Severe complications of hysterectomy: the VALUE study

A Comparative Study Between Laparoscopically Assisted Vaginal Hysterectomy and Vaginal Hysterectomy: Experience in a Tertiary Diabetes Care Hospital in Bangladesh

OBJECTIVE

The study was undertaken to compare the efficiency and outcome of Laparoscopic Assisted Vaginal Hysterectomy (LAVH) and Vaginal Hysterectomy (VH) in terms of operative time, cost, estimated blood loss, hospital stay, quantity of analgesia use, intra- and postoperative complication rates and patients recovery.

MATERIALS AND METHODS

A total of 500 diabetic patients were prospectively collected in the study period from January 2005 through January 2009. The performance of LAVH was compared with that of VH, in a tertiary care hospital. The procedures were performed by the same surgeon.

RESULTS

There was no significant difference in terms of age, parity, body weight or uterine weight. The mean estimated blood loss in LAVH was significantly lower when compared with the VH group (126.5±39.8 ml and 100±32.8 ml), respectively. As to postoperative pain, less diclofenac was required in the LAVH group compared to the VH group (70.38±13.45 mg and 75.18±16.45 mg), respectively.

CONCLUSIONS

LAVH, is clinically and economically comparable to VH, with patient benefits of less estimated blood loss, lower quantity of analgesia use, lower rate of intra- and postoperative complications, less postoperative pain, rapid patient recovery, and shorter hospital stay.

FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors

BACKGROUND

Hysterectomy guidelines highlight an increase in urinary tract injuries with laparoscopic hysterectomy (LH). This national survey analyses complications of LH, abdominal hysterectomy (AH) and vaginal hysterectomy (VH).

METHODS

A prospective cohort undergoing hysterectomy for benign indications during 2006 was drawn from 53 hospitals in Finland; all communal hospitals participated. Detailed questionnaires covered surgical data and intra- and post-operative major and minor complications, for which risk factors were analysed by a multivariate logistic regression model adjusted for surgical data and patient characteristics.

RESULTS

Major complications rates in AH (n= 1255, 24%), LH (1679, 32%) and VH (2345, 44%) were 4.0, 4.3 and 2.6%, and total complications rates were 19.2, 15.4 and 11.7%, respectively. Logistic regression showed no statistically significant differences between approaches for any organ injuries or other major complications. Most bladder and bowel injuries (88 and 83%), but not ureter injuries (10%), were recognized intra-operatively. The ureter injury rate was low after LH (0.3%), as it was after other types of hysterectomy. Compared with LH, AH increased the odds of wound infection, and was an independent risk factor for urinary infections and febrile events. Compared with AH, LH and VH both presented a higher risk for pelvic infection; surgically treated equally often regardless of the type of hysterectomy. No differences in complications emerged between LH and VH. Obesity was a risk factor for many infections. Surgical adhesiolysis [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.38-4.21] was the strongest single risk factor for major complications as a whole. Bladder injury was associated with a history of caesarean section (OR 4.01, 95% CI 2.06-7.83) and with a large uterus ≥500 g (OR 2.88, 95% CI 1.05-7.90), while bowel injury was associated with adhesiolysis (OR 29.07, 95% CI 7.17-117.88).

CONCLUSIONS

FINHYST is a large prospective hysterectomy study illustrating actual complications. Whenever possible, hysterectomy should be minimally invasive.

Unplanned return to the operating theatre in gynaecology: five years' experience

OBJECTIVES

To review our incidence of unplanned return to the operating theatre (OT) and compare our findings with the published literature.

STUDY DESIGN

Five year retrospective review of case notes in our gynaecology department between January 2005 and April 2010. Women were eligible for recruitment if they returned to the OT for an unplanned operation during the same admission following a gynaecological operation.

RESULTS

Seventeen cases were identified, mean age 40 years (range 27-52 years). The incidence of unplanned return to the OT was 0.03%. Elective and emergency initial operations accounted for 72% and 28% respectively. Over 80% of the cases followed a hysterectomy, giving an overall risk of return to OT after hysterectomy of 2%. Reactionary bleeding was the cause in all cases. A specific bleeding site was identified in 82% of the women. The mean time between primary surgery and return to the OT was 7.9 h. The triggering factors were a combination of a change in observations, postoperative bleeding, a drop in haemoglobin level and uncontrolled abdominal pain despite analgesics. Blood transfusion was required in 53% of cases and one woman was admitted to the intensive care unit for one night. No women required further reoperation, and all were discharged home with no long-term sequelae.

CONCLUSION

Unplanned reoperation is a potentially life threatening complication, and therefore early recognition; resuscitation and emergency return to the OT to stop the bleeding are the main principles of management.

Safe total intrafascial laparoscopic (TAIL) hysterectomy: a prospective cohort study

This study directly compares total intrafascial laparoscopic (TAIL) hysterectomy with vaginal (VH) and abdominal (AH) hysterectomy with regard to safety, operating time and time of convalescence. The study is a prospective cohort study (Canadian Task Force classification II-2), including data from patients of a single university-affiliated teaching institution, admitted between 1997 and 2008 for hysterectomy due to benign uterus pathology. Patient data were collected pre-, intra- and postoperatively and complications documented using a standardised data sheet of a Swiss obstetric and gynaecological study group (Arbeitsgemeinschaft Schweizerische Frauenkliniken, Amlikon/Switzerland). Classification of complications (major complications and minor complications) for all three operation techniques, evaluation of surgeons and comparison of operation times and days of hospitalisation were analysed. 3066 patients were included in this study. 993 patients underwent AH, 642 VH and 1,431 total intrafascial hysterectomy. No statistically significant difference for the operation times comparing the three groups can be demonstrated. The mean hospital stay in the TAIL hysterectomy, VH and AH groups is 5.8 +/- 2.4, 8.8 +/- 4.0 and 10.4 +/- 3.9 days, respectively. The postoperative minor complications including infection rates are low in the TAIL hysterectomy group (3.8%) when compared with either the AH group (15.3%) or the VH group (11.2%), respectively. The total of minor complications is statistically significant lower for TAIL hysterectomy as for AH (O.R. 4.52, CI 3.25-6.31) or VH (O.R. 3.16, CI 2.16-4.62). Major haemorrhage with consecutive reoperation is observed statistically significantly more frequent in the AH group when compared to the TAIL hysterectomy group, with an O.R. of 6.13 (CI 3.05-12.62). Overall, major intra- and postoperative complications occur significant more frequently in the AH group (8.6%) when compared to the VH group (3%) and the TAIL hysterectomy group (1.8%). The incidence of major complications applying the standardised TAIL hysterectomy technique is not related to the experience of the surgeons. We conclude that a standardised intrafascial technique of total laparoscopic (TAIL) hysterectomy using an anatomically developed special uterine device is associated with a very low incidence of minor and major intra- and postoperative complications. The direct comparison of complication rates with either vaginal or abdominal hysterectomy favours the total laparoscopic technique, and therefore, this technique can be recommended as a relatively atraumatic procedure. The operation times are comparable for all three techniques without any statistically significant differences. This technique for laparoscopic hysterectomy is shown to be equally safe when applied by experienced gynaecologic surgeons or by residents in training. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s10397-010-0569-0) contains supplementary material, which is available to authorized users.

Morbidity and mortality of peripartum hysterectomy

OBJECTIVE

To perform a population-based analysis to examine the morbidity and mortality of peripartum hysterectomy in comparison with nonobstetric hysterectomy.

METHODS

Data from the Nationwide Inpatient Sample were used to compare peripartum and nonobstetric hysterectomy in women younger than 50 years of age. Intraoperative, perioperative, and postoperative medical complications were examined. The outcomes of peripartum and nonobstetric hysterectomy were compared using chi square. Odds ratios were calculated using multivariable logistic regression models for each individual complication.

RESULTS

A total of 4,967 women who underwent peripartum hysterectomy and 578,179 patients who had a nonobstetric hysterectomy were identified. Bladder (9% compared with 1%) and ureteral (0.7% compared with 0.1%) injuries were more common for peripartum hysterectomy (P<.001). There were no differences in the rates of intestinal or vascular injuries between peripartum and nonobstetric hysterectomy. Rates of reoperation (4% compared with 0.5%), postoperative hemorrhage (5% compared with 2%), wound complications (10% compared with 3%), and venous thromboembolism (1% compared with 0.7%) were all higher in women who underwent peripartum hysterectomy. In multivariable analysis, the odds ratio for death for peripartum compared to nonobstetric hysterectomy was 14.4 (95% confidence interval 9.84-20.98).

CONCLUSION

Peripartum hysterectomy is accompanied by substantial morbidity and mortality. Compared with nonobstetric hysterectomy, the procedure is associated with increased rates of both intraoperative and postoperative complications. The mortality of peripartum hysterectomy is more than 25 times that of hysterectomy performed outside of pregnancy.

LEVEL OF EVIDENCE

II.

Health-related quality of life and patient satisfaction after global endometrial ablation for menorrhagia in women with bleeding disorders: a follow-up survey and systematic review

OBJECTIVE

The purpose of this study was to describe health-related quality of life and satisfaction after global endometrial ablation in women with bleeding disorders and a systematic review of the literature.

STUDY DESIGN

A follow-up survey was mailed to 36 patients with bleeding disorders and 110 reference patients (no coagulopathies) who underwent global endometrial ablation for menorrhagia. The survey included a generic (SF-12) and menorrhagia multi-attribute utility scale questionnaires.

RESULTS

Ninety-six women (66%) responded. The total menorrhagia multiattribute utility scale score increased from 35-100 in bleeding disorder cohort (P = .03) and from 48-100 in the reference cohort (P < .001). Although postablation SF-12 mental domain scores were comparable in both cohorts (55 vs 55; P = .67), physical domain scores were lower in the bleeding disorder cohort (50 vs 56; P < .001). High satisfaction was reported by both cohorts (95% vs 84%; P = .60).

CONCLUSION

Global endometrial ablation improved health-related quality of life for women with bleeding disorders and had high satisfaction rates.

Hysterectomy and perioperative morbidity in women who have undergone renal transplantation

OBJECTIVE

The purpose of this study was to compare complications from vaginal hysterectomy with abdominal hysterectomy in renal transplant recipients.

STUDY DESIGN

Women who underwent renal transplantation then hysterectomy from 1966-2008 at Mayo Clinic, Rochester, MN, were identified. Data were collected about preoperative, intraoperative, and postoperative events. Main outcome measure was loss of allograft function; secondary outcomes included types of complications and treatment methods.

RESULTS

Of 58 women with renal transplants, 42 women (72.4%) underwent abdominal hysterectomy. The most common indication for hysterectomy was menorrhagia (n = 20; 34.5%). Overall, 24 women (41.4%) had complications, the most common of which were infection (n = 15) and transfusion (n = 8). Women who underwent abdominal hysterectomy were no more likely to have perioperative complications than were women who underwent vaginal hysterectomy (odds ratio, 1.25; 95% confidence interval, 0.38-4.08).

CONCLUSION

Although patients with renal transplants had perioperative complications, none of these complications led to renal graft loss. Hysterectomy can be considered in these patients when accompanied by diligent postoperative care.

Uterine fibroid embolization: a viable alternative to hysterectomy

Benign uterine fibroids, or leiomyomas, are the most common tumors found in gynecologic practice. Symptomatic fibroids present with menorrhagia, pelvic pain, leukorrhea, pressure and bloating, increased abdominal girth, and severe dysmenorrhea. Traditional treatment has relied on surgery because long-term medical therapies have demonstrated only minimal response. Uterine fibroid embolization (UFE) using particulate emboli to occlude the uterine arteries, thereby disrupting the blood supply to fibroids and leading to devascularization and infarction, has been reported to be effective in alleviating fibroid-related symptoms. UFE is a safe, effective, and durable nonsurgical alternative to hysterectomy.

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.

Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis

Hysterectomy is a very common gynaecological procedure. The vaginal route is considered preferable for hysterectomy, although the ideal route for women unsuitable for the vaginal approach remains unclear. We performed a meta-analysis of published randomised controlled trials to compare outcomes in total abdominal hysterectomy (TAH) and total laparoscopic hysterectomy (TLH) for benign disease. Pooled odds ratios (OR) were calculated for categorical variables using random effects models as per Der Simonian and Laird. Continuous variables were compared by means of weighted mean differences (WMD). TLH is associated with reduced overall peri-operative complications (pooled OR 0.19; 95% CI 0.07-0.50) and reduced estimated blood loss (WMD -183ml; 95% CI -346ml to -21ml; p=0.03). Additionally, there are trends towards shorter hospital stay (WMD -2.5 days; 95% CI -5.1 days to 0.01 days; p=0.05) and post-operative haematoma formation (pooled OR 0.17; 95% CI 0.03-1.01) compared to TAH. The only trade-off appears to be a longer operating time in the TLH group (WMD 22min; 95% CI 5-39min; p=0.01). Rates of major complication were not statistically different (pooled OR 1.35; 95% CI 0.32-5.73) though this analysis is likely underpowered to detect many major complications. As such, TLH appears to offer benefits to women requiring total hysterectomy for benign indications compared to TAH, particularly regarding minor complications, blood loss and hospital stay. However, larger studies are needed to assess the impact on major intra-operative complications and long-term clinical outcomes, particularly pelvic organ prolapse.

Morbidity outcomes of 78,577 hysterectomies for benign reasons over 23 years

OBJECTIVE

To investigate the association of the method of hysterectomy for benign reasons with morbidity outcomes in Western Australia after taking other demographic, social and health-related factors into account.

DESIGN

Population-based retrospective observational study.

SETTING

All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003.

POPULATION

All women aged 20 years or older who underwent a hysterectomy for benign reasons.

METHOD

Logistic and zero-truncated negative binomial regression analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

Relative odds of experiencing complications during the hysterectomy admission or readmission and relative length of stay in hospital by type of hysterectomy.

RESULTS

There were 78,577 hysterectomies performed for benign reasons from 1981 to 2003. Procedure-related haemorrhage (2.4%) was the most commonly recorded complication, followed by genitourinary disorders (1.9%), infection (1.6%) and urinary tract infections (1.6%). Vaginal hysterectomy was associated with reduced odds of infection and haemorrhage compared with abdominal procedures during the hysterectomy admission. Readmission rates increased from 5.4% in 1981-84 to 7.2% in 2000-03 as average length of stay decreased by 53% over the same time period. Women who underwent laparoscopically assisted vaginal hysterectomies and vaginal hysterectomies had increased odds of readmission for haemorrhage and genitourinary disorders compared with abdominal hysterectomy. Young age, increasing number of co-morbid conditions and having a complication at hysterectomy admission were also associated with increased odds of readmission.

CONCLUSION

These findings identify women at risk of readmission following hysterectomy and highlight an opportunity to modify early discharge and patient follow-up practices to reduce this risk.

Altered responsiveness of small uterine arteries in women with idiopathic menorrhagia

OBJECTIVE

This study was undertaken to study vascular reactivity of small myometrial arteries in women with idiopathic menorrhagia.

STUDY DESIGN

Small myometrial arteries were isolated from 6 patients with idiopathic menorrhagia and 4 controls. The contractile responses to thromboxane mimetic (U46619) and endothelin-1 were assessed before and after incubation with N(w)-nitro-L arginine methyl ester alone or in combination with indomethacin (Indo). Endothelium-dependent dilation to bradykinin and basal tension were compared before and after incubation with N(w)-nitro-L arginine methyl ester alone, or with N(w)-nitro-L arginine methyl ester in combination with indomethacin.

RESULTS

Constriction to endothelin-1 was enhanced in idiopathic menorrhagia arteries (P < .05). Idiopathic menorrhagia arteries demonstrated enhanced basal tension after incubation with N(w)-nitro-L arginine methyl ester, which was further exaggerated by indomethacin. NOS inhibition had no effect on basal tension in controls, but basal tension was enhanced after inhibition of cyclooxygenase-derived products (P < .05). Bradykinin-mediated dilation was significantly increased in idiopathic menorrhagia (P < .05).

CONCLUSION

The presence of functional alterations in small myometrial arteries could contribute to idiopathic menorrhagia.

Uterine artery embolization for ureteric obstruction secondary to fibroids

This case series examines the safety and efficacy of uterine artery embolization (UAE) in the treatment of obstructive nephropathy caused by large fibroids. Between 2004 and 2007, 10 patients referred with symptomatic uterine fibroids that were found to be causing either unilateral (7 patients) or bilateral (3 patients) hydronephrosis were treated by UAE. Presenting complaints included menorrhagia, dysmenorrhea, bulk symptoms, loin pain, postobstructive atrophy, and mild renal impairment. All had posterior intramural dominant fibroids >11 cm in maximum sagittal diameter and uterine volumes between 3776 and 15,625 ml. Outcome measures at between 12 and 36 months included procedural success, repeat intervention, relief of symptoms, resolution of hydronephrosis, stable renal function and size, and avoidance of hysterectomy. In all cases the cause of renal obstruction was confirmed to be a giant fibroid compressing the ureter at the pelvic brim. In all cases UAE was technically successful, though two patients required a repeat procedure. In eight patients hydronephrosis resolved and the obstruction was relieved, though two still had some bulk symptoms not requiring further treatment. Renal function improved or was stable in all cases. Renal size was stable in all cases. Where menorrhagia was part of the symptom complex it was relieved in all cases. Two patients diagnosed as having postobstructive atrophy of one kidney underwent retrograde ureteric stenting on the nonatrophied side prior to UAE. This was unsuccessful in one of the cases due to the distortion caused by the fibroid. Despite improvement in hydronephrosis this patient underwent hysterectomy at 7 months after a renogram demonstrated persistent obstruction at the pelvic brim. In the second patient a double pigtail stent was inserted with difficulty and eventually removed at 8 months. This patient has had stable renal function and size for 3 years post-UAE. We conclude that UAE is safe and effective in treating patients with obstructive hydronephrosis caused by large fibroids.

Efficacy of laparoscopic subtotal hysterectomy in the management of menorrhagia: 400 consecutive cases

STUDY OBJECTIVE

To assess the safety and patient satisfaction of laparoscopic subtotal hysterectomy (LSH) using a standardised surgical technique.

DESIGN

Prospective observational study.

SETTING

Princess Royal University Hospital, Chelsfield Park Hospital and Sloane Hospital, Kent, UK.

PATIENTS AND MATERIALS

Four hundred consecutive women with menorrhagia underwent LSH. The procedure was performed using the Plasma Kinetic Bipolar Diathermy (Gyrus International Ltd, Berkshire, UK) for pedicle ligation and the Lap Loop system (Roberts Surgical Healthcare Ltd, Kidderminster, UK) to detach the cervix. An electromechanical morcellator (Morcellex; Ethicon Women's Health and Urology, Cincinnati, OH, USA) was used to remove the uterus from the abdominal cavity.

MAIN OUTCOME MEASURES

Patient satisfaction, morbidity rates and readmission rates.

RESULTS

A total of 400 LSH were performed between February 2003 and November 2006. The principal clinical indication for hysterectomy was menorrhagia. The mean duration of surgery was 46.4 minutes. The mean operative blood loss was 126 ml. Concurrent surgery was performed in 141 women. Minor and major perioperative complications were encountered in 5% (n= 20) of women. The major complication rate was 1.2% (n= 5): three women (0.75%) with bladder perforation, two women (0.5%) with bowel injury and one woman (0.25%) with a vesicocervical fistula. Eight women (2%) suffered from cyclical vaginal bleeding postoperatively.

CONCLUSIONS

LSH is a safe and effective treatment for menorrhagia and other menstrual disorders when hysterectomy is indicated. Women appreciate the quick recovery period, reduced time off work and faster return to normal activity. Our data suggest that LSH can replace abdominal hysterectomy in selected cases.

Cost-effectiveness of magnetic resonance-guided focused ultrasound surgery for treatment of uterine fibroids

Objective

To estimate the cost-effectiveness of a treatment strategy for symptomatic uterine fibroids, which starts with Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) as compared with current practice comprising uterine artery embolisation, myomectomy and hysterectomy.

Design

Cost-utility analysis based on a Markov model.

Setting

National Health Service (NHS) Trusts in England and Wales.

Population

Women for whom surgical treatment for uterine fibroids is being considered.

Methods

The parameters of the Markov model of the treatment of uterine fibroids are drawn from a series of clinical studies of MRgFUS, and from the clinical effectiveness literature. Health-related quality of life is measured using the 6D. Costs are estimated from the perspective of the NHS. The impact of uncertainty is examined using deterministic and probabilistic sensitivity analysis.

Main outcome measures

Incremental cost-effectiveness measured by cost per quality-adjusted life-year (QALY) gained.

Results

The base-case results imply a cost saving and a small QALY gain per woman as a result of an MRgFUS treatment strategy. The cost per QALY gained is sensitive to cost of MRgFUS relative to other treatments, the age of the woman and the nonperfused volume relative to the total fibroids volume.

Conclusions

A treatment strategy for symptomatic uterine fibroids starting with MRgFUS is likely to be cost-effective.

Please cite this paper as: Zowall H, Cairns J, Brewer C, Lamping D, Gedroyc W, Regan L. Cost-effectiveness of magnetic resonance-guided focused ultrasound surgery for treatment of uterine fibroids. BJOG 2008;115:653–662.

Asymptomatic uterine fibroids

It is estimated that at least 50% of fibroids are asymptomatic, but this figure is likely to be an underestimate as it is based on women in whom fibroids are found incidentally during another procedure (e.g. cervical screening), and there is little, if any, data from population studies on the true incidence of fibroids. If a prevalence of 50% by 50 years of age is accepted, a large number of women have asymptomatic fibroids. Working on the cliché, 'if it ain't broken, don't fix it', it may seem surprising that there should be a chapter dedicated to the issue of asymptomatic fibroids, since the simplistic approach might be to leave the asymptomatic fibroids well alone. However, asymptomatic fibroids may become symptomatic in the future, so it may be wiser to treat fibroids before they grow to a size when they become symptomatic, or treatment becomes more challenging, especially in young women who may desire fertility at a later stage, and in view of the fact that many women are starting their families in their mid-thirties when they have a 30% chance of having a fibroid(s). Despite their common occurrence, fibroids are still poorly understood. It is not known why they form in the first place, what determines their number and ultimate size, the best treatment approaches, or the factors that determine which women develop symptoms. Even when women present with disorders such as infertility, pelvic pain and abnormal bleeding, it is not always possible to be certain that a given myoma is not simply an innocent bystander rather than the cause of the symptom. This chapter addresses the challenging issue of what to do when fibroids are diagnosed incidentally. Firstly, there is the need to ascertain that the pelvic mass palpated is indeed a fibroid, and not an early, more sinister tumour, especially if conservative management is adopted. In addition, there is the issue of size, position and potential for becoming symptomatic at a later date. With the availability of uterine-preserving and largely non-invasive treatment modalities, should more asymptomatic, younger women be offered treatment if it is deemed that their fibroids may cause problems as they grow? Where treatment is not offered, is it necessary to follow-up such women, and if so, with what modality of surveillance and how frequently?

Second-generation endometrial ablation – an overview

Various methods exist to destroy the endometrium as a treatment for menorrhagia. This chapter discusses the rationale, evidence, indications, and long-term safety and efficacy of the current techniques. It also discusses endometrial ablation in the context of its clinical utility in comparison with the existing alternative treatments.

Comparison of total laparoscopic, vaginal and abdominal hysterectomy

INTRODUCTION

Due to technical improvements and growing experience, hysterectomies are performed laparoscopically more and more frequently. We analyzed 43 total laparoscopic hysterectomies (TLH) of the years 2005 and 2006 and compared them with 87 vaginal (VH) and 103 abdominal hysterectomies (AH).

METHODS

Patients' original files and surgery reports of the TLHs, VHs and AHs were analyzed retrospectively for the indication of surgery, patients' age, weight, parity, time for surgery, uterus weight, blood loss, post-operative need of analgetics, hospital stay, complications and so on. Data were compared with Student's t test and chi(2) test.

RESULTS

Indications for TLH were fibroids (n = 21), endometrial cancer (n = 10), bleeding anomalies (n = 7), dysplasia of the cervix uteri (n = 3) and others. In 23/43 cases salpingo-ovarectomy was added, in six cases laparoscopic pelvic or paraaortic lymphadenectomy (LNE) was performed. Looking at cases without LNE, patients' median age was 46 years (32-72), median weight 68 kg (53-115), median time for TLH 130 min (75-270), median uterus weight 150 g (44-954), median blood loss 200 ml (50-600), post-operative analgetica were given for 1.5 days (0-12), and post-operative hospital stay was 6 days (2-15). Indications for VH were genital prolapse (n = 53, 61%), often combined with fixative procedures (n = 50). In this group, median age was significantly higher (median 56 years, P < 0.001). VH was the fastest (median 90 min, P < 0.001), but blood loss was highest (median 300 ml, P = 0.07). In cases with AH, uterus weight was significantly higher (median 290 g, P < 0.001), as well as the need for analgetics (median 4 days, P = 0.001), and the hospital stay was longest (median 8 days, P < 0.001). Major complications of TLH were bladder injury (3x), of VH rectum lesion (2x, both at pelvic repair measures), of AH post-operative ileus (2x) and vesico-vaginal fistula (1x).

CONCLUSION

For many patients TLH is a safe and less invasive alternative, especially towards AH, and shows significantly better post-operative reconstitution. Although VH is faster and shows comparable post-operative results, TLH offers the advantage to view the intra-abdominal situs and perform additional steps in case of pathologies.

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.

Safety issues in combined gynecologic and plastic surgical procedures

OBJECTIVES

The combination of gynecologic and plastic surgery procedures in a single surgical setting is becoming increasingly common because it reduces the number of general anesthetics and shortens overall recovery time. The primary concern should be patient safety.

METHODS

A MEDLINE search from 1980 to 2007 was conducted. Articles addressing combined gynecologic surgery with one of the various plastic surgical procedures of the abdomen (abdominoplasty, panniculectomy, and abdominal liposuction) were reviewed. The authors' comprehensive approach to the management of these patients was evaluated.

RESULTS

A unique set of safety issues exists depending on the specific combination of procedures. A review of the literature is discussed, as well as recommendations for maximizing the aesthetic outcomes while optimizing patient safety. Preoperative planning, intraoperative concerns, and postoperative care are all addressed in detail.

CONCLUSIONS

Using a team approach and employing the outlined strategies to minimize complications, combined plastic and gynecologic procedures can be performed safely in appropriate patients.

Future research into abnormal uterine bleeding

Abnormal uterine bleeding in terms of menstrual disorders and postmenopausal bleeding are common clinical problems in both primary and secondary care. Advances in diagnostic and therapeutic technologies have offered opportunities to improve the outcomes of women suffering with these complaints. Future research should concentrate on a robust approach to the assessment of these health technologies, including the use of outcome assessments of importance to patients such as effects on health-related quality of life and taking account of patient preferences. In addition, economic evaluations need to be conducted alongside clinical research to facilitate a rational basis on which to allocate resources and upon which to base clinical decisions. Specific areas highlighted for research in this review include the role of diagnostic technologies incorporating the clinical context within which diagnostic work-up takes place. The clinical application of progesterone antagonists and selective progesterone receptor modulators is a developing area with potential for the treatment of menorrhagia. The place of minimally invasive therapies for the treatment of menstrual dysfunction and fibroid-associated menorrhagia needs more examination, as does the place of outpatient 'ambulatory' settings to provide convenient, effective 'see and treat' targeted services in both primary and secondary care.

Morbidity associated with vaginal hysterectomies in Queensland public teaching hospitals

Hysterectomies performed vaginally are associated with less perioperative risk than those performed abdominally but the risk is not negligible. There are little sizable and/or contemporary Australian data of adverse outcomes associated with vaginal hysterectomy available. A retrospective analysis was undertaken in each of five Queensland public teaching hospitals of the last 200 women in each centre who underwent a vaginal hysterectomy for benign reasons. Serious morbidity complicated 14.0% of vaginal hysterectomies, minor morbidity was associated with 24.0% of hysterectomies and, overall, 29.9% suffered any (ie serious or minor) morbidity. Following multivariate analysis there remained an association between serious perioperative morbidity and ASA > or = 2 (relative risk (RR) 1.89 (1.37-2.61)) and omission of prophylactic antibiotics (RR 2.0 (1.45-2.78)). There also remained an association between any morbidity and use of antidepressants (RR 1.35 (1.07-1.72)), epilepsy (RR 2.00 (136-2.95)), preoperative hypoalbuminaemia (albumin < or = 35 g/L RR 2.08 (1.33-3.24)) as well as ASA > or = 2 (RR 1.24 (1.00-1.54)) and omission of prophylactic antibiotics (RR 1.45 (1.18-1.79)).

Prevention of complications in laparoscopic hysterectomy: Experience with 1120 cases performed by a single surgeon

STUDY OBJECTIVE

The aim of this study is to describe a safe technique without any ureteral, bladder, and major vessel injuries in laparoscopic hysterectomy with a CO2 laser technique.

DESIGN

Prospective study (Canadian Task Force classification II-3).

SETTING

Centre Hospitalier Interrégional Edith Cavell, Department of Obstetrics and Gynecology, Endoscopic Laser Surgery Center, Bruxelles, Belgium; and Kadir Has University, Metropolitan Florence Nightingale Hospital, Istanbul, Turkey.

PATIENTS

One thousand one hundred twenty women with benign diseases.

INTERVENTIONS

Laparoscopic-assisted vaginal hysterectomy (LAVH) or laparoscopic hysterectomy (LH).

MEASUREMENTS AND MAIN RESULTS

Between 1992 and 2004, in 1120 women with benign diseases, consecutive LAVH or LH was planned. During laparoscopic hysterectomy, at all stages, bipolar forceps was used for hemostasis, and a CO2 laser was used for vaporization and excision. The total operating time was 35 to 180 minutes, with a median of 52 minutes (range 35-163) for LAVH (n = 542) and 55 minutes (range 42-180) for LH (n = 552). Operations were successfully completed laparoscopically in 98.8% of the patients. The mean hospital stay was 2 days. The overall major complication rate was 1%. No ureteral, bladder, or major vascular injury occurred.

CONCLUSION

The technique we used in our study is safe and effective in the prevention of ureteral, vesical, and vascular injuries during LAVH and LH; moreover, the use of bipolar coagulation and a CO2 laser in endoscopic surgery results in a shorter duration of operation. This technique provides all the advantages of both laparoscopic and vaginal surgery.

Contraceptive options during perimenopause

During the transition years leading to menopause, the possibility of conception persists, although at a lower rate. Contraceptive choices available to perimenopausal women are as varied as those for their younger counterparts, albeit with some limitations related predominantly to coexisting medical conditions rather than the advancing age itself. In this review, different contraceptive choices pertaining to this age group will be discussed, with a focus on evidence-based data.

The obstetric and gynaecological management of women with inherited bleeding disorders - review with guidelines produced by a taskforce of UK Haemophilia Centre Doctors' Organization

The gynaecological and obstetric management of women with inherited coagulation disorders requires close collaboration between obstetrician/gynaecologists and haematologists. Ideally these women should be managed in a joint disciplinary clinic where expertise and facilities are available to provide comprehensive assessment of the bleeding disorder and a combined plan of management. The haematologist should arrange and interpret laboratory tests and make provision for appropriate replacement therapy. These guidelines have been provided for healthcare professionals for information and guidance and it is also intended that they are readily available for women with bleeding disorders.

Patient selection and surgical technique may reduce major complications of laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE

To study the clinical outcome of patients who underwent laparoscopic-assisted vaginal hysterectomy especially with regard to early postoperative complications.

DESIGN

Retrospective study (Canadian Task Force classification II-3).

SETTING

Private hospital in Hamilton, New Zealand.

PATIENTS

Four hundred eighteen women.

INTERVENTION

Laparoscopic-assisted vaginal hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Primary indication for surgery, operating time, hospital stay, and major complications were analyzed. Major complications were defined as life-threatening injuries, unintended major surgical procedures, and conversions to laparotomy that occurred under duress (eg, intraoperative hemorrhage). Complications were reported up to 6 weeks of postoperative time. The total early postoperative complication rate was 11.24%. No patient had damage to the bowel, ureter, or bladder. There were no deaths. Major complications were three cases of partial vault dehiscence and one case of partial small bowel obstruction. The operation was performed successfully in 412 cases. Six patients needed laparotomy.

CONCLUSIONS

This retrospective study shows that laparoscopic-assisted vaginal hysterectomy is a safe surgical procedure. The possible reasons for the low complication rate reported are the surgical technique of ureteral dissection, the use of suitable instruments to expose the vaginal fornices, a consistent team approach, and the selection of patients.

Hysterectomy

Hysterectomy is one of the most commonly performed major surgical procedures; approximately 100,000 are performed in the UK each year. Hysterectomy can be total or subtotal. The postulated benefits of subtotal hysterectomy--better pelvic floor and sexual function--have not been confirmed in randomised trials. Traditionally, hysterectomy was performed using either an abdominal or vaginal approach. More recently, laparoscopic techniques have been used. The decision about the technique used is often related to the surgeon's training and expertise, as the indications for each technique overlap. Vaginal hysterectomy is probably the preferred route because it is quicker and cheaper than laparoscopic hysterectomy, with no other clear differences in outcome measures. Laparoscopic hysterectomy has a number of advantages over abdominal hysterectomy: specifically, shorter hospital stay and quicker return to normal activities; complication rates, however, appear to be greater. This also seems to be the case with radical hysterectomy performed for cervical cancer.

Alternative medical and surgical options to hysterectomy

The range of alternatives to hysterectomy includes 'expanded' oral medical regimens, the levonorgestrel-releasing intrauterine system (LNG-IUS), a wide range of endometrial ablative techniques, and-where fibroids are the primary pathology-myomectomy and uterine artery embolization. Since research has shown that hysterectomy is a highly effective treatment, these alternatives must be assessed against the recognized high satisfaction rates and improved quality of life reported following hysterectomy. Additional issues that would also need to be addressed include complication rates, side-effects, and cost-effectiveness. For women with prolonged abnormal uterine bleeding, recent research suggests that hysterectomy is significantly superior to an expanded medical treatment regimen for health-related quality-of-life measures. Satisfaction with treatment, and health-related quality of life and psychosocial well-being, are reportedly similar between hysterectomy and the LNG-IUS, but the latter has the advantage of reduced cost. Endometrial ablation reduces menstrual blood flow, but its benefits relative to hysterectomy lessen over time. No large-scale studies have adequately compared uterine artery embolization or myomectomy to hysterectomy. Perhaps the most telling finding from recent research with respect to the place of alternative therapies to hysterectomy is that the existence or advent of these alternatives has not reduced hysterectomy rates, but merely increased treatment options and interventions for excessive menstrual loss.

Laparoscopic hysterectomy for benign diseases

Despite more than 1000 publications on laparoscopic hysterectomy (LH), its role remains difficult to define. LH is not there to replace vaginal hysterectomy, but may be an alternative for abdominal hysterectomy when there are (relative) contraindications for vaginal hysterectomy, including concomitant oophorectomy, previous pelvic surgery and/or risk for adhesions, the larger uterus and nulliparity, and some oncological indications. Randomized trials have demonstrated that, compared to abdominal hysterectomy, LH shortens hospital stay and induces less postoperative pain and quicker recovery at the expense of a longer operation time. LH carries a higher risk for adjacent organ injury, and may be cost-effective, despite higher direct costs, because of the shorter hospital stay and quicker recovery.