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In the United Kingdom, endometrial biopsy reports traditionally consist of a morphologic description followed by a conclusion. Recently published consensus guidelines for reporting benign endometrial biopsies advocate the use of standardized terminology. In this project we aimed to assess the acceptability and benefits of this simplified "diagnosis only" format for reporting non-neoplastic endometrial biopsies. Two consultants reported consecutive endometrial biopsies using 1 of 3 possible formats: (i) diagnosis only, (ii) diagnosis plus an accompanying comment, and (iii) the traditional descriptive format. Service users were asked to provide feedback on this approach via an anonymized online survey. The reproducibility of this system was assessed on a set of 53 endometrial biopsies among consultants and senior histopathology trainees. Of 370 consecutive benign endometrial biopsies, 245 (66%) were reported as diagnosis only, 101 (27%) as diagnosis plus a brief comment, and 24 (7%) as diagnosis following a morphologic description. Of the 43 survey respondents (28 gynecologists, 11 pathologists, and 4 clinical nurse specialists), 40 (93%) preferred a diagnosis only, with 3 (7%) being against/uncertain about a diagnosis only report. Among 3 histopathology consultants and 4 senior trainees there was majority agreement on the reporting format in 53/53 (100%) and 52/53 (98%) biopsies. In summary, we found that reporting benign specimens within standardized, well-understood diagnostic categories is an acceptable alternative to traditional descriptive reporting, with the latter reserved for the minority of cases that do not fit into specific categories. This revised approach has the potential to improve reporting uniformity and reproducibility.

Objective There are widespread efforts to increase symptom awareness of ‘pelvic/abdominal pain, increased abdominal size/bloating, difficulty eating/feeling full and urinary frequency/urgency’ in an attempt to diagnose ovarian cancer earlier. Long-term survival of women with these symptoms adjusted for known prognostic factors is yet to be determined. This study explored the association of symptoms, routes and interval to diagnosis and long-term survival in a population-based cohort of postmenopausal women diagnosed with invasive epithelial tubo-ovarian cancer (iEOC) in the ‘no screen’ (control) UKCTOCS arm. Methods Of 101,299 women in the control arm, 574 were confirmed on outcome review to have iEOC between randomisation (2001–2005) and 31 December 2014. Data was extracted from medical notes and electronic records. A multivariable model was fitted for individual symptoms, time interval from symptom onset to diagnosis, route to diagnosis, speciality, morphological Type, age at diagnosis, year of diagnosis (period effect), stage, primary treatment, and residual disease. Results Women presenting with symptoms listed in the NICE guidelines (HR1.48, 95%CI1.16–1.89, p = 0.001) or the modified Goff Index (HR1·68, 95%CI1·32–2.13, p, Highlights • This study explored the association of symptoms of ovarian cancer, interval and route to diagnosis with survival. • Focus on ‘high alert’ symptoms: pelvic/abdominal pain, increase abdominal size/bloating and difficulty eating/feeling full • The ovarian cancer ‘high alert’ symptom complexes identify postmenopausal women with a significantly poorer prognosis. • The study could not however exclude the possibility of better outcomes in those who are aware and acted on these symptoms.

IntroductionThe SARS-CoV-2 global pandemic has caused a crisis disrupting health systems worldwide. While efforts are being made to determine the extent of the disruption, the impact on gynecological oncology trainees/training has not been explored. We conducted an international survey of the impact of SARS-CoV-2 on clinical practice, medical education, and mental well-being of surgical gynecological oncology trainees.MethodsIn our cross-sectional study, a customized web-based survey was circulated to surgical gynecological oncology trainees from national/international organizations from May to November 2020. Validated questionnaires assessed mental well-being. The Wilcoxon rank-sum test and Fisher’s exact test were used to analyse differences in means and proportions. Multiple linear regression was used to evaluate the effect of variables on psychological/mental well-being outcomes. Outcomes included clinical practice, medical education, anxiety and depression, distress, and mental well-being.ResultsA total of 127 trainees from 34 countries responded. Of these, 52% (66/127) were from countries with national training programs (UK/USA/Netherlands/Canada/Australia) and 48% (61/127) from countries with no national training programs. Altogether, 28% (35/125) had suspected/confirmed COVID-19, 28% (35/125) experienced a fall in household income, 20% (18/90) were self-isolated from households, 45% (57/126) had to re-use personal protective equipment, and 22% (28/126) purchased their own. In total, 32.3% (41/127) of trainees (16.6% (11/66) from countries with a national training program vs 49.1% (30/61) from countries with no national training program, p=0.02) perceived they would require additional time to complete their training fellowship. The additional training time anticipated did not differ between trainees from countries with or without national training programs (p=0.11) or trainees at the beginning or end of their fellowship (p=0.12). Surgical exposure was reduced for 50% of trainees. Departmental teaching continued throughout the pandemic for 69% (87/126) of trainees, although at reduced frequency for 16.1% (14/87), and virtually for 88.5% (77/87). Trainees reporting adequate pastoral support (defined as allocation of a dedicated mentor/access to occupational health support services) had better mental well-being with lower levels of anxiety/depression (p=0.02) and distress (pConclusionSARS-CoV-2 has negatively impacted the surgical training, household income, and psychological/mental well-being of surgical gynecological oncology trainees. The overall clinical impact was worse for trainees in countries with no national training program than for those in countries with a national training program, although national training program trainees reported greater distress. COVID-19 sickness increased anxiety/depression. The recovery phase must focus on improving mental well-being and addressing lost training opportunities.

Background Image guidance has been clinically available for over a period of 20 years. Although research increasingly has a translational emphasis, overall the clinical uptake of image guidance systems in surgery remains low. The objective of this review was to establish the metrics used to report on the impact of surgical image guidance systems used in a clinical setting. Methods A systematic review of the literature was carried out on all relevant publications between January 2000 and April 2016. Ovid MEDLINE and Embase databases were searched using a title strategy. Reported outcome metrics were grouped into clinically relevant domains and subsequent sub-categories for analysis. Results In total, 232 publications were eligible for inclusion. Analysis showed that clinical outcomes and system interaction were consistently reported. However, metrics focusing on surgeon, patient and economic impact were reported less often. No increase in the quality of reporting was observed during the study time period, associated with study design, or when the clinical setting involved a surgical specialty that had been using image guidance for longer. Conclusions Publications reporting on the clinical use of image guidance systems are evaluating traditional surgical outcomes and neglecting important human and economic factors, which are pertinent to the uptake, diffusion and sustainability of image-guided surgery. A framework is proposed to assist researchers in providing comprehensive evaluation metrics, which should also be considered in the design phase. Use of these would help demonstrate the impact in the clinical setting leading to increased clinical integration of image guidance systems. Electronic supplementary material The online version of this article (10.1007/s00464-019-06876-x) contains supplementary material, which is available to authorized users.

Objective – To compare surgical safety and efficiency of two image guidance modalities, perfect augmented reality (AR) and side-by-side unregistered image guidance (IG), against a no guidance control (NG), when performing a simulated laparoscopic cholecystectomy (LC). Background – Image guidance using AR offers the potential to improve understanding of subsurface anatomy, with positive ramifications for surgical safety and efficiency. No intra-abdominal study has demonstrated any advantage for the technology. Perfect AR cannot be provided in the operative setting in a patient, however it can be generated in the simulated setting. Methods – Thirty six experienced surgeons performed a baseline LC using the LapMentor™ simulator before randomisation to one of three study arms: AR, IG or NG. Each performed three further LC. Safety and efficiency-related simulator metrics, and task workload (SURG-TLX) were collected. Results –The IG group had a shorter total instrument path length and fewer movements than NG and AR groups. Both IG and NG took a significantly shorter time than AR to complete dissection of Calot’s triangle. Use of IG and AR resulted in significantly fewer perforations and serious complications than the NG group. IG had significantly fewer perforations and serious complications than AR group. Compared to IG, AR guidance was found to be significantly more distracting. Conclusion – Side-by-side unregistered image guidance (IG) improved safety and surgical efficiency in a simulated setting when compared to AR or NG. IG provides a more tangible opportunity for integrating image guidance into existing surgical workflow as well as delivering the safety and efficiency benefits desired.

Subcutaneous metastases at presentation in cervical cancer are rare and they are associated with ominous prognosis. In this literature review, we present a case of skin metastasis and systematically review the current literature with the aim to discuss trends, treatment and survival of the reported cases.

Introduction Older patients undergoing cancer surgery are at increased risk of post-operative morbidity and mortality. Frailty is particularly prevalent in this patient cohort and is a major contributor to adverse outcomes. A survey was conducted to assess the confidence and knowledge of trainees in obstetrics and gynaecology (O&G) regarding identification and management of perioperative issues encountered in frail gynaecological oncology patients. Methods A web-based survey on the management of frail perioperative patients was disseminated to doctors-in-training (trainees) in O& G in the United Kingdom (UK) and Ireland. Results Of the 666 trainees who participated, 67% (n=425/666) reported inadequate training in the perioperative management of frail patients. Validated frailty assessment tools were used by only 9% (n=59/638) of trainees and less than 1% (n=4/613) were able to correctly identify the diagnostic features of frailty. Common misconceptions included the use of chronological age and gender in frailty assessments. The majority trainees (>75%) correctly answered a series of questions relating to mental capacity; however, only 6% (n=36/606) were able to correctly identify all three diagnostic features of delirium. 87% (n=495/571) of trainees supported closer collaboration with geriatricians and a multi-disciplinary approach. Conclusions O&G trainees reported inadequate training in the perioperative care of frail gynaecological oncology patients, and overwhelmingly favoured input from geriatricians. Routine use of validated frailty assessment tools may aid diagnosis of frailty in the perioperative setting. There is an unmet need for formal education in the management of frail surgical patients within the UK and Irish O&G curriculum.

IntroductionOlder patients undergoing cancer surgery are at increased risk of post-operative complications, prolonged hospital stay, and mortality. Identification of frailty can help predict patients at high risk of peri-operative complications and allow a collaborative, multidisciplinary team approach to their care. A survey was conducted to assess the confidence and knowledge of trainees in obstetrics and gynecology regarding identification and management of peri-operative issues encountered in frail gynecological oncology patients.MethodsA web-based survey was distributed via the Audit and Research in Gynaecological Oncology (ARGO) collaborative and UK Audit and Research Collaborative in Obstetrics and Gynaecology (UKARCOG) . The survey on the management of frail peri-operative patients was disseminated to doctors-in-training (trainees) working in obstetrics and gynecology in the United Kingdom (UK) and Ireland. Specialty (ST1–7), subspecialty, and general practice trainees, non-training grade doctors, and foundation year doctors currently working in obstetrics and gynecology were eligible. Consultants were excluded. Study data were collected using REDCAP software hosted at the University of Manchester. Responses were collected over a 6-week period between January and February 2020.ResultsOf the 666 trainees who participated, 67% (425/666) reported inadequate training in peri-operative management of frail patients. Validated frailty assessment tools were used by only 9% (59/638) of trainees and less than 1% (4/613) were able to correctly identify all the diagnostic features of frailty. Common misconceptions included the use of chronological age and gender in frailty assessments. The majority of trainees (76.5%, 448/586) correctly answered a series of questions relating to mental capacity; however, only 6% (36/606) were able to correctly identify all three diagnostic features of delirium. A total of 87% (495/571) of trainees supported closer collaboration with geriatricians and a multidisciplinary approach.ConclusionsObstetrics and gynecology trainees reported inadequate training in the peri-operative care of frail gynecological oncology patients, and overwhelmingly favored input from geriatricians. Routine use of validated frailty assessment tools may aid diagnosis of frailty in the peri-operative setting. There is an unmet need for formal education in the management of frail surgical patients within the UK and Irish obstetrics and gynecology curriculum.

A 44-year-old woman presented to the spinal surgeons with mass over her sacrum. She was experiencing back pain, constipation and recent weight loss. MRI showed a 15 cm presacral mass displacing the rectosigmoid junction while being inseparable from S4 to the coccyx. In view of the anatomical

Background/aim Radiology provides increasingly accurate and complex information. Understanding the clinicians' interpretation of scans could improve surgical planning, decision-making; informed training and development of augmented imaging. This was a survey exploring the interpretation of imaging by clinicians and its use in operative preparation and prediction. Materials and methods The survey was open for two-months and circulated online to British Gynaecological Cancer society members. Results Seventy-three (19%) members completed the survey. Respondents had a confidence level of 51% in their ability to interpret computed tomography (CT) and/or magnetic resonance imaging (MRI) images independently. Preoperative imaging was commonly used to plan operations, predict complications and complete resection. Images were reviewed for primary (96.3%)/interval (92.6%) ovarian debulking, but less so for vulvectomy (45%). Scan (79.6%) and multidisciplinary team meeting (MDT) (66.6%) reports were used more often than scan images (50%) for operative planning. Amount and pattern of disease on scan were the most important factors predicting operating time. Conclusion Imaging influences the surgeon's planning, however respondents lack confidence. Training of clinicians in radiological interpretation needs to improve. Augmented image interfaces could facilitate this.

Robotic surgery may improve technical performance and reduce mental demands compared to laparoscopic surgery. However, no studies have directly compared the impact of robotic and laparoscopic techniques on surgeons’ brain function. This study aimed to assess the effect of the operative platform (robotic surgery or conventional laparoscopy) on prefrontal cortical activation during a suturing task performed under temporal demand. Eight surgeons (mean age ± SD = 34.5 ± 2.9 years, male:female ratio = 7:1) performed an intracorporeal suturing task in a self-paced manner and under a 2 min time restriction using conventional laparoscopic and robotic techniques. Prefrontal activation was assessed using near-infrared spectroscopy, subjective workload was captured using SURG-TLX questionnaires, and a continuous heart rate monitor measured systemic stress responses. Task progression scores (au), error scores (au), leak volumes (mL) and knot tensile strengths (N) provided objective assessment of technical performance. Under time pressure, robotic suturing led to improved technical performance (median task progression score: laparoscopic suturing = 4.5 vs. robotic suturing = 5.0; z = − 2.107, p = 0.035; median error score: laparoscopic suturing = 3.0 mm vs. robotic suturing = 2.1 mm; z = − 2.488, p = 0.013). Compared to laparoscopic suturing, greater prefrontal activation was identified in seven channels located primarily in lateral prefrontal regions. These results suggest that robotic surgery improves performance during high workload conditions and is associated with enhanced activation in regions of attention, concentration and task engagement. Electronic supplementary material The online version of this article (10.1007/s10439-018-2049-z) contains supplementary material, which is available to authorized users.

Introduction/Background Minimally invasive surgery (MIS) is the preferred route for women with endometrial cancer. Although robotic surgery is not yet NHS standard, it was introduced at Royal London Hospital in November 2017. The effect of introducing robotic surgery (RAH) on the length of stay (LOS) and laparotomy rates in women undergoing surgery for endometrial cancer was assessed. Methodology Electronic patient records were reviewed for all women undergoing surgery for endometrial cancer in 2016 and 2018 and analysed using Microsoft Excel and IBM SPSS. Results A total of 95 and 103 women (same mean age of 66) had surgery in 2016 and 2018 respectively. In 2016, after examination under anaesthetic (EUA), 53 (56%) proceeded to TAH and 42(44%) to TLH. 2 (0.02%) were converted from TLH to TAH. The median BMI, estimated blood loss (EBL) and LOS for the TAH group were 32 kg/m2, 350 ml and 6 days respectively whereas for TLH were 30 kg/m2, 100 ml and 2 days. In 2018, 37 (35%) had TAH and 67 (65%) MIS hysterectomy. In the MIS group, 21 (31%) had TLH and 45 (69%) RAH. 7 (11%) and 1(1%) were converted from RAH to TAH and vaginal hysterectomy respectively. Of these 8, 7 were draped but not docked. The median BMI, EBL and LOS for the TAH group were 28.6 kg/m2, 400 ml and 5 days, for TLH were 28 kg/m2, 100 ml and 1 day and for RAH were 39.3 kg/m2, 100 ml and 2 days respectively. The overall LOS has fallen from 5 days in 2016 to 3 in 2018 (p Reasons for conversion included anaesthetic, adhesions, intraoperative complications and uterine perforation. Conclusion RAH has enabled complex operating in high-risk cases while significantly reducing LOS and laparotomy rates. Disclosure Nothing to disclose.

ObjectiveThis study aimed to determine the frequency of malignant pathology in a macroscopically normal appendix during surgery for a borderline or malignant mucinous ovarian tumor (MOT).MethodsWomen with borderline and malignant MOT were identified from the pathology database from 2000 to 2014. Women who had a benign MOT and had an appendicectomy were excluded from the study. Data were collected from the electronic patient record and case notes.ResultsOf 310 women identified with MOT, 203 patients with benign MOT were excluded. Of the remaining 107 patients, 15 patients with previous appendicectomy were also excluded. The study population consisted of 92 patients. There were 57 (62%) patients with borderline MOT and 35 (38%) patients with malignant MOT. In the borderline subgroup, 40/57 (70%) patients had appendicectomy of whom 8 (20%) had macroscopically abnormal appendices. One patient had pseudomyxoma peritonei secondarily involving the appendix and 7 patients had a histologically normal appendix. Normal histology was found in all macroscopically normal appendices. In the malignant subgroup, 29/35 (83%) patients had an appendicectomy. There were 8 (27.5%) macroscopically abnormal appendices with a malignant pathology in 7 (87.5%) patients and 1 patient had a resolving appendicitis. There were 21 macroscopically normal appendices of which, serrated adenoma was found in 1 (4.8%) patient, whereas the remaining 20 (95.2%) patients had normal histology.ConclusionsIn MOT, an abnormal appearing appendix should be excised. If the appendix is grossly normal, our data do not support performing an appendicectomy as part of a surgical staging procedure.

Background Transvaginal ultrasound and serum CA125 are routinely used for differential diagnosis of pelvic adnexal mass. Use of human epididymis 4 was approved in the United States in 2011. However, there is scarcity of studies evaluating the additional value of human epididymis 4. Objective The objective of the study was to evaluate the performance characteristics of transvaginal ultrasound, CA125, and human epididymis 4 for differential diagnosis of ovarian cancer in postmenopausal women with adnexal masses. Study Design This was a cohort study nested within the screen arms of the multicenter randomized controlled trial, United Kingdom Collaborative Trial of Ovarian Cancer Screening, based in England, Wales, and Northern Ireland. In United Kingdom Collaborative Trial of Ovarian Cancer Screening, 48,230 women randomized to transvaginal ultrasound screening and 50,078 to multimodal screening (serum CA125 interpreted by Risk of Ovarian Cancer Algorithm with second line transvaginal ultrasound) underwent the first (prevalence) screen. Women with adnexal lesions and/or persistently elevated risk were clinically assessed and underwent surgery or follow-up for a median of 10.9 years. Banked samples taken within 6 months of transvaginal ultrasound from all clinically assessed women were assayed for human epididymis 4 and CA125. Area under the curve and sensitivity for diagnosing ovarian cancer of multiple penalized logistic regression models incorporating logCA125, log human epididymis 4, age, and simple ultrasound features of the adnexal mass were compared. Results Of 1590 (158 multimodal, 1432 ultrasound) women with adnexal masses, 78 were diagnosed with ovarian cancer (48 invasive epithelial ovarian, 14 type I, 34 type II; 24 borderline epithelial; 6 nonepithelial) within 1 year of scan. The area under the curve (0.893 vs 0.896; P = .453) and sensitivity (74.4% vs 75.6% ;P = .564) at fixed specificity of 90% of the model incorporating age, ultrasound, and CA125 were similar to that also including human epididymis 4. Both models had high sensitivity for invasive epithelial ovarian (89.6%) and type II (>91%) cancers. Conclusion Our population cohort study suggests that human epididymis 4 adds little value to concurrent use of CA125 and transvaginal ultrasound in the differential diagnosis of adnexal masses in postmenopausal women.

There is a changing dynamic in research that aims to increase the participation of patients in its design and implementation. Patient and public involvement (PPI) is essential for achieving valid, clinically applicable results. A systematic review by Brett et al 1 demonstrated the potential benefits of PPI in establishing and undertaking research, and writing-up and disseminating results. Eye tracking is an innovative technology used extensively in allied fields such as psychology and aerospace.2 It is increasingly used in surgical research,3 particularly assessment and training. Despite the growing popularity of the technology, there are no data investigating the patient's experience and views relating to this technology. This study aims to elicit the perception of patients' involvement in eye tracking research in order to improve their experience and the overall quality of the research. This was a cross-sectional, qualitative study of participants concurrently involved in eye tracking research for two different ongoing clinical studies at Imperial …

Background Over the last three decades, surgical practice has undergone a significant change with a move towards minimally invasive surgery (MIS) as the standard of care [1]. Although this has brought with it significant benefits, problems have also been associated with the advent of MIS. Perhaps the most substantial limitation associated with MIS is the loss of haptic feedback; this deficit is at its most extreme in robot-assisted surgery, where at present such feedback is lost entirely [2]. The image-enhanced operating environment looks to mitigate for the loss of haptic feedback by providing the surgeon with visual cues to the subsurface anatomy. The use of intraoperative image guidance can be divided into that used for operative planning, to facilitate the rapid identification of critical anatomical structures, for example, and that used for task execution, an example of which is tumour resection [2]. These two steps have very different requirements, with the first needing a large amount of anatomical information to be displayed without the need to account for tissue deformation or accurate registration, while the second requires less information to be displayed, but with much greater spatial accuracy.

Assessment based on change in serial CA125 values rather than absolute cut-off would have allowed earlier diagnosis of invasive epithelial ovarian cancer.

OBJECTIVE—This study examines the association of A1C with cardiovascular disease (CVD) risk factors, coronary artery disease (CAD), and metabolic syndrome in Asian Indians with normal glucose tolerance (NGT). RESEARCH DESIGN AND METHODS—This cross-sectional study recruited subjects from phase III of the Chennai Urban Rural Epidemiology Study (CURES), an epidemiological study in a representative population of Chennai (formerly Madras) in South India, conducted between January 2003 and June 2004. Included were 1,644 subjects with NGT, i.e., fasting plasma glucose RESULTS—The mean ± SD A1C value in the study cohort was 5.5 ± 0.4%. A1C showed a significant association with BMI (β = 0.017, P < 0.001), systolic (β = 0.002, P = 0.028) and diastolic (β = 0.202, P = 0.017) blood pressure, waist circumference (β = 0.007, P < 0.001), serum cholesterol (β = 0.002, P < 0.001), triglycerides (β = 0.001, P < 0.001), LDL cholesterol (β = 0.002, P < 0.001), fasting insulin (β = 0.009, P < 0.001), and homeostasis model assessment of insulin resistance (β = 0.047, P < 0.001) after adjusting for age and sex. Regression analysis showed that A1C had a strong association with metabolic syndrome that persisted after adjusting for age and sex (odds ratio [OR] 2.9 [95% CI 2.08–4.00]; P < 0.001). A1C also had a strong association with CAD (2.6 [1.23–5.63]; P = 0.01), but the significance was lost when adjusted for age and sex. CONCLUSIONS—There is a strong association of A1C with prevalent CVD risk factors in Asian-Indian subjects with NGT.

In a random assignment study, substance-abusing patients with HIV/AIDS in a public general hospital received a brief contact condition or received 12 months of case management delivered by paraprofessionals. Patient outcomes included substance use, HIV transmission risk, physical health, psychological status, and quality of living situation. In both conditions, a significant decrease occurred in a range of problems from Intake to the 6-month interview, followed by no significant pattern of change at 12- and 18-month interviews. On major outcome variables, there were no significant differences between the brief contact and case management conditions. Sixteen percent had died by the 18-month interview. Process data indicated wide variation in the amount of case management received by participants, and the amount of case management was not related to improvement in the outcome measures. The study has limitations yet does not support the hypothesis that case management improves outcomes better than brief contact for this population.

Two cases that typify the psychiatric disturbances seen in patients with Acquired Immune-Deficiency Syndrome (AIDS) are described. Given the increasing incidence of this disorder, the authors recommend that psychiatrists become more familiar with its psychiatric manifestations.