Objectif Fournir une mise à jour de la directive actuelle fondée sur des données probantes relativement aux techniques et technologies utilisées pour l’ablation de l’endomètre, une technique minimalement invasive pour la prise en charge des saignements utérins anormaux d’origine bénigne. Population cible Femmes en âge de procréer présentant des saignements utérins anormaux et une pathologie bénigne avec ou sans anomalies structurelles. Bénéfices, risques et coûts La mise en œuvre des recommandations de la directive améliorera la prestation de l’ablation de l’endomètre en tant que traitement efficace des saignements utérins anormaux. Le respect de ces recommandations permet de réaliser l’intervention chirurgicale de façon sécuritaire et de maximiser le succès du traitement pour les patientes. Données probantes La directive a été mise à jour à partir de la littérature publiée, telle que relevée par des recherches dans les bases de données Medline et Cochrane Library pour la période de janvier 2014 à avril 2023 en utilisant des termes et mots clés pertinents prédéterminés (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy). Seuls les résultats de revues systématiques, d’essais cliniques randomisés ou comparatifs et d’études observationnelles en anglais ont été retenus.La littérature grise (non publiée) a été récupérée auprès de l’Association des obstétriciens et gynécologues du Québec (AOGQ) en 2023. Méthodes de validation Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l’annexe A (tableau A1 pour les définitions et tableau A2 pour l’interprétation des recommandations fortes et faibles). Professionnels concernés Obstétriciens, gynécologues et prestataires de soins primaires. Résumé des médias sociaux Cette directive est une version mise à jour de la directive de 2015 de la SOGC sur l’ablation de l’endomètre. Les auteurs abordent les considérations particulières, fournissent une mise à jour des données probantes et formulent de nouvelles recommandations concernant le déficit liquidien.

Hysteroscopic surgery requires a balance of continuous controlled irrigation and aspiration to distend the endometrial cavity to a degree that provides the clear and stable visual environment necessary for diagnostic and therapeutic procedures. Whereas the preferred distending solution should be isotonic and isonatremic, radiofrequency (RF) electrosurgery with monopolar instrumentation can only be performed with non-ionic (hyponatremic) solutions. Absorption of as little as 500 mL and certainly more than 1000 mL of non-ionic solutions can result in fluid overload and/or dilutional hyponatremia with potentially serious adverse effects under certain conditions and patient characteristics. Both hysteroscopic RF electrosurgery with bipolar instrumentation and electro-mechanical morcellation and aspiration systems use isotonic and isonatremic solutions. Depending on the clinical context, absorption of more than 1500 mL of isonatremic solutions can also result in serious adverse effects. Automated fluid management systems are preferred and recommended, and surgeons should aim to maintain the maximum allowable intravasation of distending media below 1000 and 1500 mL for non-ionic and ionic fluids, respectively.

Objective To provide an update of the current evidence-based guideline on the techniques and technologies used in endometrial ablation, a minimally invasive technique for the management of abnormal uterine bleeding of benign origin. Target Population Women of reproductive age with abnormal uterine bleeding and benign pathology with or without structural abnormalities. Benefits, Harms, and Costs Implementation of the guideline recommendations will improve the provision of endometrial ablation as an effective treatment for abnormal uterine bleeding. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients. Evidence The guideline was updated with published literature retrieved through searches of Medline and the Cochrane Library from January 2014 to April 2023, using appropriate controlled vocabulary and keywords (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English.Grey (unpublished) literature was retrieved from the Association of Obstetricians and Gynecologists of Quebec (AOGQ) in 2023. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). Intended Audience Obstetricians, gynaecologists, and primary care providers. Social Media Abstract This is an updated version of the 2015 SOGC Endometrial Ablation guideline. The authors discuss special considerations, update evidence, and make new fluid deficit recommendations.

Objectives: Our objective was to identify predictors of morcellation during a total laparoscopic hysterectomy (TLH). Methods: A retrospective cohort study (Canadian Task Force classification II-2) taking place in a university hospital center in Quebec, Canada. Participants were women undergoing a TLH for a benign gynaecologic pathology from January 1, 2017, to January 31, 2019. All women underwent a TLH. If the uterus was too voluminous to be removed vaginally, surgeons favoured in-bag morcellation by laparoscopy. Uterine weight and characteristics were assessed before surgery by ultrasound or magnetic resonance imaging to predict morcellation. Results: A total of 252 women underwent a TLH and the mean age was 46 +/- 7 (30-71) years old. The main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17-1572) +/- 272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least 1 leiomyoma. Among women with a uterine weight <250 grams, 120 (95%) did not require morcellation. On the opposite, among women with a uterine weight >500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (similar to 250 vs. <250 grams; OR 3.7 [CI 1.8 to 7.7, P < 0.01]), having >= 1 leiomyoma (OR 4.1, CI 1.0 to 16.0, P = 0.01) and leiomyoma of >= 5 cm (OR 8.6, CI 4.1 to 17.9, P < 0.01) were other significant predictors morcellation in multivariate logistic regression analysis. Conclusions: Uterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation.

Background: Mechanical bowel preparation before gynecologic surgeries has been administered for decades but its use is controversial today. Objectives: To assess the efficacy and tolerance of mechanical bowel preparation before benign laparoscopic or vaginal gynecologic surgeries. Search strategy: MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Sciences published up to December 2021. Selection criteria: Randomized clinical trials in any language comparing mechanical bowel preparation before laparoscopic and vaginal gynecologic surgeries with no preparation were included. Data collection and analysis: Two reviewers independently screened and extracted data from selected articles and assessed the risk of bias. Surgeon findings, operative outcomes and patient’s pre-operative symptoms and satisfaction were collected. Main results: Twelve studies (1715 patients) of the 925 records screened were included. No significant differences were observed on surgical field view (RR=1.01, 95%CI 0.97-1.05, p=0.66, I =0%); bowel handling (RR=1.01, 95%CI 0.95-1.08, p=0.78, I =67%). There were no statistically significant differences in peri-operative findings. Mechanical bowel preparation was associated with increased pain (MD=11.62[2.80-20.44], I =76, p=0.01); weakness (MD=10.73[0.60-20.87], I =94, p=0.04); hunger (MD=17.52[8.04-27.00], I =83, p=0.0003); insomnia (MD=10.13[0.57-19.68], I =82, p=0.04); and lower satisfaction (RR=0.68 95%CI 0.53-0.87, I =76%, p=0.002). Conclusion: In view of the adverse effects induced by mechanical bowel preparation and the lack of any surgical benefit, the routine its use prior to benign gynecological surgeries should be abandoned. Funding: This work was granted by the French network of University Hospitals HUGO and Fonds de recherche du Québec-Santé.

Objective: To assess the effect of a standardized questionnaire for premenopausal women with abnormal uterine bleeding (AUB) on clinical information collection and duration of consultation. Methods: We conducted a before and after study involving 100 premenopausal women undergoing consultation for AUB. During stage 1, 50 consultations were recorded on a consultation sheet with no specific template. During stage 2, 50 women completed a 26-item auto-administered standardized questionnaire before the consultation, which was then reviewed with the consultant and added to the medical record. The duration of consultation was assessed in subgroups of 27 women in each stage. Two independent evaluators assessed the quality and completeness of data collected in the medical records using a score sheet developed by experts. Outcomes from both stages were compared using the t test. Results: The descriptive characteristics were similar in both groups. The mean global scores of the quality and completeness of data collected improved significantly between stages 1 and 2, from 67% +/- 12% to 95% +/- 5% (P < 0.0001), as did medical background scores (54% +/- 29% vs. 85% +/- 13%; P < 0.0001) and AUB-related symptoms scores (69% +/- 13% vs. 97% +/- 5%; P < 0.0001). A mean reduction in duration of consultation of nearly 4 minutes was observed (24.6 +/- 4.3 min vs. 20.7 +/- 4.8 min; P < 0.0001). Conclusion: The AUB-specific standardized questionnaire improves quality and completeness of data collected in medical records and reduces duration of consultation.

OBJECTIVE: To evaluate the effect of hormonal suppression on fertility when administered to infertile patients or patient wishing to conceive after surgery for endometriosis. DATA SOURCES: A systematic search of MEDLINE, EMBASE, CENTRAL and was performed by two independent reviewers from the databases' inception until December 2020. METHODS OF STUDY SELECTION: We included randomized controlled trials comparing any suppressive hormonal therapy to an inactive control (placebo or absence of treatment) after conservative surgery for endometriosis. Studies that did not report fertility outcomes after surgery were excluded. TABULATION, INTEGRATION AND RESULTS: This systematic review and meta-analysis was registered in PROSPERO. Two reviewers extracted data and assessed the risk of bias as well as the strength of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed. Relative risks (RRs) were pooled by quantitative random effect meta-analysis. From 3,138 citations, 19 trials (2,028 patients) were included. Overall, no difference was observed between the treatment and the control group for pregnancy (RR 1.15; 95% CI 1.00-1.32) and live births (RR 1.05; 95% CI 0.84-1.32). When pooling all hormonal therapies, the duration of administration of postoperative therapy was identified as a substantial source of heterogeneity between studies (I-2 difference=74%) with increased chances of pregnancy compared with control when administered for at least 3 months (RR 1.22; 95% CI 1.04-1.43). Gonadotropin-releasing hormone (GnRH) agonists (14 trials, 1,721 patients) were associated with increased chances of pregnancy compared with placebo or no treatment (RR 1.20; 95% CI 1.03-1.41; I-2=25%). Data were limited for other hormonal treatments with no significant difference between groups. Subgroup analyses taking into account the use of fertility treatments (insemination or in vitro fertilization), stages of the disease and risk of bias of included trials did not modify the results. CONCLUSION: Postoperative hormonal suppression should be considered on a case-by-case basis to enhance fertility while balancing this benefit with the risks of delaying conception. If chosen, GnRH agonists would be the treatment of choice, and a duration of at least 3 months should be favored.

We read with great interest the editorial written by Dr. Tulandi in the January edition of JOGC on the dangers of fluid absorption during hysteroscopic surgery. We fully agree on the importance of carefully monitoring fluid absorption and also agree on tips and tricks to mitigate absorption, which are recommended in his editorial. We add to these suggestions minimizing the use of general anesthesia, which is associated with more fluid absorption than local anesthesia with intravenous sedation.1 However, Dr.

Objective: To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery. Target population: All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications. Options: The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars. Outcomes: Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery. Evidence: We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. Validation methods: The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A). Intended audience: Surgeons performing laparoscopic gynaecological surgery.

Introduction: Cervical myomectomy can compromise cervical integrity and the risk of subsequent cervical incompetence is unclear. In this case report, the literature on cervical myomectomies is reviewed as well as that on the potential benefits of cervical cerclage. Case presentation: A 30-year-old woman, nulligravida, with a 12 cm cervical leiomyoma consulted for heavy menstrual bleeding and pelvic pain. After failure of multiple medical therapies, a laparoscopic cervical myomectomy was successfully performed after pre-operative uterine artery embolization using absorbable gelatin sponges to reduce surgical blood loss. Discussion: A concomitant laparoscopic cerclage was achieved in order to prevent cervical incompetence, given that the full thickness of the anterior cervix was penetrated during the myomectomy.

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.

Les auteurs sont désolés que la référence 51 de la version papier de cet article soit erronée. La référence 51 correcte est la suivante :Bernante P, Foletto M, Toniato A. Creation of pneumoperitoneum using a bladed optical trocar in morbidly obese patients: technique and results. Obes Surg. 2008 Aug;18(8):1043-6. doi: 10.1007/s11695-008-9497-8. La version en ligne de l'article a été corrigée. Les auteurs souhaitent s'excuser pour toute confusion que cette erreur aurait pu causer. DOI de l'article original : https://doi.org/10.1016/j.jogc.2020.12.013 Directive clinique n° 412: Entrée laparoscopique en chirurgie gynécologiqueJournal of Obstetrics and Gynaecology Canada Vol. 43Issue 3PreviewÉvaluer les risques et bénéfices de la chirurgie laparoscopique et fournir une orientation clinique sur les techniques et technologies d'entrée et sur leurs complications associées en chirurgie gynécologique. Full-Text PDF

This editorial was published with reference number errors and errors in the reference list. The online version of the editorial has been now corrected. The Editorial Office apologizes for any inconvenience caused. Technicity in Canada: The Long and Short of Hysterectomy IncisionsJournal of Obstetrics and Gynaecology Canada Vol. 41Issue 9PreviewNearly a decade ago, the concept of technicity was introduced to the Canadian gynaecologic community by Drs. Philippe Laberge and Sukhbir S. Singh.1 The word refers to the extent to which a group possesses technical skills or technology.2 In the context of hysterectomy, the concept, which originated in France, represents the use of less invasive approaches over laparotomy, and is calculated as the sum of vaginal and laparoscopic hysterectomies divided by the total number, expressed as a percentage. Full-Text PDF

I read with interest the article by Bergeron et al., 1 Bergeron A-M Chen I Laberge PY et al. Minimally invasive hysterectomy rates in Québec: trends over the last decade and predictors of technicity. J Obstet Gynaecol Can. 2020; 42: 1469-1474 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar “Minimally Invasive Hysterectomy Rates in Québec: Trends Over the Last Decade and Predictors of Technicity.” I would like to challenge both their reported trend and predictors with data from a small, rural, single-specialist practice. Minimally Invasive Hysterectomy Rates in Québec: Trends Over the Last Decade and Predictors of TechnicityJournal of Obstetrics and Gynaecology Canada Vol. 42Issue 12PreviewTo assess trends and predictors of a high technicity index for hysterectomies performed in the province of Québec. Full-Text PDF Reply to “Letter: Re: Bergeron et al., Predictors of Technicity”Journal of Obstetrics and Gynaecology Canada Vol. 43Issue 6PreviewWe would like to thank Dr. Pienaar for his comment and stimulating the discussion about the evolution of the technicity index. Full-Text PDF

A 38-year-old woman was referred to our centre for symptomatic leiomyoma. The patient had a large uterus, heavy menstrual bleeding, and compressive symptoms refractory to medical treatments. The patient was then scheduled for total laparoscopic hysterectomy with contained morcellation. After circular colpotomy completion, a strong, folded, 4-L bag with an additional sleeve for the optics was inserted into the abdominal cavity through the vagina. The colored tabs on the edge of the bag mouth served as landmarks during bag deployment. After ensuring optimal positioning, the entire bag was fully deployed, and the specimen was placed inside. Thereafter, the coloured tabs were joined together, and a monofilament drawstring was cinched to close the bag and pulled out through the suprapubic trocar. Next, the small extra sleeve was brought up through the umbilical incision. The bag was then insufflated, and the power morcellator was inserted through the suprapubic incision. After completing the morcellation, the pneumo bag was evacuated, and knots were made in both openings of the bag to avoid spillage. The closed bag was finally removed through the vagina, with final laparoscopic closure of the vaginal vault.

BACKGROUND: Endometrial ablation/resection and the levonorgestrel intra-uterine system (LNG-IUS) are well-established treatment options for heavy menstrual bleeding to avoid more invasive alternatives, such as hysterectomy. OBJECTIVE: The aim was to compare the efficacy and safety of endometrial ablation or resection with the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and to investigate sources of heterogeneity between studies. SEARCH METHODS: We searched the databases MEDLINE, EMBASE, CENTRAL, Web of Science, Biosis and Google Scholar as well as citations and reference lists published up to August 2019. Two authors independently screened 3701 citations for eligibility. We included randomized controlled trials published in any language, comparing endometrial ablation or resection to the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and a normal uterine cavity. OUTCOMES: Thirteen studies (N=884) were eligible. Two independent authors extracted data and assessed the quality of included studies. Random effect models were used to compare the modalities and evaluate sources of heterogeneity. No significant differences were observed between endometrial ablation/resection and the LNG-IUS in terms of subsequent hysterectomy (primary outcome, risk ratio (RR)=1.13, 95% CI 0.60 to 2.11, P=0.71, I-2=14%, 12 studies, 726 women), satisfaction, quality of life, amenorrhea and treatment failure. However, side effects were less common in women treated with endometrial ablation/resection compared to the LNG-IUS (RR=0.52, 95% CI 0.37 to 0.71, P<0.001, I-2=0%, 10 studies, 580 women). Three complications were reported in the endometrial ablation/resection group and none in the LNG-IUS group (P=0.25). Mean age of the studied populations was identified as a significant source of heterogeneity between studies in subgroup analysis (P=0.01). In fact, endometrial ablation/resection was associated with a higher risk of subsequent hysterectomy compared to the LNG-IUS in younger populations (mean age <= 42 years old, RR=5.26, 95% CI 1.21 to 22.91, P=0.03, I-2=0%, 3 studies, 189 women). On the contrary, subsequent hysterectomy seemed to be less likely with endometrial ablation/resection compared to the LNG-IUS in older populations (mean age >42 years old), although the reduction did not reach statistical significance (RR=0.51, 95% CI 0.21 to 1.24, P=0.14, I-2=0%, 5 studies, 297 women). Finally, sensitivity analysis taking into account the risk of bias of included studies and type of surgical devices (first and second generation) did not modify the results. Most of the included studies reported outcomes at up to 3 years, and the relative performance of endometrial ablation/resection and LNG-IUS remains unknown in the longer term. WIDER IMPLICATIONS: Endometrial ablation/resection and the LNG-IUS are two excellent treatment options for heavy menstrual bleeding, although women treated with the LNG-IUS are at higher risk of experiencing side effects compared to endometrial ablation/resection. Otherwise, younger women seem to present a lower risk of eventually requiring hysterectomy when treated with the LNG-IUS compared to endometrial ablation/resection.