80; VH aOR, 1.65; 95% CI, 1.02–2.68; LH aOR, 1.37; 95% CI, 1.13–1.66) than white women. Hispanic women were less likely than white women to experience major complications after VH (aOR, 0.28; 95% CI, 0.08–0.98). Compared with white women, the mean length of stay was longer for black women who underwent AH or LH. The mean total operation time was higher for all minority groups (except for Asian/other undergoing AH) regardless of surgical approach.ConclusionWomen of minority race/ethnicity were more likely to undergo abdominal rather than MIH for leiomyomas. Even when controlling for route of surgery, they were more likely to experience perioperative complications.     

Type of Pelvic Disease as a Risk Factor for Surgical Site Infectionin Women Undergoing Hysterectomy

Study ObjectiveTo quantify the relationship between type of benign pelvic disease and risk of surgical site infection (SSI) after hysterectomy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingHospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).PatientsWomen who underwent hysterectomy from 2006-2015 and recorded in NSQIP database.InterventionNone.Measurements and Main ResultsSSI risk was compared for type of benign pelvic disease, patient characteristics (i.e., age, race, and selected comorbidities) and process of care variables (i.e., admission status, type of hysterectomy, and operative time). SSI occurred in 2.48% of the 125,337 women who underwent hysterectomy. SSI was most frequent in patients with endometriosis and least frequent in those with genital prolapse (3.13% vs 1.39%; p <.0001). Following adjustment for potential confounders, the odds of SSI were higher in women undergoing hysterectomy for endometriosis (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.43– 2.25), uterine myomas (aOR, 1.28; 95% CI, 1.05–1.55), menstrual disorders (aOR, 1.46; 95% CI, 1.20–1.78), and pelvic pain (aOR, 1.75; 95% CI, 1.34–2.27) compared with women undergoing hysterectomy for genital prolapse. Other patient factors associated with SSI included age, body mass index, smoking, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and American Society of Anesthesiologists classification. Among process-of-care factors, inpatient status, route of hysterectomy, total vs subtotal hysterectomy, and operative time were also associated with SSI.ConclusionIn addition to various patient and process-of-care factors known to be associated with SSI, type of underlying pelvic disease is an independent risk factor for SSI in women undergoing hysterectomy for benign indications.