Self-reported bladder function five years post-hysterectomy

We have examined the contribution of hysterectomy, compared with less invasive surgery, for dysfunctional uterine bleeding (DUB) on the prevalence of bladder problems five years after surgery. We report a prospective cohort study of over 25,000 women treated for benign cause menorrhagia by three types of surgery - transcervical endometrial resection/ablation and hysterectomy with or without bilateral oophorectomy. Postal questionnaires were sent five years after surgery investigating satisfaction with surgery and bladder function. When adjusted for confounders the odds of severe urinary incontinence (OR = 1.59, CI 95%, 1.35 - 1.87), urinary frequency (1.23 (1.04 - 1.45)), and nocturia (1.19, (1.03 - 1.38)) - were increased for women who had a hysterectomy compared with endometrial ablation. Hysterectomy with bilateral oophorectomy was not as strongly associated with severe bladder problems. Women who had the LAVH were most likely to report severe urinary incontinence (2.02, CI 95% 1.32 - 3.07), but not severe frequency or nocturia.

Two- and three-dimensional saline contrast sonohysterography: interobserver agreement, agreement with hysteroscopy and diagnosis of endometrial malignancy

OBJECTIVES

The aims of our study were to compare the interobserver reproducibility of two-dimensional (2D) and three-dimensional (3D) saline contrast sonohysterography (SCSH) and agreement of these techniques with hysteroscopy, and to determine which SCSH findings best discriminate between benign and malignant endometrium.

METHODS

Consecutive women with postmenopausal bleeding and endometrial thickness > or = 4.5 mm underwent 2D and 3D SCSH; the results were videotaped and stored electronically, respectively, for analysis by two independent experienced examiners who were blinded to each other's results. A histological diagnosis was obtained by dilatation and curettage, hysteroscopic resection or hysterectomy. The hysteroscopist was blinded to the ultrasound results and used the same standardized research protocol to describe the uterine cavity as the ultrasound examiners.

RESULTS

Of 170 consecutive women with postmenopausal bleeding and endometrial thickness > or = 4.5 mm, 84 (14 with endometrial malignancy) fulfilled our inclusion criteria. Hysteroscopy findings in 54 women (one with endometrial malignancy) were used to determine agreement with SCSH. Interobserver agreement of 2D and 3D SCSH was 95% (80/84) vs. 89% (75/84) with regard to presence of focal lesions, 89% (75/84) vs. 88% (74/84) for presence of focal lesions with irregular surface, 67% (54/81) vs. 63% (51/81) for number of focal lesions, and 77% (46/60) vs. 70% (42/60) for location of focal lesions. The agreement between 2D and 3D SCSH and hysteroscopy was 94% (51/54) vs. 93% (50/54) with regard to presence of focal lesions, 74% (40/54) vs. 76% (41/54) for presence of focal lesions with irregular surface, 63% (34/54) vs. 54% (29/54) for number of focal lesions, and 66% (29/44) vs. 64% (28/44) for location of focal lesions. The SCSH finding that best discriminated between benign and malignant endometrium was the presence of focal lesion(s) with irregular surface (for 2D SCSH: sensitivity 71%, specificity 97%, positive likelihood ratio 25, negative likelihood ratio 0.3; for 3D SCSH: sensitivity 43%, specificity 97%, positive likelihood ratio 15, negative likelihood ratio 0.6).

CONCLUSIONS

3D SCSH does not seem to be superior to 2D SCSH when performed by experienced ultrasound examiners either with regard to reproducibility, agreement with hysteroscopy findings or diagnosis of endometrial malignancy. The presence of focal lesion(s) with irregular surface is the best SCSH variable for discrimination between benign and malignant endometrium.

[Thermachoice thermal balloon therapy--a 10-year-experience]

OBJECTIVE

To evaluate the effectivness of a global method of endometrium ablation--Thermachoice (Gynecare; Johnson & Johnson) baloon therapy in treatment of excessive uterine bleeding. Our 10-year-long-experience is presented.

DESIGN

Retrospective study.

SETTINGS

Department of Gynecology and Obstetrics, First faculty of Medicine, Charles University and General Teaching Hospital, Prague.

METHODOLOGY AND RESULTS

109 patients were treated in our depatment from November 1997 till the end of the year 2007. The pacients were contacted personally, over the phone and by sending questinnaires. 92 women (84.4%) were included into the evaluation group after twelve month and after 5 years there were 54 women. The group was mostly formed by seriously polymorbid patients. The average age was 41.6 years. In the twelve-month-follow-up there were 38 percent amenorrheic, five years later there were 63 percent of them. 13 women (14%) ended with hysterectomy--two pacients without any connection with the operation. In 3 cases there was a therapeutic cycle failure, because the acquired intrauterine pressure was not reached. In one case of the monstrous obese woman, after a longer period form the operation there was a carcinoma of the endometrium found out. Two women after the termoablation became pregnant: the first one non-voluntarily, she decided for the arteficial abortion and then the hysterectomy, the second one, despite the fact, that she had been fully informed, underwent the IVF therapy and at the age of 37 she delivered by the Cesarian section in the 36-week-old pregnancy the healthy girl weighing 2900 gramms. With one patient--a young woman the operation was combined with uterine artery embolisation (UAE)--and that is why she was excluded. 51.5% of all operations were perfomed without general anestesia. There was no serious complication in the observed group.

CONCLUSION

The big advantage of the second generation ablation methods is the possibility to realise the operation without the general anestesia and with the minimum discomfort for the patient. Another favourable circumstance was the shorter determined operating time and lower percentage of complications in comparison with the first generation methods. The big benefit is mainly for the seriously polymobid pacients.

Glycine absorption in operative hysteroscopy: the impact of anesthesia

OBJECTIVE

This study aimed to evaluate the impact of anesthesia on the absorption of glycine in operative hysteroscopy.

STUDY DESIGN

A retrospective cohort study was performed over 2 years. The absorption of glycine was compared among general anesthesia, local anesthesia with intravenous sedation, and spinal anesthesia. Multiple logistic regression analyses were performed.

RESULTS

In all, 282 operative hysteroscopies were reviewed. The median absorption was 145 mL (10th-90th centile: 0-963 mL) for general anesthesia, 35 mL (10th-90th centile: 0-389 mL) for local anesthesia, and 100 mL (10th-90th centile: 0-500 mL) for spinal anesthesia (P = .002). In comparison with general anesthesia, local anesthesia was associated with lower rate of absorption of 500-1000 mL (4.2% vs 13.4%) and of 1000-1500 mL (3.6% vs 9.8; P = .002). Laparoscopic tubal ligation performed during the procedure was also associated with higher glycine absorption (odds ratio, 3.63; 95% confidence interval, 1.12-11.84).

CONCLUSIONS

Local anesthesia with sedation is associated with significantly decreased glycine absorption and lower rate of absorption > 500 mL when compared with general anesthesia.

Analgesic efficacy of intravenous paracetamol for outpatient fractional curettage: a randomised, controlled trial

OBJECTIVE

To determine the efficacy of intravenous (i.v.) paracetamol for decreasing pain associated with fractional curettage.

MATERIALS AND METHODS

This double-blind, randomised, placebo-controlled trial included 70 women who underwent fractional curettage. Patients were randomly assigned to receive i.v. infusion of either 1000 mg paracetamol (n = 36) or 0.9% normal saline as placebo (n = 34) prior to the procedure. The main outcome measure was the intensity of pain assessed by a 10-cm visual analogue scale. Pain scoring was performed at t(1) = prior to the procedure, t(2) = during the procedure and t(3) = 30 min after the procedure. Statistical analysis was performed using the Student's t-test, chi-squared and Pearson's correlation analysis.

RESULTS

The pain scores at t(2) and t(3) were significantly higher than the score at t(1) in both groups. There was no statistically significant difference between the pain scores at t(1), t(2) and t(3) among the two groups. Menopausal status had no effect on the pain scores and on the treatment outcome. The pain scores prior to the procedure were significantly higher in women with a history of endometrial curettage when compared with women who have no history.

CONCLUSIONS

Fractional curettage is associated with mild pain. We were unable to detect a significant difference in pain scores in patients undergoing fractional curettage when comparing the use of i.v. paracetamol with placebo. History of prior endometrial curettage seems to be a predictor of the basal pain scores at admission although it does not affect the pain intensity related to the procedure.

Successful management of a cervical twin pregnancy: neoadjuvant systemic methotrexate and prophylactic high cervical cerclage before curettage

OBJECTIVE

To report our experience in managing a case of viable cervical twin pregnancy with systemic methotrexate and 2 weeks later with endocervical curettage after placing prophylactic high cervical cerclage.

DESIGN

Case report.

SETTING

University medical center.

PATIENT(S)

A 36-year-old woman, gravida 2, para 0, complaining of vaginal bleeding and pelvic pain, in whom cervical twin pregnancy was diagnosed at the sixth week of gestation.

INTERVENTION(S)

Systemic methotrexate was given as first-line treatment. Two weeks later because of persisting bleeding, endocervical curettage was performed after closing cervical arteries and placing but not tightening high cervical cerclage.

MAIN OUTCOME MEASURE(S)

Pregnancy termination, bleeding control, and preservation of fertility.

RESULT(S)

Notwithstanding the ligature of cervical arteries at curettage, heavy bleeding occurred, which was controlled rapidly by tightening the cerclage. Curettage then was completed successfully. Postoperative period was uneventful. Two years later the woman delivered vaginally.

CONCLUSION(S)

In case of cervical twin pregnancy methotrexate pretreatment and prophylactic placement of high cervical cerclage, but not ligature of cervical arteries, before curettage showed to be effective in terminating pregnancy ensuring effective bleeding control and preservation of fertility.

Targeted and tailored diagnostic strategies in women with perimenopausal bleeding: advantages of the sonohysterographic approach

BACKGROUND AND AIM OF THE WORK

Diagnosis and treatment of endometrial pathology nowadays ranges from clinical examination to transvaginal ultrasound (TVS), saline infusion sonohysterography (SIS), hysterosalpingography (HSG) and hysteroscopy (HYS). However, many gynaecologists prescribe blind endometrial biopsies, such as Vacuum ABRAsion (VABRA), as single strategy. The purpose of this work is to evaluate whether the procedure of VABRA should still be performed alone in perimenopausal women with abnormal uterine bleeding, compared to biopsies and samples obtained after a previous transvaginal sonohysterography.

METHODS

We retrospectively reviewed the records of 216 patients referred to our Ultrasonography and Day-Surgery Center between November 2005 and December 2006 with persistent premenopausal uterine bleeding, spotting or postmenopausal bleeding. One hundred and five out of 216 pts.(48.6%), defined as Group "A", underwent a sole endometrial sampling by VABRA; 111 out of 216 pts. (51.4%), Group "B", had a SIS first.

RESULTS

Vabra showed a poor sensitivity in the diagnosis of polyps (19%) and submucosal myoma, with a negative predictive value of 73.4%. Likelihood ratio for test negative was 0.81, with an overall diagnostic accuracy of 75%.

CONCLUSIONS

This study confirms that blind endometrial biopsies should no longer be performed as the only diagnostic strategy in perimenopausal women with abnormal uterine bleeding. On the other hand, a sonohysteroscopy-guided approach allows an accurate detection of focal lesions; nevertheless, it should not be forgotten that SIS is an ultrasound based procedure, and may provide further information on endometrial thickness, myomas, ovaries and pelvis.

Emergency surgical procedure for failed methotrexate treatment of cervical pregnancy: a case report

Cervical pregnancy (CP) is a rare and dangerous condition, which may cause a massive haemorrhage. Ultrasonographic diagnosis consists of the visualization of the gestational sac and trophoblastic invasion in an endocervical localization. CP treatment modalities include dilatation and curettage (D&C) usually followed by intracervical tamponade, cervicotomy, angiographic embolization, ligation of the uterine arteries, and chemotherapy with methotrexate (MTX). MTX administration is a very appealing therapeutic modality of CP in the first trimester because of its convenience and efficacy. We report a case of unsuccessful treatment of a CP with systemic MTX administration, which led to an emergency surgical procedure for a sudden massive vaginal haemorrhage. A vaginal ligation of the cervical branches of the uterine arteries was carried out, followed by suction curettage, D&C and insertion of an intrauterine sterile tampon that was removed after 48 hours. The patient did not require a blood transfusion. Histological examination of the specimen confirmed the CP.

Successful management of a massive hemorrhage due to rupture of cystic cervical endometriosis by a loop electrosurgical excision procedure

OBJECTIVE

To report a case of cystic cervical endometriosis that caused a massive hemorrhage due to rupture of a cyst and successful management with a loop electrosurgical excision procedure (LEEP).

DESIGN

Case report.

SETTING

University Hospital.

PATIENT

A 37-year-old nulliparous woman.

INTERVENTION(S)

Medical management including surgical treatment.

MAIN OUTCOME MEASURE(S)

Clinical follow-up and pathologic diagnosis.

RESULT(S)

A hemorrhagic cystic cervical mass was excised with emergent LEEP. The mass was found to be cervical endometriosis. There was no evidence of recurrence until 1 year after excision.

CONCLUSION(S)

Cystic formation of cervical endometriosis--like ovarian endometrioma, which causes a massive hemorrhage due to rupture--is extremely rare, although cervical endometriosis is generally asymptomatic. Hysterectomy is considered in such cases but can be avoided via LEEP that incorporates partial excision of the uterine cervix.

Gravid hysterectomy: a decade of experience at an academic referral center

OBJECTIVE

To evaluate the incidence of gravid hysterectomy (GH) and to examine the indications as well as risk factors and complications associated with the procedure at an academic perinatal referral center.

STUDY DESIGN

Retrospective chart review of all patients who underwent GH from 1991 to 2001. Demographics, obstetric history, delivery information, complications and outcome were analyzed.

RESULTS

There were 34 GHs out of 19,491 deliveries (1.74/1000). The preoperative indications were hemorrhage associated with atony (32.4%), placenta accreta (20.6%) and uncontrolled bleeding (17.6%). Of the patients, 87.5% were parous and 53.1% had previous cesarean section. GH was performed prior to viability in 3. GH followed cesarean delivery in 24 (68.6%). Uterine and/or hypogastric artery ligation were performed in 11 (32.4%). Postoperative complications included surgical re-exploration for recurrent hemorrhage in 5, transfusion of blood products in 30, disseminated intravascular coagulopathy in 15, prolonged (> 24 hours) ventilation in 10 and admission to the SICU for prolonged intensive care in 12. There were 2 maternal deaths (5.9%). A significant rise in GH rate from 1/800 to 1/299 occurred over the past 5 years despite constant cesarean rates (chi2, p < 0.05).

CONCLUSION

Rates of GH increased over the period examined. Placenta accreta associated with previous cesarean section is the predominant risk factor for GH.

Management of vascular uterine lesions associated with persistent low-level human chorionic gonadotrophin

BACKGROUND AND METHODOLOGY

Vascular lesions of the uterus are rare but pose difficult management decisions. We reviewed the cases of four patients who presented with vascular uterine lesions following early pregnancy loss at the Royal Infirmary of Edinburgh, Edinburgh, UK in 2006.

RESULTS

All four patients had signs on colour Doppler imaging consistent with arteriovenous malformations and elevated serum human chorionic gonadotrophin (hCG) levels. In each case, once the hCG level had returned to normal the uterine lesions resolved. The first case required therapeutic embolisation but the subsequent patients were successfully managed conservatively.

CONCLUSIONS

Most uterine vascular lesions are attributed to arteriovenous malformations but those associated with pregnancy represent subinvolution of the placental bed and can be managed conservatively with monitoring of hCG concentrations.

Role of hysterectomy and its alternatives in benign uterine diseases

There is a rising trend of hysterectomy rate as too frequently it is being performed now for conditions like symptomatic fibroids and dysfunctional uterine bleeding which can be treated alternatively. Hysterectomy, as with all other major surgeries, is also associated with increased mortality and morbidity risks. Various medical and surgical lines of management, other than hysterectomy, are presently accessible for the above conditions. Availability of safer and newer treatment options is great boon for women with changing attitudes towards child-bearing and uterine conservation.

[Obstetric hysterectomy. Incidence, indications and complications]

BACKGROUND

Obstetric hysterectomy is indicated when patient's life is at risk, and it is a procedure that requires a highly experienced and skilled medical team to solve any complication.

OBJECTIVE

To identify incidence, indications, and complications of obstetric hysterectomy within a high-risk population.

PATIENTS AND METHODS

Transversal, retrospective study from July 1st 2004 to June 30 2006 at Unidad Medica de Alta Especialidad, Hospital de Ginecoobstetricia, Centro Medico Nacional de Occidente, IMSS. There were reviewed 103 patient' files with obstetric hysterectomy. Incidence was calculated, and clinical and socio-demographic characteristics, indications, and complications of obstetric hysterectomy identified and expressed in frequency, percentages, and central tendency measurements.

RESULTS

Incidence of obstetric hysterectomy was 8 cases within every 1,000 obstetric consultation. Age average was 31.1 +/- 5.1 years. 72.8% had cesarean surgery history. Main indication was placenta previa associated with placenta accreta (33%), followed by uterine hypotony (22.3%). Complications were hypovolemic shock (56.3%), and vesical injuries (5.8%). There were no maternal deaths.

CONCLUSIONS

Cesarean history induces higher obstetric hysterectomy incidence in women with high-risk pregnancy, due to its relation to placentation disorders, as placenta previa that increases hemorrhage possibility, and thus, maternal morbidity and mortality.

[A case of two intrauterine pregnancies after treatment with transcervical endometrieresection (TCRE)]

A 39 year-old patient was treated with TCRE because of uterine bleeding disorder. Three years after the treatment, the patient became pregnant and had an incomplete abortion in the ninth gestational week. Six months later the patient became pregnant again. The pregnancy was complicated but lasted and the patient gave birth to a healthy child. The case is described and discussed. Pregnancy after treatment of a bleeding disorder with TCRE is rare and risky because of the damage to the endometrial blood vessels during the treatment and scarring afterwards.

Unusual cases of cervical pregnancy and secondary abdominal pregnancy

A 22-year-old lady, 3rd gravida presented with discomfort in the lower abdomen and bleeding per vagina following 6 months amenorrhoea. USG of abdomen showed single dead foetus of 21 weeks gestation occupying in the cervical region, endometrial cavity was empty. On laparotomy, cervical region was seen enlarged and distended and over which body of uterus lied. After bilateral internal iliac artery ligation, vertical incision was made over the body of the uterus and cervical region. During the removal of foetal parts and placenta from the cervical region, there was severe haemorrhage for which immediate total hysterectomy was necessitated. In another case, a 28-year-old primigravida was admitted to the hospital with the complaints of abdominal pain at 34 weeks of gestation and she gave history of recurrent pain abdomen throughout pregnancy. USG of abdomen showed a suspected case of secondary abdominal pregnancy. Immediate laparotomy was done and after making a transverse incision over the gestation sac, a live foetus was delivered. A bulky uterus was visible behind the gestation sac and placenta was seen situated,over a part of sigmoid colon and the greatvessels. To see the location of placenta, a part of it got separated spontaneously and severe bleeding started which could not be properly controlled. She received 9 units of blood transfusion but ultimately died. The weight of the baby was 1.9 kg and it had talipes equinovarus. Baby was discharged after 5 days in good condition.

Life-saving hysterectomy in choriocarcinoma: presentation of two cases

BACKGROUND

Choriocarcinoma is a malignant tumor of the placenta. Life-saving hysterectomy was performed in two cases with choriocarcinoma who had profuse vaginal bleeding. CASE 1: A 25-year-old, gravida 3, para 1, woman was referred to our emergency clinic with the diagnosis of choriocarcinoma and massive vaginal bleeding. She had been transfused seven units of blood at the hospital where she was first admitted. Pelvic examination demonstrated heavy vaginal bleeding and a uterus equivalent to the size of 14 weeks of gestation. Her beta-hCG level was 560,000 mIU/ml. Despite four units of blood transfusion, she had a pulse rate of 130/min, arterial pressure of 90/60 mm/Hg and HCT of 19%. An emergency hysterectomy with vertical incision was performed. CASE 2: A 54-year-old, gravida 3, para 3, woman was referred to our clinic with heavy bleeding with the diagnosis of choriocarcinoma. She was scanned to look for possible metastases and pulmonary metastasis was detected. Chemotherapy was planned but as sudden vaginal bleeding began she was referred to the Gynecology Department. At pelvic examination a soft uterus the size of 20 weeks of gestation was palpated. The beta-hCG level was 554,700 mIU/ml. Due to hemodynamic instability and continuous vaginal bleeding an emergency hysterectomy was performed.

CONCLUSION

Although chemotherapy is the cornerstone of treatment for choriocarcinoma, optimal treatment results may depend on the addition of surgery in selected circumstances. Hysterectomy is indicated in cases with life-threatening hemorrhage.

[Endometrial ablation versus hysterectomy in women treated with tamoxifen]

AIM

The aim of our study is the assessment of the importance of the endometrial ablation versus hysterectomy in patients treated with tamoxifen for previous breast cancer.

METHODS

Fifty-eight outpatients in therapy with tamoxifen for 1 year were controlled in the Department of Gynaecology of the University of Naples. We have selected these patients in two groups: group A, with 28 women with abnormal uterine bleeding and endometrial thickness >8 mm and group B, with 30 normal endometrium asymptomatic women. All patient of group A and 18 of group B were treated with endometrial ablation.

RESULTS

Next follow-up showed normal hysteroscopy figures in 89% of cases and 5% of cases needed a hysterectomy for new abnormal uterine bleeding and cytology.

CONCLUSION

Our results show the utility of endometrial ablation especially in selected cases in therapy with tamoxifen for previous breast cancer.

Les hémorragies utérines fonctionnelles

Dysfunctionnal uterine bleeding (DUB) is a significant health problem in premenopausal women. First line therapy is traditionally medical therapy but often ineffective. Hysterectomy is obviously effective in stopping bleeding but is associated with morbidity and is most costly. Endometrial ablation technique is becoming the first conservative line in the management of DUB. In 2007, the Cochrane Data Base, and the NICE published the new guidelines for DUB treatment. Pharmaceutical treatments should be considered in the following order: levonorgestrel-releasing intra uterine system and if hormonal treatment is not acceptable, tranexamic acid can be used. This is the exclusive line of treatment for women who desire to be pregnant, and the first step for the others one. The rapid development of second generation technique of endometrial destruction suggests that these techniques are becoming "the gold standart" for the patients without desire of future pregnancy. These techniques are easier that endometrial resection/ablation by hysteroscopy without major complications. In France, the National Health Insurance must find a codification CCAM for giving an exact price to the procedure. This new tarification could include the device cost and could avoid either inefficient procedure like datation and curetage or morbide procedure like hysterectomy.