STUDY OBJECTIVE:To assess the efficacy of the addition of a hysteroscopic fundal block on patient's perception of intra-operative pain during NovaSure endometrial ablation in an ambulatory setting. DESIGN:Single centre, randomized, double-blind, placebo-controlled trial with a parallel design and a 1:1 treatment allocation ratio. SETTING:Canadian gynecologic ambulatory-care clinic. PARTICIPANTS:A total of 100 premenopausal female patients with abnormal uterine bleeding undergoing an ambulatory NovaSure endometrial ablation. INTERVENTION:Hysteroscopic fundal injections with 10 mL 1% lidocaine (treatment group) or hysteroscopic fundal injections with normal saline (placebo group). RESULTS:There was no difference in Numeric Rating Scale (NRS) for pain scores at 30 seconds, 60 seconds, and 1-hour postprocedure in the placebo and fundal block groups (p = .08; p = .28; p = .09). Secondary subgroup analysis revealed significantly higher NRS scores in those with a self-reported history of dysmenorrhea (NRS score >5) who received placebo compared to the lidocaine fundal block at 30 and 60 seconds (p = .02; p = .03). The procedure was found to be acceptable to the majority of participants and 95.6% would recommend the procedure to someone else with no difference between groups. There was no difference in use of intraoperative analgesics and sedatives, postoperative pain, or adverse events between the groups. CONCLUSION:When using parenteral conscious sedation and a paracervical block, the addition of a hysteroscopic fundal block during ambulatory NovaSure endometrial ablation does not improve NRS pain scores. Select patients, including those with dysmenorrhea, may benefit from the addition of a hysteroscopic fundal block.

Study Objective To determine whether the introduction of a physician remuneration incentive within certain Canadian provinces resulted in increased practice of laparoscopic hysterectomy over time. Design Retrospective population-based study with interrupted time series analysis of federal health administrative data from the Canadian Institute for Health Information Setting Hospitals in all the provinces of Canada, excluding territories Patients or Participants 81,507 patients aged ≥18 years undergoing hysterectomy for benign gynecologic indication in Canada from 2006/07 to 2016/17 Interventions Hysterectomy Measurements and Main Results Reviewof physician remuneration fee schedules for each province in Canada identified three provinces where a physician incentive (additional 25-50% remuneration) was introduced: British Columbia (BC) (2013), Saskatchewan (SK) (2012), and Prince Edward Island (PEI) (2011). During the 10-year period, the rates of laparoscopic hysterectomy increased rapidly in BC (6.0%-54.7%), SK (13.5%-66.7%), and PEI (<1.0%-36.9%) (p<0.05 for all trends). In SK (n=7,857 hysterectomies), there was a significant additional increase in the rate of laparoscopic hysterectomy from 40.6% to 49.4% in the quarter following the incentive (p<0.0001). In BC (n=16,332), there was no significant additional increase in the rate of laparoscopic surgeries after the introduction of a financial incentive. Though PEI appeared to demonstrate an increase in the rate of laparoscopic hysterectomy following the incentive, ITS analyses were not performed due to the small sample size (n=2,583). Conclusion The introduction of physician remuneration incentive appears to be associated with an increase in practice of laparoscopic hysterectomy in some provinces but not others. While physician incentive may help encourage minimally invasive surgical practice, the effects are likely modified by other important factors, such as operating room resources and training opportunities. To determine whether the introduction of a physician remuneration incentive within certain Canadian provinces resulted in increased practice of laparoscopic hysterectomy over time. Retrospective population-based study with interrupted time series analysis of federal health administrative data from the Canadian Institute for Health Information Hospitals in all the provinces of Canada, excluding territories 81,507 patients aged ≥18 years undergoing hysterectomy for benign gynecologic indication in Canada from 2006/07 to 2016/17 Hysterectomy Reviewof physician remuneration fee schedules for each province in Canada identified three provinces where a physician incentive (additional 25-50% remuneration) was introduced: British Columbia (BC) (2013), Saskatchewan (SK) (2012), and Prince Edward Island (PEI) (2011). During the 10-year period, the rates of laparoscopic hysterectomy increased rapidly in BC (6.0%-54.7%), SK (13.5%-66.7%), and PEI (<1.0%-36.9%) (p<0.05 for all trends). In SK (n=7,857 hysterectomies), there was a significant additional increase in the rate of laparoscopic hysterectomy from 40.6% to 49.4% in the quarter following the incentive (p<0.0001). In BC (n=16,332), there was no significant additional increase in the rate of laparoscopic surgeries after the introduction of a financial incentive. Though PEI appeared to demonstrate an increase in the rate of laparoscopic hysterectomy following the incentive, ITS analyses were not performed due to the small sample size (n=2,583). The introduction of physician remuneration incentive appears to be associated with an increase in practice of laparoscopic hysterectomy in some provinces but not others. While physician incentive may help encourage minimally invasive surgical practice, the effects are likely modified by other important factors, such as operating room resources and training opportunities.

Study Objective: The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. Design: A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. Setting: Canada. Patients: All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. Interventions: Hysterectomy. Measurements and Main Results: A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p<.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p<.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different. Conclusion: The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study. (C) 2021 AAGL. All rights reserved.

A healthy, 27-year-old woman with a history of 4 previous cesarean sections (CS) was referred for evaluation of pelvic pain accompanied by intermenstrual and postcoital bleeding. Initial transvaginal ultrasound suggested the presence of a uterine polyp. This was further investigated by a saline-infused sonogram, which demonstrated a retroflexed uterus and 2 discrete fluid-filled cesarean scar defects (CSDs) (Fig. 1). The first CSD was noted in the lower uterine segment measuring 8 mm in length and 6 mm in height, with an overlying myometrial thickness of 4 mm. The second CSD was 12 mm distal and located in the upper cervix. It measured 6 mm in length and 5 mm in height with an overlying myometrial thickness of 5 mm. She was counseled on options and declined medical management as she had completed her family and wished for definitive therapy. She ultimately underwent total laparoscopic hysterectomy and bilateral salpingectomy. Both CSDs were appreciated on the gross specimen (Fig. 2). The pathologic examination was consistent; the first defect was lined with benign endometrium, along with scar tissue and old suture material. The second defect was lined with endocervical cells, consistent with preoperative imaging. Although the CS scar is commonly present and visualized on ultrasound, a CSD is a discrete, triangular or wedge-shaped myometrial defect [1Bij de Vaate AJ van der Voet LF Naji O et al.Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review.Ultrasound Obstet Gynecol. 2014; 43: 372-382Crossref PubMed Scopus (166) Google Scholar,2Tulandi T Cohen A Emerging manifestations of Cesarean scar defect in reproductive-aged women.J Minim Invasive Gynecol. 2016; 23: 893-902Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar]. Transvaginal ultrasound is commonly used for diagnosis, but a saline- or gel-infused sonogram and magnetic resonance imaging can provide additional information [3Mashiach R Burke YZ Optimal isthmocele management: hysteroscopic, laparoscopic, or combination.J Minim Invasive Gynecol. 2021; 28: 565-574Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. Although the true prevalence of CSDs is unknown, current evidence suggests that 25% to 70% of women with a history of one or more CS may have a defect on imaging [1Bij de Vaate AJ van der Voet LF Naji O et al.Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review.Ultrasound Obstet Gynecol. 2014; 43: 372-382Crossref PubMed Scopus (166) Google Scholar,2Tulandi T Cohen A Emerging manifestations of Cesarean scar defect in reproductive-aged women.J Minim Invasive Gynecol. 2016; 23: 893-902Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar]. A retroflexed uterus further increases this risk [1Bij de Vaate AJ van der Voet LF Naji O et al.Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review.Ultrasound Obstet Gynecol. 2014; 43: 372-382Crossref PubMed Scopus (166) Google Scholar,2Tulandi T Cohen A Emerging manifestations of Cesarean scar defect in reproductive-aged women.J Minim Invasive Gynecol. 2016; 23: 893-902Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar]. Based on the current literature, it is difficult to ascertain how many patients are living with multiple defects. Wang et al [4Wang CB Chiu WW Lee CY Sun YL Lin YH Tseng CJ Cesarean scar defect: correlation between Cesarean section number, defect size, clinical symptoms and uterine position.Ultrasound Obstet Gynecol. 2009; 34: 85-89Crossref PubMed Scopus (166) Google Scholar] published a series of 300 patients with CSDs, but specifically only commented on the largest defect if more than one was visible. Management should be guided by the patient's symptoms and desire for future fertility [2Tulandi T Cohen A Emerging manifestations of Cesarean scar defect in reproductive-aged women.J Minim Invasive Gynecol. 2016; 23: 893-902Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar,3Mashiach R Burke YZ Optimal isthmocele management: hysteroscopic, laparoscopic, or combination.J Minim Invasive Gynecol. 2021; 28: 565-574Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar].

Objective To characterize fellowship training experiences in the 11 Canadian minimally invasive gynaecologic surgery (MIGS) programs and compare the surgical exposure of fellows in these programs to that of the American Association of Gynecologic Laparoscopists (AAGL) accredited fellowship in MIGS (FMIGS). Methods In this cross-sectional study, 2017 and 2018 MIGS fellowship graduates across Canada were given a web-based survey via SurveyMonkey software to evaluate 5 key components of postgraduate fellowship curricula: 1) surgical exposure; 2) teaching and evaluation methods; 3) research experience; 4) clinical responsibilities; and 5) pursuit of other academic endeavours. Interest in creating a national standardized curriculum and seeking accreditation for MIGS fellowships were also examined. Results The survey attained a 91% (20/22) response rate of the target population. All Canadian MIGS programs met the minimum standards for at least 62% (8/13) of the surgical competencies listed by the AAGL, with office hysteroscopy being the procedure with the largest discordance. Half of respondents (10/20) attended a program with an established curriculum, and 75% (15/20) believed there would be a benefit to standardizing training nationwide. Seventy percent (14/20) had published at least one manuscript during their fellowship and 60% (12/20) pursued postgraduate degrees. The majority (55%; 11/20) felt certain that MIGS should become a credentialed fellowship in Canada. Conclusion Canada has made meaningful progress in MIGS training over the past decade with 11 well-established fellowship programs. Although this survey identifies a general interest in standardized training and accreditation for Canadian MIGS programs, more research is needed on how best to accomplish this.

Study Objective: To analyze pregnancy delivery and safety outcomes after patient receipt of percutaneous, laparoscopic intra-abdominal ultrasound-guided radiofrequency ablation (Lap-RFA) for symptomatic uterine myomas. Design: Case series (2010- 2017); evidence was obtained from 2 randomized, controlled trials (level I), 6 cohort studies (level II-2), and in commercial settings (level II-3). Setting: Multiple sites in the United States, Canada, Europe, and Latin America (university hospitals, community hospitals, and stand-alone surgery centers). Commercial cases were United States based and followed US Food and Drug Administration clearance of Lap-RFA. Patients: Premenopausal adult women with symptomatic uterine myoma types 1 through 6. Interventions: The Lap-RFA procedure was conducted under general anesthesia with laparoscopic and intra-abdominal ultrasound guidance. Measurements and Main Results: Safety unknowns included the safety of a full-term pregnancy for mother and baby, rates of spontaneous abortion, preterm delivery, postpartum hemorrhage, placental abnormalities, intrauterine growth restriction, and vaginal versus cesarean delivery. A total of 28 women (mean age = 35.0 +/- 3.4 years) conceived a total of 30 times after Lap-RFA, either as part of a clinical study or in commercial settings. The number of myomas treated per patient ranged from 1 to 7. The diameter of treated myomas ranged from 0.9 to 11.0 cm. Most patients had 1 or 2 myomas, and most myomas were <= 5.5 cm in maximal diameter. The 30 pregnancies resulted in 26 full-term live births (86.7%), all healthy infants, with an equal distribution of vaginal and cesarean deliveries. Four (13.3%) spontaneous abortions occurred. No cases of preterm delivery, uterine rupture, placental abruption, placenta accreta, or intrauterine growth restriction were reported. One event each of placenta previa and postpartum hemorrhage were reported. Conclusion: Conception and safe, full-term pregnancy are achievable after Lap-RFA of symptomatic myomas. Additional large, rigorous, multivariate prospective studies that adjust for confounders and report pregnancy outcomes after symptomatic myoma treatment are needed. (C) 2019 AAGL. All rights reserved.

BACKGROUND:Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first-line therapy, although patient adoption remains low. Home-based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low-resource settings, remains unknown. METHODS:Smart Step is a pilot randomized trial of smartphone-enabled HBET vs walking advice in patients with symptomatic PAD in an inner-city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone-based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6-minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year. RESULTS:A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants. CONCLUSIONS:The potential significance of this trial will be to provide preliminary evidence of a home-based, "mobile-first" approach for delivering a structured exercise rehabilitation program. Smartphone-enabled HBET can be potentially more accessible than center-based programs, and if proven effective, may have a potential widespread public health benefit.

Objectives To describe treatment choices made at the time of enrollment in CAPTURE, a Canadian patient registry for women with symptomatic uterine fibroids (UFs), and to define demographic and clinical characteristics that independently predict these choices. Methods Women arranging appointments for UF care were eligible to enrol. At the time of the enrollment visit, women's self-reported treatment histories were noted, along with their clinical characteristics. Tretment options were discussed and chosen during that visit. Patients could choose medical and/or surgical treatment, or they could opt for no active treatment (i.e., “watchful waiting”); treatment decisions were not binding. Results The most common medication proposed and chosen was ulipristal acetate (UPA), and the most common procedure was myomectomy. These treatments were also the most commonly identified in patients’ histories. Medication alone and medication in combination with surgery were the most common treatment approaches chosen (46% and 26%, respectively). Surgery alone and watchful waiting were chosen by 14% and 13% of patients, respectively. Significant predictors of active treatment included patient pregnancy plans, overall symptom severity, and prior treatment history (medical and surgical). Other parameters, including patient age and history of specific UF symptoms, appear to influence the choice of medical therapies (UPA, gonadotropin-releasing hormone agonists, or other options) and procedures (myomectomy or hysterectomy). Conclusions This real-world study documents the patient factors associated with the treatment decisions of women seeking care for symptomatic UFs in contemporary Canadian gynaecology practice. Subsequent analyses will follow the outcomes of these treatments over two years in this population.

Objectives Hysterectomies are the most commonly performed gynecologic procedure and are associated with faster recovery and decreased complications when performed minimally invasively compared with abdominally. The objectives were to characterize temporal trends and variation in minimally invasive hysterectomy for Canada and each province/territory. Methods We conducted a national population-based retrospective study of all hysterectomies for benign indications in Canada FY2006/7–2016/17 using Canadian Institute for Health Information data. Cochrane-Armitage test was applied for temporal trends and p-values<0.05 were significant. Relative risk for abdominal hysterectomy and 95% confidence intervals were calculated for FY2016/17. Results 369,740 hysterectomies were included (48.4% abdominal; 28.3% laparoscopic; 23.3% vaginal). Mean age was 48.5±11.2 years, and indications for surgery were menstrual bleeding disorders (29.7%), fibroids (23.7%), pelvic organ prolapse (19.8%), other (17.4%), endometriosis (5.8%) and pelvic pain (3.6%). National technicity index (proportion of vaginal and laparoscopic hysterectomies) increased (40.5%⟶63.2%). Abdominal hysterectomy decreased (59.5%⟶36.8%); laparoscopic increased (10.8%⟶38.6%); while, vaginal decreased (29.7%⟶24.5%). (p<0.05, all trends). Increasing technicity index was observed in all provinces, though with variable increase over time. (p<0.05, all trends), and variation was seen in relative risk (RR) of abdominal hysterectomy for FY2016/17. Manitoba (36.9%⟶44.4%; RR 1.50, 95% CI [1.43–1.58]*), Nova Scotia (46.4%⟶48.5%; RR 1.39 [1.31–1.48]*), New Brunswick (43.7%⟶50.3%; RR 1.34 [1.26–1.44]*), Newfoundland (35.3%⟶55.2%; RR 1.21 [1.10–1.33]*), Ontario (39.4%⟶63.0%, RR 1.00 [reference]) Quebec (42.0%⟶61.8%; RR1.03[0.99–1.07]), Prince Edward Island (54.9%⟶64.3%; RR0.96 [0.81–1.15]), Alberta (34.0%⟶64.3%; RR 0.96 [0.92–1.01]), British Columbia (43.4%⟶72.1%; RR 0.75 [0.71–0.79]*), Saskatchewan (47.7%⟶83.9%; RR 0.44 [0.39–0.49]*). Conclusions Minimally invasive hysterectomy for benign indication has increased significantly in Canada over the past decade. However, the increase reflects increasing use of laparoscopic hysterectomy with a declining use of vaginal hysterectomy. The variation between provinces represents a technicity gap that warrants further study and intervention. Hysterectomies are the most commonly performed gynecologic procedure and are associated with faster recovery and decreased complications when performed minimally invasively compared with abdominally. The objectives were to characterize temporal trends and variation in minimally invasive hysterectomy for Canada and each province/territory. We conducted a national population-based retrospective study of all hysterectomies for benign indications in Canada FY2006/7–2016/17 using Canadian Institute for Health Information data. Cochrane-Armitage test was applied for temporal trends and p-values<0.05 were significant. Relative risk for abdominal hysterectomy and 95% confidence intervals were calculated for FY2016/17. 369,740 hysterectomies were included (48.4% abdominal; 28.3% laparoscopic; 23.3% vaginal). Mean age was 48.5±11.2 years, and indications for surgery were menstrual bleeding disorders (29.7%), fibroids (23.7%), pelvic organ prolapse (19.8%), other (17.4%), endometriosis (5.8%) and pelvic pain (3.6%). National technicity index (proportion of vaginal and laparoscopic hysterectomies) increased (40.5%⟶63.2%). Abdominal hysterectomy decreased (59.5%⟶36.8%); laparoscopic increased (10.8%⟶38.6%); while, vaginal decreased (29.7%⟶24.5%). (p<0.05, all trends). Increasing technicity index was observed in all provinces, though with variable increase over time. (p<0.05, all trends), and variation was seen in relative risk (RR) of abdominal hysterectomy for FY2016/17. Manitoba (36.9%⟶44.4%; RR 1.50, 95% CI [1.43–1.58]*), Nova Scotia (46.4%⟶48.5%; RR 1.39 [1.31–1.48]*), New Brunswick (43.7%⟶50.3%; RR 1.34 [1.26–1.44]*), Newfoundland (35.3%⟶55.2%; RR 1.21 [1.10–1.33]*), Ontario (39.4%⟶63.0%, RR 1.00 [reference]) Quebec (42.0%⟶61.8%; RR1.03[0.99–1.07]), Prince Edward Island (54.9%⟶64.3%; RR0.96 [0.81–1.15]), Alberta (34.0%⟶64.3%; RR 0.96 [0.92–1.01]), British Columbia (43.4%⟶72.1%; RR 0.75 [0.71–0.79]*), Saskatchewan (47.7%⟶83.9%; RR 0.44 [0.39–0.49]*). Minimally invasive hysterectomy for benign indication has increased significantly in Canada over the past decade. However, the increase reflects increasing use of laparoscopic hysterectomy with a declining use of vaginal hysterectomy. The variation between provinces represents a technicity gap that warrants further study and intervention.

Uterine leiomyomas (myomas, fibroids) are very common in premenopausal women and frequently are associated with abnormal uterine bleeding, bulk effects, and reproductive issues. In women who wish to retain their uterus and/or to enhance or retain fertility, interventional therapies have been introduced, including radiofrequency, laser (chromo), cryotherapy, and magnetic resonance (MR)-guided high-intensity focused ultrasound (MRgHIFU) myolysis. In formulating this commentary, all modalities of myolysis from systematic reviews, randomized controlled clinical trials, and observational studies through December 2018 were reviewed. There are only two treatment modalities available in Canada: the laparoscopic radiofrequency volumetric thermal ablation of fibroids (RFVTA) and MRgHIFU systems. In women who wish to enhance or retain their fertility, the safety and efficacy of radiofrequency and HIFU myolysis have not been clearly established, and these treatments should be offered only after extensive counselling and informed consent. Given the recent concerns regarding the incidence of undiagnosed malignant tumours, the lack of histological confirmation before or after these therapies for symptomatic fibroids mandates a thorough process of informed patient consent before any such interventions.

Study Objective The aim is to evaluate the efficacy and side effects of medical cannabis for chronic pelvic pain (CPP). Design We conducted a retrospective cohort study between 2012 and 2018. Setting N/A Patients or Participants Three gynecologists specialized in pelvic pain who prescribe medical marijuana in their practice for analgesia participated. Only patients with CPP were included. Interventions 3 grams of medical cannabis daily was prescribed. Measurements and Main Results A descriptive analysis assessing patient baseline characteristics was performed. The usage of medical cannabis was recorded. Patient outcomes following initiation of medical cannabis were studied. Primary outcome was pain response; secondary outcomes were side effects and resulting patterns of opioid use. Chi-square test was used to compare association between different variables. P-value of <0.05 was considered significant. A total of 135 women, with mean age of 35.4 years old, were prescribed medical cannabis. 92.6% were premenopausal. 8.9% underwent hysterectomy. 48.2%, 60.0% and 57% tried at least one type of NSAID, opioid, or neuromodulator respectively. The route of cannabis administration was documented in 38 charts. Some patients used more than one formulation. 25 patients used cannabis oil, 10 ingested edibles, 9 vaporized cannabis and 6 smoked marijuana. Change in pain was documented in 82 cases: 79 experienced improvements, and 3 reported no change. No patient had worsening of pain. Of the patients who had improvement, 39 reduced their opioids use. Side effects were reported by 9 patients—the most common being headache. No significant relationship between patient baseline characteristics and change in pain was found. Conclusion This is the first study reporting use of medical cannabis in CPP. Medical cannabis is a safe treatment with minimal side effects that can improve CPP and reduce opioids use. Future studies evaluating the pharmacokinetics and optimal regimen in the management of CPP are needed. The aim is to evaluate the efficacy and side effects of medical cannabis for chronic pelvic pain (CPP). We conducted a retrospective cohort study between 2012 and 2018. N/A Three gynecologists specialized in pelvic pain who prescribe medical marijuana in their practice for analgesia participated. Only patients with CPP were included. 3 grams of medical cannabis daily was prescribed. A descriptive analysis assessing patient baseline characteristics was performed. The usage of medical cannabis was recorded. Patient outcomes following initiation of medical cannabis were studied. Primary outcome was pain response; secondary outcomes were side effects and resulting patterns of opioid use. Chi-square test was used to compare association between different variables. P-value of <0.05 was considered significant. A total of 135 women, with mean age of 35.4 years old, were prescribed medical cannabis. 92.6% were premenopausal. 8.9% underwent hysterectomy. 48.2%, 60.0% and 57% tried at least one type of NSAID, opioid, or neuromodulator respectively. The route of cannabis administration was documented in 38 charts. Some patients used more than one formulation. 25 patients used cannabis oil, 10 ingested edibles, 9 vaporized cannabis and 6 smoked marijuana. Change in pain was documented in 82 cases: 79 experienced improvements, and 3 reported no change. No patient had worsening of pain. Of the patients who had improvement, 39 reduced their opioids use. Side effects were reported by 9 patients—the most common being headache. No significant relationship between patient baseline characteristics and change in pain was found. This is the first study reporting use of medical cannabis in CPP. Medical cannabis is a safe treatment with minimal side effects that can improve CPP and reduce opioids use. Future studies evaluating the pharmacokinetics and optimal regimen in the management of CPP are needed.

Video Objective In this video, we demonstrate a novel laparoscopic technique of tubal re-implantation after hysteroscopic tubal sterilization with micro-inserts. Setting The patient is a thirty-eight-year-old gravida two para two who previously underwent Essure tubal occlusion. Although she understood the permanent and irreversible nature of Essure coils, she presented with desire of another pregnancy. She was well informed that in-vitro fertilization would offer her the best chance to get pregnant. However, due to personal reasons, she absolutely wanted tubal re-implantation. Interventions Laparoscopic bilateral cornuectomy, partial salpingectomy with removal of Essure coils and tubal re-implantation was performed. Postoperative management included oral antibiotics, removal of stents under hysteroscopy and hysterosalpingography. Conclusion This is the first reported case of tubal re-implantation following hysteroscopic tubal occlusion using the proposed method. The surgical steps and technical tips discussed are safe, and may help patients with desire of pregnancy following Essure insertion who seek alternative options to assisted reproductive technology. In this video, we demonstrate a novel laparoscopic technique of tubal re-implantation after hysteroscopic tubal sterilization with micro-inserts. The patient is a thirty-eight-year-old gravida two para two who previously underwent Essure tubal occlusion. Although she understood the permanent and irreversible nature of Essure coils, she presented with desire of another pregnancy. She was well informed that in-vitro fertilization would offer her the best chance to get pregnant. However, due to personal reasons, she absolutely wanted tubal re-implantation. Laparoscopic bilateral cornuectomy, partial salpingectomy with removal of Essure coils and tubal re-implantation was performed. Postoperative management included oral antibiotics, removal of stents under hysteroscopy and hysterosalpingography. This is the first reported case of tubal re-implantation following hysteroscopic tubal occlusion using the proposed method. The surgical steps and technical tips discussed are safe, and may help patients with desire of pregnancy following Essure insertion who seek alternative options to assisted reproductive technology.

Video Objective The objective of this video is to review the anatomical landmarks, innervations and mechanisms of injury of the genitofemoral nerve in order to avoid its injury in cases with significant pelvic adhesions. Setting The patient is a thirty-two-year-old gravida three para three who is known for endometriosis. She previously underwent a caesarean hysterectomy for invasive placentation. She presented with chronic pelvic pain. She tried numerous medical treatments; only GnRH agonist controlled her pain. She was therefore consented for laparoscopic bilateral salpingo-oophorectomy which was performed at a tertiary care center by the minimally invasive gynecology surgery team. She had extensive abdominal and left pelvic side wall adhesions. In fact her left ovary was severely adherent onto the left external iliac artery and genitofemoral nerve. Interventions During the laparoscopic bilateral salpingo-oophorectomy, adhesiolysis and dissection near the genitofemoral nerve and external iliac artery were performed. Conclusion In the case of severe pelvic side wall adhesions and absence of a uterus, recognition of pelvic landmarks is of paramount importance. This facilitates identification of other pelvic structures and in this case, prevented injury to the external iliac artery and the genitofemoral nerve. Furthermore, careful tissue handling and dissection techniques are crucial. These help to maintain minimal blood loss, develop surgical planes and avoid injuries to pelvic structures.

Objective: The risk of unexpected uterine leiomyosarcoma (LMS) following surgery for presumed benign leiomyoma is quoted to be between 1 in 498 and 1 in 5000. The objectives of the present study were to determine the prevalence of uterine LMS in a specific patient population and the rate of diagnosis of occult uterine LMS and to evaluate the risk of unintended morcellation of LMS in Saskatchewan. Methods: This study was a Canadian Task Force Classification II-2 multicentre retrospective cohort study in academic-affiliated tertiary care centres. All women with the histopathologic diagnosis of uterine LMS in Saskatchewan between January 2000 and December 2014 were included. Women with metastatic LMS at diagnosis or other types of uterine sarcomas were excluded. Data including patients' characteristics, clinical presentation, physical examination findings, imaging, pathology reports, surgical interventions, and survival outcomes were reviewed. Results: A total of 28 patients had a confirmed histopathologic diagnosis of LMS over the 15-year study period. Approximately 26 212 hysterectomies were performed in Saskatchewan over the same time frame. The prevalence of uterine LMS in this patient population over the study time frame is estimated to be one in 853. Mean age at diagnosis was 53.8 +/- 10.0. Medical records of 25 patients could be retrieved, and 15 cases (60%) had an occult diagnosis. There were five cases of unintended morcellation (one power, four mechanical). Survival outcomes were comparable in women with unintended morcellation of occult disease and in those without morcellation. Conclusion: This study contributes to the existing body of literature on morcellation of occult LMS, and it ascertains the rate of LMS in a patient population. The results of this study provide valuable information to health care professionals, policy makers, and women in Saskatchewan so that they may make more informed decisions concerning uterine masses. (C) 2019 The Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.

Objective To obtain expert consensus on the patient and fibroid characteristics that affect the complexity of laparoscopic myomectomy (LM) and to use these factors to create a grading tool for objective evaluation of LM procedures. Study design Modified Delphi Methodology Study (Canadian Task Force Ill). Setting included a series of online surveys via SurveyMonkey (SurveyMonkey Inc., San Mateo, California, USA). Participants were Canadian minimally invasive gynecologic surgeons (MIGS) who perform LM. A list consisting of patient, uterine and procedural characteristics was disseminated to Canadian MIGS. Opportunity to include additional factors was provided. Consensus was predefined as Cronbach's a of >= 0.80. A second Delphi survey was then done to assign weight value for each item in the grading tool. Results Twenty-seven surgeons from across Canada participated. Most (23/27, 85%) were MIGS fellowship trained, and performed more than 6 LM per year (18/27, 66.7%). Consensus was achieved in the first round of the survey (Cronbach's alpha = 0.93). Sixteen of 27 factors met the criteria for inclusion (>80% respondents agreed or strongly agreed) and were included in the final rating tool. Factors that met the criteria for inclusion were grouped as patient factors (including body mass index), uterine factors (including number of fibroids, size of largest fibroid), and surgical factors (including ease of developing the cleavage plane). Conclusions Using the Delphi methodology to obtain expert consensus on the factors influencing the difficulty of LM, we have developed an objective grading tool to evaluate the degree of technical complexity of LM. (C) 2018 Elsevier B.V. All rights reserved.

Objective The objective of this study was to compare laparoscopic ultrasound-guided radiofrequency ablation of fibroids (Lap-RFA) and laparoscopic myomectomy in terms of 1) health care utilization and 2) serious complication rates. The secondary objectives were comparison of subject responses to validated symptom and quality-of-life questionnaires. We hypothesized that Lap-RFA health care utilization and clinical outcomes would not be worse than those of laparoscopic myomectomy in the aggregate. Patients and methods Post-market, randomized, prospective, multicenter, longitudinal, non-inferiority interventional comparative evaluation of health care utilization and clinical outcomes in premenopausal women with symptomatic uterine fibroids who desired uterine conservation was conducted. Both procedures were planned as outpatient day surgeries. Health care resource utilization was measured during the procedure day and at 1 week, 1 and 3 months post-surgery. Symptom severity and quality of life were based on patients' responses to the Uterine Fibroid Symptom Severity and Quality-of-Life Questionnaire, EuroQol-5D-visual analog scale general health status and menstrual impact questionnaires, and time from work. Results Forty-five participants provided written informed consent and were enrolled (Lap-RFA, n=23; myomectomy, n=22) in Canada. Hospitalization time (primary endpoint) was 6.7±3.0 hours for the Lap-RFA group and 9.9±10.7 hours for the myomectomy group (Wilcoxon, p=0.0004). Intraoperative blood loss was lesser for Lap-RFA subjects: 25.2±21.6 versus 82.4±62.5 mL (p=0.0002). Lap-RFA procedures took lesser time than myomectomy procedures: 70.0 versus 86.5 minutes (p=0.018), and Lap-RFA required -34.9% (130 fewer) units of surgical equipment. At 3 months, both cohorts reported the same significant symptom severity reduction (-44.8%; p<0.0001). Lap-RFA subjects also took lesser time from work: 11.1±7.6 versus 18.5±10.6 days (p=0.0193). One myomectomy subject was hospitalized overnight after experiencing a 20-second asystole during the procedure. One Lap-RFA subject underwent a reintervention. The combined per patient direct and indirect costs of the two procedures were comparable: Lap-RFA (CAD $5,224.96) and myomectomy (CAD $5,321.96). Conclusion Compared to myomectomy, Lap-RFA is associated with significantly lesser intraoperative blood loss, shorter procedure and hospitalization times, lesser consumption/use of disposable and reusable surgery equipment, reduced health care resource utilization, and faster return to work through 3 months posttreatment. Direct and indirect costs of Lap-RFA and myomectomy are comparable.

INTRODUCTION: More than 2,000 cases of laparoscopic intrabdominal ultrasound-guided radiofrequency ablation (Lap-RFA) of symptomatic myomas have been performed in the United States and internationally. Safe conception and childbearing following Lap-RFA are of great interest to patients, obstetrician-gynecologists, and reproductive endocrinologists and surgeons. Our purpose is to study the safety and gestational outcomes among reported pregnancies post Lap-RFA. METHODS: Gynecologic surgeons, who perform Lap-RFA, complete standardized data collection forms that capture specific details describing their consenting patients’ preoperative, intraoperative, and postoperative data as well as any pregnancy data. Reproductive outcomes have been collected and analyzed using descriptive statistics. RESULTS: Twenty-seven women (age range, 30-43 years old) conceived 28 times after Lap-RFA treatment. Of the 28 gestations, 23 (82.1%) resulted in full-term deliveries of healthy infants, 2 (7.1%) pregnancies are ongoing (due October and November), 2 (7.1%) pregnancies terminated in first-trimester spontaneous abortions, and 1 (3.6%) pregnancy terminated spontaneously in the second trimester. Time from treatment to conception ranged from 1 month to 28 months. Eleven (47.8%) of the births were by vaginal delivery. No cases of abnormal placentation or endometrial defect were observed. CONCLUSION: Accumulating evidence indicates that safe childbearing with full-term gestation can be achieved after Lap-RFA of symptomatic myomas. Continued collection of obstetric data from commercial Lap-RFA cases and Lap-RFA clinical trials are needed to support these preliminary findings.

Study Objective: The risk of an unexpected uterine leiomyosarcoma following surgery for presumed benign leiomyoma is quoted in the literature to be between 1 in 350 and 1 in 1000. Recent evidence indicates that disease dissemination may result from morcellation of occult uterine leiomyosarcomas. The objective of the present study is to determine the incidence of uterine leiomyosarcomas in our patient population, the rate of preoperative diagnosis of uterine leiomyosarcomas, and to evaluate the risk of unintended morcellation of leiomyosarcomas in our province.

Study Objective: To obtain expert consensus on what patient and fibroid characteristics make laparoscopic myomectomies (LM) more challenging and to use these factors to create an objective grading tool for evaluating LM.