McGree, Michaela E.

INTRODUCTION: To compare two published risk stratification criteria (Milwaukee Model vs. Mayo Criteria) to predict lymphatic dissemination (LD) in endometrioid endometrial cancer (EC). METHODS: Patients who underwent surgery for EC between 1/1/2004-9/30/2013 and had endometrioid histology without stage IV disease were included and classified as either low-risk or at-risk for LD using two independent risk stratification systems. LD was defined as positive nodes at time of surgery or lymph node recurrence within 2 years of surgery after negative lymph node assessment (LNA) or when LNA was not performed. False positive (FP) and false negative (FN) rates for each risk model were calculated. RESULTS: Among 1103 patients, 81 (7.3%) had LD (72 positive LN and 9 LN recurrences). Most patients (90.2%) had stage I disease. Integration of the Milwaukee Model was associated with a low at-risk rate for LD (38.1%) but a relatively high FN rate (13.6%, 95% CI 7.0-23.0). Conversely, the traditional Mayo Criteria using a tumor diameter (TD) cutoff of ≤2 cm (vs >2 cm) had a higher at-risk rate for LD (69.5%) but a FN rate of 0.0% (95% CI, 0-4.5). Modifying Mayo Criteria using a TD cutoff of ≤3 cm (vs >3 cm) identified fewer women at-risk than using ≤2 cm cutoff (56.8% vs. 69.5%), but had a higher FN rate of 3.7% (95% CI, 0.8-10.4). CONCLUSIONS: The Milwaukee Model had the lowest at-risk rate of LD but an unacceptable FN rate. Modifying the Mayo Criteria by increasing the TD cutoff from the traditional ≤2 cm to ≤3 cm would spare an estimated 12.7% of patients LNA, but the accompanying FN rate is unacceptably high. The traditional Mayo Criteria for low-risk EC remains the most accurate in determining which patients LNA can be omitted.

Objective We describe a novel way to calculate estimated blood loss (EBL) using an intraoperative pictographic tool in gynecologic surgery. Methods A pictographic tool to estimate sponge saturation was developed to calculate EBL during surgery. A prospective cohort of women 18 years or older undergoing benign vaginal hysterectomy with planned adnexal surgery at Mayo Clinic were consented for use of the pictographic tool. Demographic, preoperative, intraoperative, and postoperative data were abstracted. Estimated blood loss was compared among surgeons, anesthesia providers, and the pictographic tool and then correlated with change in hemoglobin. Results Eighty-one patients met inclusion with mean age of 45.3 ± 8.7 years. Successful vaginal hysterectomy was achieved in all patients with successful completion of planned adnexectomy in 69 (85.2%). Mean EBL among surgeons, anesthesia providers, and pictographic estimates, respectively, was as follows: 199.4 ± 81.9 mL, 195.5 ± 152.2 mL, and 288.5 ± 186.6 mL, with concordance correlation coefficients for surgeons and anesthesia providers versus pictographic tool of 0.40 (95% confidence interval, 0.29–0.51) and 0.68 (95% confidence interval, 0.57–0.79), respectively. The mean postoperative change in hemoglobin was −1.8 g/dL; there were no postoperative transfusions. Change in hemoglobin was more correlated with blood loss estimates from surgeons ( r = −0.31, P = 0.008) and anesthesia providers ( r = −0.37, P = 0.003) than the pictographic tool ( r = −0.19, P = 0.11). Conclusions Use of a pictographic tool to objectively estimate blood loss demonstrated significant overestimations compared with both anesthesia providers’ and surgeons’ estimates because the pictographic tool was less correlated with postoperative change in hemoglobin than anesthesia provider and surgeon estimates.

Objective The aim of this study was to compare outcomes of vaginal hysterectomy between patients with and without the following perceived contraindications to vaginal surgery: uterine weight greater than 280 g, prior cesarean delivery, no vaginal parity, and obesity. Methods Retrospective cohort of benign vaginal hysterectomies between 2009 and 2013 was obtained. Outcomes included uterine debulking, transfusion, intraoperative complications, length of stay, and Accordion grade 2+ postoperative complications. For each outcome, the association between the presence of each contraindication and the outcome was evaluated using univariate and multivariate logistic regression models. Results Among 692 vaginal hysterectomies, 11% (76/691) had a uterine weight greater than 280 g, 11.3% (78/690) had no vaginal parity, 14.9% (103/690) had a history of cesarean delivery, and 37.7% (248/657) had a body mass index of 30 kg/m2 or greater; 110 (15.9%) had 2 or more contraindications. Uterine debulking occurred in 146 women (21.1%), and both uterine weight greater 280 g (adjusted odds ratio, 39.2; 95% confidence interval, 18.4–83.5) and prior cesarean delivery (adjusted odds ratio, 2.1; 95% confidence interval, 1.2–3.7) were significantly associated with an increased likelihood of uterine debulking after adjusting for age, hematologic disease, and preoperative diagnosis. None of the contraindications were significantly associated with need for a blood transfusion, presence of an intraoperative complication, length of stay greater than 2 days, or presence of an Accordion grade 2+ postoperative complication, which occurred in 2.7%, 2.5%, 14.0%, and 6.9% of all women, respectively. Conclusions Vaginal hysterectomy can be safely performed with favorable outcomes, even in women with a uterus greater than 280 g, prior cesarean delivery, no vaginal parity, and obesity. Our findings challenge several perceived contraindications to vaginal hysterectomy.

INTRODUCTION: Postpartum hemorrhage is the leading cause of maternal mortality worldwide. There are multiple known risk factors, including induction of labor. METHODS: A retrospective cohort study was completed with review of nulliparous women undergoing labor induction at term, from July 2006 to May 2011. Baseline maternal variables and risk factors for postpartum hemorrhage were assessed. All combinations of methods of induction were sequential rather than concurrent. The need for additional uterotonics (beyond routine oxytocin) was used as a surrogate for postpartum hemorrhage. Variables were evaluated for an association with additional uterotonic use based on fitting logistic regression models. RESULTS: A total of 785 women were included in the study. Additional uterotonics were required for 84/785 (11%) of women. Based on univariate analysis, only birth weight and presence of meconium were significantly (p < 0.05) associated with additional uterotonic use, while method of induction approached statistical significance (p=0.06). The mean (SD) birth weight was 3668 (584) vs. 3463 (500) grams in those with and without additional uterotonic use. Multivariate analysis showed an increased risk of additional uterotonics with higher birth weight (adjusted odds ratio (aOR) 1.44 per 500 gram increase in birth weight; 95% CI 1.15, 1.82) and use of Foley plus oxytocin (aOR 4.40; 95% CI 1.36, 14.23). CONCLUSION: In our model, higher birth weight and induction method of Foley followed by oxytocin were associated with increased need for additional uterotonics. This data adds detail to previous studies that have broadly identified induction of labor as a risk factor for postpartum hemorrhage.

137 Background: LUTS are one of the most common reasons patients visit urologists. These symptoms have not been typically associated with the development of prostate cancer (CaP). However, we hypothesized that visiting a physician for LUTS may modify the diagnostic intensity for CaP compared to population controls. Methods: We examined data from a longitudinal, population-based cohort of 2,447 men between 40 and 79 years old who were followed prospectively from 1990 to 2010. Participants completed the American Urological Association Symptom Index (AUASI) every two years. Self-reported moderate/severe LUTS were defined as an AUASI score >7 (n=1627). Data including the treatment for LUTS (n=874), prostate biopsy (PBx), family history of CaP and diagnosis of CaP were obtained through self-report and review of medical records. Associations between self-reported LUTS, treatment for LUTS, and risk of PBx or CaP were estimated using multivariate Cox proportional hazard models. Results: An interaction was noted between age and LUTS and PBx and CaP diagnosis. In younger men, the diagnosis and treatment of LUTS was associated with increased risk of PBx (HR 2.39: 95% CI 1.83, 3.13) and CaP (HR 3.47: 95% CI 2.38, 5.07). Conversely in older men, treatment for LUTS was associated with a decreased risk of PBx and CaP (Table). Self reported LUTS was not significantly associated with CaP diagnosis in younger men and was protective in older men (Table). Conclusions: There is a differential effect of LUTS on prostate cancer testing and diagnosis when stratified by age. The reason for this difference is unclear, but appears to be due largely to diagnostic intensity rather than a true biologic association between LUTS and CaP. [Table: see text]

Background: Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life and contribute to sexual dysfunction. We aimed to determine whether sexual function in women improves after endometrial ablation for heavy menstrual periods. Methods: Validated surveys (Female Sexual Function Index [FSFI], Female Sexual Distress Scale [FSDS], and Short-Form Health Survey [SF–12]) were administered to 136 women before and after endometrial ablation from August 2008 through June 2013. Scores at baseline and 6 months after surgery were compared using the paired t test. Results: A total of 97 women completed the FSFI and FSDS surveys at baseline and 6 months after ablation. Mean full-scale FSFI score increased from 26.5 to 28.8 ( p < .001), with improvement in 5 of 6 FSFI domains. Mean FSDS score decreased from 13.6 to 9.7 ( p < .001), showing decreased personal distress regarding sexual function. In assessing quality of life, SF–12 scores improved for global physical function ( p < .001) and mental function ( p = .002). Conclusions: Female sexual function improved and personal distress associated with sexual function decreased after endometrial ablation for heavy menstrual cycles.