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The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception., (Copyright © 2021 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Study Objective: To assess the feasibility of a noncontact radio sensor as an objective measurement tool to study postoperative recovery from endometriosis surgery., Design: Prospective cohort pilot study., Setting: Center for minimally invasive gynecologic surgery at an academically affiliated community hospital in conjunction with in-home monitoring., Patients: Patients aged above 18 years who sleep independently and were scheduled to have laparoscopy for the diagnosis and treatment of suspected endometriosis., Interventions: A wireless, noncontact sensor, Emerald, was installed in the subjects' home and used to capture physiologic signals without body contact. The device captured objective data about the patients' movement and sleep in their home for 5 weeks before surgery and approximately 5 weeks postoperatively. The subjects were concurrently asked to complete a daily pain assessment using a numeric rating scale and a free text survey about their daily symptoms., Measurements and Main Results: Three women aged 23 years to 39 years and with mild to moderate endometriosis participated in the study. Emerald-derived sleep and wake times were contextualized and corroborated by select participant comments from retrospective surveys. In addition, self-reported pain levels and 1 sleep variable, sleep onset to deep sleep time, showed a significant (p <.01), positive correlation with next-day-pain scores in all 3 subjects: r = 0.45, 0.50, and 0.55. In other words, the longer it took the subject to go from sleep onset to deep sleep, the higher their pain score the following day., Conclusion: A patient's experience with pain is challenging to meaningfully quantify. This study highlights Emerald's unique ability to capture objective data in both preoperative functioning and postoperative recovery in an endometriosis population. The utility of this uniquely objective data for the clinician-patient relationship is just beginning to be explored., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Studies analyzing the impact of visceral fat excess on surgical outcomes after resection for colorectal cancer (CRC) have yielded conflicting results. Visceral obesity (VO) and sarcobesity (SO) have been recently addressed as risk factors for poor short-term results while no data are available for recovery goals after surgery. No data are available on the protective effect of ERAS in VO and SO patients. The aim of this study was to assess clinical implications of computed tomography (CT) assessed VO and SO on surgical and recovery outcomes after minimally invasive resection for CRC before and after ERAS protocol implementation., Methods: Visceral adipose tissue (VAT) and skeletal muscle area (SMA) were retrospectively assessed using pre-operative CT studies of 261 patients who underwent laparoscopic resection for CRC between January 2012 and April 2019; ERAS protocol was adopted in 160 patients operated on after March 2014. Patients' surgical and recovery outcomes were compared according to BMI categories, VO and SO which was defined using the VAT/SMA ratio (Sarcobesity Index). Predictive factors for poor surgical and recovery outcomes were evaluated by univariate and multivariate analyses., Results: Of the 261 patients, 12.6% were BMI obese while 68.6% presented visceral obesity. BMI was not associated to any of the outcomes considered. No differences in intra-operative results were found except for a lower number of retrieved lymph nodes both in VO and SO patients. While VO showed no impact on post-operative course, SO resulted an independent risk factor for cardiac complications and prolonged post-operative ileus (PPOI) at logistic regression analysis. Furthermore, sarcobese patients showed delayed recovery after surgery. Patients enrolled in the ERAS protocol showed improved recovery outcomes for both VO and SO groups, although ERAS did not result to be a protective factor for cardiac complications and PPOI., Conclusions: A high Sarcobesity Index is a risk factor for developing cardiac complications and PPOI after laparoscopic resection for CRC. A reduced number of lymph nodes retrieved is associated to VO and SO. These conditions should then be considered in clinical practice for the risk of down staging the N stage. Effect of VO and SO on recovery items after surgery should be further investigated. ERAS protocol application should be implemented to improve recovery outcomes in VO and SO patients undergoing laparoscopic colorectal resection., Competing Interests: Conflicts of interest Pedrazzani C, Conti C, Zamboni G.A, Chincarini M, Turri G, Valdegamberi A, Guglielmi A have no conflicts of interest to disclose., (Copyright © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Study Objective: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire., Design: Secondary analysis of a prospective randomized controlled trial., Setting: Three academic research centers., Patients: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included., Interventions: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications., Measurements and Main Results: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010-7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966-180.5, respectively)., Conclusion: Transvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life. (Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.)., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Enhanced recovery after surgery (ERAS), or "fast-track" protocol, aims to minimize the physiologic stress of surgery and optimize the rehabilitation of patients. However, there is limited data in obstetrics and gynecology. We reviewed the published literature on ERAS programs in gynecology to evaluate the outcomes and potential key elements for a successful program. Fifty studies were evaluated. We recommend preoperative counseling to the patient, no bowel preparation, an opioid-sparing multimodal approach to pain management, goal-directed fluid management, minimally invasive surgery when possible, and early mobilization and feeding. This is a multidisciplinary team effort and requires active patient participation in the process., (Copyright © 2019. Published by Elsevier Inc.)

Enhanced recovery after surgery (ERAS) is an evidence-based approach to perioperative care of the surgical patient. A mounting body of literature in gynecologic surgery has demonstrated that ERAS improves postoperative outcomes, shortens hospital length of stay, and reduces cost without increasing complications or readmissions. Most of the existing literature has concentrated on open surgery, questioning if patients undergoing minimally invasive surgery also derive benefit. Our aim was to systematically review the literature on ERAS after minimally invasive gynecologic surgery (MIGS) with and without bowel surgery. Given the paucity of studies on ERAS in MIGS with bowel surgery (1 study), we expanded our search to include studies of ERAS in patients undergoing minimally invasive colorectal resections alone. Twelve studies were identified through an electronic database search of PubMed, Medline, and Ovid EMBASE. These studies included patients undergoing MIGS for benign and/or malignant indications and showed that ERAS pathways decreased length of stay and/or increased the proportion of same-day discharge surgeries, improved patient satisfaction, and reduced hospital costs while maintaining low postoperative complication and readmission rates. Although limited, data from a single study suggest that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity, and less readmissions. Although the variation between the published protocols underscores the need for standardization, existing literature supports the adoption of ERAS as safe and effective when planning MIGS., (Copyright © 2018. Published by Elsevier Inc.)

Background: The feasibility, safety, and efficacy of programs for enhanced recovery after bariatric surgery (ERABS) are now well established. However, data concerning their large-scale implementation remain insufficient., Objectives: The objective of the present study was to review the multicenter implementation of ERABS SETTING: This retrospective analysis of a prospective database was conducted in 15 Groupe francophone de Rehabilitation Améliorée après ChirurgiE centers from data from March 2014 to January 2017., Methods: The Francophone working Group for Enhanced Recovery After Surgery (Groupe francophone de Rehabilitation Améliorée après ChirurgiE) edited and released protocols of ERABS for its members. Compliance with ERABS, lengths of hospital stay, and postoperative morbidity were obtained from the Groupe francophone de Rehabilitation Améliorée après ChirurgiE-audit database., Results: In this study, 1667 patients were included. Procedures were sleeve gastrectomy (n = 1011), gastric bypass (n = 300), or mini-bypass (n = 356). Mean body mass index was 41.8 ± 8.3 kg/m 2 . Global morbidity was 2.57%, and surgery-related morbidity was 1.67% (mostly anastomotic leakages and hemorrhage). Mean length of hospital stay was 2.4 ± 3.6 days. Overall compliance was 79.6%. Among the 23 elements of the ERABS program, 14 were applied in>70% of instances, 6 in between 50% and 70%, and 3 in<50%. The elements least often applied were limb intermittent pneumatic compression during surgery (23.3%), multimodal analgesia (49.5%), and optimal perioperative fluid management (43.8%)., Conclusion: This study shows that even if the overall compliance was good, the large-scale implementation of ERABS can still be improved, as several elements remain insufficiently applied. This finding highlights the importance of thorough, continuous training in addition to the need for repeated audits by centers involved in ERABS programs., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Study Objective: To analyze bowel and urinary function in patients with posterior deep infiltrating endometriosis (DIE) >30 mm in largest diameter at transvaginal ultrasound before and after surgical nerve-sparing excision., Design: Prospective observational study (Canadian Task Force classification III)., Setting: Tertiary care university hospital in Bologna, Italy., Patients: Twenty-five patients with posterior DIE were included in the study between June 2011 and December 2012. Patients did not receive hormone therapy for at least 3 months before and 6 months after surgery., Interventions: Patients underwent urodynamic studies and anorectal manometry before and after nerve-sparing laparoscopic excision of the posterior DIE nodule., Measurements and Main Results: Intestinal and urinary function was evaluated in patients with bulky posterior DIE using urodynamic and anorectal manometry. Results of urodynamic studies and anorectal manometry were similar before and after nerve-sparing surgical excision of the posterior DIE nodule. Urodynamic studies demonstrated a high prevalence of voiding dysfunction, whereas anorectal manometry showed no reduction in rectoanal inhibitory reflex and hypertone of the internal anal sphincter., Conclusions: Patients with posterior DIE >30 mm in greatest diameter demonstrate preoperative dysfunction at urodynamic study and anorectal manometry, probably due to DIE per se. The nerve-sparing surgical approach seems not to influence the motility or sensory capacity of the bladder and the rectosigmoid colon., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Laparoscopy is one of the cornerstones in the surgical revolution and transformed outcome and recovery for various surgical procedures. Even if these changes were widely accepted for basic interventions, like appendectomies and cholecystectomies, laparoscopy still remains challenged for more advanced operations in many aspects. Despite these discussion, there is an overwhelming acceptance in the surgical community that laparoscopy did transform the recovery for several abdominal procedures. The importance of improved peri-operative patient management and its influence on outcome started to become a focus of attention 20 years ago and is now increasingly spreading, as shown by the incoming volume of data on this topic. The enhanced recovery after surgery (ERAS) concept incorporates simple measures of general management, and requires multidisciplinary collaboration from hospital staff as well as the patient and the relatives. Several studies have demonstrated a significant decrease in postoperative complication rate, length of hospital stay and reduced overall cost. The key elements of success are fluid restriction, a functioning epidural and preoperative carbohydrate intake. With the expansion of laparoscopic techniques, ERAS increasingly incorporates laparoscopic patients, especially in colorectal surgery. However, the precise impact of laparoscopy on ERAS is still not clearly defined. Increasing evidence suggests that laparoscopy itself is an additional ERAS item that should be considered as routine where feasible in order to obtain the best surgical outcomes., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Evaluate the relevance of supracervical hysterectomy, in particular by laparoscopy, in the treatment of symptomatic myomas., Methods: Examination of the literature in the MEDLINE and Cochrane databases, between 1960 and 2010., Results: Because of reduced or identical complications when performed in laparotomy or laparoscopy, respectively, subtotal hysterectomy is a possible alternative to total hysterectomy (grade B). In case of previous or current cervical dysplasy, total hysterectomy is preferable to subtotal hysterectomy (grade B). Conical resection of the endocervix is recommended in case of subtotal hysterectomy (grade C). There is no advantage to subtotal hysterectomy for the sole purpose of avoiding functional or sexual pelvic troubles (grade A)., Conclusion: In case of symptomatic myomas, subtotal hysterectomy can be beneficial., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)