The association of endosalpingiosis with chronic pelvic pain

BACKGROUND

Endosalpingiosis is a pathologic diagnosis of ectopic epithelium resembling the fallopian tubes. It has been described with clinical characteristics that are similar to endometriosis. The primary objective is to determine if endosalpingiosis (ES) has a similar association with chronic pelvic pain when compared to endometriosis (EM).

METHODS

This is a retrospective case-control analysis of patients with a histologic diagnosis of endosalpingiosis or endometriosis at three affiliated academic hospitals between 2000 and 2020. All ES patients were included, and 1:1 matching was attempted to obtain a comparable EM cohort. Demographic and clinical data were obtained, and statistical analysis was performed.

RESULTS

A total of 967 patients (515 ES and 452 EM) were included. ES patients were significantly older than EM patients (median age 52 vs. 48 years, P<0.001), but other demographic variables were similar. Fewer ES patients had baseline chronic pelvic pain than EM patients (25.3% vs. 47%, P<0.001), and patients with ES were less likely to undergo surgery for the primary indication of pelvic pain (16.1% vs. 35.4%, P<0.001). Pelvic pain as the surgical indication remained lower in the ES group in multivariable analysis (OR=0.49, P<0.001). There were similar rates of persistent postoperative pain between ES and EM groups (10.1% vs. 13.5%, P=0.109).

CONCLUSIONS

Although endosalpingiosis can be associated with chronic pelvic pain, the incidence of pain is significantly lower than in patients who have endometriosis. These findings suggest that ES is a unique condition that differs from EM. Further research including long-term follow-up and patient-reported outcomes is imperative.

Robot-assisted Laparoscopic Excision of Abdominal Wall Endometrioma Utilizing Intraoperative Ultrasound and Transabdominal Needle Placement

OBJECTIVE

In patients with endometriosis, extra pelvic endometriosis is estimated to have an incidence of 11% and a rare subset of extra pelvic lesions include abdominal wall endometriosis with an incidence of 0.03% to 3.5% [1,2]. Evaluation for and surgical management of abdominal wall endometriosis are an essential skill set for the advanced gynecologic surgeon. In this video, we demonstrate a surgical technique for robot-assisted laparoscopic excision of abdominal wall endometriosis with intraoperative ultrasound-guided needle placement.

DESIGN

Description and demonstration of surgical technique.

SETTING

A patient with previous history of 2 cesarean sections and right lower quadrant cyclic abdominal wall pain; a tertiary care, academic center.

INTERVENTIONS

Intraoperative ultrasound-guided needle placement to map location and boundaries of the lesion followed by minimally invasive resection of the lesion with the intermittent advancement and withdrawal of needles to confirm clear margins.

CONCLUSION

Minimally invasive resection of abdominal wall endometriosis using intraoperative ultrasound-guided needle placement is an effective technique to guide surgical dissection and allow for clear surgical margins and successful treatment of this rare condition.

The association of endosalpingiosis with gynecologic malignancy

OBJECTIVE

Endosalpingiosis is a poorly understood condition of ectopic epithelium resembling the fallopian tubes. It has been described as an incidental pathology finding, a disease similar to endometriosis, and in association with malignancy. The objective of this study is to determine if endosalpingiosis (ES) has an increased association with gynecologic malignancy when compared to endometriosis (EM).

METHODS

This is a retrospective case-control analysis of patients with a histologic diagnosis of endosalpingiosis or endometriosis at three affiliated academic hospitals between 2000 and 2020. All ES patients were included, and 1:1 matching was attempted to obtain a comparable cohort of EM patients. Demographic and clinical data were obtained, and statistical analysis was performed.

RESULTS

A total of 967 patients (515 ES and 452 EM) were included. ES patients were significantly older than EM patients (median age 52 vs 48 years, p < 0.001). The ES group had significantly more cancer diagnoses at surgery than the EM group (40.1% vs 18.1%, p < 0.001); this difference persisted in a sub-analysis excluding patients with known or suspected malignancy (20.9% vs 5.6%, p < 0.001). ES patients had lower overall survival (10-year freedom from death: 77.0% vs 90.5%, p < 0.001). After adjusting for confounders, multivariable analysis showed that ES patients had increased cancer diagnosed at surgery (OR = 2.48, p < 0.001) and greater risk of death (OR = 1.69, p = 0.017).

CONCLUSIONS

Endosalpingiosis was found concurrently with malignancy in 40% of cases, and this effect was preserved in multi-variable and sub-group analyses. Further research consisting of longer follow-up and exploration of molecular relationships between ES and cancer are forthcoming.

Sex and Racial/Ethnic Diversity in Accredited Obstetrics and Gynecology Specialty and Subspecialty Training in the United States

OBJECTIVE

To compare trends in racial and gender diversity in Obstetrics and Gynecology (OBGYN) residency and fellowship programs from beginning of program accreditation in 2012 to the most recently published report for 2018.

DESIGN

Data was abstracted in August 2020 from publicly available reports on the Accreditation Council for Graduate Medical Education (ACGME) website. Reports from 2012 to 2018 were compared with Chi-square tests and the Cochran-Armitage trend test assessed trends over time.

PARTICIPANTS

U.S. medical residents and fellows, with a focus on those in accredited OBGYN fellowship programs (Female Pelvic Medicine and Reconstructive Surgery (FPMRS), Gynecologic Oncology (GYNONC), Maternal Fetal Medicine (MFM), and Reproductive Endocrinology and Infertility (REI)).

RESULTS

From 2012 to 2018 men in all residency programs increased 0.88% (from 53.92% male to 54.80%, p < 0.0001). Across all years there were less men in OBGYN (16.89%) compared to all residency programs (54.39%, p < 0.0001). All OBGYN fellowships combined had more men proportionately than OBGYN residencies (24.14% vs. 16.89%, p < 0.0001). MFM had the most men (26.7%) then GYNONC (25.18%), FPMRS (21.36%), and REI (20.09%) (p = 0.024). There were no statistically significant trends in sex or race over time. From 2012 to 2018 residents overall were 42.96% white. OBGYN residents overall were 54.20% white. GYNONC had the highest percentage of white trainees (73.45%), followed by MFM (67.8%), REI (65.62%), then FPMRS (60%) (p = 0.0003).

CONCLUSIONS

According to ACGME core competencies, residents are expected to demonstrate sensitivity and responsiveness to diverse patient populations (professionalism) and advocate for improvements to systems-based practice. These results may suggest systemic issues in the recruitment of women and people of color into competitive sub-specialty programs. Such deficiencies in representation can impact patient care. Future research is needed to assess trends over time as data become available and to evaluate specific barriers to applications and selection of minority applicants.

Changing US trends in contraceptive choices

Long-acting reversible contraceptives (ie, intrauterine devices and the etonogestrel subdermal implant) have become increasingly popular methods of contraception because of their convenience and safety profile. At the same time, the use of depot medroxyprogesterone acetate, one of the most prescribed contraceptives in the United States since its approval in 1992, is on the wane. The history and pros and cons of these contraceptive methods are reviewed.

Impact of Legislation on Opioid Prescribing following Hysterectomy and Hysteroscopy in Arizona and Florida

OBJECTIVES

This study aimed to determine the oral morphine equivalents (OMEs) prescribed and refill rates following hysterectomy and hysteroscopy in the setting of opioid prescribing practice changes in 2 states.

DESIGN

This is a retrospective cohort analysis consisting of 2,916 patients undergoing hysterectomy or hysteroscopy between July 2016 and September 2019 at 2 affiliated academic hospitals in states that underwent legislative changes in opioid prescribing in 2018.

METHODS

Participants were identified using the Current Procedural Terminology procedure codes in Arizona and Florida. Hysterectomy was chosen as the most invasive gynecologic procedure, while hysteroscopy was chosen as the least invasive. Medical records were abstracted to find opioid prescriptions from 90 days before surgery to 30 days after discharge. Patients with opioid use between 90 and 7 days before surgery were excluded. Prescriptions were converted to OMEs and were calculated per quarter year. Statistical analysis included Wilcoxon rank sum t tests for OMEs and χ2 t tests for refill rates. Interrupted time-series analysis was used to determine significant change in OMEs before and after legislative change. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC, USA).

RESULTS

In Arizona, 1,067 hysterectomies were performed; 459 (43%) vaginal, 561 (52.6%) laparoscopic/robotic, and 47 (4.4%) abdominal. There were 530 hysteroscopies. Overall median OMEs decreased from 225 prior to July 2018 to 75 after July 2018 (p < 0.0001). The opioid refill rate remained unchanged at 7.4% (p = 0.966). In Florida, there were 769 hysterectomies; 241 (31.3%) vaginal, 476 (61.9%) laparoscopic/robotic, and 52 (6.8%) abdominal. There were 549 hysteroscopies. Overall median OMEs decreased from 150 prior to July 2018 to 0 after July 2018 (p < 0.0001). The opioid refill rate was similar (7.8% before July 2018 and 7.3% after July 2018; p = 0.739).

LIMITATIONS

Limitations include involvement of a single hospital institution with a total of 10 fellowship-trained surgeons and biases inherent to retrospective study design.

CONCLUSIONS

Legislative and provider-led changes coincided with decreases in opioid prescribing after 2018 in both states without increasing rates of refills and showed actual data reflected in the medical record. Gynecologists must actively participate in safe prescribing practices to decrease opioid dependence and misuse.

Surgical Management and Prevention of Ovarian Remnant

STUDY OBJECTIVE

To provide surgeons with surgical techniques necessary for management and prevention of ovarian remnant syndrome.

DESIGN

Instructional video (Canadian Task Force classification III).

SETTING

Academic medical center.

INTERVENTION

Surgical dissection and retroperitoneal anatomy.

MEASUREMENTS AND MAIN RESULTS

Ovarian remnant syndrome occurs when residual ovarian tissue inadvertently remains in situ after salpingo-oophorectomy [1-4]. It can result in pelvic pain and pelvic mass [1-4]. Risk factors include endometriosis, adhesive disease, pelvic inflammatory disease, and prior pelvic surgery [1-4]. Ovarian remnant can also occur as a result of ovarian stroma extending up to 1.4 cm into the infundibulopelvic ligament beyond the visible margin [5]. Medical management and radiotherapy are treatment options but do not provide the definitive management that surgery affords [1-4]. Surgery also avoids missing a potential malignancy within the remnant tissue [1-4]. This video demonstrates the surgical techniques necessary to treat and prevent this condition, including key retroperitoneal anatomy. Mayo Clinic Institutional Review Board approval was not required for this video article.

CONCLUSION

Both treatment and prevention of ovarian remnant syndrome follow the same basic surgical principles, including high ligation of the infundibulopelvic ligament, retroperitoneal dissection, and excision of all peritoneum and tissue adherent to the ovary.

Feasibility of Oophorectomy at the Time of Vaginal Hysterectomy in Patients with Pelvic Organ Prolapse

STUDY OBJECTIVE

To determine the feasibility of oophorectomy at the time of vaginal hysterectomy in patients with pelvic organ prolapse and to define prognostic factors and perioperative morbidity associated with the procedure.

DESIGN

A retrospective cohort study (Canadian Task Force classification II-2).

SETTING

An academic medical center.

PATIENTS

All women who underwent total vaginal hysterectomy for the treatment of pelvic organ prolapse over 5 years were considered for inclusion in the study.

INTERVENTIONS

Total vaginal hysterectomy and concomitant pelvic organ prolapse repair with or without oophorectomy.

MEASUREMENTS AND MAIN RESULTS

A total of 289 women underwent total vaginal hysterectomy with pelvic organ prolapse repair. Vaginal oophorectomy was attempted in 179 patients (61.9%). The procedure was successful in 150 patients (83.8%; 95% confidence interval [CI], 77.6%-88.9%). High ovarian location was the most commonly cited reason for the inability to perform a planned unilateral/bilateral oophorectomy (n = 24, 82.7%). Attempting oophorectomy vaginally was associated with an increased duration of surgery by 7.3 minutes (p = .03), an increased change in hemoglobin by 0.2 g/dL (p = .02), and a higher rate of readmission (7.3% vs 1.8%, p = .04). Multiple logistic regression showed that increasing age (odds ratio = 1.12; 95% CI, 1.05-1.20; p <.001) and body mass index (odds ratio = 1.17; 95% CI, 1.07-1.27; p<.001) were associated with an increased risk of vaginal oophorectomy failure. On univariate analysis, race (p = .64), parity (p = .39), uterine weight (p = .91), need for uterine morcellation (p=.21), presence of endometriosis (p=.66), prior cesarean section (p=.63), prior laparoscopy (p=.37), and prior open abdominal/pelvic surgery (p = .28) did not impact the likelihood of successfully performing oophorectomy.

CONCLUSION

In patients with pelvic organ prolapse, a planned oophorectomy at the time of vaginal hysterectomy can be successfully performed in the majority of cases. Greater age and body mass index are associated with an increased likelihood of failure.

Techniques for Preemptive Analgesia in Gynecologic Surgery

STUDY OBJECTIVE

To provide surgeons with techniques for preemptive analgesia during minimally invasive gynecologic surgery. Postoperative pain management is an important component of patient care after gynecologic surgery. There have been numerous advances in pain management, including studies that show that preoperative administration of analgesics decreases postoperative pain scores and narcotic medication requirements [1-3]. However, there is limited information on the techniques for preemptive analgesia [4,5].

DESIGN

An instructional video showing a variety of preemptive analgesia techniques and the corresponding neuroanatomy (Canadian Task Force classification III). Mayo Clinic Institutional Review Board approval was not required for this video article.

SETTING

Academic Medical Center INTERVENTIONS: Relevant abdominopelvic neuroanatomy is reviewed. This is followed by a demonstration of the preemptive analgesia techniques based on neuroanatomy principles.

CONCLUSION

Techniques for preemptive analgesia are simple and effective. These tools can be used for patients undergoing gynecologic surgeries via a vaginal or abdominal approach and can help optimize postoperative pain and narcotic usage.

Screening Women at High Risk for Cervical Cancer: Special Groups of Women Who Require More Frequent Screening

The updated cervical cancer screening guidelines recommend that women at average risk who have negative screening results undergo cervical cytological testing every 3 to 5 years. These recommendations do not pertain to women at high risk for cervical cancer. This article reviews recommendations for cervical cancer screening in women at high risk.

Impact of a robotic surgical system on hysterectomy trends

OBJECTIVE

To determine the impact of introduction of a robotic surgical system on hysterectomy trends.

METHODS

A retrospective, cohort study using longitudinal medical records from a tertiary care community hospital was used to determine the surgical approach to hysterectomy. For the purposes of analysis, surgical approaches were categorized as robotically assisted, laparoscopic, laparotomy, vaginal, or laparoscopically assisted vaginal.

RESULTS

A total of 4,440 women underwent a hysterectomy between January 2007 and December 2012 (benign gynecology N = 3,127, gynecologic oncology N = 1,001, urogynecology N = 312). Amongst benign gynecologists, during the five years following introduction of the robotic system, the rate of hysterectomy performed via laparotomy decreased from 62.2 percent to 39.1 percent, p-value < 0.001. The rate of robotically assisted hysterectomy increased from 0.0 percent to 26.4 percent, p-value < 0.001. When subspecialties were examined, the rate of hysterectomy performed by a gynecologic oncologist via laparotomy decreased from 89.7 percent to 20.0 percent, p-value < 0.001. The rate of robotically assisted hysterectomy increased from 0.0 percent to 78.3 percent, p-value < 0.001. Amongst urogynecologists, the rate of hysterectomy performed vaginally decreased from 80.0 percent to 33.6 percent, p-value < 0.001, while the rate of robotically assisted hysterectomy increased from 0.0 percent to 54.2 percent, p-value < 0.001.

CONCLUSIONS

The percentage of robotically assisted hysterectomies has dramatically increased and is now the primary modality for performing hysterectomy amongst subspecialists.

Developmental and persistent developmental stuttering: an overview for primary care physicians

Stuttering is a speech disorder characterized by a disruption in the fluency, timing, and rhythm of normal speech. It affects approximately 5% of children at some point in their lives. Although dysfluency often resolves before adulthood, it may cause periods of extreme anxiety for patients, especially those who continue to stutter in adolescence and adulthood. Although these patients are unlikely to stop stuttering, treatment options are available to reduce anxiety and therefore the severity of symptoms. In the present review article, the authors discuss the pathophysiology, diagnosis, and management of developmental stuttering in children and adults.

Pathophysiologic mechanisms, diagnosis, and management of dapsone-induced methemoglobinemia

Dapsone is a leprostatic agent commonly prescribed for the treatment of patients with leprosy, malaria, and a variety of blistering skin diseases, including dermatitis herpetiformis. Methemoglobinemia, a potentially life-threatening condition in which the oxygen-carrying capacity of blood in body tissues is reduced, is a known adverse effect of dapsone use. The authors report a case of dapsone-induced methemoglobinemia observed in the emergency department during routine workup for contact dermatitis in a patient with celiac disease. The pathophysiologic mechanisms, diagnosis, and management of dapsone-induced methemoglobinemia are discussed.