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- [00:01]
A
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- [00:40]
B
How could I have been so careless? 1.2 watt gigawatts. Tom, how am I going to generate that kind of power? It can't be done. Can't. God. Look, all we need is a little plutonium. I'm sure that in 1985, pluton plutonium is available in every corner drugstore, but in 1955, it's a little hard to come by. Marty, I'm sorry, but I'm afraid you're stuck here.
- [01:02]
C
Yep. I can't believe it's been 40 years or so. Is that what it's been, Michael? Like 40 years since Back to the Future? I mean, 1985. My goodness. 1985. Yeah. 40 years. Cray cray. But in this episode, we are literally going back. Back to the future. Oh, see what I did there? That's pretty good. Now, let me explain because we're recording this at the start of June of 2026. Start of June of 2026. And what we're going to cover today in true fashion, is something that is not yet officially even out yet. It will be out in July of 2026. In other words, the future. And we're going back to. To the future because it's going to cover something that we've already talked about in this show a variety of times. Okay. And it's not aspirin for preeclampsia, even though that's coming up as well. But it's still in that same vein as what is the best technique for something. Okay, so let me explain. We've covered many times in the past leaving the uterus in or taking it out, otherwise known as exteriorization drop during C section for hysterotomy repair. And what's best? Well, coming out July of 2026. In other words, in the future, we're gonna go back to discuss this very issue because there's a brand new systematic review and meta analysis of RCTs, mind you, so level one evidence that's going to answer this question once and for all. Thank you very much. Should we leave the uterus in or take it out. And let me. When I. When I say it's going to answer this question once and for all, I hope you understand I'm being very, very facetious because. Yeah, no, it's not going to. But nonetheless, it gives us new ammunition, new data. So when somebody says, hey, I want you to leave the uterus in and you can ask and say, well, why they should give these reasons, or I always take it out and you say why they should state these reasons. So again, this is a brand new systematic review and meta analysis from the European Journal of Obstetrics and Gynecology and Reproductive Biology. That is the EJ O G. So out of ejog. New systematic review and meta analysis of level one evidence. Should we take the uterus in or take it out? And the good news is, is that we don't even need to use a gigawatt.
- [03:34]
B
How could I have been so careless? 1.21 gigawatts. Tom.
- [03:39]
C
All right, that's enough. That's enough. I think I've said it up enough. We'll be right back.
- [03:45]
B
Hi. Look, all we need is a little plutoni. I'm sure that in 1985 plutonium is available in every corner drugstore, but in 1955, it's a little hard to come by.
- [04:02]
C
We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OB GYN no Spin podcast Podcast Family. I am so thankful for Tona Activewear. Yep, it's our brand new sponsor. And what that means to you is that you get 16% off. That's 1, 6. 16% off anything that you buy on Tona Activewear through the link in our show notes. Again, that link is tonaactive.com discount chopanospinobg. The link is in our show notes. Tonaactive.com discount choppa no spinobg altogether. Again, the link is in our show notes. 16% off for premium leggings that you can wear to the gym or every day because it's the same designers for from Lululemon. So, Tona Activewear, thank you for your sponsorship. Thank you for being part of our podcast community. Go to tonaactive.com discount chopanospinobg for your 16% discount. Well, I don't want to belabor this because unfortunately, as I've already alluded to in the intro. No, no. This new systematic review and meta analysis is not some sort of brand new enlightenment that's going to solve this debate that's been going on for decades. This is not put to bed, this is not put to rest, this is not settled. Let me just give you the quick synopsis here and we're going to break down very quickly, but the short answer is, hey, pros and cons to either one, pros to leave it in and cons to leave it in. Pros to take it out and cons to take it out. So the short of it is kind of do what you want to do, do what your surgeon preference is and do what the needs demand. In other words, if you can't see well at a hysterotomy angle and there may be an extension, take it out to see. Even though it's going to give you some increased post op pain and perhaps some post op nausea. But if you need to get bleeding under control, then take it out. In other words, after the systematic review and meta analysis From July of 2026, we're left with the whopping conclusion, technique choice should be individualized given the very low certainty of evidence. End quote. Wow. Really? Really? So after a systematic review, meta analysis and the debate has been going on for decades, the answer these authors came up with, and I'm not minimizing this, I just think it's, the whole thing is comical that the answer is, nah, you can't do what you want to do. Pros and cons to each, bro. Pros and cons to each. But look how long this has been going on. Let's go back over a decade to 2008. This was a randomized controlled trial published in the Green Journal and the title was Uterine Exteriorization Compared with In Situ Repair at Cesarean Delivery. And this is one of the most heavily cited clinical trials on the subject. This was by Cutino and Ramos de Amorin who looked at this, there's also cats, a lot of great people in this. And they found, look, pros and cons, man, pros and cons. The truth is if you exteriorize it, you are going to have much more moderate to severe pain at 6 hours post op compared to the non exteriorized group. But there is some potentially some advantages like you can see better and potentially some decreased blood loss. Okay, we get that. That takes us from 2008 to 2021. So now let's just go back in time five years for a separate separate systematic review and meta analysis on the exact same subject. I mean the title is the same Uterine Exteriorization versus Insight to Repair at C Section. The exact same idea that we're reviewing now. This was five Years ago. Now, at that time, five years ago, this was in the Canadian Journal of Anesthesia. And guess what? The results are strikingly similar, if not identical, to this systematic review and meta analysis that we're about to discuss. So if your goal is to see the hysterotomy edge or the angle better because you think there's an extension, then take it out. In other words, you got to do what you got to do, knowing, of course, that there's risks and benefits to both sides of this camp. Let me read you the results here very quickly. We're going to wrap this up because unfortunately, this is not a big, you know, game changer. It's not a big enlightenment, as we've already stated. But it just goes to show that sometimes in medicine, we can have a good, healthy debate and not really have a clear answer. There's no clear winner here, but again, pros and cons. Now, if you want to know what I do, I love to leave it in. I don't think we should take out an organ to fix it. However, I've obviously taken it up and exteriorized in cases where there's an extension and I have to have better visualization. But routinely, I do try to leave the uterus in. By the way, if there's a weird echo is because I am on call, I'm at the hospital, I'm not in a recording studio, but I do have my portable microphone podcast mic with me. And so I'm sure that there's some weird echo because I'm literally in a hospital room. All right, so real quick, guys, here's the results. 29 randomized controlled trials were included. So, first of all, a couple of things to note there. 29, pretty darn good. And these are all RCTs, all level one. So that's really good. And it totals about 23,000 participants. Again, high numbers. So you're going to get anything that potentially could be chance is going to be washed out. With the more numbers, the more participants that you get. Okay, so here it is. Quote, uterine exteriorization was associated with lower EBL, but the mean difference was like 43 MLS. Again, guys, you see this? I mean, so which one gives you less bleeding? Yeah, exteriorization for about 50mls. So this isn't game changing, like I said, Unfortunately. I was really hoping this was going to answer it. This is going to seal the deal. This isn't even out yet. I thought, man, coming up in July, we're going to get this. No, I don't think so. Uterine exteriorization was associated with lower EBL with a mean difference of about 43ml less. Okay, but there was a smaller post op hemoglobin decrease, but we're talking about a decrease less than 0.26 grams per deciliter. Again, not a huge change. And there was a shorter uterine closure time with a mean difference of about a minute. None of those are game changing. Okay? So unless you really have to go to the bathroom to go pee an extra minute of or time to take your time and do it right and leaving it in utero. In utero inside. To. To fix the utero. To fix the uterus. I don't know what I was talking about there. I'm on call my brain somewhere else. But I wanted to knock this out because I just saw this. I'm like, ooh, I send Michael, our producer, a text. I'm like, I'm sending you something. I just want to knock this out because again, I was so hopeful that it was going to show something and it did not. Wah, wah. So a shorter uterine closure time. So somebody asks you, how long is it faster you can gain brother, a whole 60 seconds. If that's important to you, phenomenal. But it's not a game changer. Now here's the however part. Quote. However. Yeah, I told you. However, a higher risk of intraoperative hypotension, nausea, vomiting and delayed return of bowel function was observed. End quote. So the take home message, guys, leave it in or take it out. It depends what you got to do. Do what you got to do. But the whole idea of I'm always going to take it out just because that's what I do maybe should be thought of differently. Knowing, of course, that everything comes with baggage. And in this baggage, it's a little bit of hypertension, a little bit some nausea with a relative risk of 1.41 and some vomiting, that's the biggest issue. And because of the parasympathetic, you know, flare that happens when you take the uterus out, that's a relative risk of 2.25. That alone, that was the highest change out of all the other things. Both on the good side and the not so good side, it was the vomiting that makes women puke. But that and the quick, the longer delayed of bowel function, those are the two biggest issues. All right, so vomiting with a relative risk of 2.25 and then the delayed return of bowel function, that actually had a, a mean difference time of about three hours. Okay. Compared to leaving it in those are the cons of it. So I'm not against, you know, anyone. I'm not mad at somebody who takes out the uterus. Do what you want to do. But the truth is, is that the conclusion says, hey, don't do this routinely. That's not what it says. It doesn't say do this routinely. It says that uterine exteriorization, an insight to repair, can be considered comparable in terms of safety and in overall surgical outcomes. Just have a reason for what you're doing. And the short answer is, quote this really should be left to individual preference and need of the surgery. Favoring, of course, the higher weighted one, there is need of surgery. If you have to see and you can't see well with it in situ, then take it out. Quote. Given the very low certainty of evidence, technique choice should be individualized, end quote. And that's individualized for the surgeon and individualized for the surgical needs at that time.
- [13:20]
D
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- [13:49]
C
So just be aware if you can take it out. Okay, maybe a little drop in blood pressure and none of these became, you know, less than, you know, 50 over pout. We're talking about massive high hypotension. These are small changes with the two biggest issues in exteriorization being vomiting with a relative risk of 2.25 and then a delay of bowel function of about 3 hours. Again, none of those are whoppingly horrifying. Okay, I'm going to be very clear. These are not whoppingly horrifying. That's why they're pretty much equivalent. Just know that they potentially could cause those issues. And then you do you. So what's the take home answer here if you get ready to do your oral boards coming up in the fall of 2026? Because right now we're in the summer of 2026 and somebody tells you, well, are you telling me that you exteriorize all the time? You go, yeah, because it's my individualized preference. I think I see better. I think I get a little bit less blood loss, even though clinically probably not that much of a deal. And all of the systematic reviews and meta analysis going back close to two decades have said that there's not enough data to say one way or the other is the preferred approach. The There is some benefits to leaving it in, but it still allows for individualized care. And so my individualized care is to exteriorize. If that's the case, and if you like to leave it in like I do, be able to justify that by the reasons that we've just discussed. So, Podcast family, leave it in or take it out. The debate continues, and July of 2026, at least from the European Journal of Obstetrics, Gynecology and Reproductive Biology, is not the game changer that we thought it was going to be. As always, podcast family, we're thankful for you. We're glad you're part of our podcast community. See, I told you we went back to the future, back to an old topic. And in the future, because this is coming out in about a month to a month and a half of what we're recording this. As always, podcast family, we're thankful for you. We'll see you on the next episode of the Ob GYN no Spin Podcast. This is Dr. Chapma's obgyn no spin podcast.