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This investigation sought systematically to review and meta-analyze evidence on reproductive outcomes following uterine artery occlusion (UAO) at myomectomy. Databases searched included PubMed, EMBASE, Ovid MEDLINE, Web of Science, and ClinicalTrials.gov. Eligible studies included observational and randomized controlled trials in which patients underwent abdominal, laparoscopic, or robotic myomectomy and in which at least one measure of clinical pregnancy rate, live birth rate, or ovarian reserve was reported. The primary outcome was live birth rate. Secondary outcomes included clinical pregnancy rate, miscarriage rate, adverse pregnancy outcomes, and measures of ovarian reserve. Twelve articles involving 689 women were included in the systematic review. The intervention group underwent UAO at laparoscopic or abdominal myomectomy (UAO+M) (n = 470). The control group underwent myomectomy alone (n = 219). Seven articles involving 420 women were included in the meta-analysis (201 underwent UAO+M; 219 underwent myomectomy alone). Live births occurred in 54 of 201 (27%) women in the UAO+M group and in 74 of 219 (34%) women in the control group. Clinical pregnancies occurred in 73 of 201 (36%) women in the UAO+M group and in 102 of 219 (47%) control subjects. There was no difference in live birth rates (odds ratio 0.89; 95% CI 0.56–1.43; P = 0.51; 7 studies, 420 patients) or clinical pregnancy rates (odds ratio 0.81; 95% confidence interval 0.53–1.24; P = 0.33; 7 studies, 420 patients) between the UAO+M and control groups. Data on miscarriage rates, adverse pregnancy outcomes, and measures of ovarian reserve precluded meta-analysis. In conclusion, UAO at myomectomy is not associated with reductions in live birth or clinical pregnancy rates. Before routine use can be recommended in women desiring future fertility, more research is required on reproductive outcomes and effects on ovarian reserve.

Objectives An isthmocele is a cesarean section scar defect with a depth of >2mm, and can cause both obstetric and gynecologic complications. To date, no study has determined the impact of a locked versus unlocked double-layer uterine closure technique on isthmocele prevention. The primary objective of this study is to evaluate protocol feasibility amongst our own patients and physicians, with the ultimate goal of a larger-scale randomized controlled trial (RCT). Secondary objectives include determining: (a) isthmocele incidence; (b) isthmocele measurements on postoperative transvaginal ultrasound; and (c) adverse surgical outcomes related to suture technique. Methods This is a single-centre parallel-group pilot RCT enrolling 50 participants (25 per arm) including all term singleton pregnant women >18 years old undergoing primary cesarean section. Exclusion criteria include previous uterine hysterotomy, known uterine anomalies, active labour, known bleeding disorders, and maternal connective tissue disorders. Subjects are randomized to locked versus unlocked first layer uterine closure, followed by an unlocked second layer. Women will undergo transvaginal ultrasound to evaluate isthmocele formation six months postoperatively. Results At time of submission 31 subjects have been recruited. Data will be analyzed on an intention-to-treat basis. Demographic data will be reported using descriptive statistics. Rates of isthmocele will be compared between groups using chi-square analysis; subgroup analysis of the variable suture material will be performed. Other outcomes will be assessed using a t test (continuous variables) or chi-square test (categorical variables) as appropriate. Conclusions This study design appears feasible at this time. Further outcome data will be reported once the study is complete.

Video abstract summary When a Pfannenstiel incision does not provide adequate exposure, the Maylard and Cherney incisions may be considered as alternatives to midline laparotomy due to their unique advantages. Both provide superior pelvic exposure compared to the Pfannenstiel incision while offering significant benefits over a midline incision such as lower post operative pain scores, decreased pulmonary complications, abdominal adhesions and improved cosmesis. These incisions can be used for a multi-fibroid uterus, endometriosis, or when access to the retropubic or other pelvic spaces is needed. This video reviews the surgically relevant anatomy of the anterior abdominal wall and provides a stepwise approach for performing both the Maylard and Cherney incisions using narrated illustrations and video footage. When a laparotomy is indicated, a Maylard or Cherney incision should be considered as both provide excellent pelvic exposure with all the benefits of a transverse abdominal incision.

Objective To demonstrate three approaches to uterine artery occlusion at time of myomectomy as a blood-sparing intraoperative technique. Design A step-by-step explanation of the procedure with surgical video footage. Setting Academic medical center. Patient(s) Patients undergoing laparoscopic myomectomy, for whom a uterine artery occlusion was performed before any uterine incision. Intervention(s) A step-wise approach is applied before beginning the myomectomy portion of the procedure, which includes the following: [1] selecting the appropriate approach to uterine artery occlusion (lateral vs. posterior vs. anterior) on the basis of individual anatomy; [2] identification of relevant anatomy and important landmarks for the procedure; [3] isolating the uterine artery and identifying the ureter; [4] occluding the uterine artery. Main Outcome Measure(s) Successful identification of the ureter and uterine artery, and occlusion of the latter by surgical clipping. Result(s) In all cases, the uterine artery was clearly identified, as was the ureter, and surgical clips were placed, resulting in successful uterine artery occlusion. Conclusion(s) Uterine artery occlusion can be performed by three different approaches, as have been demonstrated in this video. A systematic review and meta-analysis of the literature supports the efficacy of this procedure in terms of limiting blood loss, blood transfusion, and fibroid recurrence, albeit at slightly longer operative times.

Study Objective Subendothelial (intracavitary) leiomyomas are rare and can be challenging to manage. They commonly recur and can present with significant abnormal uterine bleeding or infertility. Our objective is to discuss the clinical presentation, diagnosis and management of this rare condition. The patients in these series presented with either heavy menstrual bleeding or infertility. Preoperative imaging studies showed multiple small fibroids, however the diagnosis was not confirmed until the uterus was surgically evaluated. Design Case Series. Setting n/a Patients or Participants We present three cases of disseminated intracavitary leiomyomatosis. Interventions n/a Measurements and Main Results Case 1: A 31 year old female presented with abnormal uterine bleeding and primary infertility. Preoperative imaging showed multiple submucosal fibroids. This patient had a hysteroscopic myomectomy two years prior for abnormal bleeding. She was taken for a laparotomy/myomectomy and intraoperatively, the fibroids were found to be subendothelial; nearly 40 fibroids were resected. Case 2: A 37 year old female presented with primary infertility. This patient had a previous hysteroscopic myomectomy but was still unable to conceive. Imaging studies reported multiple submucosal and intramural fibroids. Intraoperatively the entire endometrial cavity was lined with 2cm subendothelial fibroids; over 30 fibroids were removed. Case 3: A 37 year old female presented with abnormal uterine bleeding. The patient had imaging that demonstrated multiple submucosal fibroids. The bleeding was not well managed with medical therapy. Intraoperatively she was found to have multiple 1cm subendothelial fibroids. She was managed with Lupron and multiple hysteroscopic procedures for resection for these fibroids. Conclusion Intracavitary subendothelial leiomyomas have not been widely described in the literature. The diagnosis can be challenging as transvaginal ultrasound, sonohysterogram and MRI are unable to distinguish subendothelial from submucosal leiomyomas. These patients also had hysteroscopic procedures prior to development of intracavitary leiomyomatosis. In all our cases, the diagnosis was made intraoperatively, and resulted in the removal of a large number of leiomyomas.

Study Objective To determine the impact of postoperative hormonal suppression with dienogest on recurrence of endometriosis following conservative endometriosis surgery. Design We performed a meta-analysis and systematic review of observational (retrospective and prospective) studies and randomized controlled trials. Setting The following databases were search from inception to March 2019: Ovid MEDLINE, Ovid EMBASE, PubMed (Non-Medline records only), EBM Reviews - Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov and International Standard Randomised Controlled Trial Number Registry. Patients or Participants We included studies of pre-menopausal women undergoing conservative surgery for endometriosis followed by post-operative dienogest suppression for at least 6 months. Interventions Post-operative suppression with dienogest for at least 6 months duration. Measurements and Main Results Primary outcome was the rate of endometriosis/endometrioma recurrence on imaging. For studies with a comparator group, we compared post-operative suppression with dienogest to no treatment. We screened 361 studies and 11 met inclusion criteria (10 retrospective and 1 prospective cohort studies). These studies included 2243 patients (1314 treated with dienogest and 929 controls). Treatment duration ranged from 6 months to 79 months post-operatively. The mean follow-up period ranged from 6 months for 1 study to 60 months for another, with the remaining 9 studies reporting follow-up periods ranging from 12 months to 43 months. For patients treated with dienogest there were 3 recurrences per 100 women (2.92 events/100 women, 95% CI 2.08, 4.10; 11 studies, 1314 patients, I2=21%, fixed effects model). The odds of recurrence were significantly lower in women treated with dienogest compared to no post-operative hormonal suppression (Log odds -2.09, 95%CI -2.59, -1.59, p Conclusion Post-operative hormonal suppression with dienogest following endometriosis surgery is associated with a low overall recurrence rate, and is superior to no post-operative suppression.

Abnormal uterine bleeding (AUB) is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for the problem during their reproductive years.To provide current evidence-based guidelines on the techniques and technologies used in endometrial ablation (EA), a minimally invasive technique for the management of AUB of benign origin.Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise and general background in gynaecology. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated surgical and patient outcomes for the various EA techniques. Recommendations were established by consensus.Published literature was retrieved through searches of MEDLINE and The Cochrane Library in 2013 and 2014 using appropriate controlled vocabulary and key words (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, AUB, hysterectomy). RESULTS were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English from January 2000 to November 2014. Searches were updated on a regular basis and incorporated in the guideline to December 2014. Grey (unpublished) literature was identifies through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).This document reviews the evidence regarding the available techniques and technologies for EA, preoperative and postoperative care, operative set-up, anaesthesia, and practical considerations for practice.Implementation of the guideline recommendations will improve the provision of EA as an effective treatment of AUB. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients.EA is a safe and effective minimally invasive option for the treatment of AUB of benign etiology. Summary Statements 1. Endometrial ablation is a safe and effective minimally invasive surgical procedure that has become a well-established alternative to medical treatment or hysterectomy to treat abnormal uterine bleeding in select cases. (I) 2. Endometrial preparation can be used to facilitate resectoscopic endometrial ablation (EA) and can be considered for some non-resectoscopic techniques. For resectoscopic EA, preoperative endometrial thinning results in higher short-term amenorrhea rates, decreased irrigant fluid absorption, and shorter operative time than no treatment. (I) 3. Non-resectoscopic techniques are technically easier to perform than resectoscopic techniques, have shorter operative times, and allow the use of local rather than general anaesthesia. However, both techniques have comparable patient satisfaction and reduction of heavy menstrual bleeding. (I) 4. Both resectoscopic and non-resectoscopic endometrial ablation (EA) have low complication rates. Uterine perforation, fluid overload, hematometra, and cervical lacerations are more common with resectoscopic EA; perioperative nausea/vomiting, uterine cramping, and pain are more common with non-resectoscopic EA. (I) 5. All non-resectoscopic endometrial ablation devices available in Canada have demonstrated effectiveness in decreasing menstrual flow and result in high patient satisfaction. The choice of which device to use depends primarily on surgical judgement and the availability of resources. (I) 6. The use of local anaesthetic and blocks, oral analgesia, and conscious sedation allows for the provision of non-resectoscopic EA in lower resource-intense environments including regulated non-hospital settings. (II-2) 7. Low-risk patients with satisfactory pain tolerance are good candidates to undergo endometrial ablation in settings outside the operating room or in free-standing surgical centres. (II-2) 8. Both resectoscopic and non-resectoscopic endometrial ablation are relatively safe procedures with low complication rates. The complications perforation with potential injury to contiguous structures, hemorrhage, and infection. (II-2) 9. Combined hysteroscopic sterilization and endometrial ablation can be safe and efficacious while favouring a minimally invasive approach. (II-2) Recommendations 1. Preoperative assessment should be comprehensive to rule out any contraindication to endometrial ablation. (II-2A) 2. Patients should be counselled about the need for permanent contraception following endometrial ablation. (II-2B) 3. Recommended evaluations for abnormal uterine bleeding, including but not limited to endometrial sampling and an assessment of the uterine cavity, are necessary components of the preoperative assessment. (II-2B) 4. Clinicians should be vigilant for complications unique to resectoscopic endometrial ablation such as those related to fluid distention media and electrosurgical injuries. (III-A) 5. For resectoscopic endometrial ablation, a strict protocol should be followed for fluid monitoring and management to minimize the risk of complications of distension medium overload. (III-A) 6. If uterine perforation is suspected to have occurred during cervical dilatation or with the resectoscope (without electrosurgery), the procedure should be abandoned and the patient should be closely monitored for signs of intraperitoneal hemorrhage or visceral injury. If the perforation occurs with electrosurgery or if the mechanism of perforation is uncertain, abdominal exploration is warranted to obtain hemostasis and rule out visceral injury. (III-B) 7. With resectoscopic endometrial ablation, if uterine perforation has been ruled out acute hemorrhage may be managed by using intrauterine Foley balloon tamponade, injecting intracervical vasopressors, or administering rectal misoprostol. (III-B) 8. If repeat endometrial ablation (EA) is considered following non-resectoscopic or resectoscopic EA, it should be performed by a hysteroscopic surgeon with direct visualization of the cavity. Patients should be counselled about the increased risk of complications with repeat EA. (II-2A) 9. If significant intracavitary pathology is present, resectoscopic endometrial ablation combined with hysteroscopic myomectomy or polypectomy should be considered in a non-fertility sparing setting. (II-3A).

Study Objective To evaluate the clinical characteristics of women presenting with catamenial pneumothorax and compare them with those with noncatamenial pneumothorax. Design A case-control study (Canadian Task Force II-2). Setting A multicenter study. Patients Forty-two women with pneumothorax: 21 women had catamenial pneumothorax (study group), and 21 were age-matched women with noncatamenial pneumothorax (control group). Interventions All patients underwent video-assisted thoracoscopy and pleural biopsy. We also evaluated the presence and stage of pelvic endometriosis in 16 women with catamenial pneumothorax who had undergone laparoscopic surgery. Measurements and Main Results The number of known episodes of catamenial pneumothorax before treatment was between 2 and 8 episodes. Symptoms were mainly chest pain and shortness of breath; 1 patient had hemoptysis. The prevalence of right-sided pneumothorax was 95.2% in the study group and 57.1% in the control group (p = .004). Besides 2 cases with complete collapse of the right lung, most of the cases in the study group had apical pneumothorax. Pelvic endometriosis was found in 15 of 16 women (93.7%), mainly stage 3 or 4, and thoracic endometriosis in 12 of 20 women (60%). None of the patients in the control group had thoracic endometriosis. Conclusion Thoracic endometriosis is found in over half of women with catamenial pneumothorax but absent in those with noncatamenial pneumothorax. Right apical pneumothorax is predominant in women with catamenial pneumothorax. Endometriosis plays an important role in the mechanism of catamenial pneumothorax.

Background Uterine fibroids are smooth muscle tumours arising from the uterus. These tumours, although benign, are commonly associated with abnormal uterine bleeding, bulk symptoms and reproductive dysfunction. The importance of progesterone in fibroid pathogenesis supports selective progesterone receptor modulators (SPRMs) as effective treatment. Both biochemical and clinical evidence suggests that SPRMs may reduce fibroid growth and ameliorate symptoms. SPRMs can cause unique histological changes to the endometrium that are not related to cancer, are not precancerous and have been found to be benign and reversible. This review summarises randomised trials conducted to evaluate the effectiveness of SPRMs as a class of medication for treatment of individuals with fibroids. Objectives To evaluate the effectiveness and safety of SPRMs for treatment of premenopausal women with uterine fibroids. Search methods We searched the Specialised Register of the Cochrane Gynaecology and Fertility Group, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and clinical trials registries from database inception to May 2016. We handsearched the reference lists of relevant articles and contacted experts in the field to request additional data. Selection criteria Included studies were randomised controlled trials (RCTs) of premenopausal women with fibroids who were treated for at least three months with a SPRM. Data collection and analysis Two review authors independently reviewed all eligible studies identified by the search. We extracted data and assessed risk of bias independently using standard forms. We analysed data using mean differences (MDs) or standardised mean differences (SMDs) for continuous data and odds ratios (ORs) for dichotomous data. We performed meta-analyses using the random-effects model. Our primary outcome was change in fibroid-related symptoms. Main results We included in the review 14 RCTs with a total of 1215 study participants. We could not extract complete data from three studies. We included in the meta-analysis 11 studies involving 1021 study participants: 685 received SPRMs and 336 were given a control intervention (placebo or leuprolide). Investigators evaluated three SPRMs: mifepristone (five studies), ulipristal acetate (four studies) and asoprisnil (two studies). The primary outcome was change in fibroid-related symptoms (symptom severity, health-related quality of life, abnormal uterine bleeding, pelvic pain). Adverse event reporting in the included studies was limited to SPRM-associated endometrial changes. More than half (8/14) of these studies were at low risk of bias in all domains. The most common limitation of the other studies was poor reporting of methods. The main limitation for the overall quality of evidence was potential publication bias. SPRM versus placebo SPRM treatment resulted in improvements in fibroid symptom severity (MD -20.04 points, 95% confidence interval (CI) -26.63 to -13.46; four RCTs, 171 women, I2 = 0%; moderate-quality evidence) and health-related quality of life (MD 22.52 points, 95% CI 12.87 to 32.17; four RCTs, 200 women, I2 = 63%; moderate-quality evidence) on the Uterine Fibroid Symptom Quality of Life Scale (UFS-QoL, scale 0 to 100). Women treated with an SPRM showed reduced menstrual blood loss on patient-reported bleeding scales, although this effect was small (SMD -1.11, 95% CI -1.38 to -0.83; three RCTs, 310 women, I2 = 0%; moderate-quality evidence), along with higher rates of amenorrhoea (29 per 1000 in the placebo group vs 237 to 961 per 1000 in the SPRM group; OR 82.50, 95% CI 37.01 to 183.90; seven RCTs, 590 women, I2 = 0%; moderate-quality evidence), compared with those given placebo. We could draw no conclusions regarding changes in pelvic pain owing to variability in the estimates. With respect to adverse effects, SPRM-associated endometrial changes were more common after SPRM therapy than after placebo (OR 15.12, 95% CI 6.45 to 35.47; five RCTs, 405 women, I2 = 0%; low-quality evidence). SPRM versus leuprolide acetate In comparing SPRM versus other treatments, two RCTs evaluated SPRM versus leuprolide acetate. One RCT reported primary outcomes. No evidence suggested a difference between SPRM and leuprolide groups for improvement in quality of life, as measured by UFS-QoL fibroid symptom severity scores (MD -3.70 points, 95% CI -9.85 to 2.45; one RCT, 281 women; moderate-quality evidence) and health-related quality of life scores (MD 1.06 points, 95% CI -5.73 to 7.85; one RCT, 281 women; moderate-quality evidence). It was unclear whether results showed a difference between SPRM and leuprolide groups for reduction in menstrual blood loss based on the pictorial blood loss assessment chart (PBAC), as confidence intervals were wide (MD 6 points, 95% CI -40.95 to 50.95; one RCT, 281 women; low-quality evidence), or for rates of amenorrhoea (804 per 1000 in the placebo group vs 732 to 933 per 1000 in the SPRM group; OR 1.14, 95% CI 0.60 to 2.16; one RCT, 280 women; moderate-quality evidence). No evidence revealed differences between groups in pelvic pain scores based on the McGill Pain Questionnaire (scale 0 to 45) (MD -0.01 points, 95% CI -2.14 to 2.12; 281 women; moderate-quality evidence). With respect to adverse effects, SPRM-associated endometrial changes were more common after SPRM therapy than after leuprolide treatment (OR 10.45, 95% CI 5.38 to 20.33; 301 women; moderate-quality evidence). Authors' conclusions Short-term use of SPRMs resulted in improved quality of life, reduced menstrual bleeding and higher rates of amenorrhoea than were seen with placebo. Thus, SPRMs may provide effective treatment for women with symptomatic fibroids. Evidence derived from one RCT showed no difference between leuprolide acetate and SPRM with respect to improved quality of life and bleeding symptoms. Evidence was insufficient to show whether effectiveness was different between SPRMs and leuprolide. Investigators more frequently observed SPRM-associated endometrial changes in women treated with SPRMs than in those treated with placebo or leuprolide acetate. As noted above, SPRM-associated endometrial changes are benign, are not related to cancer and are not precancerous. Reporting bias may impact the conclusion of this meta-analysis. Well-designed RCTs comparing SPRMs versus other treatments are needed.

Objectives Differentiation of an eccentric intrauterine pregnancy (IUP) from an interstitial ectopic pregnancy (EP) is challenging. No sign for differentiation is reported. The purpose of this study was to determine whether the presence of surrounding endometrium (SE) can distinguish eccentric IUP from interstitial EP. Methods This study was approved by the institutional ethics board; consent acquisition was waived. Cases were identified using ultrasound (US) reports that included the words "interstitial," "cornual," and "angular." Blinded to official reports, one reviewer reviewed US examinations retrospectively for the presence of SE, defined as the extension of endometrial lining around the gestational sac (GS) as an indication of an eccentric IUP. US examinations without SE on the retrospective review were diagnosed as interstitial EP. Results Forty-four cases were identified from 2007 to 2015. On retrospective review, 20 cases were labeled as eccentric IUP and 24 as interstitial EP. Ten of the 20 cases retrospectively labeled as eccentric IUP had been reported and managed as eccentric IUP prospectively: four followed to a viable second trimester, and six had spontaneous abortion/termination. The remaining 10 cases retrospectively labeled eccentric IUPs because of the presence of SE had been reported and managed as interstitial EP on the official prospective report. There was follow-up suggestion of eccentric IUP in six of the latter discordant pregnancies with non-concordant retrospective and prospective diagnosis: three had hysteroscopy/curettage demonstrating retained products, two had US follow-up showing the GS moving farther down in the uterine cavity, and in one patient, the GS was shown to pass per vagina. Twenty-four of the 44 cases were called interstitial EP both on the retrospective and prospective reviews and were managed as interstitial EP. None of these patients (without SE) had follow-up suggestive of eccentric IUP. Conclusion Our results suggest that the presence of surrounding endometrium around the GS allows for differentiation of eccentric IUP from interstitial EP.

Resume Contexte Les saignements uterins anormaux (SUA) sont directement a l'origine d'un fardeau de sante considerable que doivent porter les femmes, leur famille et la societe en general. Jusqu'a 30 % des femmes chercheront a obtenir l'aide d'un medecin pour contrer ce probleme au cours de leurs annees de fertilite. Objectif Fournir des lignes directrices factuelles a jour quant aux techniques et aux technologies utilisees aux fins de l'ablation de l'endometre (AE), soit une intervention a effraction minimale permettant la prise en charge des SUA d'origine benigne. Methodes Les membres du comite sur la directive clinique ont ete selectionnes en fonction de leurs specialisations respectives en vue de representer une gamme d'experiences pratiques et universitaires : le milieu de pratique au Canada, le type de pratique, la sous-specialite et les antecedents generaux en gynecologie ont donc ete pris en consideration. Le comite a analyse les donnees pertinentes issues de la litterature medicale anglophone (y compris les lignes directrices publiees), en plus d'evaluer les issues chirurgicales et les issues qu'ont connues les patientes a la suite de l'utilisation de diverses techniques d'AE. Les recommandations ont ete formulees par consensus. Donnees La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library en 2013 et en 2014 au moyen d'un vocabulaire controle et de mots cles appropries (p. ex. « endometrial ablation », « hysteroscopy », « menorrhagia », « heavy menstrual bleeding », « AUB », « hysterectomy »). Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 2000 et novembre 2014. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en decembre 2014. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Resultats Le present document passe en revue les donnees quant aux techniques et aux technologies disponibles en ce qui concerne l'AE, les soins preoperatoires et postoperatoires, le milieu d'intervention, l'anesthesie et les facteurs pratiques a prendre en consideration. Avantages, desavantages et couts La mise en œuvre des recommandations de la presente directive clinique entrainera une amelioration de l'offre de l'AE a titre de traitement efficace contre les SUA. Le respect de ces recommandations permettrait l'execution de l'intervention chirurgicale en cause de facon sure et en maximiserait la reussite pour les patientes. Conclusions L'AE est une option a effraction minimale sure et efficace pour la prise en charge des SUA d'etiologie benigne. Declarations sommaires 1.L'ablation de l'endometre est une intervention chirurgicale a effraction minimale sure et efficace qui en est venue a constituer, dans certains cas, une solution de rechange bien etablie au traitement medical ou a l'hysterectomie pour la prise en charge des saignements uterins anormaux. (I) 2.Une preparation de l'endometre peut etre mise en œuvre pour en faciliter l'ablation resectoscopique et peut egalement etre envisagee dans le cas de certaines techniques non resectoscopiques. Lorsque l'on a recours a l'ablation resectoscopique de l'endometre, l'amincissement preoperatoire de ce dernier donne lieu a une hausse des taux d'amenorrhee a court terme, a une attenuation de l'absorption du liquide de distension et a une reduction de la duree operatoire, par comparaison avec l'absence de traitement. (I) 3.Les techniques non resectoscopiques sont techniquement plus faciles a utiliser que les techniques resectoscopiques, necessitent des temps operatoires plus courts et permettent l'utilisation d'une anesthesie locale (plutot que d'avoir recours a une anesthesie generale). Toutefois, ces deux techniques comptent des taux comparables de satisfaction des patientes et d'attenuation des saignements menstruels abondants. (I) 4.Les techniques resectoscopiques et non resectoscopiques d'ablation de l'endometre comptent toutes de faibles taux de complication. La perforation uterine, la surcharge liquidienne, l'hematometre et les lacerations cervicales sont plus courantes dans le cas de l'AE resectoscopique; les crampes uterines, la douleur et les nausees / vomissements perioperatoires sont plus courants dans le cas de l'AE non resectoscopique. (I) 5.L'efficacite de tous les dispositifs d'ablation non resectoscopique de l'endometre disponibles au Canada a ete demontree en ce qui concerne l'attenuation du flux menstruel; de plus, ils menent tous a des taux eleves de satisfaction des patientes. Le choix du dispositif a utiliser depend principalement de l'opinion du chirurgien et de la disponibilite des ressources. (I) 6.L'utilisation d'anesthesiques et de blocs locaux, d'une analgesie orale et d'une sedation consciente permet la tenue d'une ablation non resectoscopique de l'endometre au sein de milieux necessitant des ressources moindres, y compris dans des milieux non hospitaliers reglementes. (II-2) 7.Les patientes n'etant exposees qu'a de faibles risques et presentant une tolerance satisfaisante a la douleur sont de bonnes candidates pour ce qui est de la tenue d'une ablation endometriale dans un milieu autre qu'en salle d'operation ou dans un centre chirurgical autonome. (II-2) 8.Les techniques d'ablation de l'endometre tant resectoscopiques que non resectoscopiques sont relativement sures et ne comptent que de faibles taux de complication. Parmi les complications les plus graves, on trouve la perforation (s'accompagnant de lesions potentielles aux structures adjacentes), l'hemorragie et l'infection. (II-2) 9.La tenue concomitante d'une sterilisation hysteroscopique et d'une ablation endometriale peut etre sure et efficace tout en favorisant une approche a effraction minimale. (II-2) Recommandations 1.L'evaluation preoperatoire devrait etre exhaustive, de facon a pouvoir ecarter toute contre-indication a l'ablation de l'endometre. (II-2A) 2.Les patientes devraient etre avisees de la necessite d'une contraception permanente a la suite de l'ablation de l'endometre. (II-2B) 3.Les evaluations recommandees en presence de saignements uterins anormaux (dont, entre autres, le prelevement endometrial et l'evaluation de la cavite uterine) sont des composantes necessaires de l'evaluation preoperatoire. (II-2B) 4.Les cliniciens devraient demeurer a l'affut des complications propres a l'ablation resectoscopique de l'endometre, comme celles qui sont associees au produit de distension et aux lesions electrochirurgicales. (III-A) 5.Dans le cas de l'ablation resectoscopique de l'endometre, un protocole strict devrait etre respecte pour ce qui est de la surveillance liquidienne et de la prise en charge, et ce, afin de minimiser le risque de voir se manifester des complications associees a la surcharge de produit de distension. (III-A) 6.Lorsque l'on soupconne qu'une perforation uterine s'est manifestee au cours de la dilatation cervicale ou dans le cadre de l'utilisation du resectoscope (sans electrochirurgie), l'intervention devrait etre abandonnee et la patiente devrait faire l'objet d'une surveillance etroite de facon a ce que l'on puisse demeurer a l'affut des signes d'hemorragie intraperitoneale ou de lesion viscerale. Lorsque la perforation se manifeste dans le cadre d'une electrochirurgie ou lorsque le mecanisme de la perforation demeure incertain, la tenue d'une exploration abdominale est justifiee pour assurer l'hemostase et ecarter la presence de lesions viscerales. (III-B) 7.Dans le cas de l'AE resectoscopique, lorsque la presence d'une perforation uterine a ete ecartee, l'hemorragie aigue pourrait etre prise en charge au moyen d'un tamponnement intra-uterin par sonde de Foley, d'une injection intracervicale de vasopresseurs ou de l'administration de misoprostol par voie rectale. (III-B) 8.Lorsqu'une nouvelle ablation de l'endometre est envisagee a la suite d'une intervention non resectoscopique ou resectoscopique, elle devrait etre menee par un chirurgien hysteroscopique sous visualisation directe de la cavite. Les patientes devraient beneficier de services de counseling au sujet des risques de complications qui sont associes a la tenue d'une nouvelle ablation de l'endometre. (II-2A) 9.En presence d'une pathologie intracavitaire considerable, la tenue concomitante d'une ablation resectoscopique de l'endometre et d'une myomectomie / polypectomie hysteroscopique devrait etre envisagee. (II-3A)

Objective Professional societies have recently urged gynaecologists to counsel patients about the risks of encountering uterine sarcoma at fibroid surgery especially when morcellation is used. Our objective was to learn the preoperative and postoperative characteristics of patients with uterine sarcoma to better counsel patients undergoing surgery for presumably benign fibroids. Methods This is a multicentre, retrospective cohort study. Three academic tertiary cancer centres in Southern Ontario over a 13-year period (2001-2014). Patients diagnosed with leiomyosarcoma or endometrial stromal sarcoma were included after identification using pathology databases. A retrospective chart review was conducted to determine clinical characteristics and survival data. Results The study included 302 patients with uterine sarcomas (221 leiomyosarcomas, 81 endometrial stromal sarcomas). Mean age at diagnosis was 55 years, and 59% were postmenopausal. Sarcoma diagnosis was made following endometrial sampling (25%), hysterectomy (69% laparotomy, 2.7% laparoscopic/vaginal), and myomectomy (3.3%). Of all the patients who underwent endometrial sampling, 65% were diagnosed with a uterine sarcoma in this manner. A general gynaecologist performed the primary surgical procedure in 166 of 302 patients (55%). Tumour disruption at the time of primary surgery occurred in 57 of 295 patients (19%): subtotal hysterectomy (21), myomectomy (10), dissection of adherent tumour (17), and morcellation (9). Morcellation, to facilitate a minimally invasive approach, was performed with scalpel (2 at laparotomy, 5 vaginally) and with a laparoscopic electro-mechanical morcellator (2). At a median follow-up of 2.9 years, there was no significant difference in survival for stage I and II patients with tumour disruption (n = 32) compared with those without tumour disruption (n = 143), regardless of sarcoma type ( P = 0.6). Conclusion The majority of patients with uterine sarcomas were postmenopausal. Many can be diagnosed preoperatively with endometrial sampling. Forty-one percent of patients with uterine sarcomas had a high preoperative index of suspicion, resulting in intervention by an oncologist. Morcellation with laparoscopic electro-mechanical morcellator was rare.

Objective To demonstrate an approach to the hysteroscopic repair of cesarean scar isthmocele and discuss its association with secondary infertility. Design A step-by-step explanation of the procedure with surgical video footage. Setting Academic medical center. Patient(s) Two patients undergoing hysteroscopic repair of symptomatic cesarean scar isthmoceles. Surgical candidates for this procedure include patients with a symptomatic isthmocele and a residual myometrial thickness of at least 3 mm confirmed with pre-operative imaging. Intervention(s) Operative hysteroscopy is performed using a step-wise approach: identification of relevant anatomy; resection of the cephalad edge of fibrosis; resection of the caudad edge of fibrosis; and ablation of the isthmocele base. Main Outcome Measure(s) Restoration of the contour between the uterine cavity and cervical canal. Result(s) Hysteroscopic resection of cesarean scar isthmocele is successfully performed in both cases presented. Postoperatively, both patients had resolution of their symptoms. Conclusion(s) The surgical approach presented in this video can result in the successful revision of a cesarean scar isthmocele. Current literature supports a role for hysteroscopic isthmoplasty in treating isthmocele-related abnormal uterine bleeding. However, more evidence is required on the safety of conceiving following hysteroscopic isthmoplasty, and its use in the setting of secondary infertility.

Study Objective To determine the impact of postoperative hormonal suppression on recurrence and pain following conservative endometriosis surgery. Design Systematic review and meta-analysis of prospective observational and randomized controlled trials. Setting The following databases were searched: MEDLINE, Embase, Cochrane CENTRAL, and Web of Science from inception until October 2018. Patients or Participants Pre-menopausal women undergoing surgical treatment of endometriosis, conserving at least one ovary. Interventions Post-operative medical treatment of at least 6 months with oral contraceptive pills (OCP), levonorgesterel intra-uterine device (LNG-IUD), progestin therapy, or gonadotropin releasing hormone agonist (GnRH-a). Measurements and Main Results Post-operative hormonal suppression decreased the odds of disease recurrence (OR: 0.40; 95% CI: 0.27 – 0.60, p Hormonally suppressed patients had greater reductions in pain versus controls (SMD -0.54; 95% CI: -0.68 – -0.39, p Conclusion Post-operative hormonal suppression following conservative endometriosis surgery decreases the odds of disease recurrence and results in greater reductions in pelvic pain/dysmenorrhea compared to expectant management.

Study Objective Evaluate differences in patient outcomes for hysterectomies performed by Fellowship-trained surgeons compared to Generalists. Design Retrospective review. Setting 5 Toronto hospitals. Patients or Participants Patients undergoing hysterectomy from July 2016-June 2018. Interventions Patient outcomes for surgeons with 6 months (minimum) of fellowship training in minimally invasive gynecology (Fellowship) were compared to those without post-residency training (Generalist). Hysterectomies performed by urogynecologists were excluded. Measurements and Main Results Primary outcome was complications (in-hospital and within 30-days of discharge). Secondary outcomes were grade of complication, return to emergency room (ER), surgeon case volume. Binary logistic regression analysis was performed comparing hysterectomies by Fellowship versus Generalist surgeons controlling for factors associated with case complexity. Odds ratios (OR), 95% confidence intervals (CI) and p-values were calculated. 1379 hysterectomies were included (702 cases by 17 Fellowship surgeons and 677 cases by 41 Generalists). Fellowship cases were more likely to have endometriosis (19.9% vs. 7.9%, p Conclusion There was no difference in complications for hysterectomies performed by Fellowship compared to Generalist surgeons. Fellowship surgeons had greater technicity rate. Cases performed by Fellowship surgeons were more complex with higher chance of additional procedures.

Study Objective To determine hysterectomy complication rate and patient, surgical and provider factors associated with complications. Design Retrospective review Setting 5 Toronto hospitals Patients or Participants Patients undergoing hysterectomy from July 2016-December 2017 Interventions Hysterectomy procedure Measurements and Main Results Retrospective review of Generalist hysterectomies at 5 Toronto hospitals from July 2016 to Dec 2017. Data was extracted from health records coding (ICD-10) and electronic medical records. Complications (in-hospital to 30 days of discharge) were classified using Clavien-Dindo Scale. Patient characteristics (BMI, anemia status), surgical factors (technicity, uterine presence of endometriosis and adhesions, uterine weight) and provider characteristics (case volume) were obtained. Logistic models were used to evaluate variables associated with complications. 1328 hysterectomy cases were performed by 67 surgeons over 1.5 years. The 294 recorded complications were classified as: 119 (40%) Grade 1, 102 (35%) Grade 2, 12 (4%) Grade IIIA, 61 (21%) Grade IIIB. Presence of endometriosis increased odds of any complication (OR 1.87, 95%CI 1.05-3.35, p=0.035). For every 100g increase in uterine weight, odds of ≥ Grade II complication increased by 4.5% (95%CI 0.3% - 9.4%, p=0.035). Low volume surgeons (≤1 hysterectomy/month) had higher unadjusted complication rate (28.6% vs 15.3%, p=0.01). After adjusting for case complexity (composite score incorporating BMI, presence of adhesions, endometriosis and uterine weight) and technicity, low volume surgeons had 2.21 OR (95% CI 1.08 – 4.52, p=0.03) of having ≥ Grade II complication. Conclusion Endometriosis and uterine weight increase risk of hysterectomy complications. Low volume surgeons perform more challenging hysterectomies and have lower technicity rates. After adjusting for patient and surgical factors, low volume surgeons have higher odds of complications.

Placenta Percreta Involving Maternal Bladder A 32-year-old woman presented with painless hematuria at 24 weeks of gestation. Cystoscopy revealed placenta percreta involving the maternal bladder.

Video abstract summary This video presents a stepwise approach to an internal iliac artery ligation (IIAL) at laparotomy. Internal iliac artery ligation is an important technique for the gynecologic surgeon as it can bea life-saving intervention for gynecologic or obstetric hemorrhage. Internal iliac artery ligation can also be performed prophylactically when severe hemorrhage is anticipated. This video reviews the history of this surgical technique, the mechanism of action and the anatomy of the pelvic vasculature. We outline five key surgical steps required to successfully perform an internal iliac artery ligation: 1. Access the retroperitoneum; 2. Dissect the pararectal space; 3. Identify the anatomy; 4. Isolate the internal iliac artery; and 5. Ligate the vessel through either using a traditional suture ligation technique or contemporary clipping technique.

Video abstract summary Objective To demonstrate three approaches to uterine artery occlusion at time of myomectomy as a blood-sparing intra-operative technique and review available evidence in the literature. Study methods We proceed with a step-by-step explanation of the procedure with surgical video footage and discuss the available literature on its effectiveness. Results A step-wise approach is applied prior to beginning the myomectomy portion of the procedure which includes the following: 1) selecting the appropriate approach to uterine artery occlusion (lateral vs. posterior vs. anterior) based on individual anatomy; 2) identifying relevant anatomy and important landmarks for the procedure 3) isolating the uterine artery and identifying the ureter; 4) occluding the uterine artery. A recent systematic review and meta-analysis supports uterine artery occlusion as a technique to reduce blood loss and blood transfusion, while minimally increasing operative times. Conclusion(s) Uterine artery occlusion can be performed by three different approaches, as have been demonstrated in this video, and is an effective measure at reducing intra-operative blood loss, albeit at the cost of slightly longer operative times.

Objectives To evaluate the type of imaging performed for uterine fibroids, as well as assess whether ultrasound reporting of fibroids in Canada meets the quality standard defined by the Morphological Uterus Sonographic Assessment (MUSA) guideline Methods Women with symptomatic fibroids were enrolled in a prospective, non-interventional, observational registry at 19 Canadian sites (CAPTURE registry). Five ultrasound reporting quality criteria were evaluated: number of fibroids, largest fibroid volume, fibroid type, location and uterine volume. Results Of 1493 women, 1148 had ultrasound, 135 had MRI, 80 other, and 130 did not have imaging reported . After adjusting for demographic and clinical characteristics, patients with MRI were more likely to have larger fibroids (OR per 1cm increase 1.11 95% CI 1.05, 1.17) and more numerous (1 versus >1 fibroids) (OR 1.74, 95% CI 1.14, 2.64) compared to those with ultrasound only. For ultrasound reporting, all quality criteria were met by 268/1148 (23.3%) reports. TThere was a difference (p =400,000) were more likely to receive a high quality ultrasound report (OR 6.15, 95%CI 2.20, 17.18). Conclusions Choice of imaging modality for uterine fibroids is associated with patient characteristics. The quality of fibroid ultrasound reporting in Canada does not meet internationally endorsed guidelines and is in need of improvement.

ResumeObjectifs La presente directive clinique a pour objectif d'aider les cliniciens a mieux comprendre la pathophysiologie, la prevalence et l'importance clinique des myomes, et de leur faire part des meilleures donnees probantes disponibles quant aux modalites de traitement. Options Dans le cadre de la redaction de la presente directive clinique, nous avons tenu compte des aspects suivants de la pratique clinique : evaluation, traitements medicaux, traitements conservateurs par myolyse, occlusion selective de l'artere uterine et solutions de rechange chirurgicales (dont la myomectomie et l'hysterectomie). Le rapport risques-avantages doit faire l'objet d'une analyse personnalisee dans le cadre des discussions menees entre la patiente et son fournisseur de soins. Issues La mise en œuvre de la presente directive clinique devrait optimiser le processus decisionnel pour les patientes et les fournisseurs de soins en ce qui a trait a la tenue d'autres explorations ou a la facon d'assurer la prise en charge des leiomyomes uterins, en ayant tenu compte du processus pathogenique (et des options disponibles en matiere de traitement) et en ayant passe en revue les risques et les avantages anticipes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed, CINAHL et Cochrane Systematic Reviews en fevrier 2013 au moyen d'un vocabulaire controle (p. ex. « uterine fibroids », « myoma », « leiomyoma », « myomectomy », « myolysis », « heavy menstrual bleeding » et « menorrhagia ») et de mots cles (p. ex. « myoma », « leiomyoma », « fibroid », « myomectomy », « uterine artery embolization », « hysterectomy », « heavy menstrual bleeding », « menorrhagia ») appropries. Des recherches ont egalement ete menees dans les listes de references des articles identifies en vue d'en tirer d'autres publications pertinentes. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n'a ete appliquee en matiere de date, mais les resultats ont ete limites aux documents rediges en anglais ou en francais. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en janvier 2014. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Avantages, desavantages et couts La majorite des fibromes sont asymptomatiques et ne necessitent aucune intervention ni aucune autre mesure exploratoire. Dans le cas des fibromes symptomatiques, tels que ceux qui sont a l'origine d'anomalies menstruelles (p. ex. saignements uterins abondants, irreguliers et prolonges), d'une anemie ferriprive ou de symptomes de masse (p. ex. pression / douleur pelvienne, symptomes obstructifs), l'hysterectomie constitue une solution definitive; toutefois, cette solution n'est pas a privilegier pour ce qui est des femmes qui souhaitent preserver leur fertilite et/ou leur uterus. Le traitement choisi devrait viser une amelioration de la symptomatologie et de la qualite de vie. Les couts du traitement (pour le systeme de sante et les patientes presentant des fibromes) doivent etre interpretes dans le contexte des couts associes aux pathologies non traitees et a la mise en œuvre continue ou repetee de modalites d'exploration ou de traitement. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Declarations sommaires 1. Les fibromes uterins sont courants (leur incidence etant de 70 % a l'âge de 50 ans). De 20 % a 50 % de ces fibromes sont symptomatiques et exercent des effets sociaux et economiques considerables au Canada. (II-3) 2. La presence de fibromes uterins peut mener a diverses difficultes cliniques. (III) 3. Les preoccupations au sujet de possibles complications associees a la presence de fibromes pendant la grossesse ne constituent pas une indication justifiant la tenue d'une myomectomie, sauf chez les femmes qui ont deja connu une grossesse ayant presente des complications associees a ces fibromes. (III) 4. Les femmes chez qui des fibromes sont detectes pendant la grossesse pourraient necessiter la mise en œuvre de modalites additionnelles de surveillance maternelle et fœtale. (II-2) 5. Parmi les traitements medicaux efficaces pouvant etre offerts aux femmes qui connaissent des saignements uterins anormaux associes a la presence de fibromes uterins, on trouve le systeme intra-uterin a liberation de levonorgestrel, (I) les analogues de la gonadoliberine, (I) les modulateurs selectifs des recepteurs de la progesterone, (I) les contraceptifs oraux, (II-2) les progestatifs (II-2) et le danazol. (II-2) 6. Parmi les traitements medicaux efficaces pouvant etre offerts aux femmes qui connaissent des symptomes de masse associes a la presence de fibromes, on trouve les modulateurs selectifs des recepteurs de la progesterone et les analogues de la gonadoliberine. (I) 7. L'hysterectomie constitue le moyen le plus efficace d'assurer la prise en charge des fibromes uterins symptomatiques. (III) 8. Bien que la myomectomie constitue une option pour les femmes qui souhaitent conserver leur uterus ou rehausser leur fertilite, elle expose la patiente a un risque de devoir subir d'autres interventions. (II-2) 9. Parmi les traitements interventionnels conservateurs actuellement disponibles, l'embolisation de l'artere uterine est celui pour lequel nous disposons du plus grand nombre de donnees; de plus, l'efficacite de cette intervention a ete demontree chez des patientes adequatement selectionnees. (II-3) 10. Des methodes novatrices faisant appel a l'application d'energie focalisee s'averent prometteuses; toutefois, nous ne disposons pas de donnees a long terme a leur sujet. (III) Recommandations 1. Rien n'indique que la presence de fibromes asymptomatiques devrait susciter des preoccupations importantes au sujet de leur malignite potentielle; de plus, le recours a l'hysterectomie dans un tel cas n'est pas indique, ce qui devrait rassurer les femmes qui presentent de tels fibromes. (III-D) 2. La prise en charge des femmes qui presentent des leiomyomes uterins doit etre personnalisee en fonction de la symptomatologie, de la taille et de l'emplacement des fibromes, de l'âge de la patiente et de ses besoins et souhaits en matiere de preservation de la fertilite ou de l'uterus, de la disponibilite du traitement et de l'experience du therapeute. (III-B) 3. Chez les femmes qui ne souhaitent pas preserver leur fertilite et/ou leur uterus et qui ont beneficie de services de counseling a l'egard des solutions de rechange et des risques, l'hysterectomie (menee au moyen de l'approche la moins effractive possible) peut etre offerte a titre de traitement definitif contre les fibromes uterins symptomatiques et est associee a un taux eleve de satisfaction. (II-2A) 4. La myomectomie hysteroscopique devrait etre consideree comme etant un traitement chirugical conservateur de premiere intention pour la prise en charge des fibromes endocavitaires symptomatiques. (II-3A) 5. Dans le cas de la myomectomie, la planification de la chirurgie devrait etre fondee sur les resultats d'une intervention d'imagerie cherchant a determiner, de facon precise, l'emplacement, la taille et le nombre des fibromes. (III-A) 6. Lorsqu'il s'avere necessaire d'avoir recours au morcellement pour retirer un prelevement, la patiente devrait etre avisee des risques et des complications possibles (dont la possibilite, dans de rares cas, d'en venir a constater la presence inattendue d'une tumeur maligne et de voir celle-ci etre disseminee par l'utilisation du morcellement motorise laparoscopique, ce qui pourrait aggraver le pronostic). (III-B) 7. L'anemie devrait etre corrigee avant la tenue d'une chirurgie planifiee. (II-2A) Les modulateurs selectifs des recepteurs de la progesterone et les analogues de la gonadoliberine constituent des moyens efficaces de corriger l'anemie, et leur utilisation preoperatoire devrait etre envisagee dans le cas des patientes anemiques. (I-A) 8. L'utilisation de vasopressine, de bupivacaine et d'epinephrine, de misoprostol, d'un garrot pericervical ou d'une matrice gelatine- thrombine attenue la perte sanguine au cours de la myomectomie et devrait etre envisagee. (I-A) 9. L'occlusion de l'artere uterine par embolisation ou au moyen de methodes chirurgicales peut etre offerte a certaines femmes presentant des fibromes uterins symptomatiques qui souhaitent preserver leur uterus. Les femmes qui choisissent d'avoir recours a l'occlusion de l'artere uterine pour la prise en charge de leurs fibromes devraient etre avisees des risques possibles et du fait que les issues en matiere de fertilite et de grossesse pourraient en etre affectees. (II-3A) 10. Chez les femmes qui connaissent des saignements uterins aigus associes a la presence de fibromes uterins, bien que la mise en œuvre d'une prise en charge conservatrice (œstrogenes, modulateurs selectifs des recepteurs de la progesterone, antifibrinolytiques, sonde de Foley et/ou intervention hysteroscopique operatoire) puisse etre envisagee, la tenue d'une hysterectomie pourrait devenir necessaire dans certains cas. Au sein des centres qui disposent des capacites necessaires, la mise en œuvre d'une embolisation de l'artere uterine pourrait etre envisagee. (III-B)

Objective To develop an integrated checklist for the management of patients with suspected morbidly adherent placenta (MAP). Methods A checklist process was developed incrementally by clinicians in the disciplines of maternal-fetal medicine, gynaecology, medical imaging, and anaesthesia for management of women with suspected MAP. Results Over a five-year period of debriefing after individual cases, a comprehensive checklist system was developed. The checklist is activated upon referral if MAP is suspected at an initial maternal-fetal medicine consultation; the process is subsequently guided by a clinical nurse specialist, leading to a standardized program of care. Conclusions Having a checklist process facilitates standardized care and optimal communication between specialists, providing team-based care for women with this potentially serious complication of pregnancy.

Objective To study differences in treatment effect between black and white premenopausal women prescribed ulipristal acetate (UPA) for symptomatic uterine fibroids. Design Prospective observational cohort study. Setting Gynecology clinics. Patient(s) Premenopausal women aged 18–55 years, at least one symptomatic uterine fibroid, UPA-naive, and no contraindications for UPA treatment. Intervention(s) One 3-month course of UPA at 5 mg daily. Main Outcome Measure(s) Patients' ethnicity self-identification adapted from Statistics Canada National Household Survey. Change in fibroid symptoms according to Uterine Fibroid Symptoms Quality of Life Questionnaire symptom severity and health-related quality of life score. Bleeding symptoms and amenorrhea rates according to Aberdeen Bleeding Score. Result(s) A total of 148 patients enrolled (45 black, 59 white, 44 other ethnicity). Black patients were younger (40.3 y vs. 44.5 y) with larger uteri (523 mL vs. 351 mL) than white counterparts. Baseline symptom severity was similar between groups. After 3 months of UPA treatment, both groups experienced similar improvements in symptom severity. White women had 52% greater improvement in bleeding score (−40.3 vs. −26.5) and were more likely to be amenorrheic at the end of treatment (66% vs. 41%). Both groups experienced adverse events at similar frequencies. Black women were more dissatisfied with UPA compared with white women (27.3% vs. 8%). Conclusion(s) Black women had greater fibroid burden at baseline. Both ethnicities had similar improvement in fibroid symptomatology following UPA treatment, but white women experienced higher amenorrhea rates. Black women were more dissatisfied with UPA treatment, which may be related to the lower amenorrhea rates.

A 42-year-old woman presented to the emergency department with a four-day history of severe constipation, bilious vomiting and colicky abdominal pain. Her symptoms started with the onset of menses but differed from the crampy dysmenorrhea for which she had taken over-the-counter analgesics for many

Objective To determine pregnancy and fetal outcomes following treatment with ulipristal acetate (UPA) for symptomatic uterine fibroids. Methods We conducted a systematic review and case series. We searched MEDLINE, EMBASE, PubMed, Web of Science, and Cochrane Register from inception to February 2017. From January 2014 to July 2017, we carried out a multi-centre retrospective chart review. All human studies that reported at least one pregnancy following UPA treatment were included. The case series included patients who conceived during/following UPA treatment. Titles and abstracts were screened for eligibility by two independent reviewers, and full texts were evaluated for inclusion and study quality. Data from the systematic review and case series were synthesized and reported separately. Results Seven studies were included (six case reports, one retrospective series) and contributed 24 post-UPA pregnancies (19 live births, six spontaneous abortions [SA]). The case series contributed 47 post-UPA pregnancies (31 live births, 13 SA, 1 fetal death, 2 terminations, 1 ongoing). In total, 71 pregnancies were evaluated (44 underwent myomectomy post-UPA; 27 without interval surgery). Five pregnancies occurred during UPA use (10–36 days of exposure) and resulted in three live births, one SA, and one termination. Five women who did not undergo interval myomectomy experienced delivery complications related to their fibroid. Conclusions This is the first systematic review and largest reported case series evaluating pregnancy outcomes following UPA treatment for uterine fibroids. UPA alone, or in conjunction with surgery, can permit conception and favorable pregnancy outcomes.

Uterine fibroids are common in women of reproductive age and can have a significant impact on quality of life and fertility. Although a number of international obstetrics/gynecology societies have issued evidence-based clinical practice guidelines for the management of symptomatic uterine fibroids, many of these guidelines do not yet reflect the most recent clinical evidence and approved indication for one of the key medical management options: the selective progesterone receptor modulator class. This article aims to share the clinical experience gained with selective progesterone receptor modulators in Europe and Canada by reviewing the historical development of selective progesterone receptor modulators, current best practices for selective progesterone receptor modulator use based on available data, and potential future uses for selective progesterone receptor modulators in uterine fibroids and other gynecologic conditions.

The use of frozen section histological analysis in primary obstetrical brachial plexus palsy reconstruction, though widespread, is not universally practiced. Our objective was to develop a histological grading scale that could be used to determine whether further resection of a microscopically suboptimal, though grossly satisfactory stump could lead to a measurable improvement in histological appearance. A 13-point grading tool assessing attributes of the epineurium, perineurium, and endoneurium was tested for interrater reliability. The histological appearance of initial nerve biopsies and of subsequent nerve reexcisions stained with toluidine blue was reviewed retrospectively (n = 52). Specimens were graded in a blinded fashion by a neuropathologist and a medical student. There was high agreement between expert and novice global rating scores with an intraclass correlation coefficient of 0.89 (95% confidence interval 0.85 to 0.93). A comparison of scores between subsequent sections of the same nerve stump revealed a significant decrease of 3.00 (expert) and 2.00 (novice) points ( P < 0.001) in the median global rating score, demonstrating improvement in histological grade. The novel grading tool was used to demonstrate that recutting a microscopically poor, though grossly acceptable nerve stump in obstetrical palsy surgery can yield a significantly improved histological grade.

Objective To evaluate the safety and effectiveness of conservative management for cervical ectopic pregnancies. Methods We conducted a retrospective review of all cases of cervical ectopic pregnancy diagnosed at our tertiary care academic centre between January 2002 and July 2014. The diagnosis of cervical ectopic pregnancy was made using transvaginal ultrasound according to published criteria. Management decisions were made by individual clinicians. Results Cervical ectopic pregnancy was diagnosed in 27 women with a median age of 34years. Two thirds of them were nulliparous, and 44% (12/27) reported infertility. The mean gestational age at diagnosis was seven weeks. The median serum human chorionic gonadotropin level was 11 300IU/L (range 610 to 163 700). Fetal cardiac activity was present in 19 pregnancies (70%). Vaginal bleeding was the most common presentation, occurring in 23 cases (85%). Three women presented with acute life-threatening hemorrhage. All cases were successfully managed conservatively, allowing uterine preservation. Systemic methotrexate (single or multi-dose protocol) was the mainstay of therapy. Other minimally invasive interventions included ultrasound-guided injection of potassium chloride into the pregnancy, uterine artery embolization, vaginal ligation of cervical branches of the uterine arteries, and dilatation and curettage, with or without dilute vasopressin cervical infiltration and Foley catheter tamponade. Conclusion Systemic methotrexate alone or in combination with other minimally invasive techniques can be effective conservative treatment for cervical pregnancies. A fertility-sparing approach is the optimal treatment for this patient population, which has high rates of infertility and nulliparity. We present a management algorithm based on our results to aid in standardizing the management of cervical ectopic pregnancies.

Objectives At our institution, diagnostic hysteroscopy (DH), often combined with uterine curettage, commonly has been performed in the main OR with the patient under general anaesthesia. Our objective was to create targeted interventions aimed at decreasing the number of DHs performed in the OR by 75% over one year. Methods This quality improvement initiative had a quasi-experimental (time-series) design. To obtain baseline numbers of DHs performed each month, we conducted a retrospective chart audit at a university teaching hospital. We implemented the following three groups of interventions: (1) staff education and case review, (2) accessible sonohysterography, and (3) an operative hysteroscopy education program. Procedures were tracked prospectively over a 12-month intervention period and an additional 12-month maintenance period. Results One hundred eleven DHs were performed at baseline. During the intervention period, 33 DHs were performed, a 70% reduction from baseline. This resulted in related savings of $126 984 and 12.5 surgical days. In the final quarter of the intervention period, there was an 81% reduction in the number of DHs with adequate preoperative evaluation compared with baseline. Twenty DHs were performed in the maintenance period, an 82% reduction from baseline. The absolute number of complications from DH remained constant during the study period. Conclusion Carefully planned and targeted interventions to change the culture at our institution decreased the number of DHs performed in the main OR. These initiatives improved patient care, saved costs, and improved OR utilization. Long-term follow-up showed maintenance of the improvements in the year subsequent to the interventions.