Faculty Bibliography

Electronic health records (EHRs) present opportunities to study uterine fibroids uterine fibroids and endometriosis within diverse populations. When using EHR data, it is important to validate outcome classification via diagnosis codes. We performed a validation study of three approaches (1: ICD-10 code alone, 2: ICD-10 code + diagnostic procedure, and 3: ICD-10 code + all diagnostic information) to identify incident uterine fibroids and endometriosis patients among n=750 NYU Langone Health 2016-2023. Chart review was used to determine the true diagnosis status. When using a binary classification system (incident vs. non-incident patient), Approaches 2 and 3 had higher positive predictive values (PPVs) for uterine fibroids (0.86 and 0.87 vs. 0.78) and for endometriosis (0.70 and 0.73 vs. 0.66), but Approach 1 outperformed the other two in negative predictive values (NPVs) for both outcomes. When using a three-level classification system (incident vs. prevalent vs. disease free patients), PPV for prevalent patients was low for all approaches, while PPV/NPV of disease-free patients was generally above 0.8. Using ICD-10 codes alone yielded higher NPVs but resulted in lower PPVs compared with the other approaches. Continued validation of uterine fibroids/endometriosis EHR studies is warranted to increase research into these understudied gynecologic conditions.

STUDY OBJECTIVE:To analyze hysterectomy trends and vaginal cuff dehiscence (VCD) rates by mode of surgery at a tertiary care medical center and to describe characteristics of VCD cases. DESIGN:Observational retrospective cohort study. SETTING:Large academic hospital and affiliated community hospital. PATIENTS:4722 patients who underwent hysterectomy at Columbia University Irving Medical Center between January 2010 and August 2021. INTERVENTIONS:Current Procedural Terminology and International Classification of Diseases codes identified hysterectomies and VCD cases. Hysterectomy trends and VCD rates were calculated by mode of surgery. Relative risks of VCD for each mode were compared with total abdominal hysterectomy (TAH). Clinical characteristics of VCDs were reviewed. MEASUREMENTS AND MAIN RESULTS:There were 4059 total hysterectomies. Laparoscopic hysterectomies, including total laparoscopic hysterectomies (TLHs), laparoscopic-assisted vaginal hysterectomies, and robot-assisted TLHs (RA-TLHs), increased from 41.9% in 2010 to 65.9% in 2021 (p <.001). RA-TLH increased from 5.7% in 2010 to 40.2% in 2021. Supracervical hysterectomies followed similar trends and were excluded from VCD analysis. There were 15 VCDs (overall rate 0.37%). VCD was highest after RA-TLH (0.66%), followed by TLH (0.32%) and TAH (0.27%), with no VCDs after laparoscopic-assisted vaginal hysterectomy or total vaginal hysterectomy. Compared with TAH, the relative risk for VCD after RA-TLH was 2.44 (95% confidence interval 0.66-9.00) and after TLH was 1.18 (95% confidence interval 0.24-5.83), which were not statistically significant. The mean time to dehiscence was 39 days (range 8-145 days). The most common trigger event was coitus (41%). CONCLUSION:VCD rates were low (<1%) for all modes of hysterectomy, and rates after robotic and laparoscopic hysterectomy were much lower than previously reported. Although VCD rates trended higher after robotic and laparoscopic hysterectomy compared with abdominal hysterectomy, the difference was not significant. It is difficult to determine whether this finding represents true lack of difference vs a lack of power to detect a significant difference given the rarity of VCD.

Leiomyomas (fibroids) are common, usually benign, monoclonal tumors that arise from the uterine myometrium. Clinical presentation is variable; some patients are asymptomatic, whereas others experience heavy menstrual bleeding, pain, bulk symptoms, and/or alterations in fertility. Previously, treatment options for fibroids were largely surgical. However, over the last decade, options have grown to include many medical and procedural options that allow for uterine and fertility preservation. Clinicians must become familiar with these options to adequately counsel patients desiring treatment of fibroids.

STUDY OBJECTIVE/OBJECTIVE:To determine the incidence of perioperative coronavirus disease (COVID-19) in women undergoing benign gynecologic surgery and to evaluate perioperative complication rates in patients with active, previous, or no previous severe acute respiratory syndrome coronavirus 2 infection. DESIGN/METHODS:A multicenter prospective cohort study. SETTING/METHODS:Ten institutions in the United States. PATIENTS/METHODS:Patients aged >18 years who underwent benign gynecologic surgery from July 1, 2020, to December 31, 2020, were included. All patients were followed up from the time of surgery to 10 weeks postoperatively. Those with intrauterine pregnancy or known gynecologic malignancy were excluded. INTERVENTIONS/METHODS:Benign gynecologic surgery. MEASUREMENTS AND MAIN RESULTS/RESULTS:The primary outcome was the incidence of perioperative COVID-19 infections, which was stratified as (1) previous COVID-19 infection, (2) preoperative COVID-19 infection, and (3) postoperative COVID-19 infection. Secondary outcomes included adverse events and mortality after surgery and predictors for postoperative COVID-19 infection. If surgery was delayed because of the COVID-19 pandemic, the reason for postponement and any subsequent adverse event was recorded. Of 3423 patients included for final analysis, 189 (5.5%) postponed their gynecologic surgery during the pandemic. Forty-three patients (1.3% of total cases) had a history of COVID-19. The majority (182, 96.3%) had no sequelae attributed to surgical postponement. After hospital discharge to 10 weeks postoperatively, 39 patients (1.1%) became infected with severe acute respiratory syndrome coronavirus 2. The mean duration of time between hospital discharge and the follow-up positive COVID-19 test was 22.1 ± 12.3 days (range, 4-50 days). Eleven (31.4% of postoperative COVID-19 infections, 0.3% of total cases) of the newly diagnosed COVID-19 infections occurred within 14 days of hospital discharge. On multivariable logistic regression, living in the Southwest (adjusted odds ratio, 6.8) and single-unit increase in age-adjusted Charlson comorbidity index (adjusted odds ratio, 1.2) increased the odds of postoperative COVID-19 infection. Perioperative complications were not significantly higher in patients with a history of positive COVID-19 than those without a history of COVID-19, although the mean duration of time between previous COVID-19 diagnosis and surgery was 97 days (14 weeks). CONCLUSION/CONCLUSIONS:In this large multicenter prospective cohort study of benign gynecologic surgeries, only 1.1% of patients developed a postoperative COVID-19 infection, with 0.3% of infection in the immediate 14 days after surgery. The incidence of postoperative complications was not different in those with and without previous COVID-19 infections.

STUDY OBJECTIVE:The purpose of this study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical volume and emergency department (ED) consults across obstetrics-gynecology (OB-GYN) services at a New York City hospital. DESIGN:Retrospective cohort study. SETTING:Tertiary care academic medical center in New York City. PATIENTS:Women undergoing OB-GYN ED consults or surgeries between February 1, 2020 and April 15, 2020. INTERVENTIONS:March 16 institutional moratorium on elective surgeries. MEASUREMENTS AND MAIN RESULTS:The volume and types of surgeries and ED consults were compared before and after the COVID-19 moratorium. During the pandemic, the average weekly volume of ED consults and gynecology (GYN) surgeries decreased, whereas obstetric (OB) surgeries remained stable. The proportions of OB-GYN ED consults, GYN surgeries, and OB surgeries relative to all ED consults, all surgeries, and all labor and delivery patients were 1.87%, 13.8%, 54.6% in the pre-COVID-19 time frame (February 1-March 15) vs 1.53%, 21.3%, 79.7% in the COVID-19 time frame (March 16-April 15), representing no significant difference in proportions of OB-GYN ED consults (p = .464) and GYN surgeries (p = .310) before and during COVID-19, with a proportionate increase in OB surgeries (p <.002). The distribution of GYN surgical case types changed significantly during the pandemic with higher proportions of emergent surgeries for ectopic pregnancies, miscarriages, and concern for cancer (p <.001). Alternatively, the OB surgery distribution of case types remained relatively constant. CONCLUSION:This study highlights how the pandemic has affected the ways that patients in OB-GYN access and receive care. Institutional policies suspending elective surgeries during the pandemic decreased GYN surgical volume and affected the types of cases performed. This decrease was not appreciated for OB surgical volume, reflecting the nonelective and time-sensitive nature of obstetric care. A decrease in ED consults was noted during the pandemic begging the question "Where have all the emergencies gone?" Although the moratorium on elective procedures was necessary, "elective" GYN surgeries remain medically indicated to address symptoms such as pain and bleeding and to prevent serious medical sequelae such as severe anemia requiring transfusion. As we continue to battle COVID-19, we must not lose sight of those patients whose care has been deferred.

STUDY OBJECTIVE:To compare the Fundamentals of Laparoscopic Surgery (FLS) exam scores between obstetrics and gynecology (OBGYN) and general surgery (GS) providers. DESIGN:This is a retrospective cohort study at a single institution from July 2007 to May 2018. Categorical and continuous variables were analyzed with χ2 test, t test, and Wilcoxon rank sum test. SETTING:Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, a tertiary care academic medical center. PATIENTS:All providers who took the FLS exam at the Carl J. Shapiro Simulation and Skills Center at BIDMC. INTERVENTIONS:FLS certification. MEASUREMENTS AND MAIN RESULTS:A total of 205 BIDMC trainees and faculty took the FLS exam between July 2007 and May 2018, of which 176 were identified to be OBGYN or GS providers. The FLS certification pass rate was high for both specialties (97.0% OBGYN vs 96.1% sGS, p = .76). When comparing all providers, no significant difference was found in the mean manual skill test scores between surgical specialties (594.9 OBGYN vs 601.0 GS, p = .59); whereas, a significant difference was noted in the mean cognitive scores, with GS providers scoring higher than OBGYN providers (533.8 OBGYN vs 583.4 GS, p <.001). However, when adjusting for several variables in a multivariate linear regression model, surgical specialty was not a predictor for cognitive scores. In the multivariate analysis, age, sex, and test year were predictors for cognitive scores, with higher scores associated with younger age, male sex, and advancing calendar year. None of the variables were significant predictors of manual scores. CONCLUSION:Both OBGYN and GS providers had extremely high FLS pass rates. In the multivariate analysis, surgical specialty was not a predictor for higher FLS test scores for either manual or cognitive test scores. Although OBGYN residency programs offer fewer years of training, OBGYN trainees demonstrate the capacity to perform well on the FLS exam.

OBJECTIVE:To evaluate differences in standardized scores and surgical confidence in the completion of a standardized total laparoscopic hysterectomy and bilateral salpingo-oophorectomy (TLH-BSO) among obstetrician-gynecologists (ob-gyns) with different levels of training, and to assess a TLH-BSO model for validity. METHODS:We conducted a prospective cohort study of 68 participants within four categories of ob-gyns: 1) graduating or recently graduated residents (n=18), 2) minimally invasive gynecologic surgery graduating or recently graduated fellows (n=16), 3) specialists in general obstetrics and gynecology (n=15), and 4) fellowship-trained minimally invasive gynecologic surgery subspecialists (n=19) who completed a TLH-BSO simulation. Participants completed presimulation questionnaires assessing laparoscopic confidence. Participants performed a video-recorded TLH-BSO and contained specimen removal on a standardized 250-g biological model in a simulated operating room and completed a postsimulation questionnaire. RESULTS:Randomized videos were scored by blinded experts using the validated OSATS (Objective Structured Assessment of Technical Skills). The surgery was divided into five standardized segments: 1) adnexa, 2) dissection and pedicles, 3) colpotomy, 4) cuff closure, and 5) tissue extraction. Minimally invasive gynecologic surgery subspecialists averaging 8.9 years in practice scored highest in all categories (overall median score 91%, P<.001), followed by fellows (64%, P<.001), specialists in obstetrics and gynecology averaging 19.7 years in practice (63%, P<.001), and residents (56%, P<.001). Residents, fellows and specialists in obstetrics and gynecology were comparable overall. Fellows scored higher on cuff closure (63% vs 50%, P<.03) and tissue extraction (77% vs 60%, P<.009) compared with specialists in obstetrics and gynecology. Minimally invasive gynecologic surgery subspecialists were fastest overall and on each individual component. Residents were slowest in almost all categories. CONCLUSION:When performing a TLH-BSO of a standardized 250-g uterus on a simulation model, fellowship-trained minimally invasive gynecologic surgery subspecialists achieved higher OSATS in all areas and completed all components faster. Similar performances were noted between residents, fellows, and specialists in obstetrics and gynecology in practice an average of 19.7 years. FUNDING SOURCE:Support from Applied Medical, Medtronic, CooperSurgical, and Karl Storz in the form of in-kind equipment was obtained through unrestricted educational grants.