Papers by Nicholas Leyland
Journal of Minimally Invasive Gynecology, Jul 1, 2017
Laparoscopic/robotic myomectomies of premenopausal women pretreated with ulipristal acetate and w... more Laparoscopic/robotic myomectomies of premenopausal women pretreated with ulipristal acetate and women who were not medically pretreated were compared and assessed with a novel grading tool.
CMAJ open, Jul 1, 2020
terine fibroids are benign smooth muscle tumours with a prevalence of up to 70%-80% in women by t... more terine fibroids are benign smooth muscle tumours with a prevalence of up to 70%-80% in women by the age of 50 years. 1 About half of women with uterine fibroids will experience symptoms of abnormal uterine bleeding, pressure and reproductive issues. 2 Fibroids can vary in size, shape, location and number among patients. This topographical information is needed to help guide treatment decisions and is particularly important for surgical planning. 3 Although ultrasonography is the mainstay for the diagnosis and monitoring of uterine fibroids, magnetic resonance imaging (MRI) can also be used. 4 There are no clinical practice guidelines to help determine when an MRI should be ordered to characterize fibroids, and guidelines on the management of fibroids de-emphasize the role of MRI. 5 The Society of Obstetricians and Gynaecologists of Canada clinical practice guideline on the management of uterine fibroids advises that while ultrasonography imaging is the most widely used imaging modality because of its availability, ease of use and cost-effectiveness, MRI is more accurate in characterizing fibroids in terms of size, location, number and perfusion. 3
Journal of Minimally Invasive Gynecology, Nov 1, 2021
Study Objective To demonstrate a unique case of both a laparoscopic correction of a uterine AVM a... more Study Objective To demonstrate a unique case of both a laparoscopic correction of a uterine AVM and hysteroscopic resection of retained products of conception secondary to invasive placenta. Design A brief literature review and case report with demonstration of surgical technique. Setting Operating Room environment. Patients or Participants In this video we explore the case of a 28-year-old patient who in 2019 had a 20-week loss followed by PPH requiring manual removal of retained placenta and D&C. Subsequent to this first pregnancy she a delayed PPH with IR embolization of the left uterine artery for a uterine AVM. In 2020, the patient delivered vaginally, preterm at 27 weeks and again had a PPH requiring manual removal of retained placenta and D&C. After 2 months of continued spotting an ultrasound queried residual RPOC with hypervascularity in the right uterine wall suggestive of a right AVM with CT angiography confirming a uterine AVM. Interventions The patient wished for fertility preservation and ultimately underwent laparoscopic clipping of the feeding vessel, the right internal iliac artery followed by hysteroscopic removal of retained products of conception. Measurements and Main Results The patient's post-operative course was uncomplicated and final pathology confirmed normal placental tissue consistent with placenta accreta. The post-op sonohysterogram confirmed an empty uterine cavity and the 2D colour doppler US confirmed reduced right uterine wall vascularity. Conclusion A laparoscopic approach to uterine AVM management is possible and can be combined with hysteroscopic investigation and management of RPOC.
Frontiers in reproductive health, Jul 22, 2021
Extrapelvic endometriosis, although rare, can present in the musculoskeletal system of reproducti... more Extrapelvic endometriosis, although rare, can present in the musculoskeletal system of reproductive-age women and cause significant pain and morbidity. The pathophysiology of this disease is not well understood. In this study, we described the case of a 39-year-old women with an inner-thigh mass causing catamenial pain. Core-biopsy of the mass confirmed endometriosis and she was referred to minimally-invasive gynecology for management. Surgical excision was performed by a multidisciplinary team and she remains pain-free postoperatively on hormonal therapy. Unique to this case, the patient had a history of pelvic fracture. Through this case report, we discuss possible pathophysiologic mechanisms of extrapelvic musculoskeletal endometriosis including the stem/progenitor cell theory and the role that musculoskeletal trauma may have in the development of this condition. Gynecologists play an important role in the recognition, diagnosis, and management of musculoskeletal endometriosis.
Journal of endometriosis and pelvic pain disorders, Jul 29, 2019
Background: The daily pain burden experienced by women with endometriosis has not been well studi... more Background: The daily pain burden experienced by women with endometriosis has not been well studied. Objective: To characterize baseline pain among women with moderate-to-severe endometriosis-associated pain enrolled in phase 3 studies of elagolix, an oral, nonpeptide gonadotropin-releasing hormone antagonist. Study design: Data were pooled from the screening phase of two randomized, double-blind, placebo-controlled clinical trials. After cessation of endometriosis medications, patients entered the screening phase during which symptoms (dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia) and rescue medication use were recorded daily in electronic diaries. Endometriosis-associated pain was also scored using the Numeric Rating Scale (range 0-10). Baseline was defined as the last 35 days during the screening period. Results: Endometriosis-associated pain was reported by the 1686 study participants on most days during the baseline interval. Pain was often moderate or severe, with a mean Numeric Rating Scale score of 5.6 ± 1.7. Women reported dysmenorrhea an average of 8.1 ± 3.0 days (97.9% ± 7.0% of menstruating days), nonmenstrual pelvic pain on 20.5 ± 5.4 days (90.3% ± 15.8% of nonmenstruating days), and dyspareunia on 8.7 ± 8.0 days (81.7% ± 29.7% of sexually active days). When they occurred, dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia were frequently moderate or severe in intensity. Women were free of pelvic pain for an average of 2.4 ± 3.9 days during the 35-day evaluation interval. Conclusion: Among women with untreated moderate-to-severe endometriosis pain, the daily burden of pain was extensive, both during menstruation and on nonmenstruating days.
Gynecologic Oncology, Oct 1, 1999
The use of a combined treatment option for endometrial cancer in a medically compromised patient ... more The use of a combined treatment option for endometrial cancer in a medically compromised patient is outlined. A case of a 49-year-old severely medically compromised patient with endometrial cancer is described. A complete hysteroscopic endometrial resection with insertion and suturing in place of an endocervical cannula allowed weekly outpatient delivery of high-dose-rate intracavitary radiation without anesthetic or repeat dilatation of the endocervical canal. The use of hysteroscopic endometrial resection with adjuvant high-dose-rate radiation therapy is a feasible treatment option for patients with endometrial cancer in whom surgery is contraindicated.
Fertility and Sterility, Sep 1, 2017
AbbVie Inc. funded these studies and participated in the study design, research, analysis, data c... more AbbVie Inc. funded these studies and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication.
Journal of obstetrics and gynaecology Canada, 2016
Background: Episodes of acute abnormal uterine bleeding related to uterine fibroids can cause sig... more Background: Episodes of acute abnormal uterine bleeding related to uterine fibroids can cause significant morbidity. Traditional management with high-dose hormonal regimens may not be as effective when used in women with fibroids. Case: A 32-year-old woman with a 12 cm uterine fibroid presented with an episode of acute abnormal uterine bleeding requiring blood transfusion. In lieu of using a hormonal maintenance regimen after the bleeding had stabilized, the patient was treated with ulipristal acetate 5 mg daily for three months. Amenorrhea was induced rapidly and the patient had no further episodes of acute excessive uterine bleeding. She subsequently underwent a laparoscopic myomectomy with a satisfactory outcome. Conclusion: Ulipristal acetate has been shown to induce amenorrhea rapidly in women with uterine fibroids, and it can be a useful treatment in the emergency management of fibroid-related acute abnormal uterine bleeding. prise en charge d'urgences liées aux saignements utérins anormaux aigus associés aux fibromes.
Journal of obstetrics and gynaecology Canada, 2018
Objective: Previous studies have demonstrated that outpatient total laparoscopic hysterectomy (TL... more Objective: Previous studies have demonstrated that outpatient total laparoscopic hysterectomy (TLH) is both safe and feasible. Our objective was to decrease length of stay for patients undergoing TLH by implementing a same-day discharge protocol at two Canadian teaching hospitals. Methods: We conducted a prospective cohort study assessing length of stay (primary outcome), perioperative complications, and readmission rates over a 12-month period following implementation of a same-day discharge protocol for TLH. These data were compared with pre-intervention baseline data collected retrospectively over a 12-month period immediately before protocol introduction. Our protocol consisted of patient education, instructions for perioperative care, and close follow-up. Results: In the year prior to our protocol, 256 TLHs were performed. Forty-seven patients (18.3%) were discharged the same day, 191 patients (74.5%) were discharged on the first postoperative day, and 18 patients (7%) were admitted for 2 or more days. In the year following implementation, 215 patients underwent TLH of which 129 were enrolled in our study. The overall outpatient hysterectomy rate during that time period was 62% (134/215 patients). Among study participants, 102 patients (79.1%) were discharged the same day, 22 patients (17.0%) were discharged on the first postoperative day, and 5 patients (3.9%) were admitted for 2 or more days. There were no significant differences in perioperative complications or readmission rates and patient satisfaction scores were high. Conclusion: Implementation of a same-day discharge protocol successfully increased the rate of outpatient TLH without impacting patient safety. This protocol was acceptable to both surgeons and patients and can be easily adapted for use at other centers. Résumé Objectif : Des études ont montré que la réalisation d'une hystérectomie laparoscopique totale (HLT) en chirurgie d'un jour est possible et sécuritaire. Notre objectif était de réduire la durée du séjour des patientes subissant une HLT par la mise en oeuvre d'un protocole de congé le jour même dans deux hôpitaux universitaires canadiens. Méthodologie : Nous avons mené une étude de cohorte prospective portant sur la durée du séjour (critère d'évaluation principal), les complications périopératoires et le taux de réadmission des patientes dans les 12 mois suivant la mise en oeuvre du protocole de congé. Les données recueillies ont été comparées à celles des 12 mois précédant la mise en place du protocole, obtenues rétrospectivement. Notre protocole comprenait l'enseignement aux patientes, des consignes sur les soins périopératoires et un suivi étroit. Résultats : Au cours de l'année précédant la mise en oeuvre du protocole, 256 patientes ont subi une HLT. Parmi celles-ci, 47 (18,3 %) ont obtenu leur congé le jour même, 191 (74,5 %) l'ont obtenu le lendemain et 18 (7 %) ont été hospitalisées pendant deux jours ou plus. Dans l'année suivant la mise en place du protocole, 215 patientes ont subi une HLT, et 129 d'entre elles ont été recrutées pour cette étude. Le taux global d'hystérectomies d'un jour effectuées durant cette période a été de 62 % (134 patientes sur 215). Parmi les participantes à l'étude, 102 (79,1 %) ont obtenu leur congé le jour même, 22 (17,0 %) l'ont obtenu le lendemain et 5 (3,9 %) ont été hospitalisées pour deux jours ou plus. Aucune différence statistiquement significative n'a été observée en ce qui a trait aux complications périopératoires et au taux de réadmission, et la satisfaction des patientes était élevée. Conclusion : La mise en place d'un protocole de congé le jour même a permis d'accroître le taux d'HLT d'un jour sans compromettre la sécurité des patientes. Ce protocole, jugé acceptable par les chirurgiens et les patientes, peut facilement être modifié pour qu'il soit adapté aux besoins des autres centres.
Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Dec 1, 2002
Gas embolism is a rare but well documented entity during operative hysteroscopy, with an incidenc... more Gas embolism is a rare but well documented entity during operative hysteroscopy, with an incidence of 10-50%. Catastrophic outcomes occur at a rate of three in 17,000 procedures. The purpose of this report is to present a non-fatal case of gas embolism probably caused by the gaseous products of combustion. C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 50-yr-old woman with a history of menorrhagia was scheduled for hysteroscopy and endometrial ablation and polypectomy. Fifteen minutes into the procedure, with the patient in lithotomy position, 20° head down tilt, and breathing spontaneously, a sudden oxygen desaturation occurred from 97% to 87%. The patient's end-tidal carbon dioxide dropped from 46 mmHg to 27 mmHg. The patient's breathing pattern remained normal, respiratory rate remained 11-12 breaths•min-1 but amplitude of the reservoir bag movement was increased. Cardiovascular variables remained stable. She responded rapidly to 100% oxygen and made an uneventful recovery. Having ruled out other possible causes, we concluded gas embolism was responsible for the fall in oxygen saturation and end-tidal CO 2. C Co on nc cl lu us si io on n: : With all the precautions in place to minimize the likelihood of fluid overload and ambient air embolism occurring, we surmised that products of combustion were the cause of the gas embolism. During endometrial ablation, gaseous products of combustion, mainly carbon dioxide, accumulate. The gases may then contribute to the rise in uterine pressure that occurs as irrigation fluid enters the uterus and this rise in pressure in turn encourages passage of gas into the open venous sinuses. Objectif : L'embolie gazeuse est un état pathologique rare, mais bien documentée, survenant pendant l'hystéroscopie peropératoire selon une incidence de 10-50 %. Des conséquences catastrophiques surviennent dans trois interventions sur 17 000. Nous avons voulu présenter un cas d'embolie gazeuse non mortelle causée probablement par des produits de combustion gazeux.
Journal of obstetrics and gynaecology Canada, Apr 1, 2021
RESUME Objectif : L'objectif principal de la presente directive clinique est de fournir aux g... more RESUME Objectif : L'objectif principal de la presente directive clinique est de fournir aux gynecologues un algorithme et des donnees probantes pour guider l'utilisation de la thromboprophylaxie en chirurgie gynecologique. Population cible : Toutes les patientes devant subir une intervention chirurgicale gynecologique pour des indications benignes ou malignes. Benefices, risques et couts : La mise en œuvre de la presente directive profitera aux patientes devant subir une intervention chirurgicale gynecologique et fournira aux medecins un algorithme standardise pour l'utilisation de la thromboprophylaxie perioperatoire. Donnees probantes : Les termes de recherche suivants ont ete utilises dans les bases de donnees PubMed-Medline, Google Scholar et Cochrane pour la periode de publication de 2017 a 2018 : VTE, PE, DVT, thromboprophylaxis, gynaecologic surgery, heparin, graduated compression stocking, intermittent pneumatic stocking, obesity, pediatrics, minimally invasive surgery, heparin induced thrombocytopenia, regional anesthesia. Les articles retenus sont des essais cliniques randomises, des meta-analyses, des revues systematiques et des etudes observationnelles. Des publications supplementaires ont ete relevees a partir des notices bibliographiques de ces articles. Aucune contrainte n'a ete appliquee quant a la date de publication, mais seuls les articles en anglais ont ete retenus. Les recherches ont ete mises a jour et integrees a la directive clinique jusqu'en septembre 2018. Methodes de validation : Les auteurs ont evalue la qualite des donnees probantes et la force des recommandations en utilisant le cadre methodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les definitions et tableau A2 pour l'interpretation des recommandations fortes et faibles). Professionnels cibles : Gynecologues et autres membres de l'equipe chirurgicale.
Journal of obstetrics and gynaecology Canada, Sep 1, 2013
Journal of Minimally Invasive Gynecology, Nov 1, 2017
DIE = Deep Infiltrative Endometriosis. a-menstrual and mid-cycle phases (CA-125 <35 IU/ml). b-men... more DIE = Deep Infiltrative Endometriosis. a-menstrual and mid-cycle phases (CA-125 <35 IU/ml). b-menstrual and mid-cycle phases (CA-125 >35 IU/ml); (p <.00001). Conclusion: CA-125 may be useful for the diagnosis of deep endometriosis, especially when both are collected during menstruation and in midcycle. Multicentric studies with larger samples should be performed to better evaluate the cost-effectiveness of measuring CA-125 in two different phases of the menstrual cycle.
Canadian Medical Association Journal, Aug 23, 2020
Placenta accreta spectrum describes abnormally adherent or invasive placentas In normal pregnancy... more Placenta accreta spectrum describes abnormally adherent or invasive placentas In normal pregnancy, a blastocyst implants into the endometrium, and after delivery, the placenta detaches from the uterus. In placenta accreta spectrum, the placenta forms at a site of disruption between the endometrium and myometrium. Placental tissue implants onto the myometrium (accreta), into the myometrium (increta) or through the myometrium to surrounding organs (percreta) (Figure 1). This prevents placental detachment, which can result in severe hemorrhage and increased risk of maternal morbidity and mortality. 1-4 Competing interests: Nicholas Leyland reports receiving research support grants from AbbVie and Allergen, and consulting fees from AbbVie. No other competing interests were declared. This article has been peer reviewed.
Surgical Endoscopy and Other Interventional Techniques, Feb 19, 2016
Background Answering telephone calls and pagers is common distraction in the operating room. We s... more Background Answering telephone calls and pagers is common distraction in the operating room. We sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulationbased surgical performance. Methods We conducted a randomized crossover study of obstetrics and gynecology residents. After studying a patient sign-out list, subjects performed a virtual salpingectomy. They were randomized to a distraction phase followed by quiet phase or vice versa. In the distraction phase, a pager beeped and subjects were asked questions based on the sign-out list. Accuracy of responses and the number of unsafe responses were recorded. In the quiet phase, trainees performed the task uninterrupted. Measures of surgical performance were successful task completion, time to task completion and operative blood loss. Results The mean score for correct responses to clinical questions during the distracted phase was 80 % (SD ±14 %). Nineteen residents (63 %) made at least 1 unsafe clinical decision while operating on the simulator (range 0-3). Subjects were more likely to successfully complete the surgical task in the allotted time under the quiet compared to distraction condition (OR 11.3, p = 0.03). There was no difference between the conditions in paired analysis for mean time (seconds) to task completion [426 (SD 133) vs. 440 (SD 186), p = 0.61] and mean operative blood loss (mL) [73.14 (SD 106) vs. 112.70 (SD 358), p = 0.47]. Conclusions Distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents' ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.
International Journal of Gynecological Pathology, Oct 1, 1999
Ablation of the endometrium is now an established treatment modality for dysfunctional uterine bl... more Ablation of the endometrium is now an established treatment modality for dysfunctional uterine bleeding (DUB). There have been few reports of the inflammatory and healing reaction within the endomyometrium subsequent to this therapy, and its identifying characteristics. The morphologic reaction after electrosurgical ablation in particular has received scant attention. In this retrospective study, 19 women were identified who had undergone both an endometrial ablation using electrosurgical rollerball ablation and a subsequent endometrial sampling or hysterectomy. The average age of the patients was 47 years (range, 28 to 60). Fifteen patients had been ablated for DUB, while four had been ablated immediately after a resection that later revealed atypical hyperplasia. Histopathologic specimens were examined from 1 to 48 months postablation. The six specimens examined at 3 months or less after ablation all exhibited necrotic myometrium, and in five of these six cases, a florid foreign body and granulomatous reaction to necrotic myometrium and spicules of thermally damaged myometrium. A variable degree of acute inflammation was evident in all six cases and was exclusively present in one case. The remaining 13 cases were examined at > 3 months posttreatment. Necrotic myometrium was no longer evident, but a persistent granulomatous, a foreign-body reaction, or both was detected in 5 of 12 cases up to 16 months postablation. In most cases (9 of 12), there was striking endometrial scarring. The morphologic response of the endometrium after electrosurgical endometrial ablation is similar to that reported previously for both resection and laser ablation. Post-hysteroscopic ablative reaction should be recognized and distinguished from other causes of granulomatous endometritis.
Journal of Minimally Invasive Gynecology, Nov 1, 2017
This video demonstrates the technique for laparoscopic lateral transposition of the ovaries. For ... more This video demonstrates the technique for laparoscopic lateral transposition of the ovaries. For patients diagnosed with malignancy, pelvic radiation therapy is associated with loss of ovarian function in more than 50% of cases with subsequent menopausal symptoms, loss of fertility, osteoporosis and cardiovascular disease. To decrease this likelihood, ovarian transposition may be offered to women of reproductive age with malignancy and planned pelvic radiotherapy. Here, we describe a laparoscopic ovarian transposition in a 31-year old female with locally advanced rectal carcinoma prior to starting radiotherapy. Key steps involve: performing a salpingectomy, dividing the utero-ovarian ligament, incising the peritoneum lateral to the infundibulopelvic ligament, dissecting the paracolic gutter, pediculization of the infundibulopelvic ligament, mobilizing the ovary above the pelvic brim, suturing it to the sidewall, marking the ovarian final position using metallic clips. When performed laparoscopically, lateral transposition of the ovaries is simple and safe and allows immediate postoperative pelvic irradiation.
Journal of obstetrics and gynaecology Canada, Jul 1, 2022
Journal of obstetrics and gynaecology Canada, 2022
OBJECTIVE The primary objective of this clinical practice guideline is to provide gynaecologists ... more OBJECTIVE The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the use of thromboprophylaxis in gynaecological surgery. TARGET POPULATION All patients undergoing gynaecological surgery for benign or malignant indications. BENEFITS, HARMS, AND COSTS The implementation of this guideline will benefit patients undergoing gynaecological surgery and provide physicians with a standard algorithm for the use of perioperative thromboprophylaxis. EVIDENCE The following search terms were entered into MEDLINE, Google Scholar, and Cochrane in 2017 and 2018: VTE, PE, DVT, thromboprophylaxis, gynaecological surgery, heparin, graduated compression stocking, intermittent pneumatic stocking, obesity, pediatrics, minimally invasive surgery, heparin induced thrombocytopenia, regional anesthesia). Articles included were randomized controlled trials, meta-analyses, systematic reviews, and observational studies. Additional publications were identified from the reference lists of these articles. There were no date limits, but search results were limited to English language articles only. Searches were updated and incorporated into the guideline up to September 2018. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED USERS Gynaecologists and other members of the surgical team.
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Papers by Nicholas Leyland