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Abstract
BACKGROUND Hysterectomy might adversely affect pelvic floor functions and result in many different symptoms, such as urinary and anal incontinence, obstructed defecation, and constipation. OBJECTIVE The aim of this prospective study was to evaluate the influence of hysterectomy on pelvic floor disorders. DESIGN This was a prospective and longitudinal study. SETTINGS The study was conducted at the Ankara University Department of Surgery and the Dr Zekai Tahir Burak Women's Health Research and Education Hospital between September 2008 and March 2011. PATIENTS The study was performed on patients who underwent hysterectomy for benign pathologies. MAIN OUTCOME MEASURES A questionnaire about urinary incontinence (International Continence Society scoring), anal incontinence, constipation, and obstructed defecation (Rome criteria and constipation severity score), along with an extensive obstetric history, was administered preoperatively and postoperatively annually for 4 years. RESULTS Patients (N = 327) who had completed each of the 4 annual postoperative follow-ups were included in this study. Compared with the preoperative observations, the occurrence of each symptom was significantly increased at each of the follow-up years (p < 0.001). Over the 4 postoperative years, the frequencies for constipation (n = 245) were 7.8%, 8.2%, 8.6%, and 5.3%; those for obstructed defecation (n = 269) were 4.5%, 5.2%, 4.1%, and 3.0%; those for anal incontinence (n = 252) were 4.8%, 6.3%, 6.0%, and 5.2%, and those for urinary incontinence (n = 99) were 12.1%, 12.1%, 11.1%, and 13.1%. In addition, patients who had no preoperative symptom (n = 70) from any of the selected symptoms showed a postoperative occurrence of at least 1 of these symptoms of 15.8%, 14.3%, 11.4%, and 8.6% for the postoperative years 1, 2, 3, and 4. LIMITATIONS Although the study had several limitations, no comparison with a control population was the most important one. CONCLUSIONS Hysterectomy for benign gynecologic pathologies had a significant negative impact on pelvic floor functions in patients who had no previous symptoms.
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Selcuk S, Cam C, Asoglu MR, Kucukbas M, Arinkan A, Cikman MS, Karateke A. Effect of simple and radical hysterectomy on quality of life – analysis of all aspects of pelvic floor dysfunction. Eur J Obstet Gynecol Reprod Biol 2016; 198:84-88. [DOI: 10.1016/j.ejogrb.2016.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/10/2015] [Accepted: 01/01/2016] [Indexed: 10/22/2022]
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Bowel dysfunction after total abdominal hysterectomy for benign conditions: a prospective longitudinal study. Eur J Gastroenterol Hepatol 2013; 25:1217-22. [PMID: 23765125 DOI: 10.1097/meg.0b013e328362dc5e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM On the basis of retrospective studies, hysterectomy has been considered a risk factor for functional bowel disorders. The aim of this study was to prospectively evaluate the patients' bowel function and general health-related quality of life (QoL) before and after hysterectomy. Our hypothesis was that hysterectomy in properly selected patients can impact positively on the patients' self-reporting of their general health and bowel function. MATERIALS AND METHODS A prospective longitudinal observational study was conducted in a university-based teaching hospital. Eighty-five patients who were scheduled for total abdominal hysterectomy for a nonmalignant cause completed the study. The main outcome measure was the patient's perception of her bowel function, which was assessed preoperatively and at 6, 12, 26 and 52 weeks postoperatively using the gastrointestinal quality of life questionnaire. The patient's general health was also assessed using a generic general health questionnaire (EQ5D and EQVAS). The effect of time on change in questionnaire score was assessed using mixed model repeated measures at a significance level of 0.05. RESULTS The scores in the three questionnaires declined significantly at 6 weeks postoperatively as compared with those obtained preoperatively. However, there was a subsequent increase in the scores up to 12 months postoperatively. Smoking and use of laxative were identified as potential confounding variables. CONCLUSION Apart from a transient negative effect, total abdominal hysterectomy improves the patient's gastrointestinal-related QoL, probably as part of general improvement in their QoL.
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Park SK, Myung SJ, Jung KW, Chun YH, Yang DH, Seo SY, Ku HS, Yoon IJ, Kim KJ, Ye BD, Byeon JS, Jung HY, Yang SK, Kim JH. Biofeedback therapy for female patients with constipation caused by radical hysterectomy or vaginal delivery. J Gastroenterol Hepatol 2013; 28:1133-40. [PMID: 23425064 DOI: 10.1111/jgh.12158] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIM Chronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy. METHODS Of the constipated patients, a hysterectomy group (n = 40), delivery group (n = 41), and a control group (n = 89), who had no history of either surgery or delivery before developing functional constipation were included. Their anorectal physiological tests and the effectiveness of biofeedback therapy were investigated. RESULTS The volume of desire to defecate was greater in the hysterectomy group than in the control group (86.5 ± 55.0 mL vs 62.9 ± 33.7 mL; P = 0.03), and more than 240 mL of maximal volume of toleration was more frequently noted in the hysterectomy group (32.5%) than in the delivery group (14.6%) and control group (13.5%) (P = 0.02).The failure of balloon expulsion was more frequently noted in the delivery group (44.0%) than in the hysterectomy group (15.0%) and control group (25.0%) (P = 0.01). The defecation satisfaction score was significantly increased after biofeedback therapy in the hysterectomy group (2.0 ± 2.7 vs 7.8 ± 1.5, P < 0.001), the delivery group (1.6 ± 2.1 vs 6.7 ± 2.0, P < 0.001), and the control group (2.5 ± 2.7 vs 6.9 ± 2.1, P < 0.001). CONCLUSIONS Rectal hyposensitivity could have been the characteristic mechanism in the hysterectomy group, whereas dyssynergic defecation could have been the cause in the delivery group. Biofeedback therapy was effective for both groups.
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Affiliation(s)
- Soo-Kyung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Ridolfi TJ, Tong WD, Kosinski L, Takahashi T, Ludwig KA. Recovery of colonic transit following extrinsic nerve damage in rats. Scand J Gastroenterol 2011; 46:678-83. [PMID: 21561284 DOI: 10.3109/00365521.2011.560682] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Injury to pelvic sympathetic and parasympathetic nerves from surgical and obstetrical trauma has long been cited as a cause for abnormal colorectal motility in humans. Using a rat model, acute transaction of these extrinsic nerves has been shown to effect colorectal motility. The aim of this study is to determine in a rat model how transection of these extrinsic nerves affects colonic transit over time. METHODS Eighty-two Sprague-Dawley rats underwent placement of a tunneled catheter into the proximal colon. Bilateral hypogastric, pelvic nerves (HGN and PN) or both were transected in 66 rats. The remaining 16 rats received a sham operation. Colonic transit was evaluated at postoperative days (PODs) 1, 3, and 7 by injecting and calculating the geometric center (GC) of the distribution of (51)Cr after 3 h of propagation. RESULTS At POD 1, transection of PNs significantly delayed colonic transit (GC = 4.9, p < 0.05), while transection of HGNs (GC = 8.5, p < 0.05) or transection of both nerves (GC = 7.8, p < 0.05) significantly accelerated colonic transit, when compared with sham operation (GC = 6.0). A significant trend toward recovery was noted in both the HGN and PN transection groups at POD 7. CONCLUSIONS Damage to the extrinsic sympathetic and/or parasympathetic PNs affects colonic transit acutely. These changes in large bowel motor function normalize over time implicating a compensatory mechanism within the bowel itself.
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Affiliation(s)
- Timothy J Ridolfi
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Tong W, Kamiyama Y, Ridolfi TJ, Zietlow A, Zheng J, Kosinski L, Ludwig K, Takahashi T. The role of 5-HT3 and 5-HT4 receptors in the adaptive mechanism of colonic transit following the parasympathetic denervation in rats. J Surg Res 2010; 171:510-6. [PMID: 20691988 DOI: 10.1016/j.jss.2010.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 04/20/2010] [Accepted: 05/04/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Clinical studies show that disturbed colonic motility induced by extrinsic nerves damage is restored over time. We studied whether 5-HT3 and 5HT4 receptors are involved in mediating the adaptive mechanisms following parasympathetic denervation. METHODS Parasympathetic denervation of the entire colon was achieved by bilateral pelvic nerve transection and truncal vagotomy in rats. Colonic transit was measured by calculating the geometric center (GC) of 51Cr distribution. Expression of 5-HT3 and 5HT4 receptor mRNA was determined by real time RT-PCR. RESULTS Parasympathetic denervation caused a significant delay in colonic transit (GC=4.36) at postoperative day (POD) 1, compared with sham operation (GC=6.31). Delayed transit was gradually restored by POD 7 (GC=5.99) after the denervation. Restored colonic transit was antagonized by the administration of 5-HT3 and 5HT4 receptors antagonists at POD 7. 5-HT3 and 5HT4 receptors mRNA expression were significantly increased in the mucosal/submucosal layer at POD 3 or POD 7, whereas no significant difference was observed in the longitudinal muscle layers adherent with the myenteric plexus (LMMP). CONCLUSIONS It is suggested that up-regulation of 5-HT3 and 5-HT4 receptors expression in the mucosal/submucosal layer is involved to restore the delayed transit after the parasympathetic denervation in rats.
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Affiliation(s)
- Weidong Tong
- Department of Surgery, Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, Wisconsin 53295, USA
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Tong W, Kamiyama Y, Ridolfi TJ, Zietlow A, Zheng J, Kosinski L, Ludwig K, Takahashi T. The role of 5-HT3 and 5-HT4 receptors in the adaptive mechanism of colonic transit following the parasympathetic denervation in rats. THE JOURNAL OF SURGICAL RESEARCH 2010. [PMID: 20691988 DOI: 10.1016/j.jss] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical studies show that disturbed colonic motility induced by extrinsic nerves damage is restored over time. We studied whether 5-HT3 and 5HT4 receptors are involved in mediating the adaptive mechanisms following parasympathetic denervation. METHODS Parasympathetic denervation of the entire colon was achieved by bilateral pelvic nerve transection and truncal vagotomy in rats. Colonic transit was measured by calculating the geometric center (GC) of 51Cr distribution. Expression of 5-HT3 and 5HT4 receptor mRNA was determined by real time RT-PCR. RESULTS Parasympathetic denervation caused a significant delay in colonic transit (GC=4.36) at postoperative day (POD) 1, compared with sham operation (GC=6.31). Delayed transit was gradually restored by POD 7 (GC=5.99) after the denervation. Restored colonic transit was antagonized by the administration of 5-HT3 and 5HT4 receptors antagonists at POD 7. 5-HT3 and 5HT4 receptors mRNA expression were significantly increased in the mucosal/submucosal layer at POD 3 or POD 7, whereas no significant difference was observed in the longitudinal muscle layers adherent with the myenteric plexus (LMMP). CONCLUSIONS It is suggested that up-regulation of 5-HT3 and 5-HT4 receptors expression in the mucosal/submucosal layer is involved to restore the delayed transit after the parasympathetic denervation in rats.
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Affiliation(s)
- Weidong Tong
- Department of Surgery, Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, Wisconsin 53295, USA
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Rectocele and intussusception: is there any coherence in symptoms or additional pelvic floor disorders? Tech Coloproctol 2009; 13:17-25; discussion 25-6. [PMID: 19288249 DOI: 10.1007/s10151-009-0454-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 12/04/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with a rectocele often suffer from such symptoms as obstructed defaecation, urine or stool incontinence and pain. The aim of this study was to assess other concomitant pelvic floor disorders and their influence on pelvic function. METHODS Included in the study were 37 female patients with a significant rectocele and defaecation disorder. Medical history and symptoms were analysed in terms of validated functional scores. All patients underwent open magnetic resonance defaecography (MRD) in a sitting position. Imaging was analysed for the presence and size of the rectocele, intussusception and other pelvic floor disorders. RESULTS Patients with a higher body mass index tended to have a larger rectocele, whereas age and vaginal birth did not correlate with the size of the rectocele. In 67.5% of the patients with a previously diagnosed rectocele, an intussusception was diagnosed on MRD. This group suffered from significantly worse urine incontinence (p=0.023) and from accessory enteroceles 64%, compared with 17% (p=0.013) for those with a simple rectocele. Patients with higher grade intussusception suffered more frequently from incontinence than from constipation. CONCLUSION Patients with a symptomatic rectocele frequently have other pelvic floor disorders that significantly influence the pattern of symptoms. Knowledge of all the afflictions is essential for determining the optimal treatment for each individual patient.
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Robert M, Soraisham A, Sauve R. Postoperative urinary incontinence after total abdominal hysterectomy or supracervical hysterectomy: a metaanalysis. Am J Obstet Gynecol 2008; 198:264.e1-5. [PMID: 18199420 DOI: 10.1016/j.ajog.2007.09.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Revised: 07/14/2007] [Accepted: 09/19/2007] [Indexed: 01/08/2023]
Abstract
OBJECTIVE A metaanalysis of randomized trials was conducted to evaluate if the type of hysterectomy, total abdominal hysterectomy or supracervical hysterectomy, has an impact on the development of urinary incontinence. STUDY DESIGN We searched MEDLINE, EMBASE, CINAHL, Biological Abstract, and the Cochrane Library up to February 2007; abstracts at major meetings and bibliographies of retrieved articles were scanned. A fixed effect model was used to calculate summary relative risk estimates and 95% confidence intervals (CIs). RESULTS Analysis showed no statistical difference in the risk of developing stress or urge urinary incontinence in women who underwent supracervical hysterectomy compared with women who underwent total abdominal hysterectomy (relative risk, 1.3; 95% CI, 0.94-1.78; P = 0.16 and relative risk, 1.37; 95% CI, 0.77-2.46; P = .25). CONCLUSION There is no statistical evidence of a different risk for developing either stress or urge urinary incontinence after a supracervical hysterectomy or a total hysterectomy.
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Affiliation(s)
- Magali Robert
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada.
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Forsgren C, Zetterström J, Lopez A, Nordenstam J, Anzen B, Altman D. Effects of hysterectomy on bowel function: a three-year, prospective cohort study. Dis Colon Rectum 2007; 50:1139-45. [PMID: 17587089 DOI: 10.1007/s10350-007-0224-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Catharina Forsgren
- Pelvic Floor Center, Department of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden.
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de Tayrac R, Chevalier N, Chauveaud-Lambling A, Gervaise A, Fernandez H. Is vaginal hysterectomy a risk factor for urinary incontinence at long-term follow-up? Eur J Obstet Gynecol Reprod Biol 2007; 130:258-61. [PMID: 16876308 DOI: 10.1016/j.ejogrb.2006.01.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2005] [Revised: 11/22/2005] [Accepted: 01/30/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the prevalence of urinary symptoms at long-term follow-up after vaginal hysterectomy. STUDY DESIGN One hundred and seventeen patients, who had a vaginal hysterectomy for menorrhagia, from January 1991 to December 2001, answered to a self-report questionnaire about de novo urinary symptoms. The control group was a population of 116 patients who had a conservative treatment for dysfunctional uterine bleeding by endometrial thermocoagulation from January 1994 to December 2001. RESULTS Patient characteristics (mean age, mean parity, menopausal status, smoking status, drink habits) were similar in the two groups. Mean follow-up was 4.6+/-2.2 years (range 1.5-11) after vaginal hysterectomy and 4+/-1.8 years (range 1.5-7) after conservative treatment. The prevalence of urinary symptoms, included urge and stress incontinence, were statistically similar in the two groups. CONCLUSION This study reveals no risk of urge or stress urinary incontinence at long-term follow-up after vaginal hysterectomy, compared with conservative treatment.
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Affiliation(s)
- Renaud de Tayrac
- Department of Obstetrics and Gynecology, Antoine Beclere Hospital, Clamart, France.
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Gustafsson C, Ekström A, Brismar S, Altman D. Urinary incontinence after hysterectomy—three-year observational study. Urology 2006; 68:769-74. [PMID: 17070350 DOI: 10.1016/j.urology.2006.04.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Revised: 02/28/2006] [Accepted: 04/03/2006] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Catharina Gustafsson
- Division of Obstetrics and Gynecology, Pelvic Floor Center, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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Abstract
Although the survival outcome for treated, early-stage, node-negative cervical cancer is excellent, the operation of radical hysterectomy conveys major morbidity, particularly with respect to bladder and bowel function. There may be some degree of spontaneous recovery, but a significant proportion of postoperative women will have to live with the disabling effects of surgery for decades, and few seek help for their distress. As such, quality of life issues have become highly relevant in the management of this disease, and attention has turned to reducing morbidity, especially to the pelvic viscera. This review presents an overview of the surgical mechanisms presumed to be responsible for pelvic floor denervation and describes subsequent bladder and bowel dysfunction, together with future possibilities for minimizing morbidity, including less radical, more individual surgery, and nerve-sparing techniques.
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Affiliation(s)
- K S Jackson
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, United Kingdom.
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de Tayrac R, Chevalier N, Chauveaud-Lambling A, Gervaise A, Fernandez H. Risk of urge and stress urinary incontinence at long-term follow-up after vaginal hysterectomy. Am J Obstet Gynecol 2004; 191:90-4. [PMID: 15295347 DOI: 10.1016/j.ajog.2004.01.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the prevalence of urinary symptoms at long-term follow-up after vaginal hysterectomy. STUDY DESIGN One hundred seventeen patients who had a vaginal hysterectomy for menorrhagia from January 1991 to December 2001 answered a self-report questionnaire about de novo urinary symptoms. The control group was a population of 116 patients who had a conservative treatment for dysfunctional uterine bleeding by endometrial thermocoagulation from January 1994 to December 2001. RESULTS Patient characteristics (mean age, mean parity, menopausal status, smoking status, drink habits) were similar in the 2 groups. Mean follow-up was 4.6+/-2.2 years (range, 1.5-11 years) after vaginal hysterectomy and 4+/-1.8 years (range, 1.5-7 years) after conservative treatment. The prevalence of urinary symptoms, which included urge and stress incontinence, was statistically similar in the 2 groups. CONCLUSION This study reveals no risk of urge or stress urinary incontinence at long-term follow-up after vaginal hysterectomy, compared with conservative treatment.
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Affiliation(s)
- Renaud de Tayrac
- Department of Obstetrics and Gynecology, Antoine Beclere Hospital, Clamart, France.
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Altman D, Zetterström J, López A, Pollack J, Nordenstam J, Mellgren A. Effect of hysterectomy on bowel function. Dis Colon Rectum 2004; 47:502-8; discussion 508-9. [PMID: 14994113 DOI: 10.1007/s10350-003-0087-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Daniel Altman
- Department of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden.
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Complications of Hysterectomy. Obstet Gynecol 2001. [DOI: 10.1097/00006250-200109000-00028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Williams NS, Fajobi OA, Lunniss PJ, Scott SM, Eccersley AJ, Ogunbiyi OA. Vertical reduction rectoplasty: a new treatment for idiopathic megarectum. Br J Surg 2000; 87:1203-8. [PMID: 10971429 DOI: 10.1046/j.1365-2168.2000.01528.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aetiology of idiopathic megarectum is unknown and the results of surgery are often unsatisfactory. Rectal hyposensation is common and poor perception of rectal filling may contribute to the poor evacuatory function. By reducing the capacity of the rectum, it was hypothesized that sensory thresholds to rectal distension and perception of urge to defaecate would be improved. METHODS Vertical reduction rectoplasty (VRR) and concomitant sigmoid colectomy was performed on six patients with idiopathic megarectum. Patients were evaluated before and after operation by detailed questionnaire and anorectal physiology. Postoperative rectal compliance was also studied by means of a programmable electronic barostat. Where appropriate, physiological data were compared with those obtained in eight healthy volunteers. RESULTS Bowel frequency increased from a preoperative median of 2.5 to 16 per month after operation. Four patients reported improved rectal perception of the urge to defaecate. Thresholds for defaecatory urge and maximum tolerated volume were significantly reduced following VRR (P<0.05). Post-VRR rectal compliance was no different from that in healthy volunteers. Colonic transit time decreased significantly after VRR (P<0.05) and evacuation on proctography increased from a median of 30 per cent to 50 per cent. At a median of 57 weeks' follow-up five of the six patients expressed continued satisfaction with the results. CONCLUSION VRR is a new approach to the treatment of idiopathic megarectum. Clinical and physiological studies confirm that it can improve sensory feedback and defaecation. The procedure needs further evaluation as the number of patients undergoing the procedure increases.
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Affiliation(s)
- N S Williams
- Academic Department of Surgery, The Royal London Hospital, London, UK
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Abstract
BACKGROUND Serious complications after hysterectomy are estimated to occur in around six women per 10,000 hysterectomies in the USA. We did a systematic review of evidence that hysterectomy is associated with urinary incontinence. METHODS We identified English-language and non-English-language articles registered on MEDLINE from January, 1966, to December, 1997, did manual review of references, and consulted specialists. We identified 45 articles reporting on the association of urinary incontinence and hysterectomy. We selected reports that presented original data on development of incontinence in women who underwent hysterectomy compared with those who did not. Results were abstracted by two independent reviewers and summarised with a random-effects model. FINDINGS 12 papers met our selection criteria--eight cross-sectional studies, two prospective cohort studies, one case-control study, and one randomised controlled trial. The summary estimate was consistent with increased odds for incontinence in women with hysterectomy. Because incontinence might not develop for many years after hysterectomy, we stratified the findings by age at assessment of incontinence. Among women who were 60 years or older, the summary odds ratio for urinary incontinence was increased by 60% (1.6 [95% CI 1.4-1.8]) but odds were not increased for women younger than 60 years. INTERPRETATION When women are counselled about sequelae of hysterectomy, practitioners should discuss the possibility of an increased likelihood of incontinence in later life.
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Affiliation(s)
- J S Brown
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, USA.
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19
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Schultz I, Mellgren A, Dolk A, Johansson C, Holmström B. Long-term results and functional outcome after Ripstein rectopexy. Dis Colon Rectum 2000; 43:35-43. [PMID: 10813121 DOI: 10.1007/bf02237241] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to evaluate operative mortality, morbidity, and functional results after Ripstein rectopexy for rectal prolapse and internal rectal intussusception. METHODS Sixty-nine patients with rectal prolapse and 43 with internal rectal intussusception were included. All patient records were studied and complications registered. Long-term follow-up was possible in 105 patients and performed by clinical examination and standardized interview, telephone interview, or patient records. Seventy-six patients were prospectively evaluated, comparing bowel function before and after rectopexy. RESULTS There was no operative mortality. Operative morbidity was 33 percent, and most complications were minor. Severe early complications included one large-bowel obstruction and one transient ureteric stenosis. Median time of follow-up was seven years in patients with rectal prolapse and 5.4 years in patients with internal rectal intussusception. Late complications included two rectovaginal fistulas and one lethal sigmoid fecaloma. Five patients underwent subtotal colectomy for severe constipation. There was one recurrent prolapse (1.6 percent). Functional evaluation showed that incontinence improved (P = 0.049), whereas the number of bowel movements per week decreased (P < 0.001). Frequency of emptying difficulties did not change significantly in patients with rectal prolapse but increased in patients with internal rectal intussusception (P = 0.038). CONCLUSION Ripstein rectopexy can be performed with low mortality and recurrence rate, but with a high early complication rate. There were also some serious late complications. Continence was improved, although increased constipation was a problem in some patients, especially among those with internal rectal intussusception.
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Affiliation(s)
- I Schultz
- Department of Surgery, Karolinska Institutet at Danderyd Hospital, Stockholm, Sweden
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20
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Raz R, Gennesin Y, Wasser J, Stoler Z, Rosenfeld S, Rottensterich E, Stamm WE. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 2000; 30:152-6. [PMID: 10619744 DOI: 10.1086/313596] [Citation(s) in RCA: 220] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
To evaluate factors associated with recurrent urinary tract infection (UTI) in postmenopausal women, we conducted a case-control study comparing 149 postmenopausal women referred to an infectious diseases outpatient clinic who had a history of recurrent UTI (case patients) with 53 age-matched women without a history of UTI (control patients). Each woman completed a questionnaire providing demographic data, history and clinical characteristics of prior infections, and information regarding risk factors for UTI. In addition, each patient underwent a gynecologic evaluation, renal ultrasound and urine flow studies, and blood group and secretor status testing. Three urologic factors-namely, incontinence (41% of case patients vs. 9.0% of control patients; P<.001), presence of a cystocele (19% vs. 0%; P<.001), and postvoiding residual urine (28% vs. 2.0%; P=.00008)-were all strongly associated with recurrent UTI. Multivariate analysis showed that urinary incontinence (odds ratio [OR], 5.79; 95% confidence interval [CI], 2.05-16.42; P=.0009), a history of UTI before menopause (OR, 4.85; 95% CI, 1.7-13.84; P=. 003), and nonsecretor status (OR, 2.9; 95% CI, 1.28-6.25; P=.005) were most strongly associated with recurrent UTI in postmenopausal women. Prospective studies are needed to confirm these observations and to develop approaches for prevention.
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Affiliation(s)
- R Raz
- Infectious Diseases Unit, Haemek Medical Center, and Technion Faculty of Medicine, Haifa, Israel
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21
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Roy AJ, Emmanuel AV, Storrie JB, Bowers J, Kamm MA. Behavioural treatment (biofeedback) for constipation following hysterectomy. Br J Surg 2000; 87:100-5. [PMID: 10606919 DOI: 10.1046/j.1365-2168.2000.01324.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Constipation after hysterectomy has been postulated to be due to pelvic nerve damage, but there may be emotional or reversible physical factors of pathophysiological relevance. The aim of this study was to determine whether such constipation is responsive to behavioural treatment. METHODS Three groups of patients who had completed a course of biofeedback treatment were compared: women with no history of abdominal or pelvic surgery (n = 25), women for whom a hysterectomy had led to no change in bowel function (n = 27) and women who stated that their constipation was precipitated (n = 18) or severely worsened (n = 8) by hysterectomy. Pretreatment and post-treatment details about bowel function and symptoms were assessed using structured interview, and pretreatment whole-gut transit time and anorectal physiology testing were assessed for prognostic relevance. RESULTS Follow-up after completing treatment was a median of 28 (range 12-44) months. Forty-eight of 78 patients considered that their constipation had improved with treatment; the proportion in each group was similar (P = 0.73). Biofeedback reduced the need to strain, reduced abdominal pain, improved bowel frequency, and reduced laxative use to a similar degree in all three groups. Thirty-three of 53 patients with slow transit considered there was an improvement, compared with 15 of 22 with measured normal transit. Physiological testing did not predict outcome and did not differ between the three groups. CONCLUSION The majority of patients complaining of constipation induced or worsened by hysterectomy respond subjectively to behavioural treatment, in a similar proportion to those with idiopathic constipation. In contrast to the widely held view that nerve damage is responsible for symptoms, reversible factors are likely to be important in many patients.
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Affiliation(s)
- A J Roy
- St Mark's Hospital, Northwick Park, Harrow HA1 3UJ, UK
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22
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Thom DH, Brown JS. Reproductive and hormonal risk factors for urinary incontinence in later life: a review of the clinical and epidemiologic literature. J Am Geriatr Soc 1998; 46:1411-7. [PMID: 9809764 DOI: 10.1111/j.1532-5415.1998.tb06009.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review and integrate the current literature on the role of reproductive factors in the development of urinary incontinence in later life. DESIGN An extensive literature review using Medline and Science Citation Index for the period 1966 through 1997 was undertaken to identify published studies of the association between parturition events, hysterectomy, menopause, estrogen therapy, and later urinary incontinence. RESULTS Vaginal delivery is an established risk factor for both transient postpartum incontinence and the development of incontinence in later life. Several studies have found evidence of nerve and muscle damage that provide a physiologic basis for this association. Prospective studies of incontinence after hysterectomy have generally found no increased risk in the first few years. In contrast, cross-sectional epidemiologic studies have consistently found an increased risk many years after hysterectomy. Although menopause is often considered a risk factor for urinary incontinence, epidemiological studies have generally not found an increase in the prevalence of incontinence in the perimenopausal period. Oral estrogen replacement therapy seems to have little short-term clinical benefit in regard to incontinence and is associated consistently with increased risk of incontinence in women aged 60 years and older in epidemiologic studies. CONCLUSIONS This review provides a framework for further investigation of the complex relationships between reproductive risk factors and urinary incontinence. Integration of physiologic, clinical, and epidemiologic studies is needed to address the compelling health care issue of urinary incontinence. Suggestions are made for further areas of research.
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Affiliation(s)
- D H Thom
- Stanford University, Palo Alto, California, USA
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23
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Cutler WB, Genovese-Stone E. Wellness in women after 40 years of age: the role of sex hormones and pheromones. Dis Mon 1998; 44:421-546. [PMID: 9803240 DOI: 10.1016/s0011-5029(98)90016-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In the past twenty years hundreds of peer-reviewed studies have provided a significant body of information to guide the health care of women in the second halves of their lives. The harmonic nature of the fertile reproductive system forms the background against which hormonal replacement therapy can be understood to best serve women. In addition, the 1986 discovery of human pheromones and the subsequent 1998 confirmation of their existence increases certain sexual options for maturing women. Not all hormonal replacement therapies and wellness regimens serve women well. Some regimens have the potential to produce disease, especially over-the-counter remedies like dehydroepiandrosterone and the formulas that contain estrogen. Some regimens profoundly improve the quality of life of many women; some women do not need or want such regimens. All sex hormones affect physiologic systems including the cardiovascular system, bone metabolism, cognitive function, sexual response, and sexual attractiveness. The 7 years before menopause have recently been revealed to be an extremely complex era. During this period, some women increase their estrogen levels to new lifetime highs; others start an unequivocal decline, and still others vary from month to month. Coupled to this variability in estrogen is an equally variable set of changes in progesterone secretion by the ovary as androgen secretion patterns also change. Many women show increases in circulating androgens while many others show deficiencies. Both the adrenal and the ovarian sources of these hormones show age-related changes that alter a woman's capacity to attract sexual attention through both her physical appearance (and condition) and her pheromonal excretions. The complex contributions to the overall health of a woman may not always be understood. Often a hysterectomy can exacerbate--rather than ameliorate--the conditions that led to the surgery. One in 2 American women is offered a hysterectomy, a rate 5 times higher than that of the European countries for which data are available. Ninety percent of hysterectomies are not related to cancer; they are elective procedures. Avoidance of elective hysterectomy helps prevent its side effects: sexual deficits, acceleration of cardiovascular and bone disease, and more rapid aging. No efficacy data exist that suggest that elective hysterectomy works better than the alternative approaches that do not induce these side effects. The health and well-being of women who have already had hysterectomies, with or without ovariectomies, can be improved by a recognition of the cascade of difficulties that must addressed. Estrogen, progesterone, and androgens all tend to be compromised by hysterectomy; all should be considered for replacement. Because hormonal regimens can be prescribed to enhance the quality of life, the review of the available research can allow the medical art to greatly benefit mature women. Not surprisingly, the emerging conclusion reveals that structurally human hormones, prescribed appropriately, almost always best serve the patient.
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Affiliation(s)
- W B Cutler
- Athena Institute for Women's Wellness Chester Springs, Pennsylvania, USA
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24
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Abstract
Hysterectomy is a popular operation that has a number of complications associated with it. The most common are hemorrhage, infection, and injuries to adjacent organs. Unintended major surgical procedures and second operations occur in approximately 4% of patients undergoing hysterectomy. Laparoscopic hysterectomy is a controversial new procedure that has both advocates and detractors. In skilled hands, the complication rate of laparoscopic hysterectomy does not exceed that of traditional hysterectomy methods. At the present time, there is a growing consensus that removal of the uterus only does not lead to an increase in psychosexual morbidity. It also appears that hysterectomy procedures have little, if any, effect on lower urinary tract function.
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Affiliation(s)
- W J Harris
- East Tennessee State University, Quillen College of Medicine, Johnson City, USA
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25
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van Dam JH, Gosselink MJ, Drogendijk AC, Hop WC, Schouten WR. Changes in bowel function after hysterectomy. Dis Colon Rectum 1997; 40:1342-7. [PMID: 9369110 DOI: 10.1007/bf02050820] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE It has been suggested that hysterectomy has a disturbing influence on bowel function. To assess the incidence and nature of these changes, we performed a retrospective study. METHODS A retrospective study was performed in all 593 women who had undergone hysterectomy between 1989 and 1993. A control group consisted of 100 women who had undergone laparoscopic cholecystectomy. RESULTS The response rate was 90 percent (n = 531; median age, 45 (range, 18-84) years). Of the responding women, 315 patients (59 percent) indicated a normal defecation pattern before hysterectomy. Of these women, severe deterioration in bowel function was reported by 98 patients (31 percent), whereas 36 women (11 percent) mentioned a moderate change after hysterectomy. Most frequent symptoms were severe straining (90 patients), incomplete and/or digital evacuation (83 and 50 patients, respectively). According to most patients, the changes in bowel function were reported to have started within one month after hysterectomy. With advancing age, fewer complaints were recorded (P = 0.008). No significant difference was found in the incidence of disturbed bowel function between the different types of operation (abdominal, vaginal, supravaginal, or radical hysterectomy). In the control group, the response rate was 96 percent. Median age of these women was 46 (range, 25-78) years. Fifty-eight patients (60 percent) reported normal bowel function before laparoscopic cholecystectomy. In this group of patients, disturbed bowel function after surgery was reported by five women (9 percent), which figure is significantly (P < 0.001) lower compared with that in the corresponding hysterectomy group. CONCLUSION Hysterectomy seems to play an important role in the pathogenesis of disturbed defecation.
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Affiliation(s)
- J H van Dam
- Department of General Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands
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Roberts RN, Norman BP, Harrison CG, Heaton NR, Law JK, Wadehra V, Younger HM, West CP. A medical audit and patient survey of hysterectomies performed for menstrual disorders. Scott Med J 1996; 41:44-6. [PMID: 8735501 DOI: 10.1177/003693309604100204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The aim of the study was to carry out an audit of 283 hysterectomies performed for menstrual disorders over a one year period, and to determine the satisfaction of the women concerned towards their treatment. The medical records of these patients were examined, and they were each sent a questionnaire, 69% of which were completed and returned. The most common presenting symptoms were menorrhagia and dysmenorrhoea. In 53% of cases no clinical abnormality was postulated and in 31% of cases no pathological abnormality was found. The preoperative clinical and pathological diagnoses were in agreement for 59% of patients. Over 90% of women were satisfied with the management of their case by their GP and the gynaecology outpatient clinic. The use of patient-controlled analgesia systems was associated with better post-operative pain relief than intramuscular injections. Thirteen percent of patients required blood transfusion; 21% suffered some form of postoperative complication, most of which were minor. Ninety-four percent of the women were pleased that they had undergone hysterectomy, and 76% wished that they had had the operation sooner. It was concluded that hysterectomy is perceived positively by patients and should not necessarily be considered as a last resort treatment for menstrual disorders.
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Affiliation(s)
- R N Roberts
- Department of Obstetrics and Gynaecology, University of Edinburgh
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27
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Infantino A, Masin A, Melega E, Dodi G, Lise M. Does surgery resolve outlet obstruction from rectocele? Int J Colorectal Dis 1995; 10:97-100. [PMID: 7636382 DOI: 10.1007/bf00341206] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In order to ascertain whether plastic surgery for rectocele is of value in the treatment of outlet obstruction, a retrospective study was made of 21 women complaining of difficulty in expelling faeces: 13 patients (group A) underwent surgery with transanal longitudinal plication of the anterior rectal wall (Block's technique), and 8 patients (group B) had colpoperineoplasty which, in 2, was associated with bladder-neck suspension following the Raz-Peyrera technique for urinary incontinence. The mean follow-up was 24.2 +/- 18.7 and 36.8 +/- 17.8 months respectively. In 11 group A patients (80.9%) and 6 group B patients (75%) cure, or an improvement, was achieved. Of the remaining 4 patients (19%), recurrent rectocele was found in 2 (one group A and one group B) and intestinal transit time tests detected colonic constipation in one group A and in one group B patient. It is concluded that surgery can resolve outlet obstruction from rectocele, but Block's technique is preferable because it is more straight-forward and easier.
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Affiliation(s)
- A Infantino
- Clinica Chirurgica II, Università degli Studi, Padova, Italy
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28
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Abstract
The nervous control of the motility of the human distal bowel was investigated by two physiological studies of electrical stimulation of sacral parasympathetic outflow in patients with high spinal injuries and in patients with intractable constipation following pelvic surgery. Identical and reproducible motility responses of the left colon, rectum, and anal sphincters were obtained by sequential electrical stimulation of anterior sacral roots S2, S3, and S4 in patients with spinal injury. S2 stimulation provoked isolated low-pressure colorectal contractions. S3 stimulation initiated frequency-dependent high-pressure colorectal motor activity which appeared peristaltic and was enhanced with repetitive stimuli. S4 stimulation increased colonic and rectal tone. Quantitative responses were maximal at the splenic flexure and rectum. Pelvic floor activity was stimulated in increasing magnitude from S2 to S4. These results of distal bowel motility were achieved by an implanted Brindley stimulator. A newer generation of externally active stimulators are envisaged for the control of lower bowel in fecal incontinence. Women with intractable constipation following hysterectomy had significantly increased rectal volume and compliance together with deficits of rectal sensory function. Following stimulation with Prostigmine (neostigmine) a colorectal motility gradient was paradoxically reversed in the patients following hysterectomy, thus constituting a functional obstruction. Denervation supersensitivity was demonstrable in 2 patients tested with carbachol provocation. These findings suggest dysfunction in the autonomic innervation of the hindgut in some patients following hysterectomy.
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Affiliation(s)
- J S Varma
- Department of Surgery, Western General Hospital, Edinburgh, Scotland
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