Urinary tract injury during hysterectomy:Does surgeon specialty and surgical volume matter?

BACKGROUND Ureteral injury is a known complication of hysterectomies.Recent studies have attempted to correlate surgeon volume and experience with incidence of urinary tract injuries during hysterectomies.Some studies have reported that as surgeon volume increases,urinary tract injury rates decrease.To our knowledge,no studies have assessed the relationship between surgeon subspecialty and the rate of urinary tract injury rates during minimally invasive hysterectomy.AIM To determine the incidence of urinary tract injury between urogynecologists,gynecologic oncologists,and general gynecologists.METHODS The study took place from January 1,2016 to December 1,2021 at a large comm-unity hospital in Detroit,Michigan.We conducted a retrospective chart review of adult patients who underwent minimally invasive hysterectomy.After we identified eligible patients,the surgeon subspecialty was identified and the surgeon’s volume per year was calculated.Patient demographics,medical history,physician-dictated operative reports,and all hospital visits postoperatively were reviewed.RESULTS Urologic injury occurred in four patients(2%)in the general gynecologist group,in one patient(1%)in the gynecologic oncologist group,and in one patient(1%)in the urogynecologist group.When comparing high and low-volume surgeons,there was no statistically significant difference in urinary tract injury(1%vs 2%)or bowel injury(1%vs 0%).There were more complications in the low-volume group vs the high-volume group excluding urinary tract,bowel,or major vessel injury.High-volume surgeons had four(1%)patients with a complication and low-volume surgeons had 12(4%)patients with a complication(P=0.04).CONCLUSION Our study demonstrated that there was no difference in the urinary tract injury rate in general gynecologists vs subspecialists,however our study was underpowered.

Decreased incidence of febrile neutropenia in Michigan following masking and social distancing orders for the COVID-19 pandemic: A population based cohort study

BACKGROUND It has been theorized that 75%-80%of febrile neutropenia(FN)is caused by endogenous pathogens,while up to 20%of cases are thought to be caused by a viral infection.It is unknown if precautions such as masking and social distancing reduce the risk of FN in susceptible populations.AIM To determine whether coronavirus disease 2019(COVID-19)infection mitigation efforts,namely masking and social distancing,were associated with a reduction in the incidence of FN.METHODS This was a retrospective population based cohort study comparing the incidence of FN in the 13 mo prior to(Year 0)and 13 mo following(Year 1)the public health executive orders(PHEO)in Michigan.Data was queried for all emergency department(ED)visits from April 1,2019 to March 31,2021 from the National Syndromic Surveillance Program,a program which collects data that is voluntarily submitted by approximately 89%of Michigan EDs.The primary study outcome was the incidence of FN as a proportion of ED visits in the 13-mo before and 13-mo after COVID-19 mitigations efforts,namely masking and social distancing.We hypothesized that there would be a significant decrease in the incidence of FN in the period following the PHEO aimed at reducing the spread of the severe acute respiratory syndrome coronavirus 2 virus.RESULTS There was a total of 8979221 total ED visits captured during the study period.In Year 0 there were 5073081 recorded ED visits and 3906140 in Year 1.There was a significant reduction in the proportion of total ED visits with a diagnosis of FN,decreasing 13.3%across periods(0.15%vs 0.13%,P=0.036).In patients with a hematologic malignancy a more impressive reduction in the incidence of FN was evident following PHEO(22%vs 17%,P=0.02).CONCLUSION We found a significant association between social distancing and mask guidelines implemented on a large public scale with decreased rates of FN,particularly in those with a hematologic malignancy.These findings may be useful in the design of future research and recommendations regarding the prevention of FN.

Treatment patterns of primary care physicians vs specialists prior to subspecialty urogynaecology referral for women suffering from pelvic floor disorders

BACKGROUND There are approximately 25% of women in the United States suffering from pelvic floor disorders (PFDs) and this number is predicted to rise. The potential complications and increasing healthcare costs that exist with an operation indicate the importance of conservative treatment options prior to attempting surgery. Considering the prevalence of PFDs, it is important for primary care physician and specialists (obstetricians and gynecologists) to be familiar with the initial work-up and the available conservative treatment options prior to subspecialist (urogynecologist) referral. AIM To assess the types of treatments that specialists attempted prior to subspecialty referral and determine the differences in referral patterns. METHODS This is a retrospective cohort study of 234 patients from a community teaching hospital referred to a single female pelvic medicine and reconstructive surgery (FPMRS) provider for PFD. Specialist vs primary care provider (PCP) referrals were compared. Number, length and treatment types were studied using descriptive statistics. RESULTS There were 184 referrals (78.6%) by specialists and 50 (21.4%) by PCP. Treatment (with Kegel exercises, pessary placements, and anticholinergic medications) was attempted on 51%(n = 26) of the PCP compared to 48%(n = 88) of the specialist referrals prior to FPMRS referral (P = 0.6). There was no significant difference in length of treatment prior to referral for PCPs vs specialists (14 mo vs 16 mo, respectively, P = 0.88). However, there was a significant difference in the patient’s average time with the condition prior to referral (35 mo vs 58 mo for PCP compared to specialist referrals)(P = 0.02). CONCLUSION One half of the patients referred to FPMRS clinic received treatment prior to referral. Thus, specialists and generalists can benefit from education regarding therapies for PFD before subspecialty referral.

Randomized clinical trial comparing skin closure with tissue adhesives vs subcuticular suture after robotic urogynecologic procedures

BACKGROUND Skin closure techniques during minimally-invasive gynecologic surgery is largely based on surgeon preference.The optimum technique would theoretically be safe,rapid,inexpensive,and result in good cosmetic appearance.Cyanoacrylate tissue adhesive(Dermabond)may be a comparable and safe option for port site closure as compared with subcuticular suture.In this randomized clinical trial,we hypothesized that operative time for skin closure would be less than subcuticular suture during robotic urogynecologic procedures.AIM To compare skin closure during robotic urogynecologic surgeries for tissue adhesives and subcuticular suture.METHODS Fifty female subjects>18 years of age undergoing robotic urogynecologic procedures were randomized to have port site closure with either cyanoacrylate tissue adhesive(n=25)or subcuticular suture(n=25).All procedures and postoperative evaluations were performed by the same board certified Female Pelvic Medicine and Reconstructive Surgeon.Incisional closure time was recorded.Each subject was followed for 12-wk postoperatively.Incision cosmesis was evaluated using the Stony Brook Scar Evaluation Scale.RESULTS A total of 47 subjects(cyanoacrylate group,n=23;suture group,n=24)completed the 12-wk postoperative evaluation.Closure time was significantly less(P<0.0005)using cyanoacrylate tissue adhesive(5.4±2.0 min)than subcuticular suture(24.9±5.6 min).Cosmesis scores were significantly higher in the cyanoacrylate tissue adhesive group than subcuticular suture(P=0.025).No differences were found between bleeding,infection,or dehiscence(P=1.00,P=0.609,P=0.234,respectively).No statistical demographical differences existed between the two study arms.CONCLUSION Our study supported our original hypothesis that cyanoacrylate tissue adhesive for port site closure during robotic urogynecolgic procedures uses less time than with subcuticular suture.Our study also supports that tissue adhesive is comparable to cosmetic outcome while not jeopardizing rates of bleeding,infection,or dehiscence.

Natural course of ovarian torsion after untwisting: A case report with radiographic imaging

Background: Radiographic studies largely contribute to prompt diagnosis of ovarian torsion, though post-operative changes are not described and might contribute to unnecessary intervention. Case: We report a case of ovarian torsion diagnosed based on clinical presentation and radiographic findings. The detorsion was successfully performed through laparosopic access. Subsequently patient presented for elective ultrasonography and MRI which diagnosed multicystic ovarian mass, attributed to hematoma which resolved spontaneously with no intervention in 3 weeks. Conclusion: Ovarian changes after detorsion consistent with development of hematoma may be benign and resolve spontaneously.