Vaginal hysterectomy with anterior and posterior repair for pelvic organ prolapse under local anesthesia: results of a pilot study

Exploring the rationale of performing vaginal hysterectomy under local anaesthesia: A single-centre experience

INTRODUCTION

Vaginal hysterectomy (VH) is usually performed under general (GA) or regional anaesthesia. In recent years, the possibility of performing vaginal hysterectomy under local anaesthesia (LA) has also been explored. Our aim was to compare intraoperative and early postoperative outcomes in women who underwent VH under LA with intravenous sedation or GA.

METHODS

In this retrospective study, we collected data of patients who underwent VH at our department from June 2021 to December 2022. For every patient, the following data was obtained: hospitalisation duration, type of anaesthesia (LA or GA), accompanying procedures, the dosage of used local anaesthetic in the LA group, maximal pain score for each day of hospitalisation after the procedure, procedure duration, intraoperative blood loss, and postoperative complication rate. Data was analysed using the SPSS Statistics programme. Statistical significance was set at p < 0.05.

RESULTS

Seventy patients were included in the study. The mean age was significantly higher in the LA group compared to GA group (73.8 ± 8.0 years vs. 67.1 ± 9.3 respectively, p-value = 0.003). LA was associated with statistically lower pain scores in the first two days after the procedure (p = 0.003), and shorter procedure duration (p-value <0.001) as well as hospitalisation duration (p < 0.001). Furthermore, the cumulative dosage of different analgesics used during hospitalisation was higher in the GA group.

CONCLUSIONS

Our results show that LA is a feasible option for patients undergoing VH. Vaginal surgical procedures under LA could be especially beneficial for older patients with medical comorbidities in whom GA would be particularly hazardous.

General Versus Regional Anesthesia in Sacrospinous Ligament Fixation for Pelvic Organ Prolapse: Assessment of a National Database

IMPORTANCE

Sacrospinous ligament fixation is a prolapse repair surgical procedure that can be performed under general or regional anesthesia. Little is known about the impact of anesthesia on postoperative outcomes.

OBJECTIVES

The primary objective of this study was to compare 30-day complication rates for patients undergoing sacrospinous ligament fixation by anesthesia type. Secondary objectives were to assess factors associated with type of anesthesia selected.

STUDY DESIGN

This was a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program for the years of 2015 to 2020. Cases were selected based on procedural codes for sacrospinous ligament fixation and diagnostic codes for prolapse. Complications, readmissions, and reoperations were compared between general versus regional anesthesia cohorts.

RESULTS

A total of 2,984 cases were included with 2,742 (91.9%) performed under general and 242 (8.1%) performed under regional anesthesia. The regional anesthesia cohort was older (69.2 vs 65.4 years old; P < 0.001) with no differences in medical history variables. Fewer patients in the regional anesthesia cohort were Hispanic (0.4% in regional vs 10.8% in general cohorts, P < 0.001). More superficial surgical site infections (2.5% vs 0.8%, P = 0.026) and cardiac complications (0.8% vs 0.1%, P = 0.035) were noted in the regional anesthesia cohort. However, multivariable regression analysis showed that anesthesia type was not associated with increased rates of minor or major complications.

CONCLUSIONS

Mode of anesthesia was not a significant predictor of minor or major complications. Racial and ethnic differences in mode of anesthesia warrant further investigation to reduce racial disparities.

Enhanced Recovery Protocols in Urogynecologic and Pelvic Floor Reconstructive Surgery: A Systematic Review and Meta-Analysis

IMPORTANCE

The implementation of Enhanced Recovery After Surgery (ERAS) protocols may optimize the clinical outcome of surgical patients, by reducing the length of hospital stay (LOS) and improving the quality of recovery.

OBJECTIVE

This study aims to evaluate the impact of ERAS protocols in the intraoperative and postoperative course of patients undergoing pelvic floor reconstructive surgery.

METHODS

A systematic search of PubMed/MEDLINE, Embase, and the Cochrane Library was conducted up to January 2022, using the Systematic Reviews and Meta-analyses guidelines. Search terms, such as ERAS, urogynecology, sacrocolpopexy were tailored to each database as necessary. Statistical analysis was performed using the RevMan 5.4 software. Confidence intervals (CI) were set at 95%. Mean difference and risk ratio were used in the analysis, and the results were calculated using the random effect model.

RESULTS

Six studies that reported outcomes of 1,153 women were included. The ERAS protocols were implemented in 553 women, whereas the remaining 600 received standard perioperative care. A significantly shorter LOS (mean difference, -16.17 hours; 95% CI, -24.07 to -8.26 hours; P < 0.0001) and a higher proportion of patients discharged within 24 hours postoperatively was observed in ERAS patients compared with non-ERAS controls (risk ratio, 3.08; 95% CI, 2.00-4.75; P < 0.00001). Operative time, estimated blood loss, complications, and readmission rates did not differ between the 2 groups.

CONCLUSIONS

Our analysis showed that ERAS protocols have a favorable impact on the perioperative course of urogynecologic populations. More research is required to determine those key components of ERAS protocols, specifically applicable and more beneficial to women with pelvic floor disorders.

Preemptive Infiltration of Local Anesthetics During Vaginal Hysterectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

IMPORTANCE

Vaginal hysterectomy (VH) is the preferred route of choice for women desiring hysterectomy to treat uterine pathology, including premalignant conditions and fibroids.

OBJECTIVE

The aim of this study was to evaluate the impact of the use of preemptive local analgesia (LA) on postoperative pain and perioperative outcomes for women undergoing VH.

STUDY DESIGN

A systematic search of 4 electronic databases (MEDLINE, Scopus, Cochrane CENTRAL Register of Controlled Trials, and Clinicaltrials.gov ) was performed for articles published up to January 2021. All randomized controlled trials that presented outcomes of patients who underwent VH due to pelvic floor disorders or other benign gynecological disorders and received local infiltration analgesia were finally included.

RESULTS

A total of 5 studies with 277 women (138 LA group vs 199 no-LA group) who underwent a VH were included in the present meta-analysis. Mean pain scores at both 30 minutes to 2 hours and 3 to 6 hours postoperatively were significantly lower in the LA group compared with the non-LA group (220 patients: mean difference [MD], -1.75; 95% confidence interval [CI], -2.77 to -0.74; P = 0.0007; and 220 patients: MD, -1.68; 95% CI, -2.28 to 1.09; P < 0.00001, respectively). Morphine/narcotic opioid-based consumption up to 24 hours postoperatively was significantly reduced in the LA group compared with the non-LA group (197 patients MD, -9.47 mg; 95% CI, -16.51 to -2.43; P = 0.008).

CONCLUSIONS

The use of preemptive LA during VH seems to be beneficial especially with regard to short-term postoperative pain and opioid use. However, further studies are needed to identify the optimal anesthetic regimen, the dosage, and sites of application aiming to achieve the optimal benefit in the postoperative management.

Ultrasound Image under Artificial Intelligence Algorithm to Evaluate the Intervention Effect of Accelerated Rehabilitation Surgery Nursing on Laparoscopic Hysterectomy

To explore the application value of accelerated rehabilitation surgery (ERAS) nursing in laparoscopic total hysterectomy, 120 patients who underwent laparoscopic total hysterectomy for benign uterine diseases in the hospital were selected as the research object. According to different nursing schemes, they were divided into 60 cases in the experimental group (ERAS nursing program) and 60 cases in the control group (traditional perioperative nursing). All patients underwent postoperative ultrasonography, and the intraoperative and postoperative rehabilitation indexes of the two groups were analyzed. Moreover, an improved standard Capon beamforming (ISCB) algorithm is proposed, which is compared with SCB algorithm, sequential regression algorithm (SER), and recursive least square (RLS) algorithm. The results showed that the center average power and background average power (−46.92, −33.85) of the ISCB algorithm were significantly lower than those of SCB algorithm (−36.18, −23.64), SER algorithm (−39.02, −27.31), and RLS algorithm (−34.88, −24.66), while the contrast and resolution (19.11, 15.57) were significantly higher than those of SCB algorithm (12.74, 9.01), SER algorithm (13.86, 7.89), and RLS algorithm (13.26, 8.26) $\left(P<0.05\right)$ . The anal exhaust time (11.84 ± 2.15 hours), analgesic effect score (3.37 ± 1.03 points), hospitalization days (3.72 ± 0.74 days), and hospitalization expenses (11859.03 ± 735.24 ¥) in the experimental group were significantly lower than those in the control group (20.95 ± 3.44 hours, 6.12 ± 1.46 points, 5.48 ± 0.91 days, 16135.22 ± 680.55 ¥) $\left(P<0.05\right)$ . The score of NRS evaluation scale in the experimental group (2.28 ± 0.37) was significantly better than that in the control group (4.09 ± 0.65) $\left(P<0.05\right)$ . The proportion of patients in the experimental group (very satisfied + satisfied + generally satisfied) (100%) was significantly better than that in the control group (71%), and the difference was statistically significant $\left(P<0.05\right)$ . In the experimental group, there were 2 cases of postoperative fever, 1 case of nausea and vomiting, and 2 cases of lower extremity venous thrombosis. In the control group, there were 4 cases of postoperative fever, 4 cases of nausea and vomiting, and 2 cases of lower extremity venous thrombosis. In summary, ultrasound imaging based on the ISCB algorithm can display the pelvic floor structure of patients undergoing laparoscopic total hysterectomy with high quality and improve the diagnostic rate of doctors. ERAS nursing can accelerate patients’ postoperative rehabilitation, reduce postoperative pain, and improve patients’ satisfaction. It was worthy to be popularized and applied in the clinic.

Pelvic floor reconstructive surgery under local anesthesia: A systematic review and meta-analysis

AIMS

The decision on the appropriate type of anesthesia for pelvic floor repair depends on a variety of factors including patients' age, performance status, comorbidities, cost-effectiveness and personal preferences. We aim to review the literature on urogynecological procedures performed under local anesthesia (LA).

METHODS

A systematic search of four electronic databases was conducted for articles published up to May 2020. Studies reporting outcomes of women who underwent pelvic floor reconstructive surgery under LA with or without sedation, were considered eligible.

RESULTS

Nineteen studies (14 noncomparative and 5 comparative), including 1626 cases of urogynecological procedures under LA were recruited. Meta-analysis revealed significantly lower mean pain scores in LA group compared to general-regional anesthesia one (GA/RA) at both 4-6 h and 8-18 h postoperatively (160 patients; mean difference [MD], -1.70; 95% confidence interval [CI]: -3.12, -0.28; p = 0.02 and 160 patients; MD, -0.72; 95% CI: -1.17, 0.27; p = 0.002, respectively). Pain scores at >24 h did not differ among the two groups (160 patients; MD, -0.28; 95% CI: -0.60-0.05; p = 0.10). Intra- and postoperatively morphine use was not different among patients who received LA and GA during prolapse surgery while nausea rates were significantly lower in LA group compared to RA group 8 h postoperatively.

CONCLUSIONS

LA with or without sedation represents a safe and efficient alternative anesthetic technique for urogynecological procedures with improved pain scores in up to 18 h postoperatively especially in patients who underwent surgery for SUI. LA is feasible and could be offered to patients undergoing pelvic floor surgery allowing a prompt postoperative recovery.

Extending the limits of vaginal hysterectomy under local anesthesia and conscious sedation

INTRODUCTION AND HYPOTHESIS

In this video we present the surgical management of a 58-year-old woman presenting with a large prolapsed myomatous uterus treated with vaginal hysterectomy (VH) and pelvic floor repair (PFR) (uterosacral ligament suspension and posterior colporraphy) under local anesthesia and conscious sedation.

METHODS

The patient underwent VH and PFR by using an infiltration of a local anesthetic solution of lidocaine, ropivacaine and adrenaline in combination with intravenous (iv) conscious sedation. Debulking techniques, such as intramyometrial coring, uterine bisection, myomectomy and wedge resection, were used to facilitate VH. The final weight of the removed uterus was 870 g.

RESULTS

This video demonstrates that performing a surgically challenging VH under local anesthesia is feasible.

CONCLUSIONS

Vaginal uterine morcellation can be performed to debulk the enlarged uterus so that hysterectomy can be accomplished under local anesthesia. The use of local anesthesia may safely be offered as an alternative to patients undergoing a complex vaginal hysterectomy and reconstructive surgery.