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Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.

To evaluate the impact of body mass index (BMI) on surgical quality metrics for patients undergoing benign, non-urgent hysterectomy.A multicentre, retrospective review at 7 hospitals in Ontario, Canada (4 academic, 3 community) was conducted. Patients undergoing hysterectomy from July 2016 to June 2019 were included. Hysterectomies for premalignant, malignant and emergency indications were excluded. The primary outcome was a composite of any complication or readmission. Secondary outcomes were grade 2 or greater complication, postoperative emergency department (ED) visit, hospital readmission, operative time (ORT) and estimated blood loss (EBL). Patient characteristics (age, ASA class, preoperative diagnoses, preoperative anemia, prior surgeries), surgical factors (endometriosis, adhesions, hysterectomy route, uterine weight, concomitant procedures, ORT, EBL) and surgeon characteristics (volume, fellowship/generalist training, academic/community hospital) were recorded along with complications, hospital readmissions and ED visits. Outcomes were evaluated using logistic regression and log-regression linear analysis grouping patients by BMI category (normal, overweight, obesity class 1, 2, and 3) and by hysterectomy route (abdominal, laparoscopic, and vaginal).2528 hysterectomies were performed by 67 surgeons. 828 (33%) patients had a normal BMI, 889 (35%) were overweight. 500 (20%) patients had a BMI corresponding to obesity class 1, 205 (8%) class 2 and 106 (4%) class 3. Obese patients had higher ASA class (p .001) and more prior surgeries (p .001) compared to patients with normal BMI. Those with class 2 and 3 obesity were younger (p .001), had greater uterine weight (p .001) and more intra-operative adhesions (p .001). After controlling for covariates, there were no differences in the odds of the primary or secondary outcomes, with the exception of patients with class 2 obesity who underwent vaginal hysterectomy. They had 9.1% (11 min) significantly longer ORT (0.091, 95% CI 0.002-0.18, p .05) and patients with an overweight BMI who underwent vaginal hysterectomy had 28 ml significantly less EBL (-0.154, 95% CI -0.26 to -0.05, p .01) compared to patients with normal BMI.BMI was not independently associated with surgical quality outcomes in patients undergoing hysterectomy for benign, non-urgent indications. Abdominal, laparoscopic, and vaginal hysterectomy can be performed safely in overweight and obese patients.

Per the BJOG Author Guidelines, a Research Letter should not include an abstract or subheadings.

To evaluate the effect of hormonal suppression on fertility when administered to infertile patients or patient wishing to conceive after surgery for endometriosis.A systematic search of MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov was performed by two independent reviewers from the databases' inception until December 2020.We included randomized controlled trials comparing any suppressive hormonal therapy to an inactive control (placebo or absence of treatment) after conservative surgery for endometriosis. Studies that did not report fertility outcomes after surgery were excluded.This systematic review and meta-analysis was registered in PROSPERO. Two reviewers extracted data and assessed the risk of bias as well as the strength of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed. Relative risks (RRs) were pooled by quantitative random effect meta-analysis. From 3,138 citations, 19 trials (2,028 patients) were included. Overall, no difference was observed between the treatment and the control group for pregnancy (RR 1.15; 95% CI 1.00-1.32) and live births (RR 1.05; 95% CI 0.84-1.32). When pooling all hormonal therapies, the duration of administration of postoperative therapy was identified as a substantial source of heterogeneity between studies (I2 difference=74%) with increased chances of pregnancy compared with control when administered for at least 3 months (RR 1.22; 95% CI 1.04-1.43). Gonadotropin-releasing hormone (GnRH) agonists (14 trials, 1,721 patients) were associated with increased chances of pregnancy compared with placebo or no treatment (RR 1.20; 95% CI 1.03-1.41; I2=25%). Data were limited for other hormonal treatments with no significant difference between groups. Subgroup analyses taking into account the use of fertility treatments (insemination or in vitro fertilization), stages of the disease and risk of bias of included trials did not modify the results.Postoperative hormonal suppression should be considered on a case-by-case basis to enhance fertility while balancing this benefit with the risks of delaying conception. If chosen, GnRH agonists would be the treatment of choice, and a duration of at least 3 months should be favored.PROSPERO, CRD42021224424.

Evaluate the proportion of justified bilateral salpingo-oophorectomy (BSO) at hysterectomy, based on pathologic diagnosis, and determine prevalence of avoidable BSO based on pre- and intraoperative considerations and pathologic diagnosis.Retrospective review of hysterectomies at seven Ontario, Canada hospitals from 2016 to 2019. Surgeries completed by oncologists or for invasive placentation were excluded. Patient, case, and surgeon characteristics were recorded along with pathologic diagnoses. Avoidable BSO criteria were: preoperative diagnosis of cervical dysplasia or benign diagnosis other than endometriosis, gender dysphoria, risk reduction or premenstrual dysphoric disorder; age51 years; absence of intraoperative endometriosis and adhesions; unjustified pathology (where "justified" pathology was endometriosis or (pre)malignant diagnosis except for cervical dysplasia). Patients with avoidable BSO were compared to those having at least one criterion for BSO. Binary logistic regression identified factors most strongly associated with avoidable BSO.Four thousand one hundred ninety-one hysterectomies were completed with 1,422 (33.9%) patients having concomitant BSO. Pathologic diagnosis justified BSO in most patients (1,035/1,422, 72.8%) with endometrial cancer being most common (439/1,422, 30.9%). When preoperative characteristics, intraoperative findings, and pathologic diagnoses were considered, 79 of 1,422 (5.6%) BSOs were avoidable. Compared to cases with at least one criterion for BSO, avoidable BSOs were more frequently completed by generalists (OR 1.80, 95% CI 1.10-2.99, P = 0.021), for preoperative diagnoses of abnormal uterine bleeding/menorrhagia (OR 3.82, 95% CI 2.35-6.30, P = 0.001) and fibroids (OR 4.25, 95% CI 2.63-6.92, P 0.001).Pathologic diagnosis justified most BSOs at hysterectomy. BSO was avoidable in 5.6% of patients, underscoring the need to standardize practice of BSO.

Uterine fibroids are common benign tumors that occur in up to 80% of women. Approximately half of the women affected experience considerable physical, psychological, and economic burdens and impact on quality of life due to symptoms such as heavy menstrual bleeding, pelvic pain, and infertility. Several medical and surgical options are available to treat uterine fibroids; however, healthcare providers may benefit from practical guidance in the development of individualized treatment plans based on a personalized approach. Medical treatments and minimally invasive procedures are generally preferred by most patients before considering more invasive, higher risk surgical interventions. In general, patient-centered, uterine-preserving procedures may be prioritized based on the patient’s goals and the clinical scenario. Occasionally, hysterectomy may be the preferred treatment option for some patients who require definitive treatment. This call-to-action highlights recent challenges to patient care, including radical shifts in physician–patient interactions due to the COVID-19 pandemic and recent changes to evidence-based, clinically approved therapies. This report also reviews contemporary recommendations for women’s health providers in the diagnosis and medical and surgical management of uterine fibroids. This call-to-action aims to empower healthcare providers to optimize the quality of care for women with uterine fibroids utilizing the best available evidence and best practices.

Compare maternal and perinatal outcomes between emergency and electively scheduled cesarean-hysterectomy for placenta accreta spectrum (PAS) disorders.Single-center retrospective cohort study including 125 cases of antenatally suspected and pathologically confirmed PAS disorders. Maternal and perinatal outcomes were analyzed. Multivariate logistic regression was used to test associations. Survival curves exploring risk factors for emergency birth were sought.25 (20%) and 100 (80%) patients had emergency and electively scheduled birth, respectively. Emergency birth had a higher estimated blood loss (2772 [2256.75] vs. 1561.19 [1152.95], P 0.001), with a higher rate of coagulopathy (40% vs. 6%; P 0.001) and bladder injury (44% vs. 13%; P 0.001); and was associated with increased rates of blood transfusion (aOR 4.9, CI95% 1.3-17.5, P = 0.01), coagulopathy (aOR 16.4, CI95% 2.6-101.4, P = 0.002) and urinary tract injury (aOR 6.96, CI95% 1.5-30.7, P = 0.01). Gestational age at birth was lower in the emergency group (31.55 [4.75] vs. 35.19 [2.77], P = 0.001), no difference in perinatal mortality was found. A sonographically short cervix and/or history of APH had an increased cumulative risk of emergency birth with advancing gestational age.Patients with PAS disorders managed in a tertiary center by a multidisciplinary team requiring emergency birth have increased maternal morbidity and poorer perinatal outcomes than those with electively scheduled birth.

Objective To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we evaluated for factors associated with treatment success and pregnancy outcomes after medical management. Design Systematic review and meta-analysis. Setting Not applicable. Patient(s) Thirty-two studies representing 121 premenopausal women with medically-treated uterine AVM were identified via database searches of MEDLINE, Embase, Web of Science, and cited references. Intervention(s) Medical treatment with progestins, gonadotropin-releasing hormone agonists (GnRH-a), methotrexate, combined hormonal contraception , uterotonics, danazol, or combination of the above. Main Outcome Measure(s) Primary outcome of treatment success was defined as AVM resolution without subsequent procedural interventions. Secondary outcome was treatment complication (readmission or transfusion). Result(s) The overall success rate of medical management was 88% (106/121). After adjusting for clustering effects, success rates for progestin (82.5%; 95% confidence interval [CI], 70.1%–90.4%), GnRH-a (89.3%; 99% CI, 71.4%–96.5%) and methotrexate (90.0%; 99% CI, 55.8%–98.8%) were significantly different from the null hypothesis of 50% success. The agents with the lowest adjusted proportion of complications were progestins (10.0%; 99% CI, 3.3%–26.8%) and GnRH-a (10.7%; 99% CI, 3.5%–28.4%). No clinical factors were found to predict treatment success. Twenty-six subsequent pregnancies are described, with no reported recurrences of AVM. Conclusion(s) Medical management for uterine AVM is a reasonable approach in a well selected patient. These data should be interpreted in the context of significant publication bias.

Study Objective 1. To determine whether there are differences in patient and case characteristics among male versus female surgeons. 2. To determine whether there are differences in performance among male versus female surgeons with respect to several quality metrics for hysterectomies. Design Multi-center retrospective cohort study. Primary outcome: composite of any complication or return to emergency room (ER) within 30 days of hysterectomy Secondary outcomes: Grade II or greater complications (based on the Clavien-Dindo classification), return to ER, and operative time. Covariates included patient, case, and surgeon characteristics. Setting Eight hospitals (4 academic and 4 community) in Ontario, Canada. Patients or Participants Consecutive hysterectomies performed between July 1, 2016, and December 30, 2019. Hysterectomies performed by gynecologic oncologists and those completed for invasive placentation were excluded. We included 2664 hysterectomies performed by 77 surgeons (54 females, 23 males). Interventions N/A. Measurements and Main Results We matched surgeries performed by female surgeons to those by male surgeons using a propensity score and compared outcomes by gender after adjusting for years in practice and additional post-residency surgical fellowship training. After matching, 963 surgeries performed by females were compared with 963 by males. There were no differences between hysterectomies performed by male and female surgeons for the primary outcome of any complication or return to emergency room within 30 days (RR 0.92, 95% CI 0.71-1.20, p=0.56), and no differences for the secondary outcomes of Grade II or greater complication (RR 1.01, 95% CI 0.71-1.45, p=0.96) or return to emergency room within 30 days (RR 0.81, 95% CI 0.55-1.20, p=0.30). Surgeries performed by males, however, were 24.72 minutes shorter compared to those performed by female surgeons (95% CI 18.09 – 31.34 minutes, p Conclusion Complication and readmission rates following elective hysterectomy are similar for male and female surgeons, however male surgeons have a shorter operating time. Further research is required to elucidate contributing factors.

OBJECTIVE: Inadequate communication about endometriosis symptom burden between women and healthcare providers is a barrier for optimal treatment. This study describes the development of the EndoWheel, a patient-reported assessment tool that visualizes the multi-dimensional burden of endometriosis to facilitate patient-provider communication. METHODS: Assessment questions for the tool were developed using an iterative Delphi consensus process. A consensus phase included additional practitioners and specialists to broaden perspectives and select revised statements. Semi-structured qualitative interviews were conducted with 13 women with endometriosis to assess the scoring and content of the measures. RESULTS: Symptoms included in the tool were pelvic pain, vaginal bleeding, bowel/bladder symptoms, energy levels, fertility, impact on activities, emotional and sexual well-being, and self-perceived global health. Additional life impact areas included relationships, social and occupational activity, and self-perception. The 13 interviewees completed the tool in approximately 5-6 minutes (range 4.0-7.5 minutes). Most participants (92%) perceived that the tool would enable better patient-provider communication, including addressing symptoms and areas of impact not normally discussed during office visits. CONCLUSION: Similar to visual circular tools used in burden assessment of other chronic diseases, the tool may facilitate improved patient dialogue with providers around endometriosis treatment goals and options.

To describe the diagnostic and surgical challenges in the management of second trimester placenta percreta.Stepwise demonstration of the surgical technique with the use of an educational video.Second trimester placenta percreta is a rare entity, with very few case reports in the literature. Our video demonstrates the challenges of a minimally invasive approach toward definitive surgical management with hysterectomy. A 39-year-old G7P3 (3 previous cesarean deliveries) female at 17 weeks and 2 days gestation presented with acute abdominal pain to a community hospital. This was a spontaneously conceived pregnancy. Her hemoglobin level on admission was 92 g/L. An ultrasound showed a normal uterus, and the appendix was not visualized. One unit of packed red blood cells was transfused, and she underwent exploratory laparoscopy for a possible retrocecal hematoma/mass seen on computerized tomography. In the operating room, acute hemoperitoneum was visualized with placenta-like tissue invading through the anterior lower uterine segment (Figures 23). A hemostatic agent (Floseal, Baxter) was placed over the bleeding, and she was then transferred to a tertiary academic center for further management.Magnetic resonance imaging was performed on the following day after transfer to our facility, which confirmed placenta percreta at the level of the bladder (Figure 1). Following counseling with a multidisciplinary team and given that there was ongoing bleeding from the invading placental tissue, pregnancy continuation and uterine conservation were not possible. The patient was offered preprocedure termination of pregnancy with intra-cardiac injection of potassium chloride and 350 cc of amniotic fluid was drained at that time. This was done to facilitate visualization for a minimally invasive approach. We describe 5 main challenges of minimally invasive hysterectomy for placental percreta and provide a stepwise approach to mitigating them: visibility, vascular control, bladder dissection, colpotomy, and specimen retrieval. We adapted the previously described laparotomy techniques of progressive uterine devascularization and approach to bladder dissection and colpotomy to laparoscopy [1,2]. In addition, we performed dilatation and evacuation to allow for vaginal specimen removal. The patient's postoperative course was uncomplicated, and she was discharged home in a stable condition.Midtrimester placenta percreta poses significant challenges in diagnosis and surgical management. Total laparoscopic hysterectomy for this condition poses unique challenges but is feasible and safe.

To evaluate the accuracy of gynecologic surgeons' self-reflection across hysterectomy case volume, proportion of cases performed using a minimally invasive approach (minimally invasive rate), and complication rate and to assess whether accuracy is associated with specific surgeon or practice characteristics.This was a cross-sectional cohort study of gynecologic surgeons at eight Canadian hospitals between 2016 and 2019. Surgeons estimated case volume, minimally invasive rate, and complication rate for hysterectomies for a 6-month period using an online survey. Kendall's tau-beta correlation coefficient (τ) measured association between estimated and actual performance. Differences (delta) between each surgeon's estimated and actual performance were calculated. The central tendency of differences among the cohort was represented by a median (median delta) and compared with 0 (perfect accuracy) using the Wilcoxon signed rank test. Differences in characteristics between surgeons classified as underestimators, accurate estimators, and overestimators by tertile of delta were evaluated using analysis of variance and χ2 tests.Eighty-four surgeons across eight hospitals were included. Association between estimated and actual performance was moderate for case volume (τ=0.46, P.001) and minimally invasive rate (τ=0.52, P.001) and weak for complication rate (τ=0.14, P=.080). Surgeons underestimated their complication rate (median delta -7.0%, 95% CI -11.0% to -3.5%, P.001) but accurately estimated case volume (median delta 1.0, 95% CI 0.0-2.5, P=.082) and minimally invasive rate (median delta 4.0%, 95% CI -4.5% to 10.0%, P=.337). Surgeons who underestimated their complication rates had higher average complication rates (33.7%) than those who estimated accurately (12.1%, P.001) or overestimated (7.7%, P.001) and were more likely to be fellowship-trained (P.001).Attending gynecologic surgeons inaccurately reflect on their complication rates, and those who most underestimate their complication rates have higher rates than their peers.

OBJECTIVE To evaluate predictors of bilateral salpingo-oophorectomy at hysterectomy and determine rate of unnecessary bilateral salpingo-oophorectomy. METHODS Retrospective review of hysterectomies at six Ontario, Canada hospitals from July 2016 to June 2018. Data was extracted from health records coding and electronic medical records. Of patients with concurrent bilateral salpingo-oophorectomy, age, preoperative diagnoses, surgical factors (presence of endometriosis/adhesions), and surgeon training (fellowship/no fellowship) were recorded. Chi-square tests compared indicated and nonindicated bilateral salpingo-oophorectomy cases based on preoperative diagnosis. Criteria for unnecessary bilateral salpingo-oophorectomy were: age under 51 years, benign preoperative diagnosis, and absence of intraoperative endometriosis and adhesions. RESULTS Concurrent bilateral salpingo-oophorectomy occurred in 749/2,656 (28%) cases with 509/749 (68%) indicated based on preoperative diagnosis. There was interhospital variation in rate of indicated bilateral salpingo-oophorectomy based on preoperative diagnosis (45.3%-76.9%, χ2P

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.

BACKGROUND: Uterine fibroids are common in women and their management is heavily influenced by information gathered through imaging. We aimed to evaluate the type and quality of imaging performed for assessment of uterine fibroids in Canada. METHODS: Starting in July 2015, premenopausal women with symptomatic fibroids were enrolled in a prospective, noninterventional, observational registry (Canadian Women With Uterine Fibroids Registry [CAPTURE]) that included 19 Canadian sites. Clinical characteristics were extracted from the baseline visit. We evaluated the association between demographic and clinical variables of interest with regard to imaging type using unadjusted and adjusted logistic regression models. RESULTS: Of 1493 women, 1148 had ultrasonography, 135 had magnetic resonance imaging (MRI), 80 had other types of imaging and 130 did not have imaging reported within 12 months of the baseline visit. After adjusting for demographic and clinical characteristics, patients who underwent MRI had larger fibroids (odds ratio [OR] per 1-cm increase 1.11, 95% confidence interval [CI] 1.05–1.17) and more numerous fibroids (1 v. > 1; OR 1.74, 95% CI 1.14–2.64) compared with those who underwent ultrasonography only. For ultrasonography reporting, quality criteria were met for 268 of 1148 patients (23.3%). There was a difference in the quality of reporting among the 19 sites (p < 0.001). Logistic regression model accounting for within-site variability showed that reporting results from ultrasonography in the province of Quebec were less likely to meet all quality criteria (OR 0.20, 95% CI 0.06–0.66) and those from sites in more populated cities (≥ 400 000 inhabitants) were more likely to do so (OR 6.15, 95% CI 2.20–17.18). INTERPRETATION: We determined that imaging modality for fibroids is associated with patient characteristics. The quality of reporting results for ultrasonography of fibroids in Canada falls short of internationally endorsed guidelines and needs improvement. STUDY REGISTRATION: ClinicalTrials.gov, no. NCT02580578

To synthesize the published literature to better understand the association between cesarean scar defects (CSDs) and abnormal uterine bleeding (AUB). In particular, we aimed to evaluate the risk and pattern(s) of CSD-associated AUB in addition to exploring the relationship between defect morphology with bleeding symptoms.Systematic review and meta-analysis.Not applicable.Patients with CSD and reports of uterine bleeding as an outcome were identified in 60 studies from database searches.Studies that investigated CSD (as defined by investigators) and reported uterine bleeding, menstrual bleeding, or AUB as an outcome were included.The prevalence and risk of AUB (intermenstrual, postmenstrual, and unscheduled bleeding) in patients with confirmed CSD.Nine studies reported on the prevalence of AUB in patients with a confirmed CSD. Patients with CSD were more likely to experience AUB, compared with those without CSD (relative risk, 3.47; 95% confidence interval [CI], 2.02-5.97; 6 studies, 1,385 patients; IThere is a strong and consistent association between patients with CSD and AUB. These patients experience a unique bleeding pattern, namely prolonged menstruation and early-cycle intermenstrual bleeding. These data should provide impetus for including CSD as a distinct entity in AUB classification systems. High heterogeneity in our results calls for standardization of nomenclature and outcome reporting for this condition.

The primary objective of this study is to identify patient characteristics associated with postoperative complications or readmissions after hysterectomy for a benign indication.Retrospective cohort.The Surgical Gynecologic Scorecard Database includes performance metrics and patient outcomes for hysterectomies across 7 sites in Ontario, Canada.Individuals who underwent hysterectomy for benign gynecologic indication and were recorded in the Surgical Gynecologic Scorecard Database between July 2016 and June 2019 were included in this study.Two outcomes of interest were considered: (1) complications grade II or greater on the Clavien-Dindo classification scale and (2) emergency room visits or hospital readmissions within 6 weeks after operation. Logistic models were generated to determine the associations between outcome of interest and potential predictors using a mixed-step AIC selection algorithm. A total of 2792 patients underwent hysterectomy for a benign indication during the study period, with a mean age of 52.6 ± 11.7 years and mean body mass index of 29.0 ± 0.7 kg/mThis study identified several important risk factors for complications after hysterectomy. The utility of these data is important to help improve counseling for patients undergoing a hysterectomy and potentially optimize modifiable risk factors when identified preoperatively.

To review the existing literature on uterine cesarean scar defect repair in pregnancy and describe an approach to minimally invasive surgical repair in early pregnancy to facilitate a term live birth.A case study and literature review, followed by a demonstration of the procedure with surgical video and concurrent ultrasound footage.Academic medical center.This video is a case presentation of a 35-year-old, gravida 2, para 1 woman with a previous cesarean section. She presented at 10 weeks and 3 days gestational age with complete uterine dehiscence at the site of her previous cesarean section scar, which was diagnosed by ultrasound. Surgical video and medical images have been extracted from this patient's chart after consent was obtained.Ultrasound-guided laparoscopic repair of cesarean scar defect at 11 weeks and 3 days of gestation.The video showed a large 2.6-cm uterine scar defect in early pregnancy confirmed using ultrasound and magnetic resonance imaging. This diagnosis was confirmed by direct visualization at the time of surgery. This video demonstrates our surgical approach as follows: careful uterine manipulation and identification of the defect with laparoscopy and concurrent transvaginal ultrasound; reflection of the bladder using an ultrasound-guided approach to confirm the borders of the defect; and repair with a running 2-layer closure under transvaginal ultrasound guidance.Through ultrasound-guided laparoscopic repair, we were able to demonstrate a restoration of approximately 8 mm of myometrial thickness across the cesarean scar defect on antenatal follow-up. The patient had a term live birth via cesarean section.With an increased number of cesarean sections and improved quality of ultrasound imaging, an increase in the incidental findings of cesarean scar defects has been observed. The risk of spontaneous prelabor uterine rupture remains unknown. There is a literature gap in this area regarding the appropriate standard of care. This video demonstrates that ultrasound-guided laparoscopic repair was possible, safe, and effective in our patient. However, further studies are required to establish the safety and efficacy of this approach.

Objective To determine the proportion of patients undergoing hysterectomy for a benign indication who have unexpected malignancy (UM) on postoperative pathology and characterize the nature of UMs. Methods This was a multi-center, retrospective study of patients undergoing hysterectomy for a benign indication from July 2016 to December 2019 at 7 Ontario, Canada hospitals (4 academic, 3 community). Hysterectomies for invasive placentation, malignant, and premalignant indications were excluded. Primary outcome was rate of unexpected malignancy as defined by the number of patients with malignancy on final pathology divided by the total number of hysterectomy cases. Data was extracted from health records and electronic charts. Patient, surgical, and surgeon characteristics were compared between benign and UM groups using bivariate methods. Associations between UM status and perioperative variables were assessed using bivariate logistic regression. Results In the study period, 2779 hysterectomies were performed. UM incidence was 1.8% (51 malignancies/2779 cases), with one patient having two malignancies (total UMs = 52). The most common UM types were endometrial (27/52, 51.9%) and sarcoma (13/52, 25%). Patients with UM were older (57.2 ± 11.4 years vs. 52.8 ± 12.5 years, p = .015), had more previous laparotomies (2 (1.25, 2.0) vs. 1 (1.0, 1.0), p < .001), and higher BMI (29.7 ± 7.2 kg/m2 vs. 28.0 ± 5.9 kg/m2, p = .049) and ASA class (p < .028). Regarding surgical factors, patients with UM had more adhesions (p = .001), transfusions (p = .020), and blood loss (p = .006) compared to those with benign pathology. Patient characteristics most strongly associated with UM were age (OR 2.57, 95% CI 1.78–3.72, p < .001) and preoperative diagnosis of pelvic mass (OR 2.76, 95% CI 1.11–6.20, p = .019). Conclusion Incidence of UM at hysterectomy for benign indication was 1.8%. Several perioperative variables are associated with an increased chance of UM.

RESUME Objectifs Les directives du present addenda visent a fournir aux cliniciens une mise a jour de la directive clinique de 2015 sur la prise en charge des fibromes uterins. Comme de nouveaux renseignements et de nouvelles donnees probantes ont vu le jour depuis 2015, le comite de pratique clinique – gynecologie de la Societe des obstetriciens et gynecologues du Canada a determine qu'un addenda a ce document etait desormais necessaire pour informer les membres des modalites de traitement des fibromes uterins. Resultats La mise en application de la presente mise a jour de la directive clinique devrait contribuer a optimiser le processus de decision des femmes et de leurs fournisseurs de soins de sante pour ce qui est de poursuivre les examens diagnostiques ou les traitements relatifs aux leiomyomes uterins apres avoir tenu compte de l'evolution de la maladie ainsi que des options therapeutiques et analyse les risques et les bienfaits anticipes. Donnees probantes La litterature publiee a ete reperee entre fevrier 2015 et avril 2018 a l'aide de recherches effectuees dans les bases de donnees PubMed, CINAHL et Cochrane Database of Systematic Reviews au moyen d'une terminologie controlee appropriee (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, menorrhagia) et des mots cles (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). Les listes de references des articles reperes ont aussi fait l'objet de recherche pour en tirer des publications pertinentes. Seuls les resultats des revues systematiques, d'essais cliniques randomises ou comparatifs et d'etudes observationnelles ont ete retenus. Aucune date limite n'a ete appliquee, mais les resultats ont ete limites aux contenus en anglais ou en francais. Les recherches ont ete regulierement mises a jour et leurs resultats ont ete incorpores a la directive clinique jusqu'en avril 2018. La plupart des donnees non publiees n'ont pas fait l'objet d'evaluation scientifique. Les monographies de produit ont aussi ete analysees jusqu'au 31 decembre 2018. Avantages, prejudices et couts La majorite des fibromes sont asymptomatiques et ne necessitent aucune intervention ni aucun examen diagnostique supplementaire. Pour les fibromes symptomatiques, tels que ceux qui entrainent des anomalies menstruelles (p. ex. saignements uterins abondants, irreguliers ou prolonges), une anemie ferriprive ou des symptomes lies au volume des fibromes (p. ex. pression ou douleur pelvienne, symptomes d'obstruction), l'hysterectomie constitue une solution definitive. Par contre, elle n'est pas la solution a privilegier pour les femmes qui souhaitent preserver leur fertilite ou leur uterus. Le traitement choisi devrait viser une amelioration de la symptomatologie et de la qualite de vie. Le cout du traitement pour le systeme de soins de sante et pour la femme atteinte de fibromes doit etre interprete par rapport au cout des affections pathologiques non traitees et au cout des examens diagnostiques et modalites de traitement continus ou repetes. Criteres La qualite des donnees probantes contenues dans le present document a ete evaluee en fonction des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. Recommandations 1L'administration intermittente prolongee de modulateurs selectifs des recepteurs de la progesterone peut etre utilisee pour traiter les symptomes lies aux fibromes; elle est generalement securitaire, bien toleree et efficace (I-B). 2Il y a lieu de depister les risques d'insuffisance hepatique chez les femmes traitees a l'acetate d'ulipristal avant d'amorcer le traitement et de leur faire subir un controle mensuel des enzymes hepatiques durant la therapie puis 2 a 4 semaines apres la fin de la serie de traitements. Les medecins doivent savoir reconnaitre les signes et symptomes de l'insuffisance hepatique et les patientes doivent etre informees de ces symptomes (III-C). 3Il a ete demontre que les agonistes de la gonadoliberine diminuent le volume des fibromes, attenuent l'anemie et reduisent la probabilite de transfusions sanguines perioperatoires (I-A). 4L'anemie preoperatoire (hemoglobine

Resume Contexte Les troubles du spectre du placenta accreta (TSPA) constituent une complication de la grossesse potentiellement mortelle et exigent une coordination des soins interdisciplinaires afin d'ameliorer la possibilite d'une issue favorable. La hausse de la frequence des cas est due a l'augmentation du nombre d'interventions chirurgicales uterines, notamment a l'augmentation de la frequence des grossesses apres cesarienne. Objectif Fournir des directives cliniques factuelles courantes sur les methodes optimales pour depister, diagnostiquer et prendre en charge les TSPA de facon efficace. Methode Les membres du comite sur les directives cliniques ont ete selectionnes en fonction de leur milieu de pratique et de leur expertise actuelle en matiere de prise en charge de cette maladie au Canada. Le comite a revu toutes les donnees probantes disponibles dans la litterature medicale en anglais, y compris des lignes directrices publiees ainsi que des tests de diagnostic, des interventions chirurgicales et les issues cliniques evaluees. Donnees probantes La litterature publiee jusqu'en mars 2018, y compris les directives cliniques, a ete puisee dans les bases de donnees Medline et Cochrane Library au moyen d'un vocabulaire controle et de mots cles. Les resultats sont limites aux analyses systematiques, aux essais cliniques randomises et aux etudes observationnelles rediges en anglais. Les recherches ont ete mises a jour regulierement, et les resultats ont ete incorpores a la directive clinique jusqu'en juillet 2018. Criteres La qualite des donnees probantes dans le present document a ete evaluee en fonction des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. Resultats Le present document passe en revue les donnees probantes relatives aux techniques diagnostiques et chirurgicales utilisees pour favoriser la prise en charge optimale des femmes chez qui l'on suspecte un TSPA, notamment l'anesthesie et les considerations cliniques de la prestation de soins interdisciplinaires. Avantages, prejudices et couts La mise en application des recommandations de la presente directive clinique ameliorera la sensibilisation a cette maladie et augmentera la proportion des femmes atteintes recevant des soins interdisciplinaires dans des centres regionaux. Conclusion La prestation de soins par une equipe interdisciplinaire qui assure de bons services diagnostiques, la planification concertee et les interventions chirurgicales securitaires fournissent des soins qui ameliorent les issues cliniques comparativement aux autres modes de prise en charge. DECLARATIONS SOMMAIRES 1La frequence des troubles du spectre du placenta accreta est en hausse constante dans de nombreux pays, vraisemblablement en raison de l'augmentation de la proportion de femmes qui deviennent enceintes apres avoir subi une ou plusieurs interventions chirurgicales uterines, notamment des cesariennes multiples. 2Les troubles du spectre du placenta accreta dans un contexte d'antecedents de cesarienne decoulent de l'implantation de la grossesse dans la niche au niveau de la cicatrice pres de la jonction cervico-isthmique de l'uterus. Diverses methodes echographiques permettent de diagnostiquer la manifestation precoce d'une « grossesse sur cicatrice de cesarienne ». 3L'echographie peut servir a depister et a diagnostiquer les grossesses avec un placenta praevia anterieur complique par un trouble du spectre du placenta accreta. L'efficacite de l'echographie dans ce contexte depend de la connaissance des facteurs de risque cliniques, de la qualite de l'imagerie, de l'experience de l'echographiste, de l'âge gestationnel, des modalites d'imagerie et du volume vesical adequat. 4L'imagerie par resonance magnetique peut appuyer l'echographie multimodale dans le diagnostic et la classification des troubles du spectre du placenta accreta; cependant, la contre-indication relative de l'utilisation du gadolinium comme agent de contraste limite actuellement son efficacite. 5Les troubles du spectre du placenta accreta sont potentiellement mortels et necessitent la prestation de soins par une equipe interdisciplinaire regionale afin de maximiser les chances d'issue favorable pour la mere et le nourrisson. RECOMMANDATIONS 1Il y a lieu de diriger les femmes enceintes qui presentent un placenta praevia anterieur et des facteurs de risque cliniques des troubles du spectre placenta accreta a l'echographie obstetricale de 18-20 semaines vers des services d'imagerie specialisee afin de diagnostiquer ou d'exclure cette maladie (II-2A). 2Il y a lieu de diriger les femmes qui ont recu un diagnostic de troubles du spectre du placenta accreta vers un centre regional designe a la prise en charge interdisciplinaire de cette maladie (II-3A). 3Les soins interdisciplinaires rattaches a un protocole qui s'etend du diagnostic a l'intervention chirurgicale optimiseront les issues a la fois peroperatoires et postoperatoires (II-3A). 4L'admission prenatale dans un centre de prise en charge regional designe peut etre indiquee, surtout a la suite d'une hemorragie ante partum, ou en fonction de contraintes geographiques ou de transport (III-B). 5Chez les femmes autrement en sante dont l'historique de grossesse ne comporte aucun saignement vaginal, le meilleur moment pour proceder a la cesarienne planifiee se situe entre 34 et 36 semaines de grossesse (II-3B). Il convient d'envisager d'effectuer l'intervention plus tot en cas d'episodes repetes d'hemorragie ante partum ou de contractions afin de reduire le risque d'intervention chirurgicale d'urgence non planifiee; on doit aussi idealement administrer une corticotherapie pour favoriser la maturation pulmonaire fœtale si l'intervention a lieu avant 35+0 semaines de grossesse (II-2A). 6L'anesthesie regionale peut s'averer plus securitaire que l'anesthesie generale etant donne qu'elle est liee a une perte sanguine moindre et que les patientes et leur partenaire la prefere (II-2A). Un protocole de transfusion massive doit etre en place afin de pouvoir reagir en cas de perte sanguine importante (III-B). 7Il y a lieu d'administrer de l'acide tranexamique par voie intraveineuse au debut de l'intervention parce qu'elle diminue la perte sanguine peroperatoire (I-A). 8Il convient de realiser l'intervention chirurgicale en position de lithotomie modifiee, au moyen d'une incision mediane assez haute pour extraire le fœtus sans pratiquer d'incision dans le placenta; l'echographie pre- ou peroperatoire peut etre utilisee afin de determiner l'incision uterine optimale (III-B). Si le placenta ne montre aucun signe de decollement, il convient de ne pas tenter de l'extirper en raison de l'hemorragie importante qui peut en decouler (III-B). 9A l'heure actuelle, il n'y a pas suffisamment de donnees probantes pour recommander ou non l'administration de medicaments uterotoniques apres l'extraction du fœtus (III-C). 10A l'heure actuelle, il n'y a pas suffisamment de donnees probantes pour recommander une methode ou une autre (insertion preoperatoire de ballonnets ou ligature peroperatoire) visant a reduire le debit sanguin des arteres iliaques internes avant l'hysterectomie (II-1C). 11Une atteinte centrale focale peut se preter a la resection cuneiforme (wedge) avec retrait complet du placenta et reparation de l'uterus (triple-P) (II-3B). 12La cesarienne classique avec abandon du placenta envahissant constitue une methode d'accouchement acceptable, mais elle prolongerait le temps de recuperation et presente un risque persistant d'hysterectomie (II-3B). 13Il convient de recommander aux femmes qui demeurent fertiles apres un diagnostic de trouble du spectre de placenta accreta d'obtenir une echographie aupres d'un specialiste tot dans toute grossesse subsequente de sorte que toutes les options de prise en charge demeurent sur la table en cas de grossesse sur cicatrice de cesarienne (III-B). 14Le diagnostic prenatal des formes les plus graves de troubles du spectre du placenta accreta, designees comme des grossesses sur cicatrice de cesarienne, peut rendre possible une prise en charge au moyen de techniques chirurgicales a effraction minimale (II-3D). 15Bien que bon nombre de femmes presentant un trouble du spectre du placenta accreta recoivent des soins securitaires dans les pays bien outilles, il faut pousser la recherche et favoriser le transfert de connaissances encore davantage pour offrir efficacement toutes les options de prise en charge a la population (III-B).

Background Placenta accreta spectrum (PAS) disorders are a potentially life-threatening complication of pregnancy that demand coordinated interdisciplinary care to achieve safer outcomes. The rising incidence of this disease is due to a growing number of uterine surgical procedures, including the rising incidence of pregnancy following Caesarean section. Objective To provide current evidence-based guidelines on the optimal methods used to effectively screen, diagnose, and manage PAS disorders. Methods Members of the guideline committee were selected on the basis of their ongoing expertise in managing this condition across Canada and by practice setting. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated diagnostic tests, surgical procedures, and clinical outcomes. Evidence Published literature, including clinical practice guidelines, was retrieved through searches of Medline and The Cochrane Library to March 2018 using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized controlled trials, and observational studies written in English. Searches were updated on a regular basis and incorporated in the guideline to July 2018. Values The quality of evidence in this document was graded using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Results This document reviews the evidence regarding the available diagnostic and surgical techniques used for optimal management of women with suspected PAS disorders, including anaesthesia and practical considerations for interdisciplinary care. Benefits, Harms, and Costs Implementation of the guideline recommendations will improve awareness of this disease and increase the proportion of affected women receiving interdisciplinary care in regional centres. Conclusions Interdisciplinary team-based care providing accurate diagnostic services, coordinated planning, and safer surgery deliver effective care with improved clinical outcomes in comparison with alternative management. Summary Statements 1The incidence of placenta accreta spectrum disorders is steadily rising in many countries, likely due to the increasing proportion of women becoming pregnant following a variety of surgical procedures to the uterus, including multiple Caesarean sections. 2Placenta accreta spectrum disorders in the setting of prior Caesarean section deliveries arises from pregnancy implantation within the niche created by this surgery near the cervicoisthmic junction of the uterus. This early presentation as a "Caesarean section scar pregnancy" may be diagnosed by ultrasound methods. 3Ultrasound may be used to screen for, and to diagnose, pregnancies with anterior placenta previa that are complicated by placenta accreta spectrum disorders. The effectiveness of ultrasound in this context depends upon awareness of clinical risk factors, imaging quality, operator experience, gestational age, imaging modalities, and adequate bladder filling. 4Magnetic resonance imaging may complement multimodal ultrasound in the diagnosis and staging of placenta accreta spectrum disorders, though its effectiveness is currently limited by the relative contraindication to the use of a gadolinium contrast enhancing agent. 5Placenta accreta spectrum disorders are potentially life-threatening and demand regional interdisciplinary team-based care to deliver the safest outcomes for mothers and infants. Recommendations 1Pregnant women with clinical risk factors for placenta accreta spectrum disorders and anterior placenta previa at the 18–20-week fetal anatomical ultrasound should be referred for specialist imaging to diagnose or exclude this disorder (II-2A). 2Women with a diagnosis of placenta accreta spectrum disorder should be referred to a regional centre dedicated to the interdisciplinary management of this condition (II-3A). 3Protocol-based interdisciplinary care from diagnosis to surgery will optimize both intraoperative and postoperative outcomes (II-3A). 4Antenatal admission to a designated regional management centre may be indicated, especially following an antepartum hemorrhage, or based on considerations of geography or transport conditions (III-B). 5For otherwise healthy women with no history of vaginal bleeding, the optimal timing of elective Caesarean section delivery is around 34–36 weeks gestation (II-3B). Surgery should be considered earlier for repeated episodes of antepartum hemorrhage or contractions to reduce the risks of emergent unplanned surgery and should ideally be preceded by a course of corticosteroids to enhance fetal lung maturation if prior to 35+0 weeks gestation (II-2A). 6Regional anaesthesia may be safer than general anaesthesia as it is associated with reduced blood loss and is preferred by patients and their partners (II-2A). A massive transfusion protocol should be in place to respond to significant blood loss (III-B). 7Intravenous tranexamic acid should be administered at the commencement of surgery because it reduces intraoperative blood loss (I-A). 8Surgery should be performed in the modified lithotomy position, using midline access, sufficiently high so as to deliver the fetus without incising through the placenta; preoperative or intraoperative ultrasound can be used to guide the optimal uterine incision (III-B). No attempt should be made to remove the placenta if it shows no signs of separation as this may cause substantial hemorrhage (III-B). 9Presently there is insufficient evidence to recommend giving or withholding uterotonic drugs after delivery of the fetus (III-C). 10Presently there is insufficient evidence to recommend either approach (preoperative balloon placement or intraoperative ligation) designed to arrest blood flow from the internal iliac arteries prior to hysterectomy (II-1C). 11Focal central disease may be amenable to wedge resection, with complete removal of the placenta and repair of the uterus (the triple-P procedure) (II-3B). 12Classical Caesarean section and non-removal of the invasive placenta is an acceptable method of delivery but is associated with a protracted course of recovery and a persistent risk of hysterectomy (II-3B). 13Women who retain their fertility following a diagnosis of placenta accreta spectrum disorder should be instructed to access specialist ultrasound early in any future pregnancy so that all management options are available should a Caesarean section scar pregnancy be found (III-B). 14Prenatal diagnosis of the more severe forms of placenta accreta spectrum disorder, expressed as a Caesarean section scar pregnancy, may permit management using minimally invasive surgical techniques (II-3B). 15Though many women with placenta accreta spectrum disorder in well-resourced countries receive safe care, more research and knowledge translation are needed to effectively deliver all management options at the population-based level (III-B).

RESUME Objectif Aider les medecins qui pratiquent la chirurgie gynecologique dans leur processus decisionnel relatif aux indications benignes de l'hysterectomie. Public cible Medecins, y compris gynecologues, obstetriciens, medecins de famille, chirurgiens generalistes, urgentologues; infirmieres, y compris les infirmieres autorisees et les infirmieres praticiennes; apprentis en medecine, y compris etudiants de medecine, residents, stagiaires (fellows); et autres fournisseurs de soins de sante. Population cible Femmes adultes (18 ans et plus) qui devront subir une hysterectomie pour une indication gynecologie benigne. Options La presente directive clinique examine les differentes voies d'abord de l'hysterectomie et l'utilite des interventions chirurgicales concomitantes. Donnees probantes Pour la presente directive clinique, des recherches ont ete effectuees dans les bases de donnees PubMed, Medline et Cochrane Library pour trouver des etudes pertinentes. Les recherches ont ete effectuees parmi les publications des cinq dernieres annees (2012-2017) au moyen des termes de recherche MeSH suivants ainsi que leurs variations : vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy et total vaginal hysterectomy. Methodes de validation Le contenu et les recommandations ont ete rediges et acceptes par les auteurs principaux et membres du comite de pratique clinique – gynecologie. Le conseil d'administration de la Societe des obstetriciens et gynecologues du Canada a approuve la version definitive aux fins de publication. La qualite des donnees probantes utilisees dans le present document a ete evaluee au moyen des criteres du cadre methodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) (tableau 1, tableau 2). Le resume des conclusions est disponible sur demande. Avantages, prejudices et couts Bien que l'hysterectomie soit commune, la pratique chirurgicale varie grandement chez les medecins specialises en gynecologie. La presente directive expose les facteurs pre- et perioperatoires a prendre en compte pour ameliorer la qualite des soins prodigues aux femmes qui doivent subir une chirurgie pour une affection gynecologique benigne. Mise a jour de la directive clinique La presente directive clinique de la Societe des obstetriciens et gynecologues du Canada sera automatiquement passee en revue cinq ans apres sa publication. Les auteurs peuvent toutefois proposer une autre date de reevaluation s'ils croient qu'une periode de cinq ans est trop courte ou trop longue en fonction de leurs connaissances du sujet a titre d'experts en la matiere. Promoteurs La presente directive clinique a ete elaboree au moyen de ressources financees par la Societe des obstetriciens et gynecologues du Canada. Declarations condensees 1La technicite correspond a la proportion des hysterectomies realisees par voie d'abord a effraction minimale (laparoscopique, assistee par laparoscopie et vaginale). L'indice de technicite eleve est lie a une amelioration de la qualite chirurgicale et des soins a la patiente (elevee). 2Les voies d'abord de l'hysterectomie a effraction minimale sont liees a moins de complications perioperatoires que la laparotomie (elevee). 3Les hopitaux et chirurgiens qui traitent un grand nombre de patientes sont les plus susceptibles de detenir un indice de technicite eleve et un taux plus faible de complications (elevee). 4Les protocoles de chirurgie d'un jour pour l'hysterectomie a effraction minimale sont rentables, n'augmentent pas les taux de complications ni de readmission et sont lies a un taux eleve de satisfaction des patientes (moyenne). 5Le risque de traumas des voies urinaires est comparable entre les differentes voies d'approche chirurgicales de l'hysterectomie (moyenne). 6La laparotomie ou la mini-laparotomie peut etre indiquee comme solution de remplacement dans des cas precis en fonction de facteurs propres a la patiente, des indications chirurgicales et des pathologies sous-jacentes (moyenne). 7Le risque de dehiscence de la tranche vaginale est rare et n'est pas lie au choix du materiel de suture ni a la voie de fermeture (moyenne). 8L'hysterectomie supracervicale n'a pas demontre qu'elle peut preserver la fonction sexuelle, diminuer le risque de prolapsus des organes pelviens, ni reduire l'incidence du trauma des voies urinaires par rapport a l'hysterectomie totale (moyenne). 9Chez les femmes qui presentent des fibromyomes uterins, un traitement medicamenteux preoperatoire a l'acetate de leuprolide ou a l'acetate d'ulipristal peut reduire la taille des myomes, diminuer les saignements et corriger l'anemie. Les risques et avantages du traitement medicamenteux doivent etre abordes avant l'intervention (elevee). 10La preparation mecanique systematique des intestins n'est pas necessaire avant une chirurgie gynecologique pour une maladie benigne (elevee). 11L'ablation des ovaires normaux lors d'une hysterectomie reduit le risque de cancer de l'ovaire, mais peut entrainer des repercussions sur la sante. L'ovariectomie bilaterale peut provoquer une manifestation aigue de symptomes menopausiques chez les femmes non menopausees; elle n'a demontre aucun avantage de survie en l'absence d'une predisposition genetique au cancer de l'ovaire (elevee). 12L'hysterectomie seule affecte la reserve ovarienne (elevee). 13La salpingectomie prophylactique lors de l'hysterectomie devrait diminuer l'incidence des cas de cancer de l'ovaire grave de haut grade (faible). 14Il n'y a aucune donnee probante solide a l'appui de la suspension systematique aux utero-sacrees ou de la voute vaginale lors de l'hysterectomie chez les femmes qui ne presentent pas de prolapsus des organes pelviens (faible). Recommandations 1Pour les indications gynecologiques benignes, l'hysterectomie devrait se faire de preference par voie d'abord vaginale ou laparoscopique (forte, elevee). 2Pour realiser une hysterectomie, la voie d'abord vaginale est toujours l'option privilegiee, mais la chirurgie laparoscopique est une option de remplacement (forte, moyenne). 3La correction preoperatoire de l'anemie (hemoglobine a 4L'antibioprophylaxie preoperatoire et les mesures pour reduire le risque de thromboembolie veineuse sont recommandees pour toutes les patientes qui doivent subir une hysterectomie (forte, elevee). 5Il est important de conseiller les femmes sur les risques et avantages de l'ablation des ovaires lors de l'hysterectomie. Cette discussion doit aborder le risque de cancer de l'ovaire et les repercussions sur la sante a long terme relativement a une menopause precoce (forte, moyenne). 6La salpingectomie prophylactique peut etre envisagee lors de l'hysterectomie, mais la voie d'abord chirurgicale ne devrait pas etre modifiee pour cette seule fin (forte, faible). 7Comme le trauma des voies urinaires est une complication connue de l'hysterectomie, les cliniciens ne doivent pas hesiter a effectuer des examens supplementaires lorsqu'ils suspectent un trauma. Il convient, pour les chirurgiens qui pratiquent l'hysterectomie, d'avoir acces a la cystoscopie diagnostique, individuellement ou sur consultation, pour examiner la vessie et evaluer l'integrite ureterale (forte, moyenne). 8Pour les patientes atteintes d'endometriose qui prevoient de subir une hysterectomie, l'excision complete des lesions endometriosiques doit etre effectuee au moment de l'intervention (forte, moyenne).

RESUME Objectif La presente directive clinique conseille les gynecologues quant au recours au morcellement tissulaire pendant une chirurgie gynecologique. Resultats Le morcellement effectue au cours d'une chirurgie gynecologique peut permettre l'ablation de masses uterines volumineuses, offrant ainsi aux femmes une solution chirurgicale a effraction minimale. Les consequences oncologiques indesirables du morcellement tissulaire devraient etre attenuees par l'amelioration de la selection des patientes, la tenue d'examens preoperatoires et l'adoption de techniques novatrices reduisant au minimum la dispersion tissulaire. Evidence La litterature publiee a ete recuperee au moyen de recherches menees dans PubMed et Medline au printemps 2014 a l'aide d'une terminologie controlee (« leiomyosarcoma », « uterine neoplasm », « uterine myomectomy », « hysterectomy ») et de mots-cles (« leiomyoma », « endometrial cancer », « uterine sarcoma », « leiomyosarcoma », « morcellation »). Les resultats retenus provenaient de revues systematiques, d'essais cliniques randomises, d'essais cliniques controles et d'etudes observationnelles de langue anglaise ou francaise. Aucune restriction de date n'a ete imposee. Les recherches ont ete refaites regulierement, et les resultats ont ete incorpores a la directive clinique jusqu'en juillet 2017. Nous avons egalement tenu compte de la litterature grise (non publiee) trouvee sur les sites Web d'organismes d'evaluation des technologies de la sante et d'autres organismes lies aux technologies de la sante, dans des collections de directives cliniques et dans des registres d'essais cliniques, et obtenue aupres d'associations nationales et internationales de medecins specialistes. Valeurs La qualite des donnees probantes a ete evaluee en fonction des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. Avantages, inconvenients et couts Les gynecologues offrent aux femmes une chirurgie a effraction minimale pouvant comprendre le recours a un morcellateur electromecanique pour faciliter le retrait des tissus. Les femmes devraient etre informees que l'utilisation d'un morcellateur en presence de tumeurs uterines (sarcomes, tumeurs endometriales), cervicales ou tubo-ovariennes jusque-la insoupconnees est associee a un risque accru de dissemination. Le morcellement tissulaire devrait etre precede d'une evaluation complete, d'une selection appropriee des patientes et de l'obtention du consentement eclaire de ces dernieres, et devrait etre effectue par des chirurgiens ayant une formation adequate en matiere de pratiques de morcellement tissulaire sures. Declarations sommaires 1Comme les sarcomes uterins sont rares, il est difficile d'evaluer le risque absolu que des sarcomes occultes soient presents au moment d'une chirurgie visant des fibromes uterins. L'estimation du risque va de 1 sur 350 a 1 sur 2 000. Les conseils donnes aux patientes devraient etre adaptes en fonction de leur âge et de leurs autres facteurs de risque (II-2). 2Le morcellement, quelle que soit la methode utilisee, est contre-indique chez les femmes qui presentent une lesion precancereuse ou un cancer avere ou soupconne (III). 3Dans le cadre du processus de consentement eclaire, les patientes chez qui un morcellement est envisage devraient etre conseillees quant aux risques (tumeurs malignes et non malignes), aux avantages et aux solutions de rechange, surtout si elles ont plus de 50 ans (III). 4On peut avoir recours a des solutions de rechange au morcellement non confine pour extraire des tissus au cours d'une chirurgie visant des fibromes uterins; la solution retenue dependra de la voie chirurgicale, du volume de tissus a retirer, de la formation et des competences du chirurgien et des preferences de la patiente. Si les tissus ne peuvent etre retires intacts, aucune methode d'extraction ne peut eliminer le risque de dissemination iatrogene (II-2). 5Les avantages du morcellement confine fait dans un sac d'extraction, en ce qui a notamment trait au taux de survie et a la prevention de la dissemination des tumeurs malignes, n'ont pas ete etablis (II-2). 6Le traitement d'un sarcome uterin insoupconne au moyen d'une chirurgie primaire necessitant la fragmentation de la tumeur (y compris le morcellement) pourrait mener a la propagation intra-abdominale de la tumeur et a l'aggravation du pronostic (II-2). 7Les cliniciens devraient connaitre les complications generales autres que la propagation des cellules cancereuses malignes associees au morcellement (II-3). Recommandations 1Les patientes qui presentent un leiomyome uterin devraient faire l'objet d'une evaluation visant a detecter la presence possible d'une tumeur maligne, en fonction de leurs facteurs de risque et des resultats de l'imagerie preoperatoire, meme si la valeur de cette evaluation est limitee (III-C). 2Si l'indice de suspicion d'un sarcome uterin est eleve avant la chirurgie, l'uterus devrait etre retire intact. Le recours a une myomectomie est deconseille chez les femmes en perimenopause et les femmes menopausees (III-C). 3Il est recommande d'effectuer une biopsie endometriale et une evaluation du col uterin preoperatoires afin d'eviter le morcellement de tumeurs malignes et premalignes potentiellement detectables (II-2A). 4Le morcellement uterin devrait etre evite en presence de syndromes cancereux hereditaires associes a une hausse du risque de tumeurs uterines malignes (III-C). 5Diverses techniques peuvent etre utilisees pour le morcellement uterin; les medecins devraient se servir de techniques qui reduisent au minimum la fragmentation uterine et la propagation intra-abdominale des cellules (III-C). 6Le morcellement uterin est contre-indique en presence d'une neoplasie uterine averee ou soupconnee (II-2A).

Objective This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery. Outcomes Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. Evidence Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values 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. Benefits, harms, and costs Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation. Summary Statements 1Uterine sarcoma is rare, and as such it is difficult to characterize the absolute risk of occult sarcoma at the time of fibroid surgery. Risk estimates range from 1 in 350 to 1 in 2000. Patient counselling regarding risks should be tailored based on age and other risk factors (II-2). 2Morcellation of any type is contraindicated in women with established cancer, pre-cancerous lesions, or suspected cancer (III). 3When considering morcellation, patients should be counselled about the risks (malignant and non-malignant), benefits, and alternatives as part of the informed consent, especially in women over 50 (III). 4Alternatives to uncontained electromechanical morcellation can be used during fibroid surgery for tissue extraction depending on surgical route, specimen size, surgeon skill/training, and patient preference. If the specimen cannot be removed intact, then no method of tissue extraction can eliminate the risk of iatrogenic tissue dissemination (II-2). 5The benefits of in-bag contained morcellation, including survival rates and ability to prevent dissemination of malignant cells/tissue, have not been established (II-2). 6An unexpected uterine sarcoma treated by primary surgery involving tumour disruption, including morcellation of the tumour, has the potential for intra-abdominal tumour spread and a worse prognosis (II-2). 7Clinicians should be aware of the general complications associated with morcellation beyond the spread of malignant tissue (II-3). Recommendations 1Each patient presenting with uterine leiomyoma should be assessed for the possible presence of malignancy, based on her risk factors and preoperative imaging, although the predictive value of preoperative assessment is limited (III-C). 2If there is a high index of suspicion of a uterine sarcoma prior to surgery, attempts should be made to remove the uterus intact. Myomectomy in perimenopausal and postmenopausal women should be discouraged (III-C). 3Preoperative endometrial biopsy and cervical assessment is recommended in order to avoid morcellation of potentially detectable malignant and pre-malignant conditions of the endometrium and cervix (II-2A). 4Uterine morcellation should be avoided in hereditary cancer syndromes that increase the risk of uterine malignancy (III-C). 5Techniques for morcellation of a uterine specimen vary, and physicians should consider employing techniques that minimize specimen disruption and intra-abdominal spread (III-C). 6Uterine morcellation is contraindicated in women with established or suspected uterine neoplasia (II-2A).

Study Objective Evaluate proportion of patients with justified bilateral salpingo-oophorectomy (BSO) at hysterectomy based on pathologic diagnosis and determine rate and predictors of avoidable BSO based on preoperative considerations, surgical characteristics and pathologic diagnosis. Design Multicenter retrospective analysis. Setting 7 Ontario, Canada hospitals (4 academic, 3 community). Patients or Participants Patients with concomitant BSO at hysterectomy. Interventions All hysterectomies with concomitant BSO from July 2016 to December 2019. Cases by gynecologic oncologists were excluded. Measurements and Main Results Demographics, surgical factors, surgeon characteristics and pathologic diagnoses were recorded. BSO was considered justified if pathologic diagnosis was endometriosis or any (pre)malignant diagnosis except for gestational trophoblastic neoplasia or cervical cancer/dysplasia. Criteria for avoidable BSO included: age ˂51 years, preoperative diagnosis of cervical dysplasia or benign diagnosis other than gender dysphoria, risk reduction or premenstrual dysphoric disorder, absence of intraoperative endometriosis and adhesions, and unjustified final pathology. Those with avoidable BSO were compared to patients with at least one criterion for BSO. Multivariate analyses identified factors most strongly associated with avoidable BSO. During the study period, 4191 hysterectomies were completed with 1422 (33.9%) having concomitant BSO. Final pathologic diagnosis justified BSO in 72.8% (1035/1422). The most common pathologic diagnoses were endometrial cancer (439/1422, 30.6%), endometrial hyperplasia (275/1422, 19.3%) and endometriosis (200/1422, 14.1%). The remaining cases were unjustified, with 42/1422 (3%) BSOs deemed avoidable. Compared to cases with at least one criterion for BSO, avoidable BSOs were more frequently completed by generalists (OR 2.01, 95% CI 1.04 to 4.08, p=0.044) and for preoperative diagnoses of abnormal uterine bleeding (OR 3.75, 95% CI 1.96 to 7.43, p Conclusion Final pathologic diagnosis justified most BSOs at hysterectomy. Ovarian preservation may have been possible in 3% of women, underscoring the need to standardize practice with respect to BSO among gynecologic surgeons.

Study Objective An isthmocele is a cesarean scar site defect with a depth of >2mm and can lead to both obstetric and gynecologic complications. The primary objective was to evaluate the feasibility of a study protocol comparing different cesarean section closure techniques amongst our own patients/physicians, with the ultimate goal of a larger scale randomized controlled trial (RCT). Secondary objectives included isthmocele incidence, measurements on postoperative ultrasound, and adverse surgical outcomes related to suture technique. Design A single-center parallel-group pilot RCT comparing locked vs. unlocked first-layer uterine closure. Outpatient transvaginal ultrasound to evaluate isthmocele formation was performed at least six months postoperatively. Setting Operating room and outpatient ultrasound clinic. Patients or Participants All term pregnant patients >18 years old undergoing a primary caesarean section were eligible. Exclusion criteria included previous uterine hysterotomy, known uterine anomalies, active labour, and maternal bleeding and/or connective tissue disorders. Interventions Locked or unlocked closure of the first uterine layer. Measurements and Main Results Forty-one subjects were randomized, and 23 completed the follow-up ultrasound, with 12 in the locked group and 11 in the unlocked group. Barriers to feasibility included hesitance to participate in research during pregnancy, difficulty attending follow-up ultrasound with a newborn, and mainly Covid-19 pandemic related delays in study activities and fear of potential exposures. Isthmocele was present in 10/12 patients receiving locked closure, and in 11/11 of the unlocked group. Mean sagittal depth was 0.36 cm and 0.40 cm in the locked vs. unlocked groups, respectively. Sagittal adjacent myometrial thickness was 1.03 cm in the locked group, and 1.12 cm in the unlocked group. No adverse outcomes were noted with either surgical technique. Conclusion The study design is feasible outside of the pandemic setting. A larger trial is needed to determine differences regarding isthmocele rates and measurements between groups.

Study Objective Evaluate impact of obese body mass index (BMI) on surgical quality metrics for patients undergoing hysterectomy for benign, non-urgent indications. Design Multicenter, retrospective review. Setting Seven hospitals in Ontario, Canada (4 academic, 3 community). Patients or Participants 2528 patients undergoing hysterectomy from July 2016 to December 2019. Interventions Hysterectomy for non-urgent, benign indication. Measurements and Main Results The primary outcome was a composite of any complication or readmission to hospital within 30 days of surgery. Secondary outcomes were ≥ Grade 2 complication, emergency department visit and/or hospital readmission within 30 days of hysterectomy, median operative time and estimated blood loss. Outcomes were evaluated using logistic regression and log-regression linear analysis grouping patients by BMI class (normal, overweight, obesity class 1, 2, and 3) and by hysterectomy route (abdominal, laparoscopic, vaginal). Complications were graded using the Clavien-Dindo Classification. Patient characteristics (age, ASA, pre-operative diagnoses, pre-operative anemia, previous surgeries), surgical factors (intraoperative endometriosis and adhesions, hysterectomy route, uterine weight, concomitant procedures) and surgeon characteristics (volume, training (fellowship-trained/generalist) and hospital (academic/community)) were recorded. Distribution of BMI was: 32.8% (828/2528) normal, 35.1% (889/2528) overweight, 19.8% (500/2528) obesity class 1, 8.1% (205/2528) class 2, and 4.2% (106/2528) class 3. Compared to patients with a normal BMI, obese patients had higher ASA class (p Conclusion BMI class was not independently associated with surgical quality outcomes in patients undergoing hysterectomy for benign, non-urgent indications.

Study Objective To describe the diagnostic and surgical challenges in the management of second trimester placenta percreta. Design Case Review, review of surgical technique and video documentation. Setting Laparoscopic hysterectomy at a tertiary care centre. Patients or Participants The patient was a 39-year-old female, G7P3 at 17+2 weeks gestation who presented with acute abdominal pain to a community hospital. Imaging such as CT and ultrasound were inconclusive during initial work up for appendicitis. She experienced a drop in her hemoglobin, received a unit of pRBC and was taken to the operating room for exploratory laparoscopy. In the OR, acute hemoperitoneum was visualized with placenta like tissue invading through the anterior lower uterine segment. She was then transferred to our centre for urgent work up which confirmed the diagnosis of second trimester placenta percreta with active bleeding. Interventions Laparoscopy. Measurements and Main Results Once the patient was transferred to our centre an urgent MRI was done and this confirmed placenta percreta with invasion at the level of bladder and lateral parametrial involvement. An extensive discussion was had with our multidisciplinary team and given that were was ongoing bleeding from the invading placental tissue, pregnancy continuation was not possible. Second trimester placenta percreta is a rare entity with very few case reports in the literature. Our video demonstrates the challenges of a minimally invasive approach, which has not been previously described. We describe five main challenges and a step wise approach to mitigating these challenges. In addition, we combine the use of a dilatation and evacuation technique to allow for a complete minimally invasive approach. Conclusion Placenta accrete spectrum disorders pose significant challenges in diagnosis and management. A minimally invasive approach has not been described in the literature. We demonstrate that a minimally invasive approach to hysterectomy in management of midtrimester placenta percreta is a feasible option.

La carence en fer prenatale s’observe chez plus de 30 % des personnes enceintes au Canada[1][1]; elle a ete associee a un faible poids a la naissance, a une petite taille par rapport a l’âge gestationnel, a la prematurite, au besoin de transfusions pour la mere, a l’hemorragie

Objective To describe the evolution and evaluation of protocol-based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders. Methods A single-center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009-2011 (initial period) and 2017-2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization. Results Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 mL in the initial period to 1000 mL in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days). Conclusion These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders.

To evaluate differences in quality metrics between hysterectomies performed by fellowship-trained surgeons and those performed by generalists.Retrospective review of 2845 consecutive hysterectomies by 75 surgeons (23 fellowship-trained, 52 generalists) at 7 hospitals in Ontario, Canada. The primary outcome was a composite of any complication or return to the emergency department (ED) within 30 days of hysterectomy. Secondary outcomes were 2 quality outcome measures (grade of complication and return to ED within 30 days) and 4 quality process measures (minimally invasive hysterectomy rate, rate of preoperative anemia, same-day discharge for laparoscopic hysterectomy [LH], and performing cystoscopy at LH).Fellowship-trained surgeons were more likely to perform concurrent resection of endometriosis, bilateral ureterolysis, lysis of adhesions, uterine/internal iliac artery ligation, and morcellation (all P0.001). Generalists performed more vaginal procedures, including vaginal repair, vault suspension, and insertion of mid-urethral sling (all P0.001). After controlling for patient and surgical factors, there was no difference in the primary outcome (adjusted odds ratio [aOR] 1.07; 95% CI 0.79-1.45, P = 0.667). Fellowship-trained surgeons were more likely to perform minimally invasive hysterectomy (aOR 2.38; 95% CI 1.15-4.93, P = 0.020), had higher rates of same-day discharge for LH (aOR 2.23; 95% CI 1.31-3.81, P = 0.003), and were more likely to perform cystoscopy (unadjusted OR 2.94; 95% CI 2.30-3.85, P0.001). There were no differences in the rates of preoperative anemia, surgical complications, and ED visits.Differences exist between fellowship-trained surgeons and generalists regarding case mix and process quality metrics. Postoperative complications and readmissions were comparable for both groups of surgeons.