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BACKGROUND: Chronic pelvic pain is a debilitating problem that afflicts 15% to 20% of women in the United States. Although more than 200,000 hysterectomies are performed annually for the treatment of chronic pelvic pain, previous studies indicate that 1 in 4 women undergo the discomfort and morbidity of hysterectomy without the relief of pain. The factors that predict treatment failure remain poorly characterized. OBJECTIVE: To describe the incidence of persistent pelvic pain 6 months following hysterectomy in women with chronic pelvic pain and determine whether a simple, self-reported measure of central sensitization is associated with a greater risk of persistent pelvic pain following hysterectomy. STUDY DESIGN: We conducted a prospective, observational cohort study of women undergoing hysterectomy at an academic tertiary care center for a benign indication. Patients with preoperative chronic pelvic pain, defined as average pelvic pain ≥3 on a 0 to 10 numeric rating scale for >3 months before hysterectomy, were included in this analysis. The patients completed validated assessments of pain, anxiety, depression, and centralized pain (using the 2011 Fibromyalgia Survey Criteria, 0-31 points) preoperatively and 6 months after hysterectomy. The demographic information, surgical history, intraoperative findings, and surgical pathology were abstracted from the electronic medical records. Multivariate logistic regression was used to identify the independent predictors of persistent pelvic pain 6 months following hysterectomy, defined as <50% improvement in pelvic pain severity. RESULTS: Among 176 participants with pelvic pain before hysterectomy, 126 (71.6%) were retained at 6 months, and 15 (11.9%) reported persistent pelvic pain. There was no difference in age (P=.46), race (P=.55), average pain severity during menses (P=.68), average overall pelvic pain (P=.10), or pain duration (P=.80) in those with and without persistent pelvic pain. Whereas intraoperative findings of endometriosis (P=.05) and uterine fibroids (P=.03) were associated with a higher incidence of persistent pain on univariate analysis, the surgical route (P=.46), pelvic adhesions (0.51), uterine weight (P=.66), and adenomyosis on histopathology (P=.27) were not related to the risk of persistent pain. Higher preoperative centralized pain scores (P=.01) but not depression (P=.64) or anxiety (P=.45) were more common in women with persistent pelvic pain. Multivariate logistic regression adjusting for age, preoperative pain severity, anxiety, depression, and operative findings of endometriosis and fibroids indicated that every 1-point increase in centralized pain before hysterectomy was associated with a 27% increase in the odds of persistent pelvic pain (odds ratio, 1.27; 95% confidence interval, 1.03-1.57) 6 months after surgery. CONCLUSION: Although the majority of women with chronic pelvic pain report considerable improvement in pain following hysterectomy, higher degrees of centralized pain before hysterectomy is a robust predictor of persistent pelvic pain.

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INTRODUCTION: Patients with advanced endometriosis may be at an increased risk of surgical complications following laparoscopic treatment of endometriosis; however, this relationship has not been examined. We sought to identify predictors of major complications following laparoscopic treatment of endometriosis. MATERIAL AND METHODS: A retrospective cohort study of women who underwent laparoscopic treatment of suspected endometriosis between 2009 and 2016 within the Division of Minimally Invasive Gynecologic Surgery at Brigham and Women's Hospital, Boston, MA, USA. Predictors of major perioperative complications were assessed by comparing the characteristics of women who had any major intraoperative or postoperative complication with those of women who had no complication. RESULTS: A total of 397 women underwent laparoscopic treatment of suspected endometriosis including excision of superficial endometriosis (55.4%), excision of deep-infiltrating endometriosis (24.9%), fulguration of endometriosis (38.3%), hysterectomy (23.2%), ovarian cystectomy (35.5%), salpingectomy (18.6%), oophorectomy (15.1%), and bowel resection (1.0%). Women were followed for 60 days following surgery, over which time 18 women (4.5%) had a major perioperative complication. Patient characteristics and preoperative imaging were similar between women with and without complications. Women with advanced endometriosis, including stage III or IV endometriosis, deep-infiltrating endometriosis, or rectovaginal disease, were more likely to have a complication, though this did not reach statistical significance (77.8% of women with a complication versus 56.7% of women without a complication had advanced endometriosis, P = 0.077). Women who had a complication were more likely to have undergone adhesiolysis or ureterolysis (88.9% of women with a complication versus 52.5% without a complication underwent adhesiolysis, P = 0.002; and 61.1% of women with a complication versus 28.8% without a complication underwent ureterolysis, P = 0.003). The total number of procedures was greater for women who had a complication (4.3 ± 1.2 vs 3.2 ± 1.5, P = 0.003). All other procedure characteristics were similar between women with and without complications. CONCLUSIONS: Complications following laparoscopic treatment of suspected endometriosis could not be predicted by preoperative patient characteristics or surgical findings of advanced endometriosis. Adhesiolysis, ureterolysis, and an increased number of total procedures may be predictive of perioperative complications, suggesting that surgical complexity as measured by the procedures performed, rather than the disease severity, may increase the risk of a complication compared with women who do not undergo these procedures.

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The use of robotic-assisted laparoscopic surgery has continued to grow since the Food and Drug Administration approval for robotic-assisted gynecologic surgery in 2005. However, despite this growth in utilization, the data supporting its use in benign gynecologic surgery has not strongly supported its advantages over conventional laparoscopy. Controversy exists between supporters of robotic-assisted laparoscopic surgery and conventional laparoscopy. This article discusses the current literature regarding the use of robotic-assisted surgery in benign gynecologic surgery.

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OBJECTIVE: To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy. METHODS: We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation. RESULTS: Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P<.01), with no significant change in the number of requested refills (9.5% [n=15] vs 5.7% [n=14], P=.15). In the post-decision aid cohort, 76.6% of patients (n=121) chose fewer tablets than the guideline-allotted maximum. Approximately 76% of patients (n=102) reported having leftover tablets. CONCLUSION: This quality improvement initiative illustrates that a simple decision aid can result in a significant decrease in opioid prescribing without compromising patient satisfaction or postoperative pain management.

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STUDY OBJECTIVE: To compare outcomes following umbilical minilaparotomy and suprapubic minilaparotomy for tissue extraction. DESIGN CLASSIFICATION: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Two large academic medical centers. PATIENTS: Women who underwent a minilaparotomy for tissue extraction following a laparoscopic hysterectomy or myomectomy between 2014 and 2016. INTERVENTIONS: Umbilical or suprapubic minilaparotomy for tissue extraction. MEASUREMENTS AND MAIN RESULTS: A total of 374 women underwent laparoscopic hysterectomy or myomectomy with minilaparotomy, including 289 (77.3%) with an umbilical minilaparotomy and 85 (22.7%) with a suprapubic minilaparotomy. The 2 groups were similar in terms of age, body mass index, parity, surgical history, procedure type, surgical approach, and surgical indication. The size of the minilaparotomy incision and the specimen weight were significantly smaller in the umbilical minilaparotomy group (mean, 3.3 ± 0.8 cm vs 4.2 ± 0.6 cm [p < .001] and 472.6 ± 357.1 g vs 683.0 ± 475.7 g [p < .001], respectively). Two women in the suprapubic minilaparotomy group sustained a bladder injury during creation of the incision. There were no other complications related to the minilaparotomy in either group. Postoperative outcomes related to the minilaparotomy incision were compiled using the medical record and a follow-up survey. Of the 374 women in this cohort, 163 responded to a detailed survey about their minilaparotomy incision (response rate, 43.5%). With regard to the minilaparotomy, 52.7% of women reported incisional symptoms; 25.9% had increased pain at the incision, 8.3% had an incisional infection, and 2.7% reported an incisional hernia. There was no significant between-group difference in incisional outcomes; however nearly 3 times as many women in the umbilical minilaparotomy group reported concerns about incisional hernia (3.1% vs 1.2%; p = .833). These findings were maintained in a multivariable logistic regression analysis. No patient or procedure characteristics were significantly associated with the development of hernia. CONCLUSION: There were no significant difference in incisional symptoms, pain, or infection following umbilical minilaparotomy vs a suprapubic minilaparotomy for tissue extraction. Although not statistically significant, the rate of incisional hernia was higher at the umbilical site compared with the suprapubic site.

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STUDY OBJECTIVE: To describe opioid distribution and patient use after gynecologic procedures. DESIGN: Survey study (Canadian Task Force classification III). SETTING: An urban academic tertiary care hospital. SUBJECTS: Ninety-six gynecologists in the Boston area, and 147 patients who underwent a benign hysterectomy between January 2015 and April 2016. INTERVENTIONS: Survey study of physicians and patients composed of 2 parts: (1) a physician survey on opioid prescribing practices after gynecologic procedures and (2) a patient survey on opioid consumption after hysterectomy. Physicians were contacted via e-mail to participate in an online survey. Eligible patients were contacted via telephone and asked to participate in a telephone survey. MEASUREMENTS AND MAIN RESULTS: Fifty-one physicians responded to an online survey and prescribed a mean of 27.1 tablets (range, 5-30) of oxycodone (5 mg) or hydromorphone (2 mg) after abdominal hysterectomy (AH), a mean of 22.6 tablets (range, 5-30) after laparoscopic hysterectomy (LH), and a mean of 16.8 tablets (range 5-30) after vaginal hysterectomy (VH). Physicians prescribed more opioids for AH compared with LH, with a mean difference of 4.5 tablets (standard deviation, 4.7; p < .01), and AH compared with VH, with a mean difference of 6.8 tablets (standard deviation, 5.8; p < .01), which were both statistically significant. In addition, 40.0% of physicians prescribe opioids after a hysteroscopy and 19.2% after a dilation and curettage. Fifty-six patients participated in the telephone survey: 64.6% of patients used less than half of the opioids prescribed and 16.1% used none. For AH, patients reported being prescribed a mean of 25.7 tablets and using a mean of 8.7 tablets (range, 0-60; 33.9% used). For LH or VH, patients reported being prescribed a mean of 24.2 tablets and using a mean of 10.0 tablets (range, 0-30; 41.4% used). Opioid consumption was not significantly different for AH compared with LH or VH (p = .613 for AH to LH, p = .279 for AH to VH). CONCLUSIONS: With respect to the physician survey, we conclude there is a wide range of opioid prescription practices and patient opioid consumption after gynecologic surgery. The patient survey revealed that physicians prescribe fewer opioid tablets after a minimally invasive approach to hysterectomy versus open hysterectomy. However, most patients use less than half of prescribed opioids, and a fraction did not use any opioids at all.

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