Indications for hysterectomy

Primary and repeat surgical treatment for female pelvic organ prolapse and incontinence in parous women in the UK: a register linkage study

Objectives To determine the lifetime risk of undergoing pelvic floor surgery in a cohort of UK parous women and the re-operation rates for pelvic floor surgery, time intervals for repeat surgery and independent risk factors for undergoing primary and repeat pelvic floor surgery. Study design A register linkage study. Main outcome measures The primary outcome was lifetime risk of parous women in the UK undergoing pelvic floor surgery for pelvic organ prolapse (POP), urinary incontinence (UI), and rectal prolapse or faecal incontinence (RP-FI). Secondary outcomes were re-operation rates and time interval of repeat surgery for POP/UI, and independent risk factors for undergoing primary and repeat pelvic floor surgery. Results 34 631 women identified from the Aberdeen Maternity and Neonatal Database were linked with the Scottish Morbidity Records databases of NHS Scotland to assess relevant outcomes. The lifetime risk for women by age 80 years of undergoing any form of pelvic floor surgery was 12.2%. 2130 (6.2%) women had at least one pelvic floor surgery, of whom 407 (19%) had repeat operations. The median time intervals (IQR) between index and repeat UI and POP surgery were 2.80 (0.94-8.07) years and 3 (1.00-8.25) years, respectively. There is a reduced lifetime risk of pelvic floor surgery in women who had all deliveries by caesarean section (p<0.001) and those aged <20 years at first delivery (p=0.021). Women who sustained at least one perineal laceration (in the absence of a classified perineal tear) during delivery or who had at least one instrumental delivery with forceps use were at increased risk (p<0.001 and p=0.015, respectively). Conclusions Our study shows that in the UK more than one in 10 parous women will require at least one surgical procedure for pelvic floor disorders over their lifetime. The study also identifies independent risk and protective factors for pelvic floor surgery in parous women.

Breast cancer risk and ovariectomy, hysterectomy, and tubal sterilization in the women's contraceptive and reproductive experiences study

Removal or impairment of ovaries before menopause may affect a woman's breast cancer risk by altering her cumulative exposure to ovarian hormones. The Women's Contraceptive and Reproductive Experiences Study, a population-based, multicenter case-control study of incident invasive breast cancer, recruited women aged 35-64 years (4,490 cases and 4,611 controls) who provided data on ovariectomy, hysterectomy, and tubal sterilization during in-person interviews. Controls were frequency-matched to cases by age, race, and study site. Unconditional logistic regression analysis was used. Women who had not undergone premenopausal reproductive surgery were the referent group. Bilateral ovariectomy was associated with reduced breast cancer risk overall (odds ratio (OR) = 0.59, 95% confidence interval (CI): 0.50, 0.69) and among women <45 years of age (ORs ranged from 0.31 to 0.52), but not among those who were older at surgery. It was also associated with a reduced risk for estrogen and progesterone receptor-positive tumors (OR = 0.63, 95% CI: 0.52, 0.75) but not receptor-negative tumors. Hysterectomy with ovarian conservation (OR = 0.83, 95% CI: 0.72, 0.96) and hysterectomy with partial ovary removal (OR = 0.73, 95% CI: 0.59, 0.91) were also associated with lower risk. No association with breast cancer risk was observed with tubal sterilization only or partial ovariectomy without hysterectomy. Reproductive organ surgeries may alter ovarian hormone levels, thereby affecting breast cancer risk.

Hysterectomy and risk of cardiovascular disease: a population-based cohort study

AIMS

Hysterectomy for benign indications is one of the commonest surgical procedures in women, but the association between the procedure and cardiovascular disease (CVD) is not fully understood. In this population-based cohort study, we studied the effects of hysterectomy, with or without oopherectomy, on the risk of later life CVD.

METHODS AND RESULTS

Using nationwide healthcare registers, we identified all Swedish women having a hysterectomy on benign indications between 1973 and 2003 (n = 184,441), and non-hysterectomized controls (n = 640,043). Main outcome measure was the first hospitalization or death of incident CVD (coronary heart disease, stroke, or heart failure). Occurrence of CVD was determined by individual linkage to the Inpatient Register. In women below age 50 at study entry, hysterectomy was associated with a significantly increased risk of CVD during follow-up [hazard ratio (HR), 1.18, 95% confidence interval (CI), 1.13-1.23; HR, 2.22, 95% CI, 1.01-4.83; and HR, 1.25, 95% CI, 1.06-1.48; in women without oopherectomy, with oopherectomy before or at study entry, respectively, using women without hysterectomy or oopherectomy as reference]. In women aged 50 or above at study entry, there were no significant associations between hysterectomy and incident CVD.

CONCLUSIONS

Hysterectomy in women aged 50 years or younger substantially increases the risk for CVD later in life and oopherectomy further adds to the risk of both coronary heart disease and stroke.

Eligibility and accessibility of magnetic resonance-guided focused ultrasound (MRgFUS) for the treatment of uterine leiomyomas

OBJECTIVE

To evaluate patient eligibility and accessibility of magnetic resonance-guided focused ultrasound (MRgFUS) for women with symptomatic uterine leiomyomas who desire conservative therapy.

DESIGN

Retrospective analysis of 169 patients referred for minimally invasive treatment of leiomyomas between November 2007 and February 2009. Clinical eligibility for MRgFUS was determined by Food and Drug Administration-based treatment guidelines. All patients underwent pretreatment pelvic imaging to determine candidacy for the procedure.

PATIENT(S)

Premenopausal women with symptomatic uterine leiomyomas.

SETTING

Academic medical center.

MAIN OUTCOME MEASURE(S)

Eligibility for MRgFUS based on clinical and anatomic patient criteria.

RESULT(S)

Forty-seven percent of patients (80/169) were determined clinically eligible for the procedure. Of these, 16% of patients (27/169) were found to be eligible for MRgFUS based on imaging results. Overall, the main reasons for ineligibility were very large leiomyomas (8%; 14/169), cost (12%; 21/169), and desired fertility (14%; 23/169). An additional 48% of patients declined MRgFUS for unstated reasons, often after obtaining financial and insurance coverage information.

CONCLUSION(S)

Currently, many women with leiomyomas are unable to obtain MRgFUS treatment for multiple reasons, including uterine size, desire for fertility, and, most commonly, financial limitations. With increasing clinical experience, further research, and broadened insurance coverage, it may be possible to increase accessibility and expand eligibility criteria for this minimally invasive therapy.

Magnetic resonance-guided focused ultrasound (MRgFUS) compared with abdominal hysterectomy for treatment of uterine leiomyomas

OBJECTIVES

To compare women undergoing magnetic resonance-guided focused ultrasound (MRgFUS) to a group of contemporaneously recruited women undergoing total abdominal hysterectomy. Patient demographics, safety parameters, quality of life outcomes and disability measures are reported.

METHODS

One hundred and nine women were recruited in seven centers for MRgFUS treatment and 83 women who underwent abdominal hysterectomy were recruited in seven separate centers to provide contemporaneous assessment of safety. The adverse-event profile and disability parameters were prospectively assessed. Patients were also screened at baseline and at 1, 3 and 6 months using the SF-36 health survey questionnaire.

RESULTS

There were no life-threatening adverse events in either group. Overall, the number of significant clinical complications and adverse events was lower in women in the MRgFUS group compared to women undergoing hysterectomy. MRgFUS was associated with significantly faster recovery, including resumption of usual activities. At 6 months of follow-up, there were four (4%) treatment failures in the MRgFUS arm. Regarding SF-36 subscale scores, at 6 months there was improvement in all SF-36 subscales for both treatment groups. However, most of the SF-36 subscale scores were significantly better at this stage in the hysterectomy group than in the MRgFUS group. Women undergoing MRgFUS had steady improvement in all parameters throughout the 6-month follow-up period, despite the fact that they continued to have myomatous uteri and menstruation, which at baseline had given them significant symptomatology.

CONCLUSIONS

The results of this study show that MRgFUS treatment of uterine leiomyomas leads to clinical improvement with fewer significant clinical complications and adverse events compared to hysterectomy at 6 months' follow-up.

Symptomatic pelvic organ prolapse at midlife, quality of life, and risk factors

OBJECTIVE

To estimate quality of life, prevalence, and risk factors associated with symptomatic pelvic organ prolapse (POP) among middle-aged women.

METHODS

This was a cross-sectional study. A questionnaire was mailed to 3,114 women aged 50-61 years in the GAZEL cohort; 2,640 (85%) returned it. Symptomatic POP was defined by feeling a bulge from the vagina (sometimes, often, or all the time compared with never or rarely). Quality of life was determined with the Nottingham Health Profile questionnaire. Multiple linear regression was used to examine the association between frequency of POP symptoms and the quality-of-life score. Logistic regression was used to estimate the effect of risk factors on past or present symptomatic POP (current symptoms or previous surgery for POP).

RESULTS

The prevalence of symptomatic POP was 3.6% (96 of 2,640) and that of surgery for POP was 2.7% (70 of 2,640). Pelvic organ prolapse symptoms were associated with difficulty defecating, lower abdominal pain, and difficulty voiding. The frequency of POP symptoms was associated with a poorer quality-of-life score in each Nottingham Health Profile domain (physical mobility, pain, emotional reaction, social isolation, energy, and sleep). Even when we took general characteristics, medical history, and lifestyle associated with quality of life into account, the global Nottingham Health Profile score was significantly impaired by POP symptoms. Factors significantly associated with past or present symptomatic POP were high body mass index and the number of vaginal deliveries.

CONCLUSION

In our population of women in their 50s, POP symptoms are associated with impaired quality of life, and the number of vaginal deliveries is a risk factor for past or present symptomatic POP.

MRI-based thermal dosimetry and diffusion-weighted imaging of MRI-guided focused ultrasound thermal ablation of uterine fibroids

PURPOSE

To investigate tissue changes observed in diffusion-weighted imaging (DWI) and its relation to contrast imaging, thermal dosimetry, and changes in the apparent diffusion coefficient (ADC) after MRI-guided focused ultrasound surgery (MRgFUS) of uterine fibroids.

MATERIALS AND METHODS

Imaging data were analyzed from 45 fibroids in 42 women treated with MRgFUS. The areas of the hyperintense regions in DWI and of nonperfused regions in T1-weighted contrast enhanced imaging (both acquired immediately after treatment) were compared with each other and to thermal dosimetry based estimates. Changes in ADC were also calculated.

RESULTS

Hyperintense regions were observed in 35/45 fibroids in DWI. When present, the areas of these regions were comparable on average to the thermal dose estimates and to the nonperfused regions, except for in several large treatments in which the nonperfused region extended beyond the treated area. ADC increased in 19 fibroids and decreased in the others.

CONCLUSION

DWI changes, which includes changes in both in T2 and ADC, may be useful in many cases to delineate the treated region resulting from MRgFUS. However, clear DWI changes were not always observed, and in some large treatments, the extent of the nonperfused region was under estimated. ADC changes immediately after MRgFUS were unpredictable.

Socioeconomic position and hysterectomy: a cross-cohort comparison of women in Australia and Great Britain

OBJECTIVES

To examine the associations between indicators of socioeconomic position (SEP) and hysterectomy in two Australian and two British cohorts.

STUDY POPULATION

Women participating in the Australian Longitudinal Study on Women's Health (ALSWH), born 1921-1926 and 1946-1951, and two cohorts of British women, the British Women's Heart and Health Study and the MRC National Survey of Health and Development, born at similar times (1920 to 1939 and 1946, respectively) and surveyed at similar ages to the ALSWH cohorts.

METHODS

Relative indices of inequality were derived for own and head of household occupational class, educational level attained and age at leaving school. Logistic regression was used to test the associations between these indicators of SEP and self-reported hysterectomy and/or oophorectomy.

RESULTS

Inverse associations between indicators of SEP and hysterectomy were found in both the Australian and British cohorts of women born in 1946 or later. There was also evidence of an inverse association between education and hysterectomy in the older Australian cohort. However, the associations in this older cohort were weaker than those found in the mid-aged Australian cohort. In the older British cohort, born in the 1920s and 1930s, little evidence of association between SEP in adulthood and hysterectomy was found.

CONCLUSIONS

These results suggest that inverse associations between indicators of SEP and hysterectomy are stronger in younger than in older cohorts in both Australia and Great Britain. They provide further evidence of the dynamic nature of the association between indicators of SEP and hysterectomy.

Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study

BACKGROUND

Hysterectomy for benign indications has been associated with an increased risk for lower-urinary-tract sequela, but results have been inconclusive. We aimed to establish the risk for stress-urinary-incontinence surgery after hysterectomy for benign indications.

METHODS

We did a nationwide, population-based, cohort study from 1973 to 2003 in Sweden. We identified our population from the Swedish Inpatient Registry. We selected 165 260 women who had undergone hysterectomy (exposed cohort) and a control group of 479 506 individuals who had not had this procedure (unexposed cohort), matched by year of birth and county of residence. In both cohorts, occurrence of stress-urinary-incontinence surgery was established from the Swedish Inpatient Registry. Hazard ratios with 95% CIs were calculated by Cox's proportional-hazards regression.

FINDINGS

During the 30-year observational period, the rate of stress-urinary-incontinence surgery per 100,000 person-years was 179 (95% CI 173-186) in the exposed cohort versus 76 (73-79) in the unexposed cohort. Correspondingly, individuals in the exposed cohort were at increased risk for stress-urinary-incontinence surgery compared with those in the unexposed cohort (hazard ratio 2.4; 95% CI 2.3-2.5), irrespective of surgical technique. Risk for stress-urinary-incontinence surgery varied slightly with time of follow-up: the highest overall risk was recorded within 5 years of surgery (2.7; 2.5-2.9) and the lowest risk was seen after an observation period of 10 years or more (2.1, 1.9-2.2).

INTERPRETATION

Hysterectomy for benign indications, irrespective of surgical technique, increases the risk for subsequent stress-urinary-incontinence surgery. Women should be counselled on associated risks related to hysterectomy, and other treatment options should be considered before surgery.

The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA

The objective of this study was to describe the distribution of pelvic organ prolapse (POP) surgery across age groups in the USA in 2003. Patients were grouped into four age categories: Reproductive age, perimenopausal, postmenopausal, and elderly. Data from the 2003 National Hospital Discharge Survey and National Census were used to estimate surgical rates by age group. In 2003, 199,698 women underwent a total of 311,587 surgical procedures for POP. Prolapse surgical rates (per 10,000 women) were 7, 24, 31, and 17 in reproductive age, perimenopausal, postmenopausal, and elderly age groups, respectively. Surgical complications occurred in 28.8, 19.6, 18.6, and 22.1% of women in these age groups, respectively. Mortality was uncommon. Although often considered a condition of the elderly, this study suggests that pelvic organ prolapse is a condition affecting women across the reproductive life cycle and for which women of all ages seek surgical treatment.

Effects of hysterectomy on bowel function: a three-year, prospective cohort study

PURPOSE

This study was a prospective evaluation of the long-term effects of hysterectomy on bowel function using self-reported outcome measures on symptoms of constipation, rectal emptying difficulties, and anal incontinence.

METHODS

In this prospective cohort study, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on bowel habits and anorectal symptoms preoperatively. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. Follow-up was performed one and three years postoperatively. Data were analyzed by using multivariate regression and nonparametric statistics.

RESULTS

The bowel and anorectal survey was answered by 115 of 120 patients (96 percent) after one year and 107 of 120 patients (89 percent) after three years. Abdominal hysterectomy was associated with increased anal incontinence symptoms at one-year (P < 0.01) and three-year follow-up (P < 0.01). Vaginal hysterectomy was not associated with increased anal incontinence symptoms at one year follow-up, although there was a significant increase in incontinence symptoms at the three-year follow-up (P < 0.05). Risk factor analysis indicated that a reported history of obstetric sphincter injury was correlated to an increased risk of developing posthysterectomy anal incontinence (odds ratio, 2.07; 95 percent confidence interval, 1.05-2.87; P < 0.05). There was no significant rise in constipation symptoms or rectal emptying difficulties in either cohort through the follow-up.

CONCLUSIONS

Neither abdominal nor vaginal hysterectomy was associated with constipation, aggravation of constipation, or rectal emptying difficulties three years after surgery. Abdominal and vaginal hysterectomy was, however, associated with an increased risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence.

Hysterectomy Among Women With HIV

OBJECTIVE

To describe hysterectomy rates and indications among women with HIV and to compare them with at-risk HIV-seronegative women.

METHODS

Reports of hysterectomy were collected from 3752 participants in a prospective cohort study of women with HIV and comparison uninfected women. Available operative notes were retrieved and abstracted. Comparisons were made using the Fisher exact, chi, Wilcoxon 2-sample, and Student's t tests.

RESULTS

Incident hysterectomy was performed for 106 (4.5%) of 2361 HIV-seropositive women, most often for cervical neoplasia, and for 24 (2.9%) of 837 HIV-seronegative women (P = 0.04). The incidence of hysterectomy was 7.7 per 1000 person-years for HIV-seropositive women and 5.3 per 1000 person-years for HIV-seronegative women (P = 0.09). HIV-seropositive and HIV-seronegative women undergoing incident hysterectomy were similar, except for a higher likelihood of an abnormal preoperative Papanicolaou test result in the former (P = 0.001). Surgical indications did not differ by serostatus.

CONCLUSION

Women with HIV are more likely than uninfected women to require a hysterectomy, most often for cervical neoplasia.

Development of leiomyosarcoma of the uterus in MMTV-CR-1 transgenic mice

Overexpression of Cripto-1 (CR-1) in FVB/N mice using the MMTV-LTR promoter results in increased mammary tumourigenesis in these female transgenic mice (MMTV-CR-1). Here, we characterize uterine tumours that developed in 15/76 (19.7%) of MMTV-CR-1 female nulliparous or multiparous mice during 24 months of observation compared with 0/33 (0%) of FVB/N normal control mice observed during the same time period (p < 0.01). The uterine tumours collected from the MMTV-CR-1 mice were classified as leiomyosarcomas and found to express the CR-1 transgene by polymerase chain reaction analysis and immunohistochemistry. Detection by western blot analysis showed higher levels of phosphorylated (P) forms of c-src, Akt, GSK-3beta, and dephosphorylated (DP)-beta-catenin in lysates from MMTV-CR-1 uterine leiomyosarcomas in comparison with lysates from normal control FVB/N uteri. Immunostaining showed increased nuclear localization of beta-catenin in the MMTV-CR-1 uterine leiomyosarcomas. Increased immunostaining for CR-1 was detected in 9/13 (69.2%) cases of human leiomyosarcoma compared with staining in 3/15 (20%) human leiomyoma sections. Stronger immunostaining for P-src, P-Akt, P-GSK-3beta and increased nuclear localization of beta-catenin was also seen in human leiomyosarcomas in comparison with leiomyomas. Normal human uterine smooth muscle (UtSM) cells treated with exogenous soluble rhCR-1 showed increased levels of P-src, P-Akt, P-GSK-3beta and dephosphorylated (DP)-beta-catenin and increased proliferation (p < 0.05) and migration (p < 0.01) in comparison with untreated control UtSM cells. Inhibitors against c-src, Akt or beta-catenin, individually or in combination, significantly reduced CR-1-induced migration. These results suggest a role for CR-1 during uterine tumourigenesis either directly by activating c-src and Akt and/or via cross-talk with the canonical Wnt signalling pathway, as suggested by the increased expression of P-GSK-3beta, DP-beta-catenin, and increased nuclear localization of beta-catenin in human and MMTV-CR-1 mice leiomyosarcomas.

Is It a Fibroid? Are You Sure?

Uterine fibroids are common benign lesions. Other common benign masses include renal cysts, renal angiomyolipomas, hepatic cysts, hepatic hemangiomas, thyroid cysts, adrenal incidentalomas, pulmonary granulomas and hamartomas, ovarian cysts, and dermoids. All these conditions, especially in asymptomatic patients, almost never have clinical significance. However, it is important to differentiate them from more sinister or even malignant lesions. In general, when a lesion is described as a fibroid, no further evaluation is performed. So if we say that a lesion is a fibroid, we have to be sure. Endometrial fibroids may mimic endometrial polyps or endometrial cancer. Subserous, especially pedunculated fibroids, may need further evaluation to differentiate them from ovarian pathology, colonic pathology, or even müllerian duct anomalies. Pelvic magnetic resonance imaging may be helpful in these cases.

Extracorporeal Ablation of Uterine Fibroids With High-Intensity Focused Ultrasound

OBJECTIVE

The purpose of this study was to evaluate the therapeutic efficacy of high-intensity focused ultrasound (HIFU) in the treatment of uterine fibroids by using imaging and histopathologic examination.

METHODS

From May 2004 to June 2005, 119 consecutive patients with 187 uterine fibroids were treated with HIFU. Sixty-two fibroids received ultrasonographically guided needle puncture biopsy 1 week before and after HIFU treatment, respectively, to confirm the diagnosis and to assess the early therapeutic efficacy. Hematoxylin-eosin staining and electron microscopy were performed to characterize more subtle phenotypic changes to determine treatment success. Immediate therapeutic effects were assessed at follow-up with Doppler ultrasonography and computed tomography or magnetic resonance imaging. All patients were followed for 6 to 12 months to observe long-term therapeutic effects. Fibroid mean diameters, volumes, and reduction rates 1, 3, 6, and 12 months after HIFU treatment were calculated and compared with 1-way analysis of variance and Student-Newman-Keuls tests.

RESULTS

No severe complications were observed after HIFU ablation. Fifty-one (82.3%) of 62 biopsy specimens revealed obvious signs of necrosis under light microscopy, and more subtle changes in cellular structure that indicated nonviability could be found in 60 specimens (96.8%) under electron microscopy. However, viable cells still could be found in 16 specimens (25.8%). Follow-up images showed absence or reduction of blood supply in the lesions after HIFU ablation. Median reductions in tumor size as a percentage of initial tumor volume at 1, 3, 6, and 12 months after HIFU treatment were 21.2%, 29.6%, 44.8%, and 48.7%, respectively.

CONCLUSIONS

Imaging and histopathologic evidence directly validate HIFU ablation as an effective treatment of uterine fibroids.

Therapeutic response assessment of high intensity focused ultrasound therapy for uterine fibroid: utility of contrast-enhanced ultrasonography

PURPOSE

To assess the utility of contrast-enhanced ultrasonography (ceUS) in the assessment of the therapeutic response to high intensity focused ultrasound (HIFU) ablation in patients with uterine fibroid.

MATERIALS AND METHODS

Sixty-four patients with a total of 64 uterine fibroids (mean: 5.3+/-1.2 cm; range: 3.2-8.9 cm) treated with HIFU ablation under the ultrasound guidance were evaluated with ceUS after receiving an intravenous bolus injection of a microbubble contrast agent (SonoVue) within 1 week after intervention. We obtained serial ceUS images during the time period from beginning to 5 min after the initiation of the bolus contrast injection. All of the patients underwent a contrast enhanced MRI (ceMRI) and ultrasound guided needle puncture biopsy within 1 week after HIFU ablation. And as a follow-up, all of the patients underwent US at 1, 3, 6 and 12 months after HIFU treatment. The volume change was observed and compared to pre- and post-HIFU ablation. The results of the ceUS were compared with those of the ceMRI in terms of the presence or absence of residual unablated tumor and pathologic change in the treated lesions.

RESULTS

On ceUS, diagnostic accuracy was 100%, while residual unablated tumors were found in three uterine fibroids (4.7%) and failed treatment was found in eight uterine fibroids (12.5%). All the 11 fibroids were subjected to additional HIFU ablation. Of the 58 ablated fibroids without residual tumors on both the ceUS and ceMRI after the HIFU ablation, the volumes of all the fibroids decreased in different degrees during the 1 year follow-up USs. And histologic examinations confirmed findings of necrotic and viable tumor tissue, respectively.

CONCLUSION

CEUS is potentially useful for evaluating the early therapeutic effect of percutaneous HIFU ablation for uterine fibroids.

Global endometrial ablation: a modern day solution to an age-old problem

Menorrhagia remains a significant health issue for women worldwide. Traditionally hysterectomy has been the treatment of choice when excessive menstrual bleeding remains unresolved by hormonal manipulation. In an attempt to provide a less invasive alternative to hysterectomy, traditional techniques such as rollerball endometrial ablation were developed 20 years ago. Although extremely effective, they possessed the potential of significant intra-operative risks and their success depended on high technical proficiency of the surgeon. As surgery and technology evolved, second generation endometrial ablation devices were developed which demonstrated improved safety and efficacy rates that paralleled traditional treatments. Since 1997, the Food and Drug Administration (FDA) has approved five such devices for use in the United States. Each possesses a unique technology profile with supporting level I evidence that allows for the treatment of a wide variety of uterine anatomy.

Urinary incontinence after hysterectomy—three-year observational study

OBJECTIVES

To perform a prospective evaluation of the long-term effects of hysterectomy on symptoms of urinary incontinence.

METHODS

A prospective observational cohort study was performed. Preoperatively, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on symptoms associated with urge and stress urinary incontinence. Of the 120 patients, 44 underwent vaginal and 76 abdominal hysterectomy. Follow-up questionnaires were administered at 1 and 3 years postoperatively.

RESULTS

Postoperatively, the questionnaire was answered by 115 (96%) of 120 patients after 1 year and by 107 (89%) after 3 years of follow-up. At surgery, the mean patient age was 49.5 years (range 32 to 78). In the abdominal hysterectomy cohort, a tendency was found for decreased episodes of urinary incontinence, although the difference was not significant. No significant changes were noted in micturition frequency. In the vaginal hysterectomy cohort, no significant changes were detectable in the symptoms associated with urge or stress incontinence, and no significant changes were noted in micturition frequency. For the entire hysterectomy group, a significant decrease occurred in stress urinary incontinence symptoms (P = 0.03). Subgroup analysis did not identify any particular risk factors for the development of urinary incontinence after hysterectomy.

CONCLUSIONS

In contrast to the results of several studies, the results of our 3-year prospective study showed that total hysterectomy, independent of route, was not associated with an increase in urge or stress urinary incontinence symptoms.

Gene therapy and uterine leiomyoma: a review

Leiomyomas (fibroids) are common estrogen-dependent uterine tumours that cause significant morbidity for women and a substantial economic impact on health delivery systems. Currently, there is no effective medical treatment option for this condition-hysterectomy is the mainstay of management. This is not an attractive choice for many women, especially patients desiring to preserve their fertility potential. Gene therapy is becoming a clinical reality, with more than 600 clinical trials worldwide. Researchers have recently attempted to develop a gene-therapy-based approach for the ablation of uterine fibroids. The localized nature of this condition and its accessibility using different imaging or endoscopic techniques make it an attractive target for direct delivery of gene-based vectors. Recent work from our laboratory suggests the potential use of a dominant-negative form of estrogen receptor (ER) to inactivate estrogen signalling in leiomyoma cells and induce apoptosis. Our in vivo data in a mouse model demonstrate the ability of an adenovirus-expressing dominant-negative ER to arrest leiomyoma growth. We and others also have described the utility of the herpes simplex virus-thymidine kinase (HSV-TK) plus ganciclovir (GCV) suicide gene-therapy system to effectively eradicate leiomyoma cells by utilizing the bystandard effect phenomena and the high expression of gap-junction protein in these tumours. Further work on rat models will pave the way for future leiomyoma gene-therapy clinical trials and allow the realization of gene therapy as a viable non-surgical option for this common problem in women's health.

Administration of goserelin acetate after uterine artery embolization does not change the reduction rate and volume of uterine myomas

OBJECTIVE

To determine if goserelin immediately after uterine artery embolization (UAE) affected myoma reduction.

DESIGN

Randomized pilot study (level 1).

SETTING

Teaching hospital.

PATIENT(S)

Twenty-six women.

INTERVENTION(S)

All patients underwent UAE, and then 12 patients received 10.8 mg of goserelin 24 hours later. The treatment group was 5 years older: 43 versus 37.7 years. Uterine and myoma volumes were measured by ultrasound 2 weeks before UAE and at 3, 6, and 12 months.

MAIN OUTCOME MEASURE(S)

Uterine and fibroid volumes.

RESULT(S)

Pretreatment uterine volume was 477 versus 556 cm3, and dominant fibroid volume was 257 versus 225 cm3 in the control versus goserelin groups. Analysis of variance measurements indicated that the change over time did not significantly differ between the two groups. By 12 months, the control group had a mean uterine volume reduction of 58%, while the goserelin group had a reduction of 45%. Dominant fibroid changes over time did not differ between the two groups. At 12 months, the mean fibroid volume had decreased by 86% and 58% in the control and goserelin groups, respectively.

CONCLUSION(S)

The addition of goserelin therapy to UAE did not alter the reduction rate or volume of uterine myomas.

Reduced levels of VEGF-A and MMP-2 and MMP-9 activity and increased TNF-alpha in menstrual endometrium and effluent in women with menorrhagia

BACKGROUND

Heavy regular menstrual periods (menorrhagia) are an important cause of ill health in women and remain the leading indication for hysterectomy. Abnormalities of the endometrial blood vessels are among the possible causes of this condition. Many different factors affect endothelial cell growth, function and vessel remodelling. We sought to determine whether the levels of vascular endothelial growth factor-A (VEGF-A), tumour necrosis factor-alpha (TNF-alpha), matrix metalloproteinase (MMP)-2 and MMP-9 and soluble VEGF receptor-1 (VEGF-R1) were altered in the menstrual effluent of women with objective menorrhagia. We have also quantitated the VEGF-A mRNA in the menstruated endometrium.

METHODS AND RESULTS

We recruited 37 women and determined their menstrual blood loss (MBL) over two cycles and collected menstrual effluent during the 2nd day of bleeding for 4 h. There was no difference in the total level of VEGF-A, and neither latent MMP. However, the concentration of VEGF-A was significantly reduced in the women with menorrhagia, as was the VEGF-A mRNA level. In addition, the active forms of both MMPs were markedly reduced and the total sVEGF-R1 as well as the TNF-alpha content were increased.

CONCLUSIONS

This is the first study to show abnormalities of factors important for endothelial cell behaviour in the endometrium of women with menorrhagia. This may underlie the disordered vessel structure and/or function in this condition.

Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids

OBJECTIVE

To assess outcomes at 6 and 12 months after magnetic resonance-guided focused ultrasound surgery (MRgFUS) for symptomatic uterine leiomyomas.

DESIGN

Multicenter clinical trial.

SETTING

Academic medical centers.

PATIENT(S)

Premenopausal women with symptomatic uterine leiomyomas and no plans for future pregnancy (n = 109 at 6 months and n = 82 at 12 months).

INTERVENTION(S)

A single treatment session of MRgFUS for uterine fibroids.

MAIN OUTCOME MEASURE(S)

Reduction in fibroid symptoms as measured by the symptom severity score (SSS) of the Uterine Fibroid Quality-of-Life Instrument (UFS-QOL), the only validated measure of leiomyoma symptomatology. A 10-point reduction in the SSS was selected as the targeted improvement.

RESULT(S)

Seventy-one percent of women undergoing MRgFUS reached the targeted symptom reduction at 6 months, and 51% reached this at 12 months. The magnitude of improvement in SSS was greater than predicted, with subjects having a mean decrease of 39% and 36% at 6 and 12 months, respectively. This paralleled the improvement seen using the short form-36 instrument. A modest volume reduction similar in magnitude to the treated volume was seen. The incidence of adverse events was low.

CONCLUSION(S)

MRgFUS treatment results in short-term symptom reduction for women with symptomatic uterine leiomyomas with an excellent safety profile.

Limited Uterine Artery Embolization for Leiomyomas with Tris-Acryl Gelatin Microspheres: 1-Year Follow-up

PURPOSE

To assess the safety and efficacy of uterine artery embolization (UAE) using large calibrated tris-acryl gelatin microspheres.

MATERIALS AND METHODS

One hundred fifty-eight women with symptomatic uterine fibroids underwent UAE. Embosphere was used in 105 women and Embogold microspheres in 53 women. Major and minor complications were assessed. At 12 months, relief of symptoms and patient satisfaction were assessed and volume reductions of the uterus and dominant fibroid were calculated.

RESULTS

Median age of the subjects was 43 years (mean, 42.3 y; range, 23-53 y). Preprocedural symptoms were heavy menstrual bleeding in 89%, pain in 64%, and bulk related symptoms in 57%. At 12 months follow-up, the proportion of women with heavy menstrual bleeding, pain, and bulk-related symptoms had decreased to 9%, 8%, and 8%, respectively. Patient satisfaction was grouped as follows: very satisfied 57%, satisfied 36%, and not satisfied 7%. Mean uterine and dominant fibroid volumes before UAE were 532 cm(3) and 201 cm(3), respectively. At 12-month follow-up MR imaging, mean uterine volume decreased to 260 cm(3) and mean dominant fibroid volume to 78 cm(3). These differences were statistically significant (P < .0001). There were no procedure-related deaths. No emergency hysterectomy was needed. Permanent amenorrhea occurred in 11% of women. Transient amenorrhea occurred in 13% of women, and fibroid expulsion occurred in 10% of women. Twelve women (7.6%) had additional therapy: nine underwent additional embolization and three had hysterectomy.

CONCLUSION

Targeted UAE using large calibrated microspheres is safe and effective in the relief of symptoms in the majority of patients. At 12 months, a marked fibroid and uterine volume reduction is obtained.

Effects of hysterectomy on ovarian morphology and serum FSH level in rats

OBJECTIVE

To investigate the effects of hysterectomy with ovarian conservation on ovarian histology and FSH plasma level.

METHODS

Fifty female Wistar albino rats (30 for hysterectomy and 20 sham operated for control) were used after two complete estrous cycles. Six months after hysterectomy, the blood samples were collected from both the groups to test FSH plasma level and all animals were sacrificed by decapitation to obtain ovaries for histological examination.

RESULTS

Histologic study showed that ovaries from control group exhibited many follicles in various stages of development including primary, secondary and tertiary follicles. There were one or two secondary and tertiary follicles but no primary follicle in each histological section of the 6 months after hysterectomy. The ovaries showed that the cortex of ovary completely covered by corpora lutea, and there were many cystic follicles and atretic follicles with few normal follicles. Theca interna is absent in cysts and most of the mural granulose cell population has been depleted. Serum FSH levels showed significantly increase in hysterectomized group compared control after 6 months operation.

CONCLUSIONS

The results of present study support previous studies and suggest that hysterectomy with ovarian conservation in young patients could preserve a woman's normal hormonal milieu. The uterus could have controlling on ovulation and hysterectomy might accelerate to initiate of early menopause.

Postmenopausal bilateral oophorectomy is not associated with increased fracture risk in older women

We studied whether oophorectomy performed after menopause is associated with an increased risk of hip or vertebral fractures in 6295 Study of Osteoporotic Fractures participants. There was no association between postmenopausal oophorectomy and the risk of hip or vertebral fractures.

INTRODUCTION

Bilateral oophorectomy after natural menopause has been associated with an increased risk of osteoporotic fractures, potentially because of a decline in serum estradiol and testosterone levels after the oophorectomy. We prospectively tested this hypothesis in the Study of Osteoporotic Fractures (SOF).

MATERIALS AND METHODS

We studied 6295 white women 65 years of age participating in the SOF who were not taking estrogen therapy at baseline. Hip fracture analyses included 708 hip fractures; vertebral fracture analyses included 267 incident vertebral fractures. Baseline serum estradiol and free testosterone values were available in a small subset of participants.

RESULTS AND CONCLUSION

There were no significant differences in age, weight, or BMD between the women who underwent postmenopausal oophorectomy (n = 583) and those who did not (n = 5712). Free testosterone levels were significantly lower among women who had a postmenopausal oophorectomy. A history of postmenopausal oophorectomy was not associated with an increased risk of hip (hazard ratio [HR] = 1.1; 95% CI = 0.9-1.5) or vertebral fracture (HR = 0.7; 95% CI = 0.5-1.2). The relationship between oophorectomy and hip fracture was not altered by adding serum estradiol level (HR = 1.3; 95% CI = 0.5-3.2) or serum free testosterone level (HR = 1.7; 95% CI = 0.8-3.7) to the model. In summary, postmenopausal oophorectomy was not associated with an increased risk of hip or vertebral fracture in this cohort. These results are in contrast to previous findings, suggesting that the relationship between postmenopausal oophorectomy and fractures is not fully elucidated and that incidental oophorectomy after menopause should still be considered carefully in each potential patient.

A prospective study of hypertension and risk of uterine leiomyomata

Although uterine leiomyomata (also known as fibroids or myomas) affect the reproductive health and well-being of approximately 25% of premenopausal women, risk factors are poorly understood. Elevated diastolic blood pressure may increase fibroid risk through uterine smooth muscle injury, not unlike atherosclerosis. The authors prospectively examined the relation between diastolic blood pressure and incidence of clinically detected leiomyomata. The sample included 104,233 premenopausal nurses from 14 US states enrolled in the Nurses' Health Study II. Participants, aged 25-42 years, had intact uteri and no history of cancer or fibroids at enrollment in 1989. During the 827,348 woman-years of follow-up (1989-1999), 7,466 incident diagnoses of uterine leiomyomata, confirmed by ultrasound or hysterectomy, were reported. With a multivariable Cox proportional hazards model, the relative risk of self-reported ultrasound- or hysterectomy-confirmed uterine leiomyomata according to diastolic blood pressure in 1989 and time-varying antihypertensive use was estimated. With adjustment for age, race/ethnicity, body mass index, and reproductive history covariates, for every 10-mmHg increase in diastolic blood pressure, the risk of fibroids rose 8% (5-11%) and 10% (7-13%) among nonusers and users of antihypertensive medications, respectively. Elevated blood pressure has an independent, positive association with risk for clinically detected uterine leiomyomata among premenopausal women. Investigating this association may suggest possible pathways to prevent fibroids.

The integration of a woman's perspective in hysterectomy decisions

It has been argued, based on a limited amount of research data, that patient participation in decision-making regarding surgery, results not only in more patient satisfaction, but also in better surgery outcomes. Especially in a procedure such as hysterectomy, with far-reaching consequences and many potential side effects, it may therefore be relevant to promote an active role of the patient in the decision-making process. The article identifies contextual elements that might promote this active role. Subsequently a model of participative, informed decision-making is outlined. The model entails that clinical guidelines should be adjusted to the particular situation at hand and that patients should be fully informed about hysterectomy-involved risks. An overview of the various guidelines and risks is provided. Proper counseling in the decision-making phase as well as in the post-hysterectomy period is advocated. Throughout the article attention is paid to documented and undocumented ethnic differences regarding various aspects of hysterectomy, particularly differences in patient participation around the world.

Ciglitizone inhibits cell proliferation in human uterine leiomyoma via activation of store-operated Ca2+ channels

This study investigated the acute effects of a peroxisome proliferator-activated receptor (PPAR)-γ ligand, ciglitizone, on cell proliferation and intracellular Ca2+ signaling in human normal myometrium and uterine leiomyoma. Changes in intracellular Ca2+ concentration ([Ca2+]i) were measured with fura-2 AM, and cellular viabilities were determined by viable cell count and 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide reduction assay. Ciglitizone (100 μM) induced greater inhibition of cell proliferation in uterine leiomyoma than in myometrium. Ciglitizone also dose-dependently increased [Ca2+]i in both myometrium and uterine leiomyoma; these [Ca2+]i increases were inhibited by PPAR-γ antagonists and raloxifene. Ciglitizone-induced [Ca2+]i increase showed only an initial peak in normal myometrial cells, whereas in uterine leiomyoma there was a second sustained [Ca2+]i increase as well. The initial [Ca2+]i increase in both myometrium and uterine leiomyoma resulted from the release of Ca2+ by the sarcoplasmic reticulum via activation of ryanodine receptors. The second [Ca2+]i increase was observed only in uterine leiomyoma because of a Ca2+ influx via an activation of store-operated Ca2+ channels (SOCCs). Cell proliferation was inhibited and secondary [Ca2+]i increase in uterine leiomyoma was attenuated by cotreatment of ciglitizone with a SOCC blocker, lanthanum. The results suggest that ciglitizone inhibits cell proliferation and increases [Ca2+]i through the activation of SOCCs, especially in human uterine leiomyoma.

Gene therapy of uterine leiomyomas: adenovirus-mediated expression of dominant negative estrogen receptor inhibits tumor growth in nude mice

BACKGROUND

Leiomyomas (fibroids) are common estrogen-dependent uterine tumors with no effective medicinal treatment; hysterectomy is the mainstay of management.

STUDY DESIGN

This study was undertaken to investigate a potential therapy for leiomyoma; we used a mutated dominant-negative estrogen receptor gene delivered via an adenoviral vector (Ad-ER-DN).

RESULTS

Ad-ER-DN transduction, in both human and rat leiomyoma cell lines, induced an increase in both caspase-3 levels and BAX/Bcl-2 ratio with evident apoptosis in the TdT-mediated dUTP nick-end labeling assay. In nude mice, rat leiomyoma cells ex vivo transduced with Ad-ER-DN supported significantly smaller tumors compared with Ad-LacZ-treated cells 5 weeks after implantation. In mice treated by direct intratumor injection into preexisting lesions, Ad-ER-DN caused immediate overall arrest of tumor growth. The Ad-ER-DN-treated tumors demonstrated severely inhibited cell proliferation (BrdU index) and a marked increase in the number of apoptotic cells (TdT-mediated dUTP nick-end labeling index).

CONCLUSION

Dominant-negative estrogen receptor gene therapy may provide a nonsurgical treatment option for women with symptomatic uterine fibroids who want to preserve their uteri.

Narrow Pubic Arch and Increased Risk of Failure for Vaginal Hysterectomy

OBJECTIVE

The purpose of this study was to evaluate the risk factors involved in failed vaginal hysterectomies.

METHODS

Data on all vaginal hysterectomies performed by a single gynecologic surgeon were collected prospectively. Patients requiring pelvic floor repair were excluded. Any procedure converted to the abdominal approach was classified as a failed vaginal hysterectomy and comprised the study group. For every woman who had a failed vaginal hysterectomy, the next 2 women who had successful vaginal hysterectomies immediately after the failed vaginal hysterectomy were taken as controls. Risk factors such as age, parity, body weight, surgical indication, uterine size, presence of leiomyomata in the anterior lower uterine segment, previous pelvic surgeries, abdominopelvic adhesions, location and length of cervix, narrow pubic arch, intraoperative complications such as bleeding requiring transfusion, visceral injury, nulliparity, and adnexal removal were compared between groups.

RESULTS

We compared 25 failed vaginal hysterectomies with 50 controls whose procedures were completed successfully through the vagina. Among all the factors gynecologists can assess preoperatively, only the presence of a narrow pubic arch increased the risk of failure for vaginal hysterectomy (odds ratio [OR] 4.1; 95% confidence interval 1.32-12.69). Intraoperative bleeding with transfusion was also found as an independent cause for conversion to laparotomy (OR 7.37; 95% confidence interval 1.75-31.06).

CONCLUSION

Women with a narrow pubic arch are not good candidates for vaginal hysterectomy. The most common unpredictable cause for conversion to laparotomy from the vaginal approach is intraoperative bleeding requiring transfusion.

LEVEL OF EVIDENCE

II-2

Scutellaria barbata D. Don induces c-fos gene expression in human uterine leiomyomal cells by activating beta2-adrenergic receptors

Scutellaria barbata D. Don (Lamiaceae; SB) inhibited the growth of uterine leiomyomal (LM) cells with unknown actions. The expression patterns of beta-adrenergic receptors (beta-ARs) in human uterine LM cells and functional coupling to gene expression have also been investigated. Northern blot analysis showed that beta-AR subtypes are expressed at different levels in the uterine LM cells and myometrial smooth muscle cells (SMCs). beta1-AR expression was to be found approximately at the same level in the two cell types. beta2-ARs were expressed at higher levels in uterine LM cells than that in myometrial SMCs. beta3-AR expression was not found in both the cells. c-fos gene expression was induced by SB in uterine LM cells via increases in adenosine-3',5', cyclic monophosphate (cAMP), which in turn activated the cAMP/protein kinase A (PKA) pathway. The PKA inhibitor, H89, inhibited c-fos gene expression induced by SB. It seems that the mechanism of proto-oncogenes c-fos different leiomyoma from other myometrial cancer. Further studies are necessary to elucidate whether c-fos induction by SB in uterine LM cells influences a regression of leiomyoma or induces other differentiation.

FEMIC (Fibromes Embolis�s aux MICrosph�res calibr�es): Uterine Fibroid Embolization using Tris-acryl Microspheres. A French Multicenter Study

PURPOSE

A French multicenter registry was set up to confirm the safety and efficacy of large calibrated tris-acryl gelatin microspheres for embolization of symptomatic fibroids.

METHODS

Technical recommendations included embolization using large microspheres (>500 microm) with no secondary embolization agent. Postprocedural pain, clinical improvement and adverse events were prospectively evaluated during a follow-up period of at least 6 months.

RESULTS

Eighty-five women complaining of fibroid-related symptoms entered the study. In seven women, a secondary embolization agent was used in addition to microspheres. Complete resolution of menorrhagia was achieved in 84% of women at 24 months and significant uterine and fibroid volume reductions were noted after 6 months (37% and 73%, respectively). Three women experienced definitive amenorrhea (4%) and two women required hysteroscopic resection of a fibroid. Eight women were treated by hysterectomy because of treatment failure. In seven of these women, treatment failure was explained by an additional cause of symptoms including diffuse adenomyosis, endometrial hyperplasia or ovarian artery supply to the fibroids.

CONCLUSION

Limited uterine artery embolization using large microspheres has good clinical success rate with low postprocedural pain and complications. Women can expect excellent midterm results with a high level of symptom control and significant fibroid volume reduction. Confidence in the end-point recommended here may require the experience of several cases.

Effect of hysterectomy on incidence trends of endometrial and cervical cancer in Finland 1953-2010

The hysterectomy-corrected age-adjusted incidence rate of endometrial cancer was 29%, and for cervical cancer 11% higher than the uncorrected rate. Correction factors for such cancer sites are recommended for regular use. The levelling-off of the incidence of endometrial cancer appears to be an artefact caused by the increasing prevalence of hysterectomy.

Optimizing the Total Laparoscopic Hysterectomy Procedure for Benign Uterine Pathology

STUDY OBJECTIVE

To evaluate the influence of the learning curve in total laparoscopic hysterectomy on short- and long-term clinical results.

DESIGN

Retrospective comparative analysis (Canadian Task Force classification II-2).

SETTING

Malzoni Medical Center of Avellino, university-affiliated hospital.

PATIENTS

Three hundred and ninety-six women in the first time period (1997-1999) and 624 women in the second time period (2000-2002) were treated, using different techniques, by the same surgeon. Patients suffered from symptomatic myomas and uterine fibromatosis. No case was considered suitable for a vaginal procedure.

INTERVENTION

Total laparoscopic hysterectomy.

MEASUREMENTS AND MAIN RESULTS

No statistical differences were found between the two groups for patient age, parity, body mass index, and indications for surgery (p = NS), except for uterine weight (395 g vs. 408 g; p <.01). In the first time period, the average operating time was 105 +/- 27 minutes (range, from 65-190). In the second time period, the average operating time was 80 +/- 21 minutes (range, 45-170) (p <.001). The postoperative hemoglobin drop was 1.44 g/dL (range, 0.8-6.1) and 1.39 g/d (range, 0.7-4.3) in the first series and second series, respectively (p = NS). In the first series, the mean postoperative hospital stay was 2.4 +/- 1 days (range, 2-7). In the second series, the mean postoperative hospital stay was 2.3 +/- 1 days (range, 2-6). A significant decrease in short-term complications occurred between the first and second time period, 7.7% and 5.55% respectively (p <.03). We performed three (0.75%) and four (0.6%) conversion to laparotomy procedures, respectively, in the first and second groups (p = NS). During the first period, two reoperations were necessary; in the second period, one patient (0.15%) required a reoperation (p = NS). The rate of postoperative blood transfusion was 0.5% (n = 2) in the first period versus 0.15% (n = 1) in the second period (p = NS). Significant decrease of long-term complications occurred between first and second series, 2.0% and 0.45% respectively (p <.05). There were no differences between the two groups regarding sexual symptoms p = NS).

CONCLUSION

Laparoscopic hysterectomy is a safe, effective, and reproducible technique after completion of a period of training necessary to standardize the procedure. The results support the importance of optimizing some steps of the surgical technique to reduce severe complications.

Hysterectomies amongst teenagers in Calabar, Nigeria

A 10-year retrospective study of hysterectomies performed on teenagers in Calabar was carried out.

Effect of hysterectomy on bowel function

PURPOSE

Hysterectomy is the most common major gynecologic procedure. Unwanted postoperative effects on bowel function are a topic of recent debate. The aim of the present study was to prospectively evaluate the influence of hysterectomy on bowel function.

METHODS

One hundred and twenty consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire covering bowel habits and symptoms preoperatively and at 6 and 12 months postoperatively. Forty-four patients underwent vaginal hysterectomy and 76 underwent abdominal hysterectomy. Concomitant bilateral salpingo-oopherectomy was performed in 17 patients.

RESULTS

After abdominal hysterectomy, patients reported increased symptoms of gas incontinence, urge to defecate, and inability to distinguish between gas and feces ( P < 0.05). There was a tendency of increased fecal incontinence. Subgroup analysis indicated that concomitant bilateral salpingo-oopherectomy resulted in an increased risk of fecal incontinence. No significant changes were detected in symptoms associated with constipation. Mean defecation frequency increased and the frequency of pelvic heaviness symptoms was reduced. After vaginal hysterectomy, there was no increased frequency of incontinence or constipation symptoms. The frequency of pelvic heaviness symptoms was reduced.

CONCLUSIONS

Patients undergoing abdominal hysterectomy may run an increased risk for developing mild to moderate anal incontinence postoperatively and this risk is increased by simultaneous bilateral salpingo-oopherectomy. An increased risk of anal incontience symptoms could not be identified in patients undergoing vaginal hysterectomy. Our study does not support the assumption that hysterectomy is associated with de novo or deteriorating constipation.

Analysis of type I collagen in the parametrium of women with and without uterine prolapse, according to hormonal status

The content and quality of type I collagen in the parametrium of women with and without uterine prolapse was evaluated. Forty-four consecutive patients were selected and divided into two groups: A, 21 women without uterine prolapse, and B, 23 with uterine prolapse. Patients in group A had uterine leiomyoma and were submitted to abdominal hysterectomy; in those from group B, vaginal hysterectomy was performed for correction of the uterine prolapse. During surgery, fragments of the parametrium were removed and processed for immunohistochemical analysis using polyclonal antibodies for type I collagen. A system of computerized digital imaging analysis was used for the quantification of collagen fibers. There was no difference between collagen content in patients either with or without prolapse, nor between pre- and postmenopausal women with prolapse. A modification of the quality of the collagen fiber was observed, it being longer and more compact in the group without uterine prolapse. In contrast, in the group with prolapse, the fibers were shorter and thinner and areas with large spaces between fibers were found at several points of the parametrium. The conclusion was that patients with uterine prolapse have the same type I collagen content as those without, but the quality of the fiber is modified. The hormonal status also did not affect collagen content.