Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The Collaborative Review of Sterilization

Vaginal Hysterectomy Compared With Laparoscopic Hysterectomy in Benign Gynecologic Conditions: A Systematic Review and Meta-analysis

OBJECTIVE

To compare surgical efficacy outcomes and complications after laparoscopic hysterectomy and vaginal hysterectomy performed for benign gynecologic conditions.

DATA SOURCES

We performed an online search in major databases, including PubMed, Scopus, Web of Science, ClinicalTrials.gov , and the Cochrane Library from 2000 until February 28, 2023.

METHODS OF STUDY SELECTION

We searched for randomized controlled trials (RCTs) that compared vaginal hysterectomy with laparoscopic hysterectomy in benign gynecologic conditions. We located 3,249 articles. After reviewing titles and abstracts, we identified 32 articles that were eligible for full-text screening. We excluded nine articles as not-RCT or not comparing vaginal hysterectomy with laparoscopic hysterectomy. Twenty-three articles were included in the final systematic review, with 22 articles included in the meta-analysis.

TABULATION, INTEGRATION, AND RESULTS

Twenty-three eligible RCTs included a total population of 2,408, with 1,105 in the vaginal hysterectomy group and 1,303 in the laparoscopic hysterectomy group. Blood loss and postoperative urinary tract infection rates were lower in the vaginal hysterectomy group than in the laparoscopic hysterectomy group (mean difference -68, 95% CI -104.29 to -31.7, P <.01, I2 =95% and odds ratio 1.73, 95% CI 0.92-3.26, P =.03, I2 =0%, respectively). Vaginal hysterectomy was associated with less total operative time, less recovery time, and greater postoperative pain on the day of surgery. Other complications, including conversion to laparotomy, visceral organ damage, or wound dehiscence, were uncommon. Because of insufficient data, we were not able to stratify by surgical indication.

CONCLUSION

Vaginal hysterectomy had a shorter total operative time and recovery time but greater postoperative pain on day of surgery compared with laparoscopic hysterectomy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42023338538.

The clinical utility of routine postoperative hemoglobin and creatinine after reconstructive surgery for apical pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Postoperative laboratory tests are routinely ordered after apical prolapse repair on asymptomatic patients. We hypothesize that routine serum hemoglobin (Hb) and creatinine (Cr) have limited clinical utility in the postoperative period in asymptomatic patients.

METHODS

This is a retrospective cohort study of patients who underwent surgical repair of apical prolapse between 2017 and 2019 at our institution. Subjects were divided into two groups postoperatively: symptomatic and asymptomatic anemia. Symptomatic patients were defined as having one or more of the following: blood pressure (BP) <90/60, heart rate (HR) >100, urine output <30 cc/h, subjective dizziness, flank pain, or abdominal pain. The primary aim was to evaluate the utility of postoperative serum Hb and Cr in symptomatic and asymptomatic patients. Fisher's exact and Mann-Whitney tests analyzed categorical and continuous data respectively. A total of 325 patients were included.

RESULTS

Patients with symptomatic anemia had a larger decrease in Hb on postoperative day 1 (POD1) with a mean decrease of -18.11% (± 6.64) compared with asymptomatic patients, who had a mean difference of -15.49% (± 5.63; p < 0.001). The total cost of tests evaluating Hb was US$61,745. Patients with symptomatic acute kidney injury had an increase in Cr on POD1 compared with asymptomatic patients, with a mean increase of 0.23% (± 16.06) and -3.07% (± 13.10) respectively (p < 0.05). The total cost of tests including Cr was US$131,812.

CONCLUSIONS

Our results indicate that routine postoperative Hb and Cr testing for apical prolapse should be reserved for symptomatic patients as it has minimal clinical value in asymptomatic patients and contributes to increased overall health care cost.

A Study of Patients Undergoing Abdominal Hysterectomy in Tertiary Care Institute

Background Hysterectomy is one of the most common surgical procedures performed.Patient education, compliance, and socioeconomic status are important determinants in choosing the mode of treatment; however, medical treatment is usually inadequate.Thus, in the present study, we tried to study the various profiles of patients undergoing abdominal hysterectomies reported in tertiary care centers. Materials and Methods  Brief clinical data were noted from the case records, which include age, parity, presenting symptoms, past surgical and medical history, hemoglobin status, preoperative dilatation and curettage, and indications of hysterectomy. Results Most hysterectomies were performed on women between the ages of 41 and 45, with the average parity being 3.2 and the majority of cases having three children. Abnormal vaginal bleeding associated with various forms of menstrual irregularities was the most common complaint for which patients sought advice, and the incidence of patients undergoing tubal ligation was the most common previous surgery procedure, with anemia being the most common preoperative-associated condition. The fibroid was the most common demonstration in the current study, which brought forth abdominal hysterectomy for the chosen participants. Conclusion Findings from the current study suggest abdominal hysterectomy to be the most preferred route of surgery commonly in the women of age group 40 to 45 years or higher, precisely due to the occurrence of a higher parity rate in this age category. Fibroid uterus, dysfunctional uterine bleeding, and the presence of other menstrual complaints were the most probable indications for abdominal hysterectomy demonstrated by the individuals in the present study. Moreover, anemia was the most predominant complication associated pre-operatively, followed by other clinical manifestations such as hypertension, diabetes mellitus, and urinary tract infection.

Evaluation of complications, conversion rate, malignancy rate, and, surgeon's experience in laparoscopic assisted supracervical hysterectomy (LASH) of 1274 large uteri: A retrospective study

INTRODUCTION

Hysterectomy now belongs to standard gynecological procedures. Moreover, a shift towards laparoscopic techniques is ever more apparent as they provide many advantages such as less traumatization and shorter convalescence. Large uteri are still mentioned as contraindications for laparoscopic hysterectomy even though those patients might benefit from the lower morbidity associated with minimal invasive techniques. In this study, the largest reported so far, we analyzed intraoperative and postoperative complications as well as the surgeon's experience of laparoscopic assisted supracervical hysterectomy (LASH) in patients with a uterus weight over 500 g.

MATERIAL AND METHODS

The present retrospective study, between June 27, 1998 and August 31, 2019, evaluates 1274 patients with a uterus weight over 500 g who were treated with LASH for benign uterine diseases at the Clinic for Minimal Invasive Surgery (Berlin, Germany). All surgeries were performed by one of four in-house surgeons with experience in LASH: they had performed at least 500 LASH procedures before the study. Patients receiving surgical treatment for malignant tumors were not included in the study. Major and minor intraoperative and postoperative complications were recorded and evaluated. Additionally, medical files were evaluated for demographic data, American Society of Anesthesiologists score (I-IV), name of the surgeon, duration and indication for surgery, history of previous gynecological procedures and concomitant surgical interventions, weight of removed uterine tissue, duration of postoperative hospitalization in patients with complications, intraoperative conversion from laparoscopy to laparotomy, and malignancy rate.

RESULTS

The mean age was 47.0 ± 7.3 years and mean body mass index was 25.6 ± 7.1 kg/m² . Average parity was 1.04 ± 1.57. Average uterus weight was 761.8 ± 317.9 g (500-4065 g). The mean duration of surgery was 96.9 ± 49.5 min; 54% of all patients were treated without concomitant intervention, conversion rate was 2.12%. The malignancy rate was 0.4% and the complication rate was 6.81% with 1.36% intraoperative complications and 5.45% postoperative complications.

CONCLUSIONS

The overall low complication and malignancy rates observed in this study allow us to present LASH as a safe and efficient alternative laparoscopic approach to remove uteri of any size in the hands of experienced surgeons.

Analysis of Different Routes of Hysterectomy Based on a Prospective Algorithm and Their Complications in a Tertiary Care Institute

Introduction

Hysterectomy is the most common gynaecological operation worldwide. The objective of the study is to analyze the various routes of hysterectomy and its complications when the decision of route is based on using a prospective algorithm tree. Methodology. It is an observational study to analyze the route of hysterectomy based on using a prospective algorithm. The decision tree is based on pelvic pathology, uterine size, vaginal access, pelvic adhesion, competency of the surgeon, choice of the patient, and complication of different routes of hysterectomy. Data were collected from preoperative, intraoperative, and postoperative records. Demographic factors, indications, routes of hysterectomy, and complications were recorded and analyzed by using SPSS software version 22. Observation. Among the malignant or suspected malignant pathology groups, TAH was performed in 89 cases and TLH was performed in 3 cases. Among the benign disease groups, VH was performed in 137(38.2%) cases, TAH was performed in 118(32.9%) cases, and TLH was performed in 104 (28.9%) cases. Operative time and a number of blood transfusions were significantly less with VH (p value < 0.0001 and 0.004) compared to abdominal and total laparoscopic hysterectomy. Postoperative complication such as fever was more with abdominal hysterectomy (<i>p-</i>value<0.00001) compared to VH and TLH. Vaginal discharge was more with VH and TLH compared to TAH (p value −0.004) and wound infection was more in the abdominal route (p value 0.001).

Conclusion

The abdominal route was the route of choice for surgery in malignancy or suspected malignant pathology. In benign pathology, VH was the most common and preferable route of surgery. Complications were found to be minimal with vaginal hysterectomy.

Top-cited articles in the Journal: a bibliometric analysis

BACKGROUND

The Journal has had a profound influence in nearly 150 years of publishing. A bibliometric analysis, which uses citation analyses to evaluate the impact of articles, can be used to identify the most impactful papers in the Journal's history.

OBJECTIVE

The objective was to identify and characterize the top-cited articles published in the Journal since 1920.

STUDY DESIGN

We used the Web of Science and Scopus databases to identify the most frequently cited articles of the Journal from 1920 through 2018. The top 100 articles from each database were included in our analysis. Articles were evaluated for several characteristics including year of publication, article type, topic, open access, and country of origin. Using the Scopus data, we performed an unadjusted categorical analysis to characterize the articles and a 2 time point analysis to compare articles before and after 1995, the median year of publication from each database list.

RESULTS

The top 100 articles from each database were included in the analysis. This included 120 total articles: 80 articles listed in both and 20 unique in each database. More than half (52%) were observational studies, 9% were RCTs, and 75% were from US authors. When the post-1995 studies were compared with the articles published before 1995, articles were more frequently cited (median 27 vs 13 citations per year, P < .001), more likely to be randomized (14.0% vs 4.8%, P = .009), and more likely to originate from international authors (33.3% vs 17.5%, P = .045).

CONCLUSION

Slightly more than half of the top-cited papers in the Journal since 1920 were observational studies and three quarters of all papers were from US authors. Compared with top-cited papers before 1995, the Journal's top-cited papers after 1995 were more likely to be randomized and to originate from international authors.

Uterine Artery Embolization and Surgical Methods for the Treatment of Symptomatic Uterine Leiomyomas: A Systemic Review and Meta-analysis Followed by Indirect Treatment Comparison

PURPOSE

There is significant discussion and uncertainty about the optimal management of symptomatic uterine leiomyomas (SULs). Nonsurgical procedures such as uterine artery embolization (UAE) have been developed. The goal of this study was to conduct a meta-analysis and an indirect treatment comparison to examine the comparative efficacy and safety of the surgical procedures to treat SULs compared with UAE.

METHODS

MEDLINE, EMBASE, Lilacs, and the Cochrane Central Register of Controlled Trials databases were searched from inception to February 2016. Ten randomized controlled trials comparing UAE versus hysterectomy, myomectomy, and laparoscopic occlusion of the uterine arteries in patients with SUL published in a peer-reviewed journal were included. Two reviewers independently selected studies, assessed quality, and extracted data. Discrepancies were resolved through consensus.

FINDINGS

Data from 986 patients submitted to UEA (n = 527) or surgery (n = 459) were analyzed. UAE had a lower risk of major complications (risk ratio [RR], 0.45 [95% CI, 0.22-0.95]; P = 0.04)and a higher risk of minor complications (RR, 1.65 [95% CI, 1.32-2.06]; P < 0.00001); UAE had a higher risk of re-intervention up to 2 years (RR, 3.74 [95% CI, 1.76-7.96]; P = 0.0006) and up to 5 years (RR, 5.01 [95% CI, 1.37-18.39]; P = 0.02); UAE had a similar risk of follicle-stimulating hormone levels >40 IU/L after 6 months (RR, 1.76 [95% CI, 0.24-12.95]; P = 0.58)and of recommending the procedure to another patient up to 5 years after treatment (RR, 1.00 [95% CI, 0.87-1.14]; P = 0.94). The indirect comparison between myomectomy and hysterectomy found that the 2 procedures were similar in the studied outcomes.

IMPLICATIONS

Compared with surgery, UAE had lower rates of major complications with an increased risk of re-intervention up to 2 and 5 years after the first procedure. UAE compared with surgery had a similar risk of ovarian failure and similar recommendation of the procedure to another patient. However, the number of trials was limited, and there was a high risk of bias in at least 2 domains. None of the trials blinded the participants and personnel or the outcome assessment. PROSPERO identifier: CRD42015026319.

Evaluation of quality of life and cost-effectiveness of definitive surgery and the levonorgestrel intrauterine system as treatment options for heavy menstrual bleeding

BACKGROUND/AIM

This study aimed to compare the levonorgestrel intrauterine system (LNG-IUS) with abdominal hysterectomy (TAH) and total laparoscopic hysterectomy (TLH) as first-line treatments for heavy menstrual bleeding (HMB).

MATERIALS AND METHODS

Ninety-eight patients aged 20-55 years who complained of regular heavy menstrual bleeding were enrolled in the study. The TAH group included 29 patients, the LNG-IUS group included 34, and the TLH group included 35. These groups were compared in terms of quality of life and the cost-effectiveness of the selected methods. Quality of life was assessed using the 36-Item Short Form (SF-36), and cost-effectiveness was assessed according to the current cost of each approach.

RESULTS

The quality of life parameters, with the exception of mental health, improved significantly in the LNG-IUS, TAH, and TLH groups. The mean costs of the LNG-IUS, TAH, and TLH procedures were $99.15 ± 4.90, $538.82 ± 193.00 and $1617.05 ± 258.44, respectively (P < 0.05). Overall, LNG-IUS was the most cost-effective treatment option.

CONCLUSION

The outcome measures of the SF-36 revealed that after 6 months, these treatments were equal in terms of quality of life, except for mental health. LNG-IUS was the most cost-effective approach.

Do single-use medical devices containing biopolymers reduce the environmental impacts of surgical procedures compared with their plastic equivalents?

Background

While petroleum-based plastics are extensively used in health care, recent developments in biopolymer manufacturing have created new opportunities for increased integration of biopolymers into medical products, devices and services. This study compared the environmental impacts of single-use disposable devices with increased biopolymer content versus typically manufactured devices in hysterectomy.

Methods

A comparative life cycle assessment of single-use disposable medical products containing plastic(s) versus the same single-use medical devices with biopolymers substituted for plastic(s) at Magee-Women’s Hospital (Magee) in Pittsburgh, PA and the products used in four types of hysterectomies that contained plastics potentially suitable for biopolymer substitution. Magee is a 360-bed teaching hospital, which performs approximately 1400 hysterectomies annually.

Results

There are life cycle environmental impact tradeoffs when substituting biopolymers for petroplastics in procedures such as hysterectomies. The substitution of biopolymers for petroleum-based plastics increased smog-related impacts by approximately 900% for laparoscopic and robotic hysterectomies, and increased ozone depletion-related impacts by approximately 125% for laparoscopic and robotic hysterectomies. Conversely, biopolymers reduced life cycle human health impacts, acidification and cumulative energy demand for the four hysterectomy procedures. The integration of biopolymers into medical products is correlated with reductions in carcinogenic impacts, non-carcinogenic impacts and respiratory effects. However, the significant agricultural inputs associated with manufacturing biopolymers exacerbate environmental impacts of products and devices made using biopolymers.

Conclusions

The integration of biopolymers into medical products is correlated with reductions in carcinogenic impacts, non-carcinogenic impacts and respiratory effects; however, the significant agricultural inputs associated with manufacturing biopolymers exacerbate environmental impacts.

Do prophylactic antibiotics in gynecologic surgery prevent postoperative inflammatory complications? A systematic review

PURPOSE

The aim of this study was to systematically review the literature on antibiotic prophylaxis in gynaecologic surgeries to prevent inflammatory complications after gynaecological operations. The study was carried out as a systematic review.

METHODS

Only randomised controlled trials of women undergoing gynaecological surgery were included. The Medline and the Cochrane library databases were searched from 1966 to 2016. The trials must have investigated an antibiotic intervention to prevent an inflammatory complication after gynaecological surgery. Trials were excluded if they were not randomised, uncontrolled or included obstetrical surgery.

RESULTS

Prophylactic antibiotics prevent inflammatory complications after gynaecological surgery. Prophylactic antibiotics are more effective in surgery requiring access to the peritoneal cavity or the vagina. Cefotetan appears to be more capable in preventing the overall inflammatory complication rate than cefoxitin or cefazolin. No benefit has been shown for the combination of antibiotics as prophylaxis. No difference has been shown between the long-term and short-term use of antibiotics. There is no need for the primary use of an anaerobic antibacterial agent.

CONCLUSION

Antibiotics help to prevent postoperative inflammatory complications after major gynecologic surgeries.

Vaginal vs. robotic hysterectomy for patients with endometrial cancer: A comparison of outcomes and cost of care

OBJECTIVE

To compare outcomes and cost for patients with endometrial cancer undergoing vaginal hysterectomy (VH) or robotic hysterectomy (RH), with or without lymphadenectomy (LND).

METHODS

Patients undergoing planned VH (and laparoscopic LND) or RH (and robotic LND) between January 2007 and November 2012 were reviewed. Patients with stage IV disease, synchronous cancer, synchronous surgery, or treated with palliative intent were excluded. Patients were objectively triaged to LND per institutional protocol based on frozen section. Outcomes were compared between VH and RH groups matched 1:1 on propensity scores.

RESULTS

VH was planned in 153 patients; 60 (39%) had concurrent LND while 93 (61%) were low risk and did not require LND. RH was planned in 398 patients; 225 (56%) required concurrent LND and 173 (44%) did not. Among 50 PS-matched pairs without LND, there was no significant difference in complications, length of stay, readmission, or progression free survival. However, median operative time was 1.3h longer and median 30-day cost $3150 higher for RH compared to VH (both p<0.001). Among patients requiring LND, 42 PS-matched pairs were identified. Median operative time was not different when pelvic and para-aortic LND was performed, and 12min longer in the VH group for pelvic LND alone (p=0.03). Median 30-day cost was $921 higher for RH compared to VH when LND was required (p=0.08).

CONCLUSION

Utilization of vaginal hysterectomy for endometrial cancer results in similar surgical and oncologic outcomes and lower costs compared to RH and should be considered for appropriate patients with a low risk of requiring LND.

In-hospital complications of vaginal versus laparoscopic-assisted benign hysterectomy among older women: a propensity score-matched cohort study

OBJECTIVE

This investigation compared the outcomes of vaginal and laparoscopic hysterectomies for nonprolapsed benign indications in older women.

METHODS

We conducted a population-based, retrospective propensity score-matched cohort study using data from the Taiwan's National Health Insurance program. Women who were aged 65 years or older with vaginal hysterectomy (n = 290) were compared with women who had laparoscopic hysterectomy for nonprolapsed benign indications (n = 290). Propensity score was calculated based on both patient- (age, socioeconomic status, residential urbanicity, comorbidity, status of any prior catastrophic illness, surgical diagnosis, and year of hysterectomy) and provider-related characteristics (physician's age and sex, hospital accreditation level, and ownership type).

RESULTS

Women undergoing laparoscopic hysterectomy were not associated with increased risk of inpatient readmission within 30 days, in-hospital mortality, and in-hospital (including intraoperative) complications when compared with those who had vaginal hysterectomy. Women in the laparoscopic group had significantly shorter hospital stays than those in the vaginal group. The bleeding complications were mostly due to blood transfusion (2.1% in vaginal and 0.7% in laparoscopic hysterectomy groups) and urinary tract infection (1.0% in vaginal and 1.7% in laparoscopic hysterectomy groups). The surgical injury (intraoperative) complications included mostly surgical laceration of the urinary tract (0.7% in vaginal and 0.3% in laparoscopic hysterectomy groups).

CONCLUSIONS

Advanced age alone should not be the limiting factor for surgical referral of laparoscopic hysterectomy. The shorter hospital stay and low in-hospital complications associated with laparoscopic, as opposed to vaginal hysterectomies, are important attributes of a surgical procedure essential to the postoperative care in older women aged 65 years or more.

Non-decent Vaginal Hysterectomy in Rural Setup of MP: A Poor Acceptance

OBJECTIVE

NDVH is a minimally invasive, safe, effective, and economical surgery. Still AH is preferred for benign gynaecological indications. Our study aims to promote NDVH in all technically possible cases by adequate counselling of the patient.

METHODS

This prospective observational study enrolled 100 women seeking hysterectomy for benign gynaecological conditions (excluding prolapse) in a teaching hospital. Women were counselled on the basis of 'PREPARED' questionnaire to assess their awareness about NDVH and were offered NDVH as the proposed surgery and result is analysed.

RESULTS

We observed that there was a little awareness about NDVH and its outcome among the subjects. Ten out of 100 patients refused to perform NDVH after counselling and underwent TAH. Rest of the 90 patients opted for NDVH. Forty out of 90 patients were aware about NDVH, but they were sceptical about the outcome, and 50 were totally unaware. After applying 'PREPARED' questionnaire and counselling, we could motivate them to accept NDVH. It was successful in all cases except one where laparotomy was done for ovarian artery retraction. With no significant post-operative complications, early return to routine activity and low cost of surgery, all patients were satisfied with surgical outcome and improved quality of life.

CONCLUSION

We conclude that patients accept the surgery with open mind after proper counselling and detailing of the procedure. Most of the abdominal hysterectomy can be converted successfully to NDVH in technically feasible cases by experienced hands so adequate training to gynaecology residents is the need of the time. NDVH is economical to the patient as well as for the healthcare system.

Total vaginal and single-port total laparoscopic hysterectomy for uterine benign diseases

OBJECTIVE

This study aimed to review the surgical outcomes and health-related quality of life (HRQOL) of total vaginal (TVH) and single-port total laparoscopic hysterectomy (SP-TLH) for uterine benign diseases.

STUDY DESIGN

This study included 121 patients who had undergone TVH or SP-TLH for uterine benign diseases between April 2011 and July 2012. Surgical outcomes, complications, and HRQOL were reviewed in the two groups. Preoperative and postoperative HRQOL data from the 36-item Short Form questionnaire (SF-36) were recorded for all patients.

RESULTS

TVH was performed more often for the patients who had fewer previous operations (p = 0.32). In the TVH, there were fewer combined surgical procedures (p < 0.01), shorter operation times (p < 0.01), shorter vaginal stump suture times (p = 0.03) and lower complication rates (p < 0.01) than in SP-TLH. Overall, all SF-36 scales improved after surgery, except for the Social Functioning scale. There was no significant difference in any of the scales between the two groups.

CONCLUSIONS

TVH has equivalent effects on HRQOL as SP-TLH. SP-TLH is preferred for the cases with complicated and combined procedures.

Should we add unilateral sacrospinous ligament fixation to vaginal hysterectomy in management of stage 3 and stage 4 pelvic organ prolapse?

Objective:

To compare ‘‘vaginal hysterectomy alone’’ with ‘‘vaginal hysterectomy with prophylactic unilateral sacrospinous ligament fixation’’ in terms of intraoperative complications and 1-year anatomic outcomes and symptoms in patients aged over 50 years who presented with stage 3 or 4 pelvic organ prolapse (POP).

Materials and Methods:

Thirty-five patients underwent vaginal hysterectomy alone and 32 patients underwent vaginal hysterectomy with unilateral sacrospinous ligament fixation because of benign pathology between January 2012, and June 2014, were retrospectively analyzed in this study. The patients’ demographic data and preoperative and intraoperative findings were obtained from the hospital records and noted. The patients were invited by phone to a follow-up visit to assess their 1-year anatomic outcomes and symptoms.

Results:

There was no significant demographic difference between the patients who underwent vaginal hysterectomy alone and those who had a vaginal hysterectomy with sacrospinous ligament fixation. Both length of operation and hospital stay were significantly longer in the patients who underwent vaginal hysterectomy with sacrospinous ligament fixation (p<0.001); intraoperative complications requiring blood transfusion were also significantly more frequent in these patients compared with the patients who underwent vaginal hysterectomy only (p=0.048). Recurrence of vaginal vault prolapse was significantly more frequent in the patients with vaginal hysterectomy alone compared with those who had both vaginal hysterectomy and sacrospinous ligament fixation (p=0.035).

Conclusion:

Unilateral sacrospinous ligament fixation might be added to vaginal hysterectomy in patients with stage 3 or 4 POP who are predicted to have long survival times. However, further studies with a larger sample size are needed in this area of research.

Choosing the Route of Hysterectomy

PURPOSE

To compare the clinical results of three techniques of hysterectomy- abdominal hysterectomy (AH), non-descent vaginal hysterectomy (NDVH), and laparoscopic-assisted vaginal hysterectomy (LAVH).

METHODS

A simple prospective randomized study was performed in a tertiary care centre between June 2011 and Dec 2012, among 150 consecutive women indicated to undergo hysterectomy for benign and mobile uterine conditions. They were randomly assigned 50 each to three routes of hysterectomy; (abdominal, vaginal, and laparoscopic-assisted vaginal). Outcome measures including operating time, blood loss, rate of complications, consumption of analgesics, and length of hospital stay were assessed and compared between groups.

RESULTS

As far as duration of operation, mean blood loss, analgesic requirement, length of hospital stay, P value was significant. Incidence of complications is least among VH group.

CONCLUSION

Vaginal hysterectomy is the gold standard in the era of minimal access surgery. Some of the contraindications to VH can be overcome by assistance of laparoscope and a potential abdominal hysterectomy can be converted to a vaginal procedure.

Tactile Electrosurgical Ablation: A Technique for the Treatment of Intractable Heavy and Prolonged Menstrual Bleeding

Objective. To study the efficacy and safety of tactile electrosurgical ablation (TEA) in stopping a persistent attack of abnormal uterine bleeding not responding to medical and hormonal therapy. Methods. This is a case series of 19 cases with intractable abnormal uterine bleeding, who underwent TEA at the Women's Health Center of Assiut University. The outcomes measured were; patient's acceptability, operative time, complications, menstrual outcomes, and reintervention. Results. None of the 19 counseled cases refused the TEA procedure which took 6-10 minutes without intraoperative complications. The procedure was successful in the immediate cessation of bleeding in 18 out of 19 cases. During the 24-month follow-up period, 9 cases developed amenorrhea, 5 had scanty menstrual bleeding, 3 were regularly menstruating, 1 case underwent repeat TEA ablation, and one underwent a hysterectomy. Conclusions. TEA represents a safe, inexpensive, and successful method for management of uterine bleeding emergencies with additional long-term beneficial effects. However, more studies with more cases and longer follow-up periods are warranted.

Management of endometrial modifications in perimenopausal women

Perimenopause has a variable length and time of onset and is characterized by its variability in hormonal levels. The histological changes in the perimenopausal endometrium may be represented by nonproliferative or proliferative benign or malignant lesions. A commonly encountered manifestation of endometrium lesions during menopausal transition is the abnormal uterine bleeding (AUB). The clinical management of AUB must follow a standardized classification system for optimal results. The medical and surgical treatment must be adapted according to age, risk factors, symptoms, and cycle irregularities. Use of alternative therapies and proper diet may result in improved long-term outcomes.

Deciding the route for hysterectomy: Indian triage system

OBJECTIVES

To review the limitations, major complications, and conversion rates associated with non-descent vaginal hysterectomy (NDVH); and develop a scoring system to predict the possibility of successful NDVH.

METHODS

The risk analysis of conversion rates from vaginal to abdominal route while attempting NDVH was applied to formulate a scoring system for the assessment of successful NDVH. Parameters were selected based on Kovacs guidelines to determine the route of hysterectomy.

RESULTS

From April 2005 to December 2008, NDVH was attempted in 364/1,378 women undergoing hysterectomy for benign conditions (Gp-I). Eight out of 364 cases (2.1 %) either had to be converted to the abdominal route or had major complication. Endometriosis and repeated sections had the highest risk. Scoring system was developed based on the risk analysis. Validity of this scoring system was tested in 1,177 women from January 2009 to September 2012 (Gp-II). 460 women with a score of 16 or less underwent NDVH successfully with a conversion rate of 0.2 %.

CONCLUSION

Careful assessment by a simple scoring system can help in deciding the feasibility of performing NDVH.

Incidence of postoperative urinary retention after pelvic organ prolapse surgery in Cipto Mangunkusumo National General Hospital

Background: After vaginal delivery, every woman has 50% risk for pelvic organ prolapse (POP). The lifetime risk for a woman to undergo surgical treatment for POP was 11%, with the incidence of postoperative urinary retention (POUR) after POP surgery of 2%-43%. The aim of our study is to identify the incidence of POUR after POP surgery in Cipto Mangunkusumo National General Hospital (RSCM) and the risk factors.Methods: Medical records of 124 women undergoing pelvic prolapse surgery between 2010 and 2013 were analyzed. The incidence of POUR and the risk factors were identified by performing univariate and bivariate analysis using chi-Square test and its alternative with using SPSS 20.0. Independent variables include age, body mass index (BMI), parity, degree of prolapse, type of surgery technique, type of anesthesia, type of suture material, amount of intra-operative blood loss, and duration of surgery. POUR defined as urine residual volume more than 100cc.Results: The incidence of urinary retention after pelvic prolapse surgery was 29%. There was no correlation between age, BMI, parity, degree of prolapse, type of surgery technique, anesthesia, suture, intra-operative blood loss, duration of surgery, and the occurrence of urinary retention after pelvic organ prolapse surgery.Conclusion: The incidence of urinary retention after pelvic organ prolapse surgery was 29%. There was no correlation between the risk factors and the occurrence of urinary retention after pelvic organ prolapse surgery.

Analyzing the necessity of prophylactic antibiotic usage in laparoscopy for uncomplicated gynecologic conditions in Sri Lanka

AIM

The use of prophylactic antibiotics for laparoscopy of uncomplicated gynecologic conditions is controversial. The aim of this study was to assess whether prophylactic antibiotics is necessary to prevent early postoperative infections and febrile morbidity in elective laparoscopic surgery for benign gynecologic conditions.

MATERIAL AND METHODS

A total of 218 patients who underwent laparoscopy for uncomplicated gynecologic conditions were recruited into the study over a 1-year period. Following recruitment into the study, they were divided into two groups (ratio 1:1). Patients were divided into either group A (n = 115) the therapy arm or group B (n = 103) the placebo arm. Group A patients received oral azithromycin 1 g daily for 3 days (i.e. the day before, the day of and the day after the procedure) while group B received placebo therapy. Post-procedural febrile and infection morbidity was analyzed.

RESULTS

Morbidity was absent in 91.3% of patients in both groups A and B. The primary outcome measure of postoperative fever was present in eight patients from each group. The secondary outcome measure of postoperative infection was present in one patient from the group that did not receive prophylaxis (group B), who had a surgical site infection. There were no patients with urinary tract infection or pelvic inflammatory disease during the study.

CONCLUSION

Antibiotics prophylaxis was not able to achieve statistically significant reduction in postoperative febrile or infective morbidity in laparoscopic gynecologic surgery for benign uncomplicated conditions.

Vaginal hysterectomy: past, present, and future

Vaginal hysterectomy is the oldest and least invasive of the hysterectomy techniques and fulfills the evidence-based requirements as the preferred route of hysterectomy for benign gynecologic disease. Currently, vaginal hysterectomy is commonly utilized for treating uterine prolapse, but despite proven safety and effectiveness, the use of vaginal hysterectomy for treating non-prolapse conditions has been and remains underutilized in surgical practice. Improving the use of vaginal hysterectomy in the future will likely depend on addressing the key issues of training and maintaining skills in the technique and increasing awareness of the scientific evidence supporting its use.

Uterine fibroids: clinical manifestations and contemporary management

Uterine fibroids (leiomyomata) are extremely common lesions that are associated with detrimental effects including infertility and abnormal uterine bleeding. Fibroids cause molecular changes at the level of endometrium. Abnormal regulation of growth factors and cytokines in fibroid cells may contribute to negative endometrial effects. Understanding of fibroid biology has greatly increased over the last decade. Although the current armamentarium of Food and Drug Administration-approved medical therapies is limited, there are medications approved for use in heavy menstrual bleeding that can be used for the medical management of fibroids. Emergence of the role of growth factors in pathophysiology of fibroids has led researchers to develop novel therapeutics. Despite advances in medical therapies, surgical management remains a mainstay of fibroid treatment. Destruction of fibroids by interventional radiological procedures provides other effective treatments. Further experimental studies and clinical trials are required to determine which therapies will provide the greatest benefits to patients with fibroids.

A comparison of abdominal and vaginal hysterectomies in Benghazi, Libya

We performed a comparative study between abdominal and vaginal hysterectomies using clinical data from Al-Jamhouria hospital (one of the largest maternity hospitals in Eastern Libya). Various parameters were taken into consideration: the rates of each type (and their subtypes); average age of patients; indications; causes; postoperative complications; and duration of stay in the hospital afterwards. Conclusions and recommendations were drawn from the results of this study. In light of the aforementioned parameters, it was found that: (1) abdominal hysterectomies were more common than vaginal hysterectomies (p < 0.001); (2) patients admitted for abdominal hysterectomies are younger than those admitted for vaginal hysterectomies (p < 0.001); (3) the most common indication for an abdominal hysterectomy was menstrual disturbances, while for vaginal hysterectomies it was vaginal prolapse; (4) the histopathological cause for abdominal and vaginal hysterectomies were observed and the most common were found to be leiomyomas and atrophic endometrium; (5) there was no significant difference between the two routes in terms of postoperative complications; (6) patients who were admitted for abdominal hysterectomies spent a longer amount of time in the hospital (p < 0.01). It was concluded that efforts should be made to further pursue vaginal and laparoscopic hysterectomies as a viable option to the more conventional abdominal route.

Surgical outcome and cost comparison between total vaginal hysterectomy and laparoscopic hysterectomy for uteri weighing >500 g

STUDY OBJECTIVE

To compare surgical outcomes and overall costs of less invasive methods of hysterectomy to treat benign disease including total vaginal hysterectomy (TVH) and total laparoscopic hysterectomy (TLH) in women with a uterus weighing >500 g.

DESIGN

Retrospective review of medical records (Canadian Task Force classification III).

SETTING

University-associated hospital.

PATIENTS

One hundred three women with a uterus weighing >500 g who had undergone either total vaginal hysterectomy (TVH) (n = 52) or total laparoscopic hysterectomy (TLH) (n = 51).

MEASUREMENTS AND MAIN RESULTS

Cost data were extracted from the hospital billing system. Patient characteristics, surgical outcomes, and hospital costs were compared between the 2 groups. Patient characteristics were similar in both groups except for a history of surgery (TVH 11.5%, and TLH 37.3%; p = .01). Insofar as surgical outcomes, mean (SD) operative time was shorter in the TVH group compared with the TLH group (110.00 [28.68] minutes vs 180.47 [51.32] minutes; p < .001), and hospital stay was longer (8.08 [0.68] days vs 7.45 [1.03] days; p < .001). Other surgical outcomes including estimated blood loss (p = .20) and decrease in hemoglobin (p = .12) did not differ between the 2 groups. Total hospital costs (converted from Korean won to US dollars) were significantly lower in the TVH group than in the TLH group ($2076.59 [$666.58] vs $2744.03 [$715.76]; p < .001).

CONCLUSION

Our data suggest that TVH is a safe and economic procedure even in women with a uterus weighing >500 g. Skilled surgeons should preferentially consider TVH for treatment of benign uterine disease, regardless of uterine size.

Peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri

OBJECTIVE

To evaluate the safety of abdominal myomectomy for very large fibroid uteri, and to assess the effect of relevant confounding variables on the occurrence of major peri-operative complications.

STUDY DESIGN

A cohort study of 200 abdominal myomectomies for fibroid uteri of 16 gestational weeks or greater. Logistic regression analysis was used to examine the influence of important clinical variables on the risk of complications. A systematic literature search was conducted for evidence related to peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri.

RESULTS

The mean (±standard deviation) uterine size was 21±5 weeks. The overall rate of major complications was 30%. Peri-operative bleeding necessitating blood transfusion occurred in 49 (24.5%) cases. During surgery, two patients had bowel injury, two had bladder injury, seven women returned to theatre and two (1%) had hysterectomy. Four patients were re-admitted within 14 days of surgery. Multivariable logistic regression analysis showed that the risk of major complications was significantly higher in cases with a uterine size of 20 gestational weeks or more [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.1-10.2; p=0.03], where 10 or more fibroids were removed (OR 3.5, 95% CI 1.1-10.8; p=0.05) and where midline skin incision was required (OR 6.1, 95% CI 1.7-22.3; p=0.006). On comparison of primary vs repeat abdominal myomectomy, there was significantly higher blood loss (mean 1023±1112 ml vs 579±787 ml; p=0.02) and risk of major complications in the repeat myomectomy group (40% vs 5%; p<0.001). The systematic review identified only one study that reported a comparable risk of major complications related to abdominal myomectomy for very large fibroid uteri.

CONCLUSION

The risk of organ injury, hysterectomy, re-operation or hospital re-admission after abdominal myomectomy for very large fibroid uteri is low, but the procedure is associated with a significant risk of bleeding necessitating blood transfusion. This risk is increased after repeat myomectomy, and in patients with a uterine size of 20 gestational weeks or larger, requiring removal of 10 or more fibroids, and requiring a midline skin incision.

Which parameters may influence the duration of hospitalization after vaginal hysterectomy?

OBJECTIVE

To estimate the variables that may affect the duration of hospitalization after vaginal hysterectomy.

MATERIAL AND METHODS

An 11-year retrospective analysis was performed on data derived from 197 patients who underwent vaginal hysterectomy due to non-malignant pathology at a tertiary care center between January 2000 to November 2011.

RESULTS

The average age of the patients in our series was 60.9±11.1 with a duration of hospitalization of 11.6±6.1 days after vaginal hysterectomy. The grouping variables consisted of age, number of pregnancies, abortions, parities and the presence of intra or postoperative complications. Advanced age (>60), increased number of pregnancies (>5) and parities (>5) and occurrence of intra or postoperative complications were found to be correlated with the duration of hospitalization after vaginal hysterectomy. Categorical variables were analyzed by Pearson's chi square or the Fisher exact test. The Mann Whitney U test was used to compare groups, while the correlation of variables was assessed with the Spearman Correlation Analysis.

CONCLUSION

Vaginal hysterectomy is a safe and effective procedure. Advanced age, increased number of pregnancies and parities and occurrence of intra or postoperative complications may prolong the duration of hospitalization after surgery. Increased experience, careful surgical technique and adherence to aseptic principles may improve the cost-effectivity and decrease the duration of hospitalization.

Observational evaluation of preoperative, intraoperative, and postoperative characteristics in 117 Brazilian women without uterine prolapse undergoing vaginal hysterectomy

BACKGROUND

Despite the introduction of minimally invasive approaches for various benign uterine problems, hysterectomy is often still performed abdominally, but the vaginal route should be used whenever possible. The aim of this study was to identify the preoperative, intraoperative, and postoperative characteristics of women undergoing vaginal hysterectomy in the absence of uterine prolapse.

METHODS

A prospective, descriptive, quantitative, noncomparative study was conducted in 117 women between August 2009 and February 2011 in Petropolis, Rio de Janeiro, Brazil. The women included had a uterine indication for hysterectomy, their surgeries were performed by the same team, and they were followed up for 12 months. An adapted Pelvic Organ Prolapse Quantification system was used to check for uterine prolapse.

RESULTS

The age range of the women was 33-59 years, uterine volume was 300-900 mL, and 73.50% has undergone prior cesarean section. The main indication for hysterectomy was uterine myoma (64.95%), with a surgery time of 30-60 minutes in 55 (59.82%) and 19 (15.98%) cases, respectively. Uterine volume reduction was performed in 41 (35.05%) cases, salpingectomy was the most common associated surgery (81.19%), and anesthesia was subdural (68.37%). Common intraoperative complications included bladder lesions (8.54%), with conversion to the abdominal route being necessary in one case (1.28%), and the most common postoperative complication being vaginal cupola granuloma (32.47%). There was a statistically significant relationship between surgery time and uterine volume (χ(2) = 17.367; P = 0.002).

CONCLUSION

This study suggests that vaginal hysterectomy is a safe surgical procedure in view of its good performance and low complication rate.

NovaSure(): the bipolar radiofrequency endometrial ablation system for dysfunctional uterine bleeding

The bipolar radiofrequency endometrial ablation system (NovaSure()) has been developed to treat women suffering from menorrhagia due to dysfunctional uterine bleeding. This technology allows for a customized, controlled, contoured endometrial ablation, without the need for hysteroscopic visualization and endometrial pretreatment. Average treatment time is 90 s. Active bleeding, at the time of treatment, is not found to be a limiting factor for the use of this technology. Technical aspects of the bipolar radiofrequency ablation procedure are described and summarized in this article. The safety features employed, combined with a high level of effectiveness and patient satisfaction, qualifies this system for consideration as a logical alternative to hysterectomy as well as an alternative to hysteroscopic endometrial ablation.

A retrospective cohort study of perioperative management on the morbidity of urogynecologic surgery

INTRODUCTION AND HYPOTHESIS

To determine whether premenopausal and early (<70) and late postmenopausal women whose comorbidities were screened and managed using a standardized protocol experienced comparable perioperative complications after urogynecologic surgery.

METHODS

We retrospectively reviewed the charts of all women who presented for surgical management of their pelvic floor disorders over 4.5 years for any complications, which occurred intraoperatively to 6 weeks postoperatively.

RESULTS

Late postmenopausal women underwent more vaginal (100/124, 159/246, and 226/288, p < 0.001) and obliterative (15/124, 0/246, and 4/288, p < 0.001), and fewer abdominal (9/124, 87/246, and 58/288, p < 0.001) procedures and had lower body mass index (27.1, 31.4, and 29.4, P < 0.001) and fewer smokers (4/124, 86/246, and 52/288, p < 0.001) than premenopausal and early postmenopausal subjects. After adjusting for these differences, the proportions that experienced perioperative complications were similar among the three groups (P = 0.789).

CONCLUSIONS

With standardized screening and management, our premenopausal and early and late postmenopausal women experienced similar perioperative complications.

Uterosacral-cardinal ligament stretching prior to vaginal hysterectomy increases uterine descent: a novel technique

OBJECTIVE

To examine the effect of uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy on uterine descent.

STUDY DESIGN

A prospective trial of 25 consecutive women undergoing vaginal hysterectomy. Pre-operative, apical, anterior and posterior wall POP-Q measurements were recorded for each patient before and after uterosacral-cardinal ligament complex stretching during general anesthesia.

RESULTS

Uterosacral-cardinal ligament complex stretching yielded a significant increase in mean stage of uterine and anterior wall descent (2.6 ± 0.6 vs. 3.2 ± 0.6 cm, p<0.001, and 2.5 ± 0.8 vs. 2.9 ± 0.8 cm, respectively, p<0.004). There was no significant change in posterior wall prolapse measurements (1.3 ± 0.7 vs. 1.4 ± 0.8 cm, p=0.05).

CONCLUSION

Uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy increase uterine descent.