A Systematic Review and Meta-Analysis of the Effect of Intraoperative Bupivacaine in Gynaecologic Surgery After 24 Hours or 9 Half-Lives

ObjectiveTo review all high quality available evidence regarding the effect of intraoperative bupivacaine 24 hours (or 8.9 half-lives) after intraoperative administration at time of gynaecologic surgery and to ascertain whether a second mechanism of action, beyond the initial prevention of sodium channel depolarization and blockade of nerve impulses, may be occurring.Data SourcesWe searched all major databases with an algorithm designed to include all randomized trials that used any form of local bupivacaine, regardless of dose or route of administration, at the time of any gynaecologic surgery and compared its use with saline placebo.ResultsAs expected, we found that bupivacaine showed a significant improvement for all gynaecologic surgeries with respect to pain intensity at 6 hours after surgery when compared with a saline group (mean difference [MD] –1.28; 95% CI –1.96 to –0.61], P = 0.07). We also found a significant difference at 24 hours after surgery, giving evidence to the possibility of a second mechanism of action (MD –0.57; 95% CI –1.10 to –0.05], P = 0.01). Further subgroup analysis for pain levels at 24 hours showed significant decreases in pain for the laparoscopy (MD –0.74; 95% CI –0.93 to –0.54, P < 0.01) and laparotomy (MD –2.60; 95% CI –2.93 to –2.27, P < 0.01)) subgroups but not for the vaginal hysterectomy (MD 0.20; 95% CI –0.69 to 1.09, P = 0.66) or prolapse surgery (MD –0.11; 95% CI –0.41 to 0.19, P = 0.48) subgroups. There was no significant difference with respect to the length of hospital stay (MD –0.11; 95% CI –0.59 to 0.38, P = 0.67).ConclusionAs expected, bupivacaine significantly reduced visual analog pain scores when compared with placebo at 6 hours after surgery, but also showed a significant difference at 24 hours after surgery, giving evidence of a second mechanism of action following the initial sodium channel blockade.     

Keep Your Landmarks Close and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis Surgery

ObjectiveExcisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction 1, 2, 3, 4. This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus.DesignUsing didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery.SettingTertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy.InterventionsRadical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE.ConclusionThe hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation.     

Effect of Local Anesthetics on Postoperative Pain in Patients Undergoing Gynecologic Laparoscopy: A Systematic Review and Meta-analysis of Randomized Trials

ObjectivePain remains a common complication after gynecologic laparoscopy. Use of local anesthesia may be beneficial in reducing postoperative pain. We performed a systematic review and meta-analysis to assess whether local anesthetic decreases postoperative pain after laparoscopic gynecologic procedures.Data SourcesWe searched Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline from inception to November 2020 using Medical Subject Headings and free text combinations.Methods of Trial SelectionWe included randomized controlled trials of patients undergoing gynecologic laparoscopy receiving port site subcutaneous, subfascial, or intraperitoneal local anesthetic compared with placebo or no intervention. We included 20 trials (1861 participants) with size varying between 28 and 164 participants.Tabulations, Integration, and ResultsMeta-analysis was performed with RevMan 5.3 (Cochrane Collaboration, London, United Kingdom), with standard mean differences (SMDs) and random-effects model. Port site infiltration reduces postoperative pain at 4 hours (SMD –0.25; 95% confidence interval [CI], –0.44 to –0.06; 4 trials; 545 participants) and 6 hours (SMD –0.44; 95% CI, –0.82 to –0.06; 4 trials; 455 participants) after surgery. The administration of intraperitoneal local anesthetics reduces pain at 6 hours (–1.42; 95% CI, –3.22 to –0.30; 4 trials; 277 participants) after surgery.ConclusionsThe use of port site and intraperitoneal local anesthetic decreases immediate postoperative pain in patients undergoing gynecologic laparoscopy, although its impact on analgesia requirements is unclear. Routine usage of local anesthetics should be considered for people undergoing gynecologic laparoscopy.     

Effects of Peritoneal Ropivacaine Nebulization for Pain Control After Laparoscopic Gynecologic Surgery

Study ObjectiveTo evaluate the effects of peritoneal cold nebulization of ropivacaine on pain control after gynecologic laparoscopy.DesignEvidence obtained from a properly designed, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I).SettingTertiary care center.PatientsOne hundred thirty-five women with American Society of Anesthesiologists disease classified as ASA I-III who were scheduled to undergo operative laparoscopy.InterventionPatients were randomized to receive either nebulization of 30 mg ropivacaine before surgery (preoperative group), nebulization of 30 mg ropivacaine after surgery (postoperative group), instillation of 100 mg ropivacaine before surgery (instillation group), or instillation of saline solution (control group). Nebulization was performed using the Aeroneb Pro device.Measurement and Main ResultsPain scores, morphine consumption, and ambulation time were collected in the post-anesthesia care unit and at 4, 6, and 24 hours postoperatively. One hundred eighteen patients completed the study. Patients in the preoperative group reported lower pain Numeric Ranking Scale values compared with those in the control group (net difference 2 points; 95% confidence interval [CI], 0.3–3.1 at 4 hours, 1–3 at 6 hours, and 0.7–3 at 24 hours; p = .01) Patients in the preoperative group consumed significantly less morphine than did those in the control group (net difference 7 mg; 95% CI, 0.7–13; p = .02). More patients who received nebulization walked without assistance within 12 hours after awakening than did those in the instillation and control groups (net difference 15%; 95% CI, 6%–24%; p = .001).ConclusionsCold nebulization of ropivacaine before surgery reduced postoperative pain and morphine consumption and was associated with earlier walking without assistance.     

Placement of bupivacaine-soaked Spongostan in episiotomy bed is effective treatment modality for episiotomy-associated pain

Study ObjectiveTo investigate the efficacy of placing bupivacaine-soaked Spongostan (Ferrosan, Soeborg, Copenhagen, Denmark) in episiotomy beds for relief of postpartum pain.DesignRandomized, controlled study (Canadian Task Force classification I).SettingUniversity medical school.PatientsWomen with mediolateral episiotomy.InterventionsPatients were recruited and randomized into 2 groups by using a random number table. Group I (control group) received local lignocaine infiltration 1% up to 20 mL. For group II (Spongostan group), in addition to local lignocaine infiltration, bupivacaine-soaked Spongostan was placed in the episiotomy bed. All patients received routine postpartum perineal care in addition to the regular pain drugs (75 mg of diclofenac every 4 hours if needed). The primary outcome for the study was severity of pain, rated on a 10-cm visual analog scale from 0 to 10. Rating was recorded at 0, 1, 1.5, 2, 6, and 24 hours after delivery.Measurements and Main ResultsIn all, 48 women were randomized to group I (local lignocaine alone) and 51 women to group II (local lignocaine plus Spongostan). The Spongostan and control groups were similar with respect to maternal age, parity, gestational age, maternal weight, and neonatal birth weight (p >.05; CI for difference: –2.6/10, 0.1/0.3, 0.3/0.7, 6.9/1.7, and –7/1.9, respectively). Episiotomy length (both vaginal and perineal) and episiotomy depth were higher in Spongostan group than control group (p <.05; 95% CI: –0.9/0, –0.8/–0.1, and –0.6/0, respectively). However, episiotomy reconstruction time of both groups was similar (p >.05; CI: 1.7/6.2). The pain score of Spongostan group was lower than control group and it was statistically significant at all time intervals (0, 1, 1.5, 2, 6, and 24 hours) between the Spongostan and control groups (p <.05; CI: 0.6/1.9, 1.1/2.4, 1.0/2.5, 0.9/2.4, 0.3/1.9, and 0.5/1.8, respectively). Postpartum total analgesic requirement (mg/person) again was significantly lower in the Spongostan group than control group (p <.01; CI: 0.1/0.4).ConclusionPlacement of bupivacaine-soaked spongostan into the episiotomy bed resulted in decreased postpartum pain and drug requirement. It may be attributed to a higher drug concentration at episiotomy bed and prolonged drug effect.     

Analgesia for Office Hysteroscopy: A Systematic Review and Meta-analysis

ObjectiveTo identify the most effective analgesia for women undergoing office hysteroscopy.Data SourcesWe searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library from inception until August 2019 for studies that investigated the effect of different analgesics on pain control in office hysteroscopy.Methods of Study SelectionWe included randomized controlled trials that investigated the effect of analgesics on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting compared with the control group.Tabulation, Integration, and ResultsThe literature search returned 561 records. Twenty-two studies were selected for a systematic review, of which 16 were suitable for meta-analysis. There was a statistically significant reduction in pain during office hysteroscopy associated with preprocedural administration of nonsteroidal anti-inflammatory drugs (NSAIDs) (standardized mean difference [SMD] –0.72; 95% confidence interval [CI] –1.27 to –0.16), opioids (SMD –0.50; 95% CI –0.97 to –0.03), and antispasmodics (SMD –1.48; 95% CI –1.82 to –1.13), as well as with the use of transcutaneous electrical nerve stimulation (TENS) (SMD –0.99; 95% CI –1.67 to –0.31), compared with the control group. Moreover, similar reduction in pain was observed after office hysteroscopy: NSAIDs (SMD –0.55; 95% CI –0.97 to –0.13), opioids (SMD –0.73; 95% CI –1.07 to –0.39), antispasmodics (SMD –1.02; 95% CI –1.34 to –0.69), and TENS (SMD –0.54; 95% CI –0.95 to –0.12). Significantly reduced pain scores with oral NSAID administration during (SMD –0.87; 95% CI –1.59 to –0.15) and after (SMD –0.56; 95% CI –1.02 to –0.10) office hysteroscopy were seen in contrast to other routes. Significantly more adverse effects were reported with the use of opioids (p <.001) and antispasmodics (p <.001) when compared with the control group, in contrast to NSAIDs (p = .97) and TENS (p = .63).ConclusionWomen without contraindications should be advised to take oral NSAIDs before undergoing office hysteroscopy to reduce pain during and after the procedure. TENS should be considered as an alternative analgesic in women with contraindications to NSAIDs.     

A randomized double-blinded non-inferiority trial comparing fentanyl and midazolam with pethidine and diazepam for pain relief during oocyte retrieval

Research questionIs fentanyl and midazolam non-inferior to pethidine and diazepam in pain relief during oocyte retrieval under conscious sedation?DesignA randomized double-blinded non-inferiority trial of 170 infertile women undergoing oocyte retrieval under conscious sedation in an assisted reproduction centre. The women were randomized to receive intravenously either 0.1 mg fentanyl and 5 mg midazolam or 25 mg pethidine and 5 mg diazepam, plus paracervical block with 10 ml 1% lignocaine. The primary outcome was abdominal pain level during retrieval assessed by linear visual analogue scale from 0–10. Secondary outcomes included vaginal pain levels during and after retrieval and postoperative abdominal pain levels and side-effects, satisfaction level, clinical pregnancy and ongoing pregnancy rates. A pre-defined non-inferiority margin of 1 for the difference in pain levels between two groups was set.ResultsVaginal and abdominal pain levels during retrieval were significantly lower in the fentanyl and midazolam group compared with the pethidine and diazepam group (per-protocol analysis, vaginal pain: 1.6 versus 4.3; mean difference: –2.7, 95% CI –3.7, –1.8; P < 0.001; abdominal pain: 2.9 versus 5.2; mean difference: –2.3, 95% CI –3.3 to –1.3; P < 0.001 for non-inferiority). No differences were observed in these pain levels after retrieval. Most women experienced no postoperative side-effects. The fentanyl and midazolam group had better sedation level, satisfaction level on pain relief and satisfaction on the overall retrieval procedure than the pethidine and diazepam group. No significant differences were found in clinical pregnancy and ongoing pregnancy rates between the two groups.ConclusionThe fentanyl and midazolam group had significantly lower vaginal and abdominal pain levels during oocyte retrieval than the pethidine and diazepam group.     

A Systematic Review of the Effect of Type,Pressure, and Temperature of the Distension Medium on Pain During Office Hysteroscopy

ObjectiveTo identify the optimal distension medium type, pressure, and temperature to minimize pain during office hysteroscopy.Data SourcesMEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to January 29, 2020.Methods of Study SelectionWe included randomized controlled trials in which women undergoing office hysteroscopy were randomized to either a distension medium type, pressure, or temperature against a suitable control, where pain was an outcome. Data regarding feasibility, visualization, complications, and satisfaction were also collected.Tabulation, Integration, and ResultsThe literature search returned 847 studies, of which 18 were included for systematic review and 17 for meta-analysis. There was no significant difference in intraprocedural pain when comparing the use of normal saline against carbon dioxide (standardized mean difference [SMD], –0.12; 95% confidence interval [CI], –0.36 to 0.13). Subgroup analysis of high-quality studies revealed a statistically significant reduction in postprocedural pain with normal saline (SMD, –0.65; 95% CI, –1.14 to –0.16). Side effects were less frequent (Peto odds ratio, 0.29; 95% CI, 0.20–0.40) and patient satisfaction was higher (SMD, 1.39; 95% CI, 0.51–2.28) with normal saline compared with carbon dioxide. Pressures of ≤40 mm Hg reduced intraprocedural pain (SMD, –0.67; 95% CI, –1.09 to –0.26) at the expense of a higher proportion of unsatisfactory views (81%–89% at ≤40 mm Hg vs 95%–99% at ≥50 mm Hg). Postprocedural pain was reduced with lower filling pressures. Warming saline did not reduce intraprocedural pain (SMD, 0.59; 95% CI, –0.14 to 1.33).ConclusionNormal saline, instilled at the lowest pressure to acquire a satisfactory view, should be used for uterine distension during office hysteroscopy to minimize pain.     

Perioperative Complications of Laparoscopic versus Open Surgery for Pelvic Inflammatory Disease

Study ObjectiveTo compare complications in patients undergoing laparoscopic vs open surgery for acute pelvic inflammatory disease (PID).DesignWe performed a retrospective cohort study of patients who underwent surgery for PID, using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2015. Propensity score matching was used to balance baseline characteristics and compare complications in patients who underwent laparoscopic vs open surgery.SettingSurgical management of acute PID.PatientsPatients with a preoperative diagnosis of PID were identified using International Classification of Diseases, Ninth Revision, codes. We excluded patients with chronic PID, gynecologic malignancy, and those for whom the surgical route was unknown.InterventionsSurgery for acute PID.Measurements and Main ResultsThe study included 367 patients. The mean age was 43.0 ± 11.1 years, body mass index was 30.9 ± 11.2 kg/m², and American Society of Anesthesiology class was 2 (interquartile range 2–3). Preoperative signs of sepsis were noted in 33.8% of the patients, and septic shock was present in 1.4%. Hysterectomy was performed in 67.6%, oophorectomy in 12.0%, and salpingectomy in 4.6%. Complications were experienced by 114 patients (31.1%), 11 (3.0%) of which were potentially life-threatening. Multivariate logistic regression identified the following to be independently associated with complications: laparoscopy (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI], 0.3–0.8; p <.01), operative time (aOR 1.01; 95% CI, 1.00–1.01; p <.01), appendectomy (aOR 2.36; 95% CI, 1.0–5.4; p = .04), elevated international normalized ratio (aOR 2.30; 95% CI, 1.3–4.2; p <.01), and low hematocrit level (aOR 2.53; 95% CI, 1.4–4.5; p <.01). Propensity scores were calculated and used to generate a matched cohort of patients who underwent laparoscopic vs open surgery; the groups were similar, with p <.05 for all covariates. After balancing confounding variables, a laparoscopic approach to surgery remained significantly associated with a lower risk of complications (coefficient –0.07; 95% CI, –0.11 to –0.02; p = .008).ConclusionLaparoscopy was associated with lower complication rates than open surgery in this well-matched cohort of patients who underwent surgery for acute PID.     

A Triple-Blind Randomized Trial of Preemptive Use of Gabapentin Before Laparoscopic Hysterectomy for Benign Gynaecologic Conditions

ObjectiveThis study sought to examine the efficacy of preemptive use of gabapentin in laparoscopic hysterectomy for benign gynaecologic conditions.MethodsIn a triple-blind trial, the study investigators randomly assigned women undergoing laparoscopic hysterectomy to receive 600 mg gabapentin (n = 43) or placebo (n = 45) orally 1 hour before the procedure. Patient-controlled opioid analgesia was provided postoperatively. The primary outcome of the trial was cumulative opioid consumption in the first postoperative 24 hours. The study also assessed pain at rest and on movement, the presence of side effects, and patient satisfaction at 2, 8, and 24 hours after surgery.ResultsBetween March 10, 2016 and May 1, 2018, 215 women were assessed for eligibility, 110 were randomized, and 88 completed the study. Enrolment was started after trial registration. The investigators found no difference in 24-hour cumulative morphine equivalent opioid consumption between the gabapentin group (26.9 ± 14.7 mg) and the placebo group (27.1 ± 15.1 mg). This provided a mean difference of 0.2 mg (95% CI ?6.1 to 6.5, P = 0.943). Pain scores at 2, 8, and 24 hours were also not found to differ between groups. Gabapentin was associated with increased dizziness, but it significantly reduced the use of antiemetic at any time in the first 24 postoperative hours. Patient satisfaction in the two groups was good and not found to differ.ConclusionPreemptive administration of gabapentin before laparoscopic hysterectomy does not decrease postoperative pain scores and narcotic consumption.     

Outpatient Hysterectomy versus Inpatient Hysterectomy: A Systematic Review and Meta-analysis

ObjectiveThe aim was to investigate whether outpatient hysterectomy (OH) has benefits when compared with inpatient hysterectomy (IH) regarding postoperative complications, readmissions, operative outcomes, cost, and patient quality of life.Data SourcesA systematic search for studies comparing OH with IH was conducted through PubMed, SAGE, and Scopus from January 2010 to March 2020, without limitations regarding language and study design.Methods of Study SelectionStudies reporting on the differences between same-day discharge and overnight stay after hysterectomy were included. The study outcomes were overall complication rate, type of complication, readmission after discharge, surgery duration, estimated blood loss, payer savings, hospital savings, and health-related quality of life (HrQoL). Median and range are used to describe non-normal data, while mean ± SD and confidence interval are used to descibe data with normal distribution. A meta-analysis with sensitivity analysis and subgroup analyses was performed.Tabulation, Integration, and ResultsEight studies published between 2011 and 2019 with 104,466 patients who underwent hysterectomy were included in this systematic review and meta-analysis. All included studies except 1 were found to have a high risk of bias. OH in comparison with IH had a lower overall complication rate (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.60–0.82) and lower rates of wound infection (OR 0.60; 95% CI, 0.43–0.84), urinary tract infection (OR 0.64; 95% CI, 0.52–0.78), need for transfusion (OR 0.36; 95% CI, 0.22–0.59), sepsis (OR 0.33; 95% CI, 0.17–0.64), uncontrolled pain (OR 0.79; 95% CI, 0.66–0.95), and bleeding requiring medical attention (OR 0.82; 95% CI, 0.73–0.94). In addition, patients who underwent OH had a lower readmission rate (OR 0.81; 95% CI, 0.75–0.87), surgery duration (standardized mean difference –0.35; 95% CI, –0.61 to –0.08), and estimated blood loss (standardized mean difference –0.63; 95% CI, –0.93 to –0.33) than those who underwent IH. A qualitative analysis found that OH had a poorer patient HrQoL and a lower cost for the hospital as well as the payer.ConclusionOHs present fewer complications and have a lower readmission rate and estimated blood loss as well as a shorter surgery duration than IHs. OHs also have a cost benefit in comparison with IHs. But patients seem to have a worse HrQoL in the first postoperative week after OH. The high risk of bias of the included studies indicates that well-designed clinical trials and standardization of surgical complication reporting are essential to better address this issue.     

Comparison of laparoscopy and laparotomy for endometrial cancer

ObjectiveTo compare the safety and efficacy of laparoscopy and laparotomy on clinical outcomes among patients with endometrial cancer.MethodsEligible randomized controlled trials (RCTs) conducted between 1966 and June 2010 were analyzed by meta-analysis.ResultsEight RCTs were included, with 3599 patients in total. No significant difference was observed between laparoscopy and laparotomy in overall (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.50–1.82; P = 0.892), disease-free (OR, 0.96; 95% CI, 0.50–1.82; P = 0.892), or cancer-related (OR, 0.90; 95% CI, 0.27–3.08; P = 0.871) survival. More intraoperative complications (OR, 1.33; 95% CI, 1.03–1.73; P = 0.030), fewer postoperative complications (OR, 0.59; 95% CI, 0.46–0.75; P < 0.001), longer operative time (standardized mean difference [SMD], 0.80; 95% CI, 0.46–1.15; P < 0.001), lower blood loss (SMD, –2.29; 95% CI, –3.67 to ? 0.91; P = 0.001), and shorter hospital stay (SMD, –2.60; 95% CI, –3.47 to ? 1.72; P < 0.001) were associated with laparoscopy. There was no significant difference between the groups in pelvic (SMD, 0.22; 95% CI, –0.03 to 0.48; P = 0.086) or para-aortic (SMD, 0.54; 95% CI, –0.04 to 1.11; P = 0.067) lymph node yield.ConclusionLaparoscopy has short-term advantages and seemingly equivalent long-term outcomes and, in experienced hands, might be a feasible alternative to laparotomy for endometrial cancer.     

Bladder Backfilling versus Standard Catheter Removal for Trial of Void after Outpatient Laparoscopic Gynecologic Surgery: A Systematic Review and Meta-Analysis

ObjectiveTo compare the rate of postoperative urinary retention and time to discharge between bladder backfilling and standard catheter removal for trial of void (TOV) after outpatient laparoscopic gynecologic surgery. Our secondary objectives were to compare the time to void, postoperative complications, and patient satisfaction.Data SourcesWe searched the PubMed, Ovid MEDLINE, Embase, Cochrane Library databases, and relevant reference lists of eligible articles up to March of 2021.Methods of Study SelectionThis review included randomized controlled trials (RCTs) of TOV after outpatient laparoscopic gynecologic surgery. Odds ratios (ORs) with 95% confidence interval (CI) and weighted mean differences (WMDs) were reported. The quality of the studies was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. Data were analyzed with Review Manager 5.4 software (RevMan 5.4.1; Cochrane Collaboration, London, United Kingdom).Tabulation, Integration, and ResultsFive RCTs (N = 488) were included. The bladder backfilling group had a significantly shorter time to void than the standard TOV group (WMD, –25.19 minutes; 95% CI, ?44.60 to ?5.77; p = .01). Successful TOV was not significantly different between the 2 (OR, 0.92; 95% CI, 0.51 to –1.65; p = .77), without significant heterogeneity (I² = 24%). There was also no significant difference in the time to discharge between the 2 TOV techniques (WMD, –25.19 minutes; 95% CI, ?44.60 to ?5.77; p = .01). There was no significant difference in complication rates or patient satisfaction between the 2 groups.ConclusionThe bladder backfilling technique of TOV after outpatient laparoscopic gynecologic surgery may reduce the time to first spontaneous void without affecting patient satisfaction or postoperative complications, but it does not significantly affect the time to discharge or urinary retention.     

The long-term costs and effects of tubal flushing with oil-based versus water-based contrast during hysterosalpingography

Research questionWhat are the long-term costs and effects of oil- versus water-based contrast in infertile women undergoing hysterosalpingography (HSG)?DesignThis economic evaluation of a long-term follow-up of a multicentre randomized controlled trial involved 1119 infertile women randomized to HSG with oil- (n = 557) or water-based contrast (n = 562) in the Netherlands.ResultsIn the oil-based contrast group, 39.8% of women needed no other treatment, 34.6% underwent intrauterine insemination (IUI) and 25.6% had IVF/intracytoplasmic sperm injection (ICSI) in the 5 years following HSG. In the water-based contrast group, 35.0% of women had no other treatment, 34.2% had IUI and 30.8% had IVF/ICSI in the 5 years following HSG (P = 0.113). After 5 years of follow-up, HSG using oil-based contrast resulted in equivalent costs (mean cost difference –€144; 95% confidence interval [CI] –€579 to +€290; P = 0.515) for a 5% increase in the cumulative ongoing pregnancy rate compared with HSG using water-based contrast (80% compared with 75%, Relative Risk (RR) 1.07; 95% CI 1.00–1.14). Similarly, HSG with oil-based contrast resulted in equivalent costs (mean cost difference –€50; 95% CI –€576 to +€475; P = 0.850) for a 7.5% increase in the cumulative live birth rate compared with HSG with water-based contrast (74.8% compared with 67.3%, RR 1.11; 95% CI 1.03–1.20), making it the dominant strategy. Scenario analyses suggest that the oil-based contrast medium is the dominant strategy up to a price difference of €300.ConclusionOver a 5-year follow-up, HSG with an oil-based contrast was associated with a 5% increase in ongoing pregnancy rate, a 7.5% increase in live birth rate and similar costs to HSG with water-based contrast.     

Maternal-Newborn Health System Changes and Outcomes in Ontario,Canada, During Wave 1 of the COVID-19 Pandemic—A Retrospective Study

ObjectiveTo determine the population-level impact of COVID-19 pandemic–related obstetric practice changes on maternal and newborn outcomes.MethodsSegmented regression analysis examined changes that occurred 240 weeks pre-pandemic through the first 32 weeks of the pandemic using data from Ontario’s Better Outcomes Registry & Network. Outcomes included birth location, length of stay, labour analgesia, mode of delivery, preterm birth, and stillbirth. Immediate and gradual effects were modelled with terms representing changes in intercepts and slopes, corresponding to the start of the pandemic.ResultsThere were 799 893 eligible pregnant individuals included in the analysis; 705 767 delivered in the pre-pandemic period and 94 126 during the pandemic wave 1 period. Significant immediate decreases were observed for hospital births (relative risk [RR] 0.99; 95% CI 0.98–0.99), length of stay (median change –3.29 h; 95% CI –3.81 to –2.77), use of nitrous oxide (RR 0.11; 95% CI 0.09–0.13) and general anesthesia (RR 0.69; 95% CI 0.58– 0.81), and trial of labour after cesarean (RR 0.89; 95% CI 0.83–0.96). Conversely, there were significant immediate increases in home births (RR 1.35; 95% CI 1.21–1.51), and use of epidural (RR 1.02; 95% CI 1.01–1.04) and regional anesthesia (RR 1.01; 95% CI 1.01–1.02). There were no significant immediate changes for any other outcomes, including preterm birth (RR 0.99; 95% CI 0.93–1.05) and stillbirth (RR 1.11; 95% CI 0.87–1.42).ConclusionProvincial health system changes implemented at the start of the pandemic resulted in immediate clinical practice changes but not insignificant increases in adverse outcomes.     

Excision versus Ablation for Management of Minimal to Mild Endometriosis: A Systematic Review and Meta-analysis

ObjectiveThe aim of this systematic review and meta-analysis was to perform an updated analysis of the literature in regard to the surgical management of minimal to mild endometriosis. This study evaluated women of reproductive age with superficial endometriosis to determine if the results of surgical excision compared with those of ablation in improved pain scores postoperatively.Data SourcesThe following databases were searched from inception to May 2020 for relevant studies: Cochrane Central Register of Controlled Trials, PubMed (MEDLINE), Ovid (MEDLINE), Scopus, and Web of Science.Methods of Study SelectionFrom our literature search, a total of 2633 articles were identified and screened. Ultimately, 4 randomized controlled trials were selected and included in our systematic review. The combined total number of subjects was 346 from these 4 studies, with sample sizes ranging from 24 to 170 participants. Data from 3 of the included studies were able to be compared and analyzed for a meta-analysis. The primary outcome was reduction in the visual analog scale (VAS) score for endometriosis-associated pain (dysmenorrhea, dyschezia, and dyspareunia), with follow-up time ranging from 6 to 60 months postoperatively.Tabulation, Integration, and ResultsData extracted from each study included the mean reduction in the VAS score from baseline. A random-effects model was used owing to significant heterogeneity across the studies. Statistical analyses were performed using Review Manager 5.3 software (Cochrane Collaboration, London, United Kingdom). The meta-analyses showed no significant differences between the excision and ablation groups in the mean reduction in VAS scores from baseline to 12 months postoperatively for dysmenorrhea (mean difference [MD] –0.03; 95% confidence interval [CI], –1.27 to 1.22; p = .97), dyschezia (MD 0.46; 95% CI, –1.09 to 2.02; p = .56), and dyspareunia (MD 0.10; 95% CI, –2.36 to 2.56; p = .94). In addition, there were no significant differences between the excision and ablation groups in mean VAS scores at the 12-month follow-up and beyond for dysmenorrhea (MD –0.11; 95% CI, –2.14 to 1.93; p = .92), dyschezia (MD 0.01; 95% CI, –0.70 to 0.72; p = .99), and dyspareunia (MD 0.34; 95% CI, –1.61 to 2.30; p = .73).ConclusionOn the basis of the data from our systematic review and pooled meta-analysis, no significant difference between laparoscopic excision and ablation was noted in regard to improving pain from minimal to mild endometriosis. However, to make definitive conclusions on this topic, larger randomized controlled trials are needed with longer follow-up.