Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.

Abdominal pregnancy is a rare but life-threatening variation of ectopic pregnancy that is often treated with laparoscopic management; however, we present a case successfully treated using only minimally invasive techniques. A 36-year-old female G1P0 with a history of infertility is diagnosed with 11-weeks abdominal pregnancy by transvaginal ultrasound. She presented with vaginal bleeding and abdominal pain, and her beta-human chorionic gonadotropin was 53,680 mIU/mL. The location of the fetal sac was not amenable to surgery or percutaneous injection. We performed bilateral uterine artery embolization and subsequent intramuscular methotrexate injection. The procedure was successful with no complications. The patient was followed at postoperative week 11, and beta-human chorionic gonadotropin was 2 mIU/mL, and at 3 months, a transvaginal ultrasound revealed resolution of the abdominal pregnancy.

More than half of women with symptomatic uterine fibroids experience heavy or prolonged menstrual bleeding. This contributes to chronic anemia among reproductive aged women. Although hysterectomy provides definitive surgical treatment, laparoscopic myomectomy is considered standard of care for the surgical management of symptomatic fibroids for women desiring uterine-sparing treatment. Preoperative anemia has been associated with increased risk of postoperative morbidity and mortality in gynecologic surgery. Current research on preoperative anemia in the benign gynecologic literature has primarily focused on hysterectomy, and little has been published regarding the risk profile for patients desiring myomectomy. The purpose of this study was to determine if preoperative anemia was associated with increased risk for 30-day postoperative morbidity or mortality following laparoscopic myomectomy. The aim was to provide clinical insight for gynecologic surgeons weighing the decision of whether to proceed with laparoscopic myomectomy for an anemic patient versus delaying surgery to focus on medical management and optimization. This retrospective population-based cohort study evaluated adult women who underwent laparoscopic myomectomy from 2014-2019. Data was collected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The exposure of interest was preoperative anemia, defined at hematocrit value less than 36% documented within 14-days prior to surgery. The primary outcome of interest was the occurrence of any minor or major postoperative complication as characterized by the standardized Clavien-Dindo classification utilizing bivariate and multivariable analysis. A total of 2097 cases were included for analysis; 26.66% of these women were anemic with an average preoperative hematocrit of 32.59% (±3.19%). There was a significant difference in the distribution of race/ethnicity, with most anemic patients self-identifying as "Black" (50.09%, p-value <0.001). Anemic patients were more likely to receive perioperative blood transfusion (4.29% versus 1.56%, p-value <0.01), had higher readmission rates (2.98% versus 1.16%, p-value 0.01), and were more likely to have "any" minor complication (7.16% versus 3.84%, p-value <0.01). After multivariate analysis adjusted for potential confounders, anemic patients had increased risk of experiencing a minor postoperative complication following laparoscopic myomectomy, with adjusted odds ratio of 1.71 (95% CI 1.10-2.66, p-value 0.02). However, there was no significant risk of any major postoperative complications. Preoperative anemia was common among women undergoing laparoscopic myomectomy. Anemia was not associated with increased risk for major postoperative complications within 30-days for this specific patient population.

OBJECTIVE: To assess postoperative outcomes based on surgical approach for myomectomies with increasing leiomyoma burden. METHODS: We conducted a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2019 of benign myomectomy procedures. These cases were categorized into "smaller" and "larger" procedures based on leiomyoma burden. Smaller myomectomies included leiomyomas weighing less than 250 g or with one-four leiomyomas (Current Procedural Terminology [CPT] codes 58545 and 58140); larger myomectomies included leiomyomas weighing 250 g or more or with five or more leiomyomas (CPT codes 58546 and 58146). Postoperative complications estimated using the Clavien-Dindo classification system were compared based on surgical approach. RESULTS: Of 8,363 total myomectomy procedures, 3,117 (37.3%) were performed using minimally invasive surgery (MIS) and 5,246 (62.7%) were performed using laparotomy. Among MIS cases, 2,080 (66.7%) were categorized as smaller myomectomies and 1,037 (33.3%) cases as larger myomectomies. Among laparotomy cases, 2,587 (49.3%) were smaller myomectomies, and 2,659 (50.7%) were larger myomectomies. Regardless of myomectomy size, MIS was associated with a lower perioperative blood transfusion rate than laparotomy (1.63% vs 8.93%, respectively, P<.01). Laparotomy was associated with an increased rate of minor complications (adjusted odds ratio [aOR] 2.86 (95% CI 2.24-3.67) for smaller leiomyoma burden (11.91% vs 4.28%) and for larger leiomyoma burden (21.59% vs 6.75%, aOR 3.43, 95% CI 2.64-4.47) cases. Laparotomy demonstrated an increased cumulative major complication rate (3.31% vs 1.25%) (aOR 2.45, 95% CI 1.35-4.45) for larger myomectomies. CONCLUSION: A minimally invasive surgical approach for both smaller and larger myomectomies was associated with fewer minor complications compared with laparotomy. Minimally invasive surgery for larger myomectomies was associated with fewer cumulative major complications compared with laparotomy.

STUDY OBJECTIVE:Evaluate inter-rater and intrarater reliability of a novel scoring tool for surgical complexity assessment of endoscopic hysterectomy. DESIGN:Validation study. SETTING:Academic medical center. PARTICIPANTS:Total of 11 academic obstetrician-gynecologists with varying years of postresidency training, clinical practice, and surgical volumes. INTERVENTIONS:Application of a novel scoring tool to evaluate surgical complexity of 150 sets of images taken in a standardized fashion before surgical intervention (global pelvis, anterior cul-de-sac, posterior cul-de-sac, right adnexa, left adnexa). Using only these images, raters were asked to assess uterine size, number, and location of myomas, adnexal and uterine mobility, need for ureterolysis, and presence of endometriosis or adhesions in relevant locations. Surgical complexity was staged on a scale of 1 to 4 (low to high complexity). MEASUREMENTS AND MAIN RESULTS:Number of postresidency years in practice for participating surgeons ranged from 2 to 15, with an average of 8 years. A total of 8 obstetrician-gynecologists (72.7%) had completed a fellowship in minimally invasive gynecologic surgery. Six (54.6%) reported an annual volume of >50 hysterectomies. Raters reported that 95.4% of the images were satisfactory for assessment. Of the 150 sets of images, most were found to be stage 1 to 2 complexity (stage 1: 23.8%, stage 2: 41.6%, stage 3: 32.8%, stage 4: 1.8%). The level of inter-rater agreement regarding stage 1 to 2 vs 3 to 4 complexity was moderate (κ = 0.49; 95% confidence interval [CI], 0.42-0.56). Moderate inter-rater agreement was also found between surgeon raters with an annual hysterectomy volume >50 (κ = 0.49; 95% CI, 0.40-0.57) as well as between surgeon raters with fellowship experience (κ = 0.50; 95% CI, 0.42-0.58). Intrarater agreement averaged 80.2% among all raters and also achieved moderate agreement (mean weighted κ = 0.53; range, 0.38-0.72). CONCLUSION:This novel scoring tool uses clinical assessment of preintervention anatomic images to stratify the surgical complexity of endoscopic hysterectomy. It has rich and comprehensive evaluation capabilities and achieved moderate inter-rater and intrarater agreement. The tool can be used in conjunction with or instead of traditional markers of surgical complexity such as uterine weight, estimated blood loss, and operative time.

Study Objective To demonstrate a novel use of an abdominal viscera retainer for improving safe access to the posterior aspect of the uterus during laparoscopic myomectomy. Design Surgical film. Setting N/A. Patients or Participants Patient with a large 7 × 7cm subserosal and intramural fibroid at the posterior aspect of the uterine body and fundus. Interventions A viscera retainer is a device widely used by surgeons to retain omentum and protect underlying bowel during fascial closure of laparotomy cases. The device has been used to improve speed of closure while significantly reducing the risk of unintended needle punctures. During this laparoscopic myomectomy case, we used an umbilical port for the camera, left and right lower quadrant ports, and a midline suprapubic mini-laparotomy incision using a mini GelPoint. We used a medium sized viscera retainer, measuring approximately 6 × 9 inches. The retainer is able to be easily rolled for placement in the pelvis through the mini GelPoint. Once in the abdomen, the retainer can be positioned into the posterior cul-de-sac overtop of any underlying bowel. The weighted center spine helps to keep the device in place and prevents bowel from inadvertently moving into the surgical field. Measurements and Main Results The viscera retainer was able to be used as an intra-abdominal retraction device and physical protective barrier for the bowel during laparoscopic myomectomy, specifically during enucleation of the fibroid and suturing of the hysterotomy. Conclusion This unique use of a device typically reserved for laparotomy improved surgeon's access to the posterior aspect of the uterus for dissection and enucleation of posterior fibroids during laparoscopic myomectomy.

Study Objective: To assess whether complications incurred during hysterectomy for the treatment of endometriosis differ among racial-ethnic groups. Design: Retrospective cohort study. Setting: American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2019. This database is a robust, comprehensive, multi-institutional database with nearly 700 participating hospitals. Patients: Patients with a diagnosis of endometriosis or with an endometriosis-associated symptom as the primary indication for surgery and surgical intraoperative documentation of endometriosis. Interventions: Compare perioperative complications based on patient race and ethnicity. Measurements and Main Results: A total of 5639 patients underwent hysterectomy for endometriosis; of these, 4368 were White patients (77.5%), 528 Black patients (9.4%), 491 Hispanic patients (8.7%), 252 Asian patients (4.5%). There was no association between location of endometriosis and patient race and ethnicity. However, White patients had highest rate, and Asian patients had the lowest rate of laparoscopic hysterectomy, 85.3% vs 69.8%, respectively (p <.01). In addition, there were differences in concomitant procedures performed at time of hysterectomy based on race and ethnicity, with White patients having the highest rates of adnexal/peritoneal surgery at 12.5% (p <.01) com-pared with patients of the other racial and ethnic groups. Asian patients had the highest rate of ureteral surgery at 6.8% (p <.01) and highest rate of intestinal surgery at 16.3% (p <.01) compared with patients of other racial and ethnic groups. There was no association of rates of concomitant bladder surgery, appendectomy, or rectal surgery with patient race and ethnicity. Black patients had the highest rate of minor complications at 13.5% (p <.01) and the highest rate of major complications at 6.6% (p <.01) compared with patients of other racial and ethnic groups. After multivariable analysis, Black patients still had increased odds of having a major complication compared with patients of other racial and ethnic groups even after controlling for patient characteristics and perioperative factors such as endometriosis lesion location, surgical approach, and concomitant procedures (odds ratio 1.64; 95% confidence interval, 1.10-2.45). Conclusion: Endometriosis lesion location did not differ with patient race and ethnicity. However, patient race and ethnicity did have an impact on the surgical approach and the concomitant surgical procedures performed at time of hysterectomy. Black patients had the highest odds of major complications. Journal of Minimally Invasive Gynecology (2022) 29, 1268 -1277. (c) 2022 AAGL. All rights reserved.

Study Objective Assess postoperative outcomes based on surgical approach for myomectomies with increasing fibroid burden. Design Retrospective analysis of benign myomectomy procedures, categorized into “smaller” and “larger” procedures based on fibroid burden identified using Current Procedural Terminology (CPT) codes. Smaller myomectomies included fibroids weighing <250mg or with 1-4 fibroids (CPT codes 58545 & 58140), and larger myomectomy procedures were classified as fibroids weighing >250mg or with >5 fibroids (CPT codes 58546 & 58146). Postoperative outcomes were then compared using the Clavien-Dindo classification system based on surgical approach, laparoscopic versus laparotomy. Setting Analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP®) database. Patients or Participants Myomectomy procedures from 2014-2019 using the NSQIP® database, excluding malignancy and cases with concurrent procedures. Interventions Myomectomy via laparoscopy and laparotomy. Measurements and Main Results 8,363 total myomectomy procedures were identified. 4,667 (55.8%) were smaller myomectomy procedures; 2080 (44.6%) completed via laparoscopy and 2,587 (55.4%) via laparotomy. 3,696 (44.2%) were larger myomectomy procedures; 1,037 (28.1%) completed via laparoscopy and 2,659 (71.9%) via laparotomy. Regardless of myomectomy size, laparoscopy required less perioperative blood transfusions (p<0.01). Myomectomy via laparotomy demonstrated increased cumulative minor complications, adjusted OR 2.80 (95%CI 2.18-3.58) for smaller fibroid burden and adjusted OR 3.41 (95% CI 2.62-4.44) for larger fibroid burden. Laparotomy demonstrated increased cumulative major complications, adjusted OR 2.40 (95% CI 1.32-4.36) for larger fibroid burden. Conclusion Smaller and larger myomectomies had fewer cumulative minor complications when conducted via laparoscopy. Laparotomy for larger myomectomies significantly increased cumulative major complications including rates of small bowel obstruction and deep organ space surgical site infections. Providers should strongly consider the laparoscopic myomectomy over laparotomy, regardless of fibroid burden. Assess postoperative outcomes based on surgical approach for myomectomies with increasing fibroid burden. Retrospective analysis of benign myomectomy procedures, categorized into “smaller” and “larger” procedures based on fibroid burden identified using Current Procedural Terminology (CPT) codes. Smaller myomectomies included fibroids weighing <250mg or with 1-4 fibroids (CPT codes 58545 & 58140), and larger myomectomy procedures were classified as fibroids weighing >250mg or with >5 fibroids (CPT codes 58546 & 58146). Postoperative outcomes were then compared using the Clavien-Dindo classification system based on surgical approach, laparoscopic versus laparotomy. Analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP®) database. Myomectomy procedures from 2014-2019 using the NSQIP® database, excluding malignancy and cases with concurrent procedures. Myomectomy via laparoscopy and laparotomy. 8,363 total myomectomy procedures were identified. 4,667 (55.8%) were smaller myomectomy procedures; 2080 (44.6%) completed via laparoscopy and 2,587 (55.4%) via laparotomy. 3,696 (44.2%) were larger myomectomy procedures; 1,037 (28.1%) completed via laparoscopy and 2,659 (71.9%) via laparotomy. Regardless of myomectomy size, laparoscopy required less perioperative blood transfusions (p<0.01). Myomectomy via laparotomy demonstrated increased cumulative minor complications, adjusted OR 2.80 (95%CI 2.18-3.58) for smaller fibroid burden and adjusted OR 3.41 (95% CI 2.62-4.44) for larger fibroid burden. Laparotomy demonstrated increased cumulative major complications, adjusted OR 2.40 (95% CI 1.32-4.36) for larger fibroid burden. Smaller and larger myomectomies had fewer cumulative minor complications when conducted via laparoscopy. Laparotomy for larger myomectomies significantly increased cumulative major complications including rates of small bowel obstruction and deep organ space surgical site infections. Providers should strongly consider the laparoscopic myomectomy over laparotomy, regardless of fibroid burden.

Study Objective To determine if limited, post-operative changes to patient care in the model of enhanced recovery after surgery are sufficient to decrease post-operative opioid prescriptions. Design A pre- and post-implementation study of a modified Enhanced Recovery protocol. Setting Post-operative setting in a tertiary academic medical center. Patients or Participants Included women undergoing scheduled gynecologic surgery at one hospital system where minimally-invasive procedures are predominant, aged 18-95 years. Procedures included hysterectomy or urogynecologic procedures performed by physicians involved in the study. The cohorts were broken up into a year prior to implementation of the intervention (n=175), and a year after (n=149). Excluded were patients discharged on the same calendar day. Interventions A post-operative order set including scheduled non-opioid analgesics and anti-emetics, expedited diet advancement, and standardized order sets for post-operative prescriptions. Measurements and Main Results The primary outcome was the amount of opioid prescribed through post-discharge day 14. Opioids were converted today's supply and morphine milligram equivalents (MME). Baseline demographics were similar between the two groups, with exceptions being race (White race 96% in the first cohort vs. 89% in the second, p=0.0369) and tobacco use (19% use in the first cohort vs. 10% in the second, p=0.0288). Percent of patients with baseline chronic opioid use was similar between the two groups (15 vs. 10, p=0.5318). Mean pain scores before and after the intervention were not significantly different. There was a significant decrease in both day's supply (3.23 vs. 2.43, p=0.0311) and MME prescribed following the intervention (47.98 vs. 41.42, p=0.0022). There was a non-significant decrease in cumulative MME through post-discharge day 14 (210.8 vs. 143.2, p=0.3631), as well as total day's supply through post-discharge day 14 (3.45 vs. 3.15, p=0.4604). Conclusion Simple changes to the post-operative experience in line with an enhanced recovery protocol are sufficient to decrease post-operative opioid use in a population including patients with baseline chronic opioid use. To determine if limited, post-operative changes to patient care in the model of enhanced recovery after surgery are sufficient to decrease post-operative opioid prescriptions. A pre- and post-implementation study of a modified Enhanced Recovery protocol. Post-operative setting in a tertiary academic medical center. Included women undergoing scheduled gynecologic surgery at one hospital system where minimally-invasive procedures are predominant, aged 18-95 years. Procedures included hysterectomy or urogynecologic procedures performed by physicians involved in the study. The cohorts were broken up into a year prior to implementation of the intervention (n=175), and a year after (n=149). Excluded were patients discharged on the same calendar day. A post-operative order set including scheduled non-opioid analgesics and anti-emetics, expedited diet advancement, and standardized order sets for post-operative prescriptions. The primary outcome was the amount of opioid prescribed through post-discharge day 14. Opioids were converted today's supply and morphine milligram equivalents (MME). Baseline demographics were similar between the two groups, with exceptions being race (White race 96% in the first cohort vs. 89% in the second, p=0.0369) and tobacco use (19% use in the first cohort vs. 10% in the second, p=0.0288). Percent of patients with baseline chronic opioid use was similar between the two groups (15 vs. 10, p=0.5318). Mean pain scores before and after the intervention were not significantly different. There was a significant decrease in both day's supply (3.23 vs. 2.43, p=0.0311) and MME prescribed following the intervention (47.98 vs. 41.42, p=0.0022). There was a non-significant decrease in cumulative MME through post-discharge day 14 (210.8 vs. 143.2, p=0.3631), as well as total day's supply through post-discharge day 14 (3.45 vs. 3.15, p=0.4604). Simple changes to the post-operative experience in line with an enhanced recovery protocol are sufficient to decrease post-operative opioid use in a population including patients with baseline chronic opioid use.

We present the case of a 50-year-old female who underwent bilateral ovarian artery embolization for uterine fibroids in the setting of hypoplastic uterine arteries. Ovarian artery embolization is usually conducted during uterine artery embolization for fibroids to increase the procedure success when ovarian feeders are seen. The bilateral ovarian artery embolization is rarely performed due to fears of amenorrhea and early menopause from decreased blood supply to both ovaries. According to our knowledge, this the first case report describing primary bilateral ovarian artery embolization in the setting of a rare anatomic variant- hypoplastic uterine arteries. The patient had complete resolution of symptoms from her uterine fibroids after treatment with bilateral ovarian artery embolization with no ovarian failure findings on the follow-up.

Study Objective Determine the preoperative risk factors for anastomotic leak after bowel resection during non-emergent endometriosis related surgery. Design Retrospective population level case-control study. Setting Analysis of American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset. Patients or Participants Patients undergoing a bowel resection for endometriosis related surgery from 2014-2019 at a NSQIP participating site. International Classification of Diseases codes (ICD 9/10) were utilized to identify bowel resection cases with a primary surgical indication for endometriosis. Interventions Evaluation of patient demographics, perioperative management strategies and surgical technique that were associated with the occurrence of an anastomotic leak following bowel resection for endometriosis. Measurements and Main Results 289 bowel resection cases (non-emergent, benign) for endometriosis were identified. Anastomotic leak occurred in 9 cases (3.11%). There were no baseline patient demographics, perioperative management strategies (mechanical bowel preparation, preoperative oral antibiotics) or differences in surgical technique (laparoscopic vs open) that demonstrated a statistically significant association with an anastomotic leak. Multivariable logistic analysis identified that an increased preoperative albumin level was associated with a reduced risk of anastomotic leak with an adjusted odds ratio of 0.11 (95% CI 0.01-0.95). Conclusion The majority of population level data for anastomotic leak after bowel resection has included mainly data involving surgery for cancer. Data on complications after bowel resection for endometriosis has primarily been published form single site, single surgeon case series. This study using multicenter national data identified decreased preoperative albumin level as a risk factor for anastomotic leak after bowel resection for endometriosis. Further prospective studies are warranted to identify possible optimization strategies before bowel resection for endometriosis, with a particular focus on nutritional status atop perioperative management strategies and surgical techniques. Determine the preoperative risk factors for anastomotic leak after bowel resection during non-emergent endometriosis related surgery. Retrospective population level case-control study. Analysis of American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset. Patients undergoing a bowel resection for endometriosis related surgery from 2014-2019 at a NSQIP participating site. International Classification of Diseases codes (ICD 9/10) were utilized to identify bowel resection cases with a primary surgical indication for endometriosis. Evaluation of patient demographics, perioperative management strategies and surgical technique that were associated with the occurrence of an anastomotic leak following bowel resection for endometriosis. 289 bowel resection cases (non-emergent, benign) for endometriosis were identified. Anastomotic leak occurred in 9 cases (3.11%). There were no baseline patient demographics, perioperative management strategies (mechanical bowel preparation, preoperative oral antibiotics) or differences in surgical technique (laparoscopic vs open) that demonstrated a statistically significant association with an anastomotic leak. Multivariable logistic analysis identified that an increased preoperative albumin level was associated with a reduced risk of anastomotic leak with an adjusted odds ratio of 0.11 (95% CI 0.01-0.95). The majority of population level data for anastomotic leak after bowel resection has included mainly data involving surgery for cancer. Data on complications after bowel resection for endometriosis has primarily been published form single site, single surgeon case series. This study using multicenter national data identified decreased preoperative albumin level as a risk factor for anastomotic leak after bowel resection for endometriosis. Further prospective studies are warranted to identify possible optimization strategies before bowel resection for endometriosis, with a particular focus on nutritional status atop perioperative management strategies and surgical techniques.

INTRODUCTION: Millions of people use social media to share their experiences, including healthcare experiences. Data on what patients actually post is lacking. This study attempts to better understand the experience of patients, as well as examine who is posting on these platforms. METHODS: Two popular search terms were identified: #hysterectomyrecovery and #hysterectomypostop. The most recent Instagram, Twitter, and YouTube posts were reviewed. Authorship of the post was determined based on the bio of the poster and classified as patient, provider, advertisement, organization/institution, or unclassified. For patient posts, theses were further analyzed based on language/content of the post for tone: positive, neutral, or negative. RESULTS: Authorship of posts varied by platform. Identified Instagram posts were 64% by patients, 17% advertisements, 17% organization/institution, and 1% unclassified. 100% of Twitter posts originated from patients. YouTube posts were 47% patient and 47% healthcare provider. Tone of posts also varied by platform. 69% of Instagram posts were positive versus 15% negative. 83% of Twitter posts were positive versus 9% negative. 50% of YouTube posts were positive versus 43% negative. CONCLUSION: There are many posts about hysterectomy post-op and recovery on different platforms. Twitter and Instagram tend to have more patient-driven posts, whereas YouTube has equal patient and provider posts. Patients tend to have more positive tone related to hysterectomy experience on YouTube, Instagram, and Twitter, in increasing order. Prevailing wisdom suggests that social media draws negative attention to healthcare. Our study would suggest that while most of the posts on social media platforms were patient-driven, the majority were positive.

The objective of this video is to describe the preoperative and surgical strategies to perform a total laparoscopic hysterectomy for a patient with a complete uterine didelphys with large uterine fibroids. Uterine anomalies can add significant challenges to gynecologic surgery. In this video, we demonstrate how a hysterectomy, complicated by having two uteri and cervices, each with fibroids greater than 7cm in size, as well as two previous cesarean deliveries in the right uterus, can be performed laparoscopically. For a patient with uterine anomalies who requires surgical intervention, successful outcomes are dependent upon careful planning and preparation. Preoperative planning in this case included a thorough history and physical exam, a complete review of available medical records, and magnetic resonance imaging. In preparing for the operation, the surgical team reviewed each step of the surgery and planned for steps that would be different in a patient with a complete uterine didelphys. One significant challenge was using a colpotomy cup with two cervices. After the septoplasty was performed, we tied each cervix into the base of a large colpotomy cup, and a uterine manipulator was placed into the right uterus. While uterine manipulation was limited in the left uterus, we were able to use the colpotomy cup to identify and seal the uterine arteries at the appropriate level. After securing the blood supply to both uteri, a supracervical hysterectomy was performed on the left uterus to improve visualization for the colpotomy. Total laparoscopic hysterectomy for a complete uterine didelphys with large uterine fibroids is a safe approach to hysterectomy with careful preoperative and surgical planning.

Study Objective: To identify factors contributing to prolonged hospitalization for women undergoing myomectomy for uterine myomas. Patients: Women undergoing myomectomy for uterine myomas during 2014 to 2016 were identified by the Current Procedural Terminology code. Design: Retrospective population-based analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Setting: Data from the American College of Surgeons National Surgical Quality Improvement Project. Interventions: None. Measurements and Main Results: The primary outcome was length of stay longer than the median (1 day). Preoperative, intraoperative, and postoperative variables were examined to determine predictors for prolonged length of stay (LOS). Seven thousand five hundred thirty-one women underwent abdominal or laparoscopic myomectomy for uterine myomas. Nonwhite race (black: odds ratio [OR] =2.25; 95% confidence interval [CI], 2.01-2.51; Asian: OR = 1.54; 95% CI, 1.27-1.85; other/unknown: OR = 2.82; 95% CI, 2.43-3.27), preoperative hematocrit <38% (OR =1.38; 95% CI, 1.26-1.52), body mass index >= 30.1 kg/m(2) (OR =1.36; 95% CI, 1.21-1.53), preoperative blood transfusion (OR = 3.70; 95% CI, 2.03-6.74), perioperative blood transfusion (OR = 6.64; 95% CI, 4.76-9.27), removal of >= 5 myomas (OR =1.47; 95% CI, 1.28-1.70), and operative time >120 minutes (121-150 minutes: OR = 1.42; 95% CI, 1.15-1.77; 151-180 minutes: OR = 1.59; 95% CI, 1.24-2.03; >= 181 minutes: OR = 1.36; 95% CI, 1.10-1.69) predicted prolonged LOS. Laparoscopy protected against prolonged LOS (OR = 0.11; 95% CI, 0.09-0.13). Conclusions: Limited potentially modifiable perioperative factors contributing to prolonged LOS for abdominal or laparoscopic myomectomy were identified and suggest areas for targeted interventions. (C) 2019 AAGL. All rights reserved.

INTRODUCTION: Pyomyoma is a rare complication after uterine fibroid embolization. METHODS: We present a case of a 27 year old nulligravid patient who underwent uterine fibroid embolization for symptomatic uterine fibroids and subsequently developed a pyomyoma. Patient consent was obtained for submission of case report. RESULTS: She had a complex medical and surgical history, including osteosarcoma as a child and two previous open myomectomies for large fibroids. The second myomectomy was complicated by a pulmonary embolization during her postoperative hospitalization. Another large, 10.6 cm posterior uterine fibroid with a submucosal component was found three years after her second myomectomy. She was counseled about alternatives to myomectomy and hysterectomy, and she elected for uterine fibroid embolization. Forty-one days after an uncomplicated procedure, she presented to the emergency room with a two day history of abdominal pain, fever, and vaginal discharge. She appeared ill and diaphoretic, with a heart rate in the 130's and a leukocytosis of 31 k/uL. Imaging at that time revealed a mass containing air concerning for pyomyoma with endomyometritis. Exam under anesthesia revealed a soft, gray mass, prolapsing from her dilated cervix. She was treated with transvaginal myomectomy and intravenous antibiotics. She did well postoperatively and four months later has not required additional treatment. CONCLUSION: Though definitive management of a pyomyoma is hysterectomy, our patient was successfully managed conservatively with vaginal myomectomy and intravenous antibiotics. Of the six reported pyomyomas after uterine fibroid embolization, hysterectomy was performed in four cases, laparoscopic drainage in one case, and one case did not report therapy.

INTRODUCTION: Systemic contact dermatitis due to nickel component of Essure is a rare complication. METHODS: We present a case of a 31 year old who developed a rash after Essure placement that resolved with complete removal of the coils. The patient had a history significant for Crohn's disease and multiple abdominal surgeries. To avoid another surgery, she elected for surgical sterilization with Essure. Approximately two months after placement of Essure, she developed diffuse itching and blistering with scarring. Over the course of two years, she was seen by numerous subspecialists for evaluation of the rash. Allergen testing by dermatology revealed a nickel allergy. The patient was then referred to gynecologic surgeons to discuss management. On exam, she was found to have ill-defined, erythematous patches, studded with red/brown crusted papules and superficial excoriation. The patient was counseled on her options and she preferred Essure removal. She underwent a hysteroscopy and laparoscopic bilateral salpingectomy with complete removal of the Essure coils. Complete removal was confirmed by identifying the gold tag at the proximal end of the coil after removal. Her skin lesions and itching began to improve immediately, and the lesions had almost completely resolved six weeks after surgery. CONCLUSION: Allergic contact dermatitis that resolves with Essure removal has been reported. This is the fifth case report of such a reaction. With allergic reactions like this, complete removal of the coils is essential, as leaving even a small piece of the coil could result in persistent symptoms.

Uterine fibroids are common benign tumors seen in women and can be managed with a variety of treatment options, including hysterectomy, myomectomy, and uterine fibroid embolization (UFE). UFE is an acceptable alternative to surgical treatment in well-selected cases and offers the added benefit of decreased hospital stay and avoidance of general anesthesia risk. Like any other procedure, UFE carries risks and complications. Post-UFE fibroid expulsion is one of them.We present a case of impending fibroid expulsion pre-emptively identified on magnetic resonance imaging at 6-month follow-up after UFE. While the majority of fibroid expulsions occur spontaneously by 3 months post-UFE, delayed expulsions have been reported as late as 4 years following the procedure. Therefore, a high degree of clinical suspicion is paramount for early diagnosis of this complication in UFE patients.

INTRODUCTION: Obstetrics & Gynecology residents and their partners often require care during residency. Many obtain care from program faculty, but little is known about opinions on this topic. The purpose of this study is to determine if Obstetrics & Gynecology residents' opinions differ from those of their program directors regarding whether a conflict of interest exists when residents obtain personal care from program faculty. METHODS: An anonymous survey with questions using a modified Likert scale from previously validated surveys was administered to program directors and residents from United States Obstetrics & Gynecology residency programs. SAS (9. 4) was used to analyze the data via chi-squared test. Significance was defined as p<0.05. RESULTS: Data was collected on 72 surveys from 57 residents and 15 program directors. Questions regarding conflict of interest showed no significant difference between groups with one exception: program directors were more concerned that care would cause embarrassment for residents (p=0.0401). Results also trended toward significance for multiple questions. Residents felt more concerned about the cost of outside care (p=0.0878) and about care not being fully documented in their records (p=0.0668). Program directors felt more concerned about information from residents' records being seen by others (p=0.0717) and residents feeling uncomfortable about disagreeing with advice from faculty (p=0.0913). CONCLUSION: While the majority of responses between groups were not found to be significantly different, the survey did show concern for conflicts of interest among both program directors and residents. Given the concern that conflicts of interest could exist, further investigation is warranted.

INTRODUCTION: Third year medical school clerkships provide students an opportunity to see specialties first hand and observe mentors in the field. Shorter clerkships have the potential to negatively affect their decision on specialty selection. We sought to describe clerkship length at US medical schools with OB/GYN clerkships and correlate this to the OB/GYN residency match rate in 2017. METHODS: This was an observational cohort study of US allopathic medical schools with OB/GYN clerkships. Medical school websites were reviewed and clerkship coordinators contacted when necessary to determine clerkship length. The 2017 GME Track Resident Survey was utilized to determine medical schools for first-year residents. Mean number of programs and students matching into OB/GYN were reported with standard deviations. RESULTS: 147 US allopathic medical schools were identified and complete clerkship information was available for 137. The majority of medical schools provided a 5-6 week clerkship (n = 101; 73.7%) followed by 7-8 weeks (n = 28; 20.4%) and 4 weeks (n = 8; 5.8%). Residency Survey data was available for 94.8% of first year residents. Four-week, 5-6 week and 7-8 week clerkships were associated with a 3.96% (SD 0.88), 4.77 (SD 2.38) and 5.19 (2.21) match rate into OB/GYN respectively. CONCLUSION: The majority of US allopathic medical schools provide a 6-week OB/GYN clerkship experience. There was an increase in the percentage of medical students entering OB/GYN based on clerkship length that was not statistically significant. As medical schools undergo curriculum change, it is important that adequate exposure to the specialty be provided.

Uterine fibroid embolization (UFE) is an increasingly popular treatment for uterine fibroids. One extremely rare complication after fibroid embolization is pyomyoma, which is the localized infection of the leiomyoma after embolization. Only 10 cases of pyomyoma after UFE have been reported in the literature. We present a case of delayed submucosal pyomyoma identified on computed tomography after 42 days post-UFE. While the majority of previously reported cases were managed by hysterectomy, our patient was treated with a uterine-sparing hysteroscopic transcervical approach. A high level of clinical suspicion is necessary to diagnose this complication after UFE to avoid major morbidity. Submucosal pyomyomas offer a favorable anatomical location easily accessible by hysteroscopy and a conservative approach may be sufficient to manage this complication.