The Clinical Contribution of Urodynamics. Urodynamics. London: Springer; 1983. pp. 118-74. [DOI: 10.1007/978-1-4471-3513-5_5]

Total versus subtotal hysterectomy for benign gynaecological conditions

BACKGROUND

Hysterectomy using an abdominal approach removes either the uterus alone (subtotal hysterectomy) or both the uterus and the cervix (total hysterectomy). The latter is more common but the outcomes have not been systematically compared.

OBJECTIVES

To compare short term and long term outcomes of subtotal hysterectomy (STH) with total hysterectomy (TH) for benign gynaecological conditions.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (July 2011), CENTRAL (July 2011), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), CINAHL (January 2005 to July 2011), Biological Abstracts (1980 to December 2005), the National Research Register and relevant citation lists.

SELECTION CRITERIA

Only randomised controlled trials of women undergoing either total or subtotal hysterectomy for benign gynaecological conditions were included.

DATA COLLECTION AND ANALYSIS

Nine trials including 1553 participants were included. Independent selection of trials, assessment for risk of bias and data extraction were undertaken by two review authors and the results compared.

MAIN RESULTS

There was no evidence of a difference in the rates of multiple outcomes that assessed urinary, bowel or sexual function between TH and STH, either in the short term (up to two years post-surgery) or long term (nine years post-surgery). Length of operation (difference of 11 min) and amount of blood lost during surgery (difference of 57 ml) were significantly reduced during subtotal hysterectomy when compared with total hysterectomy. These differences are unlikely to constitute a clinical benefit and there was no evidence of a difference in the odds of blood transfusion. Post-operative fever and urinary retention were less likely (fever: OR 0.48, 95% CI 0.3 to 0.8; retention: OR 0.23, 95% CI 0.1 to 0.8) and ongoing cyclical vaginal bleeding up to two years after surgery was more likely (OR 16.0, 95% CI 6.1 to 41.6) after STH compared with TH. There was no evidence of a difference in the rates of other complications, recovery from surgery, alleviation of pre-surgery symptoms or readmission rates between the two types of hysterectomy carried out through the abdominal or laparoscopic route, although trials comparing the laparoscopic route were underpowered to detect some differences.

AUTHORS' CONCLUSIONS

This review has not confirmed the perception that subtotal hysterectomy offers improved outcomes for sexual, urinary or bowel function when compared with total abdominal hysterectomy. Women are more likely to experience ongoing cyclical bleeding up to a year after surgery with subtotal hysterectomy compared to total hysterectomy.

Total versus subtotal hysterectomy for benign gynaecological conditions

BACKGROUND

Hysterectomy using an abdominal approach removes either the uterus alone (subtotal hysterectomy) or both the uterus and the cervix (total hysterectomy). The latter is more common but outcomes have not been systematically compared.

OBJECTIVES

To assess and compare outcomes with subtotal hysterectomy versus total abdominal hysterectomy for benign gynaecological conditions.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of controlled trials (December 2005), Central (December 2005), Medline (1966 to December 2005), EmBase (1980 to December 2005), Biological Abstracts (1980 to December 2005), the National Research Register and relevant citation lists.

SELECTION CRITERIA

Only randomised controlled trials of women undergoing either total or subtotal hysterectomy for benign gynaecological conditions were included.

DATA COLLECTION AND ANALYSIS

Three trials that included 733 participants were included. Independent selection of trials and data extraction were undertaken by 2 reviewers and results compared.

MAIN RESULTS

There was no evidence of a difference in the rates of incontinence, constipation or measures of sexual function. In one unblinded trial, a significantly greater proportion of women indicated that they had frequent episodes of urinary incontinence after subtotal hysterectomy when compared with total hysterectomy (OR=2.1, 1.02 to 4.3), but these results were not confirmed by the other two trials that measured both stress and urge incontinence and urinary frequency. . Length of surgery and amount of blood lost during surgery were significantly reduced during subtotal hysterectomy when compared with total hysterectomy, but there was no evidence of a difference in the odds of transfusion. Febrile morbidity was less likely (OR=0.43, 0.25 to 0.75) and ongoing cyclical vaginal bleeding one year after surgery was more likely (OR=11.3, 4.1 to 31.2) after subtotal when compared with total hysterectomy. There was no evidence of a difference in the rates of other complications, recovery from surgery or readmission rates.

AUTHORS' CONCLUSIONS

This review has not confirmed the perception that subtotal hysterectomy offers improved outcomes for sexual, urinary or bowel function when compared with total abdominal hysterectomy. Surgery is shorter and intraoperative blood loss and fever are reduced but women are more likely to experience ongoing cyclical bleeding up to a year after surgery with subtotal hysterectomy compared to total hysterectomy.

A combined urodynamic and continence unit--a review of the first 19 years

We have completed a 19-year audit of all patients referred to the urodynamic/continence unit since its inception in 1972 and their subsequent clinical management; a total of 20,437 patients were referred, increasing from 51 in the first year to 1564 in 1990. Although the annual number of referrals has remained constant for the last 8 years, the need for more complex urodynamic assessment such as video-cystourethrography has increased from 5% (56/1164) in 1981 to 25% (385/1564) in 1990. The number of out-patient attendances to medical, physiotherapy and continence clinics has also increased over that period. We conclude that the number of referrals represents increasing recognition of the value of urodynamic assessment. Accurate diagnosis leads to more effective treatment, whether surgical, medical or conservative. Some methods of diagnosis are complex and suitable only for a tertiary referral centre.

Medical treatment of female urge incontinence

Urge incontinence is a common symptom in women. The etiology is multifactorial. In most patients, however, the underlying cause remains unclear. Symptomatic treatment with detrusor inhibiting drugs constitutes the mainstay of therapy in these idiopathic cases. Many drugs have been proposed although the documentary proof of their efficacy varies. Limited efficacy and systemic side effects are frequent problems using available drugs. Rational pharmacotherapy requires an up to date knowledge of the physiology, pathophysiology and the clinical pharmacology of the lower urinary tract. The principles of drug therapy should be based on: 1) meticulous assessment of the patient; 2) precise classification of the bladder dysfunction; 3) individual drug selection and dose adjustment; and 4) current control with critical assessment of the indications for continued therapy.

Incontinence among nursing home patients: clinical and functional correlates

This study was undertaken to examine the association of specific medical and genitourinary conditions, medications, and functional disabilities with urinary incontinence (UI) in a nursing home (NH) population. Seventy-six incontinent and 38 continent patients in a Veterans Administration NH were studied. Incontinence was highly associated with each of the physical and mental functional disabilities we examined. However, with the exception of recurrent urinary tract infections and dementia, no specific clinical factors were significantly more common among incontinent than continent patients. Although precise causes for the UI were not determined, these data highlight the potential role of impairments of physical and/or mental function in the pathogenesis of UI among NH patients, and emphasize the need to address these impairments in future research on the assessment and treatment of UI in this population.