Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study

Hysterectomy is not associated with increased risk of urinary incontinence-a northern Finland birth cohort 1966 study

INTRODUCTION

Hysterectomy has been suggested to increase the risk of urinary incontinence (UI), although evidence is controversial. In our population-based cohort study, we aimed to assess the independent effect of hysterectomy on the risk of de novo UI.

MATERIAL AND METHODS

This is a population-based cohort study on the women of the Northern Finland Birth Cohort 1966 (n = 5889). We identified all hysterectomies among the cohort (n = 461) using the national Care Register for Health Care and classified them according to surgical approach into laparoscopic (n = 247), vaginal (n = 107), and abdominal hysterectomies (n = 107). Women without hysterectomy formed the reference group (n = 3495). All women with UI diagnoses and operations were identified in the register, and women with preoperative UI diagnosis (n = 36) were excluded from the analysis to assess de novo UI. Data on potential confounding factors were collected from registers and the cohort questionnaire. Incidences of different UI subtypes and UI operations were compared between the hysterectomy and the reference groups, and further disaggregated by different hysterectomy approaches. Logistic regression models were used to analyze the association between hysterectomy and UI, with adjustments for several UI-related covariates.

RESULTS

We found no significant difference in the incidence of UI diagnoses or the rate of subsequent UI operations between the hysterectomy and the reference groups (24 [5.6%] vs. 166 [4.7%], p = 0.416 and 14 [3.3%] vs. 87 [2.5%], p = 0.323). Hysterectomy was not significantly associated with the risk of any subtype of UI (overall UI: OR 1.20, 95% CI 0.77-1.86; stress UI (SUI): OR 1.51, 95% CI 0.89-2.55; other UI: OR 0.80, 95% CI 0.36-1.74). After adjusting for preoperative pelvic organ prolapse (POP) diagnoses, the risk was decreased (overall UI: OR 0.54, 95% CI 0.32-0.90; other than SUI: OR 0.40, 95% CI 0.17-0.95). Regarding different hysterectomy approaches, the risks of overall UI and SUI were significantly increased in vaginal, but not in laparoscopic or abdominal hysterectomy. However, adjusting for preoperative POP diagnosis abolished these risks.

CONCLUSIONS

Hysterectomy is not an independent risk factor for de novo UI. Instead, underlying POP appears to be a significant risk factor for the incidence of UI after hysterectomy.

Prevalence of Lower Urinary Tract Symptoms in Women Planning to Undergo Hysterectomy for Uterine Leiomyoma and Abnormal Uterine Bleeding

Introduction: Leiomyomas are associated with lower urinary tract symptoms (LUTS), but more specific characterization of their impact on LUTS is needed. Methods: This is a retrospective cohort study of 202 participants (101 per group) who underwent hysterectomy for leiomyomas versus abnormal uterine bleeding nonclassified (AUB-N) from July 2015 to May 2019. Baseline demographics, leiomyoma characteristics, and presence of baseline LUTS were collected. The main objective was to compare the prevalence of LUTS between these two groups. Secondary objectives were to analyze the association between leiomyoma characteristics and the prevalence of LUTS. Results: There was no difference in baseline prevalence of LUTS between the hysterectomy for leiomyoma versus AUB-N groups (42.6% vs. 45.5%, p = 0.67). When examining the entire study cohort of participants, irrespective of hysterectomy indication, leiomyoma size >6 cm was associated with an increased prevalence of LUTS when compared with leiomyoma <6 cm (64.9% vs. 40.4%, p = 0.02), and specifically difficulty passing urine (p = 0.02), nocturia (p = 0.04), and urinary frequency (p = 0.04). When controlling for age, body mass index, parity, chronic pelvic pain, and diabetes, leiomyomas >6 cm remained significantly associated with the presence of LUTS (odds ratio 3.1, 95% confidence interval = 1.2-8.3) when compared with leiomyoma <6 cm. Presence of >1 leiomyoma was associated with urinary frequency (67.9% vs. 32.1%, p = 0.02) when compared with ≤1 leiomyoma. Anterior location and uterine volume were not associated with a difference in LUTS. Conclusion: LUTS are prevalent in those planning hysterectomy for leiomyoma and AUB-N. Leiomyomas >6 cm are associated with the presence of LUTS. Future studies should evaluate change in LUTS following hysterectomy for leiomyomas.

Pelvic Floor Therapy and Initial Interventions for Pelvic Floor Dysfunction in Gynecologic Malignancies

PURPOSE OF REVIEW

This review provides evidence-based updates for the first-line management approaches for pelvic floor disorders in patients with gynecologic malignancies, as well as important provider considerations when referring for pelvic floor physical therapy.

RECENT FINDINGS

Currently, there is strong evidence to recommend pelvic floor muscle training as initial treatment for urinary incontinence and for pelvic organ prolapse; some evidence to recommend a more targeted pelvic floor muscle training program for fecal incontinence; and mostly expertise-based evidence to recommend vaginal gels or estrogen to aid with dyspareunia causing sexual dysfunction. More research is greatly needed to understand the role of overactive pelvic floor muscles in survivors with chronic pelvic pain and the treatment of post-radiation pelvic complications such as vaginal stenosis and cystitis. While pelvic floor disorders are common concerns in gynecologic cancer survivors, there are evidence-based initial noninvasive treatment approaches that can provide relief for many individuals.

Pelvic floor and sexual function 3 years after hysterectomy - A prospective cohort study

INTRODUCTION

Long term effects after hysterectomy, such as a worsening of pelvic floor and sexual function, have been studied with diverse results. Therefore, we investigated the long-term effects of hysterectomy for benign indication on pelvic floor and sexual function as well as differences in outcome depending on mode of hysterectomy.

MATERIAL AND METHODS

In a prospective clinical cohort study, we included 260 women scheduled for hysterectomy who answered validated questionnaires; pelvic floor impact questionnaire (PFIQ-7), pelvic floor distress inventory (PFDI-20) and female sexual function index (FSFI). Participants were followed up to 3 years after surgery. Nonparametric statistics and mixed effect models were used in analyses of the data.

RESULTS

After exclusions, 242 women remained in the study, with a response rate at the 3-year follow-up of 154/242 (63.6%) for all questionnaires. There was an improvement of pelvic floor function with a mean score of PFIQ-7 at baseline of 42.5 (SD 51.7) and at 3 years 22.7 (SD 49.4), (p < 0.001) and mean score of PFDI-20 at baseline was 69.6 (SD 51.1) and at 3 years 56.2 (SD 54.6), (p = 0.001). A deterioration of sexual function was seen among the sexually active women after 3 years with a mean score of FSFI at baseline 25.2 (SD 6.6) and after 3 years 21.6 (SD 10.1), (p < 0.001). However, this was not consistent with the unaltered sexual function for the whole cohort. No difference in pelvic floor or sexual function was detected when comparing robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy.

CONCLUSIONS

Three years after surgery robotic assisted laparoscopic hysterectomy, total laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent. Among the sexually active women, a decline of sexual function was seen after 3 years, not consistent with the entire cohort and independent of surgical methods. Whether this is a trend associated with aging or menopausal transition remains to be studied.

Incidence and risk factors of stress urinary incontinence after laparoscopic hysterectomy

OBJECTIVE

To observe the long-term effects of total hysterectomy on urinary function, evaluate the effects of preoperative nutritional status, urinary occult infection, and surgical factors on the induction of postoperative stress urinary incontinence (SUI), and explore the incidence and risk factors of SUI.

STUDY DESIGN

From January 2017 to December 2017, 164 patients with benign non-prolapsing diseases who underwent a laparoscopic total hysterectomy in the First People's Hospital of Taicang were selected as the analysis objects. The International Incontinence Standard Questionnaire for Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and Pelvic Floor Impact Questionnaire-short version 20 (PFDI-20) were used for telephone follow-up to subjectively assess the urinary function of patients, collect their medical records, and statistically analyze the number of postoperative SUI cases. Logistic multivariate analysis was used to analyze the influencing factors of postoperative female SUI, presented as adjusted odds ratios with 95% confidence intervals.

RESULTS

Only 97 out of 164 patients completed the ICIQ-FLUTS and PFDI-20 questionnaires. Among these participants, 28 patients (28.86%) were diagnosed with SUI (study group), while 69 patients (71.13%) were classified as women without SUI (control group). The age, menopause, parity ≥ 2 times, Body mass index (BMI) ≥ 28 kg/m2, neonatal weight ≥ 4000 g, history of chronic cough, preoperative hemoglobin ≤ 100 g/L, preoperative urine bacteria ≥ 100u/L, preoperative uterine volume ≥ 90 cm3, intraoperative blood loss, and operation time of the study group were compared with those of the control group. The differences were statistically significant (P < 0.05). Further Logistic multivariate analysis showed that menopause, preoperative hemoglobin ≤ 100 g/L, preoperative urine bacteria ≥ 100u/L, uterine volume ≥ 90 cm3, history of chronic cough, BMI ≥ 28 kg/m2 were risk factors for postoperative SUI in patients undergoing hysterectomy (P < 0.05).

CONCLUSIONS

Hysterectomy for benign non-prolapse diseases has a long-term potential impact on the urinary system of patients, and the risk of postoperative SUI increases. The main risk factors of SUI are parity, menopausal status, obesity, preoperative nutritional status, and occult infection of the urinary system.

The Risk of Stress Urinary Incontinence After Hysterectomy for Uterine Fibroids

PURPOSE

We evaluated the relationship between previous hysterectomy for uterine fibroids and subsequent stress urinary incontinence (SUI).

METHODS

This study analyzed national health insurance data. The hysterectomy group (aged 40 to 59) comprised patients who underwent hysterectomy for uterine fibroids between January 1, 2011 and December 31, 2014, and the control group (aged 40 to 59) comprised patients who visited a medical facility for a checkup during the same time span. One-to-one propensity score matching was performed to balance confounders. SUI was defined as the need for SUI surgery accompanied by a diagnosis code for SUI.

RESULTS

After matching, 81,373 cases (hysterectomy group) and 81,373 controls (nonhysterectomy group) were enrolled. The mean follow-up period was 7.9 years for the cases and 7.8 years for the controls. The incidence of anti-incontinence surgery was slightly but significantly higher in the cases than in the controls (2.0% vs. 1.7%, P<0.001). Compared to the control group, abdominal hysterectomy significantly increased the likelihood of anti-incontinence surgery both before (hazard ratio [HR], 1.235; 95% confidence interval [CI], 1.116-1.365) and after adjusting for confounders (HR, 1.215; 95% CI, 1.097-1.347). In contrast, laparoscopic hysterectomy, laparoscopic hysterectomy with adnexal surgery, and abdominal hysterectomy with adnexal surgery were not associated with an increased rate of anti-incontinence surgery. The significant association between abdominal hysterectomy and an elevated rate of anti-incontinence surgery persisted even after stratifying patients by age group.

CONCLUSION

Prior abdominal hysterectomy without adnexal surgery was associated with an increased incidence of subsequent anti-urinary incontinence surgery.

Counselling of path_BRCA carriers who are considering risk-reducing oophorectomy

path_BRCA 1/2 increases a woman's lifetime risk of breast and ovarian cancer. Interventions can be offered which manage cancer risk; annual breast screening from age 30, chemoprevention and, once a woman's family is complete, risk-reducing surgery. The latter is the most effective method of reducing cancer in path_BRCA carriers; salpingo-oophorectomy reduces breast and ovarian cancer, respectively, by up to 50% and 95%. Factors affecting a woman's decision to undergo risk-reducing surgery are complex; dominant factors include risks of surgery, effect on cancer outcomes and menopausal sequelae. Specific information relating to hormone replacement and non-hormonal alternatives are an important consideration for women but, are often overlooked. Informative counselling is required to enable satisfaction with the chosen intervention whilst improving survival outcomes. This review paper outlines the current data pertaining to these decision-making factors and provides a proforma to enable effective counselling.

Quality of life and sexual function in patients aged 35 years or younger undergoing hysterectomy for benign gynecologic conditions: A prospective cohort study

OBJECTIVE

To evaluate how hysterectomy performed for benign gynecologic pathologies affects the quality of life and sexual function of patients aged 35 years or younger, and if outcomes differ according to the surgical technique.

METHODS

Seventy-three patients who underwent total laparoscopic hysterectomy (TLH), supracervical laparoscopic hysterectomy (SLH), or vaginal hysterectomy (VH) for benign uterine disorders between April 2014 and June 2020 at the Department of Gynecology and Obstetrics, Saarland University Hospital, Homburg, Germany, were enrolled in this prospective observational cohort study. Quality of life and sexual function were assessed preoperatively and 6 months postoperatively using standardized validated questionnaires: the European Quality of Life Five-Dimension Scale (EQ-5D) and the Female Sexual Function Index (FSFI).

RESULTS

Thirty-three (45%) patients underwent TLH, 25 (34%) underwent SLH, and 15 (21%) patients underwent VH. The median preoperative EQ-5D score, FSFI score, and EQ-5D visual analog scale were 0.9 (range 0.62-1), 19.25 (range 2.4-27.4), and 50 (range 0-100); postoperative scores were 1 (range 0.61-1), 24.15 (range 3.9-29.3), and 90 (range 30-100), respectively (P ≤ 0.001). Postoperative scores were significantly higher than preoperative scores, with no significant difference according to the surgical technique.

CONCLUSION

Hysterectomy for benign indication in women aged 35 years or less significantly improved the patients' quality of life and sexual function with no differences regarding the surgical technique.

CLINICAL TRIAL REGISTRATION

The study was registered in the German trial registry (no. DRKS00005622).

Stress Urinary Incontinence After Operations for Uterine Prolapse: A Nationwide Cohort Study

IMPORTANCE

Concomitant surgery for stress urinary incontinence (SUI) during pelvic organ prolapse (POP) operations are debated.

OBJECTIVES

We aimed to assess the risk of an SUI operation after a uterine prolapse operation and compare the risk after the Manchester procedure versus vaginal hysterectomy.

STUDY DESIGN

We performed a nationwide historical cohort study including women with no history of hysterectomy undergoing the Manchester procedure (n = 6065) or vaginal hysterectomy (n = 9,767) for POP during 1998 to 2018. We excluded women with previous surgery for SUI and POP, concomitant surgery for SUI (n = 34, 0.2%), and diagnosed with gynecological cancer before or within 90 days from surgery. Women were followed up until SUI operation/death/emigration/diagnosis of gynecological cancer/December 31, 2018, whichever came first. Women undergoing the Manchester procedure were censored if they had undergone hysterectomy.We assessed the rate of SUI surgery with cumulative incidence plots. We performed Cox Regression to analyze the risk of SUI surgery, adjusting for age, calendar year, income level, concomitant surgery in anterior and posterior compartments, and diagnosis of SUI before POP operation.

RESULTS

We found that 12.4% women with and 1.6% without SUI diagnosed before the POP surgery who underwent SUI surgery within 10 years.During follow-up (median, 8.5 years), 129 (2.1%) underwent SUI surgery after the Manchester procedure and 175 (1.8%) after vaginal hysterectomy (adjusted hazard ratio, 1.06 [0.84-1.35]).

CONCLUSIONS

Of women diagnosed with SUI before POP operation 1 in 8 subsequently underwent SUI surgery. Few women not diagnosed with SUI subsequently underwent SUI surgery. There was no difference in risk of SUI after the Manchester procedure and vaginal hysterectomy.

Quality of Life after Risk-Reducing Hysterectomy for Endometrial Cancer Prevention: A Systematic Review

BACKGROUND

Risk-reducing hysterectomy (RRH) is the gold-standard prevention for endometrial cancer (EC). Knowledge of the impact on quality-of-life (QoL) is crucial for decision-making. This systematic review aims to summarise the evidence.

METHODS

We searched major databases until July 2022 (CRD42022347631). Given the paucity of data on RRH, we also included hysterectomy as treatment for benign disease. We used validated quality-assessment tools, and performed qualitative synthesis of QoL outcomes.

RESULTS

Four studies (64 patients) reported on RRH, 25 studies (1268 patients) on hysterectomy as treatment for uterine bleeding. There was moderate risk-of-bias in many studies. Following RRH, three qualitative studies found substantially lowered cancer-worry, with no decision-regret. Oophorectomy (for ovarian cancer prevention) severely impaired menopause-specific QoL and sexual-function, particularly without hormone-replacement. Quantitative studies supported these results, finding low distress and generally high satisfaction. Hysterectomy as treatment of bleeding improved QoL, resulted in high satisfaction, and no change or improvements in sexual and urinary function, although small numbers reported worsening.

CONCLUSIONS

There is very limited evidence on QoL after RRH. Whilst there are benefits, most adverse consequences arise from oophorectomy. Benign hysterectomy allows for some limited comparison; however, more research is needed for outcomes in the population of women at increased EC-risk.

Transcatheter Uterine Artery Embolisation in Treating Secondary Haemorrhage Post Hysterectomy: A Life-Saving Approach

Hysterectomy, which is a surgical procedure to remove all or a part of the uterus, is one of the most commonly done procedures by a gynaecologist. However, it may be associated with a number of complications. Haemorrhage following hysterectomy is a life-threatening complication. One of the most common complications is haemorrhage, whether primary or secondary. The various options to treat secondary haemorrhage post hysterectomy are uterine artery embolization (UAE) or surgical re-exploration. Here, we present a case of secondary haemorrhage post hysterectomy treated with uterine artery embolization and describe the numerous advantages of UAE as a novel approach to stop bleeding post hysterectomy over the traditional surgical re-exploration method.

Effect of hysterectomy on re-operation for stress urinary incontinence: 10 year follow-up

Purpose

Hysterectomy and mid-urethral sling (MUS) are common operations, but little is known about how hysterectomy after MUS affects the risk for stress urinary incontinence (SUI) relapse.

Methods

We included 49 women with a MUS before hysterectomy and 41 women with a MUS concomitant with hysterectomy. The controls, matched by age (± 2 years), MUS type (retropubic vs transobturator) and operation year (± 2 years), included 201 women who underwent the MUS operation without a subsequent hysterectomy. We used health care registers for follow-up of 12.4 years in median (IQR 10.9–14.7) after the MUS operation to compare the number of SUI re-operations and hospital re-visits for urinary incontinence.

Results

The re-operation rates for SUI did not differ between the women with MUS before hysterectomy (n = 2, 4.1%), women with MUS concomitant with hysterectomy (n = 2, 4.9%) and their controls (n = 4, 4.9%, p = 0.8 and n = 6, 5.0%, p = 1.0, respectively). There were significantly fewer urinary incontinence re-visits among women who had a MUS concomitant with the hysterectomy compared to their matched controls (n = 2 and 31, 5 and 31%, p < 0.01) and to the women with a MUS prior to hysterectomy (n = 2 and 10, 5 and 20%, respectively, p = 0.03).

Conclusion

Hysterectomy after or concomitant with MUS does not seem to increase the risk for SUI re-operation or hospital re-visits for urinary incontinence. These results can be used to counsel women considering hysterectomy after MUS operation or concomitant with MUS operation.

Effects of hysterectomy on pelvic floor function and sexual function-A prospective cohort study

INTRODUCTION

Hysterectomy is one of the most common major surgical procedures in women. The effects of hysterectomy on pelvic floor and sexual function are uncertain. Our objective was to investigate the effects of hysterectomy for benign indications on pelvic floor and sexual function and to compare different modes of surgery.

MATERIAL AND METHODS

We performed a prospective clinical cohort study. In all, 260 women scheduled for hysterectomy answered validated questionnaires (Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory and Female Sexual Function Index). Participants were followed 6 months and 1 year after surgery. Data were analyzed using nonparametric statistics and mixed effect models.

RESULTS

Women with subtotal hysterectomy, vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy, and previous prolapse/incontinence surgery were excluded from further analysis, leaving the remaining cohort to 242 patients. The response rate at 6 months and 1 year follow-up was 180/242 (74.3%) and 169/242 (69.8%), respectively. There was an improvement of pelvic floor function at both follow-ups; mean score of Pelvic Floor Impact Questionnaire at baseline was 42.5 (51.7), at 6 months 19.9 (42.2) and at 1 year 23.7 (50.3) (p < 0.001). The mean score of Pelvic Floor Distress Inventory at baseline was 69.6 (51.1), at 6 months 49 (43.2) and at 1 year 49 (43.2) (p < 0.001). There was an improvement of sexual function after 6 months (mean score of Female Sexual Function Index at baseline 17.9 [SD 11.7] and at 6 months 21.0 [SD 11.7]) (p < 0.001). There was no difference in pelvic floor or sexual function when comparing surgical techniques.

CONCLUSIONS

Robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent at 6 months and 1 year after surgery. There was an overall improvement of sexual function 6 months after hysterectomy, but this did not persist after 1 year.

Recurrent surgery in uterine prolapse: A nationwide register study

INTRODUCTION

One in three women with pelvic organ prolapse (POP) undergoing surgery have a relapse. Currently, no optimal surgical treatment has been identified for correcting a uterine prolapse. This population-based register study aims to compare the relapse rate in patients with uterine prolapse undergoing hysterectomy with suspension or uterine-sparing surgical procedures.

MATERIAL AND METHODS

All women with uterine prolapse undergoing prolapse surgery in Sweden from January 1, 2015 to December 31, 2018, were identified from the Gynecological Operation Register (GynOp). The primary outcome was the number of recurrent POP surgeries up to December 31, 2020.

RESULTS

Sacrospinous hysteropexy (SSHP) without graft and sacrohysteropexy (SHP) were associated with a significantly higher rate of recurrent POP surgery (SSHP without graft: adjusted odds ratio [aOR] 2.6, 95% CI 2.0-3.5; SHP aOR 2.6, 95% CI 1.8-3.7) and patients describing a sense of globe (SSHP without graft, aOR 2.0, 95% CI 1.6-2.6; SHP, aOR 1.8, 95% CI 1.1-3.1) compared with cervical amputation with uterosacral ligament fixation (Manchester procedure). There was no difference in the reoperation rate or sense of a globe between SSHP with graft and Manchester procedure. Patients undergoing SSHP without graft had a higher frequency of 1-year postoperative complications compared with Manchester procedure (aOR 2.0, 95% CI 1.6-2.6) and SHP (aOR 2.4, 95% CI 1.4-3.9). Moreover, the frequency of 1-year postoperative complications was higher in SSHP with graft (aOR 1.6, 95% CI 1.1-2.2) than in Manchester procedure.

CONCLUSIONS

The Manchester procedure was associated with a low rate of recurrent POP surgery, symptomatic recurrence and low surgical morbidity compared with other surgical methods in women with uterine prolapse.

Stress urinary incontinence after hysterectomy: a 10-year national follow-up study

Purpose

Hysterectomy has been associated with increased risk for developing stress urinary incontinence (SUI) and having a SUI operation. We examined the long-term rate of SUI operations after hysterectomy and associated risk factors.

Methods

We followed up 5000 women without prior urinary incontinence (UI) who had a hysterectomy in a prospective FINHYST 2006 cohort study until the end of 2016 through a national health register. The main outcome was SUI operations, and secondary outcomes were outpatient visits for UI, and their association of preoperative patient and operation factors.

Results

During the median follow-up time of 10.6 years (IQR 10.3–10.8), 111 (2.2%) women had a SUI operation and 241 (4.8%) had an outpatient visit for UI. The SUI operation rate was higher after vaginal hysterectomy and laparoscopic hysterectomy (n = 71 and 28, 3.3% and 1.8%, respectively) compared to abdominal hysterectomy (n = 11, 0.8%). In a multivariate risk analysis by Cox regression, the association with vaginal hysterectomy and SUI operation remained significant when adjusted for vaginal deliveries, preceding pelvic organ prolapse (POP), uterus size, age and BMI (HR 2.4, 95% CI 1.1–5.3). Preceding POP, three or more deliveries and laparoscopic hysterectomy were significantly associated with UI visits but not with SUI operations.

Conclusion

After hysterectomy, 2.2% of women underwent operative treatment for SUI. The number of SUI operations was more than double after vaginal hysterectomy compared to abdominal hysterectomy, but preceding POP explained this added risk partially. Preceding POP and three or more vaginal deliveries were independently associated with UI visits after hysterectomy.

What We Know about the Long-Term Risks of Hysterectomy for Benign Indication-A Systematic Review

Hysterectomy is the most common treatment option in women with uterine fibroids, providing definitive relief from the associated burdensome symptoms. As with all surgical interventions, hysterectomy is associated with risk of complications, short-term morbidities, and mortality, all of which have been described previously. However, information on the potential long-term risks of hysterectomy is only recently becoming available. A systematic literature review was performed to identify studies published between 2005 and December 2020 evaluating the long-term impact of hysterectomy on patient outcomes. A total of 29 relevant studies were identified. A review of the articles showed that hysterectomy may increase the risk of cardiovascular events, certain cancers, the need for further surgery, early ovarian failure and menopause, depression, and other outcomes. It is important to acknowledge that the available studies examine possible associations and hypotheses rather than causality, and there is a need to establish higher quality studies to truly evaluate the long-term consequences of hysterectomy. However, it is of value to consider these findings when discussing the benefits and risks of all treatment options with patients with uterine fibroids to allow for preference-based choices to be made in a shared decision-making process. This is key to ensuring that patients receive the treatment that best meets their individual needs.

A Systematic Review of Minimally Invasive Treatments for Uterine Fibroid-Related Bleeding

Newer minimally invasive techniques provide treatment options for symptomatic uterine fibroids while allowing uterus preservation. The objective of this review was to analyze the efficacy of uterine-preserving, minimally invasive treatment modalities in reducing fibroid-related bleeding. A comprehensive search was conducted of PubMed, Embase, PsycINFO, ClinicalTrials.gov, Scopus, and Cochrane Library databases from inception to July 2020. English-language publications that evaluated premenopausal women with fibroid-related bleeding symptoms before and after treatment were considered. Randomized controlled trials were assessed for bias with the established Cochrane Risk of Bias Tool 2.0 and observational studies were assessed for quality under the New Castle-Ottawa Scale guidelines. Eighty-four studies were included in the review, including 10 randomized controlled trials and 74 observational studies. Six studies on myomectomy demonstrated overall bleeding symptom improvement in up to 95.9% of patients, though there was no significant difference between mode of myomectomy. Forty-one studies on uterine artery embolization reported significant reduction of fibroid-related bleeding, with symptomatic improvement in 79 to 98.5% of patients. Three studies suggested that embolization may be superior to myomectomy in reducing fibroid-related bleeding. Six studies reported that laparoscopic uterine artery occlusion combined with myomectomy led to greater reduction of bleeding than myomectomy alone. Fifteen studies demonstrated significantly reduced bleeding severity after radiofrequency ablation (RFA). Additional research is needed to establish the superiority of these modalities over one another. Long-term evidence is limited in current literature for magnetic resonance-guided focused ultrasound surgery, cryomyolysis, microwave ablation, and laser ablation.

Impact of Hysterectomy on Quality of Life, Urinary Incontinence, Sexual Functions and Urethral Length

The aim of the study was to evaluate the influence of different types of hysterectomy on UI symptoms, quality of life and sexual functions using dedicated questionnaires. We investigated a correlation between the urethral length (UL), UI symptoms and the length of the cervix (left after LSH and SH) with sexual functions. The study enrolled 500 consecutive women referred for hysterectomy: 121 underwent VH, 171 underwent LSH, 96 underwent SH, 68 underwent TAH, and 44 underwent TLH. The patients filled in the UI-specific questionnaires and FSFI before and 12 months after hysterectomy. The UL was measured by introital ultrasound before and 12 months after hysterectomy. Before surgery, 137 out of 399 (34.3%) patients had UI symptoms; afterwards, 139 (34.8%) indicated the same (p > 0.05). There was no statistically significant difference in the UL in the patients before and after the procedure, and the cervix length did not differ between patients after LSH and SH. When the entire investigated population was analyzed, a significant improvement of the QoL was found on the IIQ-7. Hysterectomy performed due to benign diseases has effects on UI regardless of the surgical technique used. The UI symptoms improved only in the patients after LSH. The UL measured 12 months after hysterectomy did not change.

Risk-efficacy balance of ulipristal acetate compared to surgical alternatives

Aims

Uterine fibroids are benign tumours that cause various complaints. These complaints may significantly compromise quality of life, necessitating a clinical intervention in 25–50% of the affected women. Hysterectomy, myomectomy or embolization may offer symptomatic relief, but are costly, include a recovery period, can cause serious side‐effects, sometimes fail to treat symptoms completely and are not always desired by patients. Ulipristal is a conservative long‐term treatment that has a fibroid‐volume decreasing effect, acceptable side‐effects while preserving fertility and may be an alternative to surgical alternatives. Currently, ulipristal is investigated by the European Medicine Agency and suspended from marketing authorization because it may cause drug‐induced liver injury (DILI). However, many drugs can cause severe DILI and prospective studies estimate 14–19 DILI cases/100 000 people.

Methods

This overview will discuss the risk–benefit balance between ulipristal and DILI, describe the safety–efficacy balance of ulipristal and its alternative treatments and the arguments that led to the suspension of its marketing authorization.

Results

Ulipristal may be associated with DILI resulting in a risk of severe liver injury in 1.5:100 000 patients and fatal liver injury in 0.1:100 000 patients. This risk needs to be weighed against the higher mortality risk of >1:1000 and higher incidence of severe complications after surgery.

Conclusion

The DILI risk of ulipristal is considerably lower than that of other medicines that are not suspended, nor need additional safety measures. When evaluating drugs and drug safety, risks that apply to the alternative nonpharmacological treatment options should be taken into consideration.

Urinary and fecal incontinence in patients with advanced ovarian cancer treated with CRS + HIPEC

PURPOSE

The objective of this work was to analyze the long-term prevalence of urinary and fecal incontinence and their impact on quality of life in patients with advanced and recurrent ovarian cancer treated with cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy (CRS + HIPEC).

METHODS

This cross-sectional study included a series of patients with advanced and recurrent ovarian cancer treated by CRS + HIPEC, with a disease-free period of at least 12 months after the procedure. Urinary incontinence was evaluated using the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF), fecal incontinence using the Wexner test and the Fecal Incontinence Quality of Life (FIQL) questionnaire and global quality of life using the Short Form 36 (SF-36) survey.

RESULTS

A total of 64 patients were included in the study, with a median age of 55 years (range 28-78). The urinary incontinence rate was 45% and the fecal incontinence rate was 20%. Up to 14% of the patients presented both types of incontinence. The presence of urinary or fecal incontinence generated a significant negative impact on quality of life in relation to patients without incontinence.

DISCUSSION

Urinary and fecal incontinence is frequent in the follow-up of ovarian cancer patients treated with CRS + HIPEC. Reconsidering the approach to the pelvis without peritoneal metastases in the peritoneum could modify the incidence of these pelvic floor dysfunctions.

Long-term mesh complications and reoperation after laparoscopic mesh sacrohysteropexy: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

The paucity of long-term safety and efficacy data to support laparoscopic mesh sacrohysteropexy is noteworthy given concerns about the use of polypropylene mesh in pelvic floor surgery. This study is aimed at determining the incidence of mesh-associated complications and reoperation following this procedure.

METHODS

This was a cross-sectional postal questionnaire study of women who underwent laparoscopic mesh sacrohysteropexy between 2010 and 2018. Potential participants were identified from surgical databases of five surgeons at two tertiary urogynaecology centres in the UK. The primary outcome was patient-reported mesh complication requiring removal of hysteropexy mesh. Secondary outcomes included other mesh-associated complications, reoperation rates and Patient Global Impression of Improvement (PGI-I) in prolapse symptoms. Descriptive statistics and Kaplan-Meier survival analyses were used.

RESULTS

Of 1,766 eligible participants, 1,121 women responded (response proportion 63.5%), at a median follow-up of 46 months. The incidence of mesh complications requiring removal of hysteropexy mesh was 0.4% (4 out of 1,121). The rate of chronic pain service use was 1.8%, and newly diagnosed systemic autoimmune disorders was 5.8%. The rate of reoperation for apical prolapse was 3.7%, and for any form of pelvic organ prolapse it was 13.6%. For PGI-I, 81.4% of patients were "much better" or "very much better".

CONCLUSIONS

Laparoscopic mesh sacrohysteropexy has a low incidence of reoperation for mesh complications and apical prolapse, and a high rate of patient-reported improvement in prolapse symptoms. With appropriate clinical governance measures, the procedure offers an alternative to vaginal hysterectomy with apical suspension. However, long-term comparative studies are still required.

Prevention of Urinary Incontinence in Women

PURPOSE OF REVIEW

Despite available treatments for urinary incontinence, the data regarding prevention is less established. This review sought to identify prevention measures and discuss their underlying evidence base with an attempt to include the most recent updates in the field.

RECENT FINDINGS

Urinary incontinence is a prevalent issue among women, particularly surrounding pregnancy and menopause. Interventions regarding pregnancy include not only general health promotion but also potentially interventions such as pelvic floor muscle training and decisions regarding method of delivery. With regard to menopause, the literature suggests avoiding treatments that have adverse effects on continence. Lastly, promoting healthy life style and reducing effects of co-morbid conditions can impact a woman's continence. The literature indicates that preventative strategies exist for urinary incontinence, though the data is limited in this area. Further work is needed to determine the impact of prevention measures and how best to implement them.

Hemorrhoids Are Associated with Urinary Incontinence

Background: Hemorrhoids are a common anal disorder and are more frequent in women than in men. Urinary incontinence (UI) also occurs more frequently in women than in men. Although both diseases share similar risk factors, research on the association between the two diseases is lacking. This study aimed to investigate the relationship between hemorrhoids and UI in adult Korean women. Methods: This study was based on the data of the 2008-2009 Korean National Health and Nutrition Examination Survey. Logistic regression test was performed to determine the relationship between hemorrhoids and UI after adjusting for age, body mass index (BMI), smoking, heavy drinking, physical activity, education level, income, diabetes mellitus, and hypertension. Results: Analysis of the data of 8,139 adult women revealed that the prevalence of hemorrhoids, which were self-reported and diagnosed by a physician, was 17.5% and 7.9%, respectively. Both types of hemorrhoids were more prevalent in older women with spouses, those with a large waist circumference, and those with a high BMI. The prevalence of UI was significantly high in the hemorrhoid group, regardless of whether it was self-reported or diagnosed by a physician. Multiple logistic regression analyses revealed a significant association between the prevalence of UI and hemorrhoids, both of which were found to peak at 19-39 years of age. Conclusions: Our findings demonstrate that hemorrhoids are significantly correlated with UI in adult Korean women. When treating adult women with hemorrhoids, it is, therefore, necessary to consider other pelvic floor diseases such as UI.

[Impact of hysterectomy on urinary incontinence: A systematic review]

INTRODUCTION

The impact of a hysterectomy on urinary incontinence is a controversial subject in the literature.

OBJECTIVE

To evaluate the prevalence and incidence of urinary incontinence after a hysterectomy as well as associated risk factors such as the type of hysterectomy, the surgical approach, urodynamic criteria and uterine disease.

STUDY DESIGN

We conducted a systematic review in Pubmed database with the following keywords and MeSH term: hysterectomy, urinary incontinence.

RESULTS

A total of 1340 articles were retrieved, 42 articles were selected for the final text analysis. The results of the different studies were heterogeneous. Hysterectomy seemed to increase the rate of sphincter deficiency (VLPP<60mmH₂O for 20% of cases versus 1,7% without hysterectomy, P=0.003). The vaginal route could increase the incidence of UI with OR of 2.3 (95%CI 1.0-5.2). Subtotal hysterectomy appears to increase UI with a 0,74 RR for total hysterectomy (95%CI 0.58-0.94). A radical hysterectomy with nerve conservation would preserve urinary functions, unlike pelvic radiotherapy, which is responsible for irreversible nerve damage by demyelination and bladder fibrosis.

Experience of Palestinian Women After Hysterectomy Using a Descriptive Phenomenological Study

Background:

Universally, hysterectomy is considered as the second most frequent surgery after cesarean section performed on women in the reproductive age. After a hysterectomy, women no longer have menstrual periods, so they cannot become pregnant. Like most other countries, hysterectomy is the most common major gynecological operation in Palestine. However, the psychological, physical, and sexual consequences of hysterectomy are conflicting, and the findings are mixed. While some studies report that patients experience more significant improvement in their mental health, sexual desire, and overall satisfaction, other studies show that patients report various adverse outcomes, with detrimental effects on sexual functioning being the main concern.

Objective:

This study aimed to describe women's experiences of hysterectomy and identify their fears, concerns, and what coping mechanisms do they adopt to enhance the quality of their lives.

Methodology:

Qualitative descriptive phenomenological research design was used in this study. The study aims to gain insight into the experiences of fifteen patients after hysterectomy using semi-structured in-depth interviews. The interview was conducted in both private and governmental hospitals using purposeful sampling.

Results:

Giorgi's phenomenological analysis process was used as a tool for analyzing data. Analysis of the interview transcripts led to five themes, including a total of eighteen subthemes. The first theme is physical change that has pain, insomnia, eating habits, and immobility as subthemes. The second theme is psychological changes with depression, de-socialization, anxiety, and aggressiveness as its subthemes. The third theme is defense mechanisms with praying, listening to music, reciting the Holy Quran, walking, and sports as subthemes. The fourth theme is self-esteem and body image with confidence, appearance, and concerns as subthemes. Lastly, the fifth them is sexuality with excitement and sexual pattern as subthemes.

Conclusion:

The results of this study demonstrated that hysterectomy had significant adverse effects on patients' body image, and self-esteem. Moreover, the study identified common meanings and themes associated with hysterectomy stressors. These are difficulties or limitations in physical and psychological aspects perceived by patients after hysterectomy. The health care provider must be aware of these potentially problematic issues to provide competent health care.

Função sexual e incontinência urinária por esforço em mulheres submetidas à histerectomia total com ooforectomia bilateral

RESUMO O objetivo deste artigo é avaliar o índice de função sexual de mulheres submetidas à histerectomia total com ooforectomia bilateral (HT-OB), a prevalência de incontinência urinária por esforço (IUE) e sua associação com a realização desse procedimento cirúrgico em um hospital de referência em Belém (PA). Foram incluídas 162 mulheres, com vida sexual ativa, alocadas em dois grupos: aquelas que realizaram HT-OB em período superior a 12 meses (n=68), e aquelas que não realizaram (n=94). Utilizou-se o questionário female sexual function index (FSFI) para avaliação da função sexual, e um questionário desenvolvido pelos pesquisadores para coletar dados sociais, econômicos e clínicos, incluindo informações quanto à presença de IUE. O valor de significância foi definido como p<0,05. Houve diferença significativa no índice de função sexual entre o grupo HT-OB e o grupo-controle, com escore geral do FSFI de 23,56 e 28,68, respectivamente (p=0,0001). Os domínios desejo, excitação, lubrificação (p<0,0001), orgasmo (p=0,04), satisfação (p=0,0006) e dor (p=0,015) apresentaram escores inferiores em mulheres histerectomizadas. A prevalência de sintomas de IUE no grupo HT-OB foi de 35,3%, sendo observada associação significativa entre a presença desses sintomas e a realização da histerectomia (p=0,02). Mulheres que realizam HT-OB têm maior risco de disfunção sexual, e este procedimento cirúrgico é associado ao desenvolvimento de IUE.

Time-frame comparison of hystero-preservation in the surgical treatment of uterine prolapse: a population-based nation-wide follow-up descriptive study, 2006-2013 versus 1997-2005

INTRODUCTION AND HYPOTHESIS

The purpose of our study was to describe the surgical trend and time-frame comparison between 1997-2005 (1^stperiod) and 2006-2013 (2nd period) of hystero-preservation for uterine prolapse, based upon a nationwide population-based National Health Insurance (NHI) claim data in Taiwan.

METHODS

Women, who underwent primary surgeries for uterine prolapse, either uterine suspension with hystero-preservation or hysterectomy during 1997-2013, were identified from National Health Insurance Research Database (NHIRD).We analyzed the related variables including surgical types (hystero-preservation or hysterectomy), patient age and concomitant anti-incontinence surgery, surgeon age, gender, and service volume; and hospital accreditation level, and service volume.

RESULTS

We identified a total of 46,968 inpatients, 6629 (14.11%) hystero-preservation group, and 40,339 (85.89%) hysterectomy group. Hystero-preservation significantly increased during the 17 year follow-up study period (1997 to 2013) (P value =0.0147). The overall surgeries for uterine prolapse increased among patients ≥70 years, with concomitant anti-incontinence surgery, surgeons ≥45 years, high volume surgeons, and hospitals. Multiple logistic regression revealed hysterectomy was less used in 2nd period (OR 0.45, 95%, confidence interval (CI) 0.43-0.48). Hysterectomy was more often used in patient aged ≥50 years, surgeon aged ≥45 years, and low volume hospitals. In case of concomitant anti-incontinence surgery (OR 0.48, CI 0.45-0.52), high volume surgeons (more than 30 surgeries) and hospitals (more than 73 surgeries) hystero-preservation was more often used.

CONCLUSIONS

Time-frames, younger patients, concomitant anti-incontinence surgery, younger surgeons, and high volume surgeons and hospitals increase hystero-preservation for uterine prolapse. Surgeons and hospitals should be ready to respond to the wishes of female patients who want to preserve the uterus.

Cancer Risk After Midurethral Sling Surgery Using Polypropylene Mesh

OBJECTIVE

To assess whether there is any association between the implantation of synthetic polypropylene mesh slings for the treatment of stress urinary incontinence (SUI) and risk of cancer.

METHODS

We performed a nationwide cohort study based on the general female population in Sweden. All women entered the observational period as unexposed on January 1, 1997, and contributed person-time as unexposed unless they underwent a midurethral sling procedure for SUI, after which they contributed person-time as exposed until first occurrence of any cancer, death, emigration, or end of the observational period (December 31, 2009). Occurrence of primary cancer was ascertained from the Cancer Register. Hazard ratios (HRs) with 95% CIs were calculated by Cox proportional hazards regression.

RESULTS

The final study population included 5,385,186 women, including 20,905 exposed, encompassing a total of 44,012,936 person-years at risk. Other than an inverse association with rectal cancer (HR 0.5, 95% CI 0.3-0.8), there were no significant differences in risk between exposed and unexposed women for pelvic organ cancers including ovarian (HR 0.8, 95% CI 0.5-1.2), endometrial (HR 1.1, 95% CI 0.8-1.4), cervical (HR 0.4, 95% CI 0.2-1.0), bladder, and urethra (HR 0.7, 95% CI 0.4-1.2). No significant association was observed between exposed women and primary cancer in any organ system when compared with unexposed women. The relative risk for cancer after exposure showed little variation over time except for an inverse overall correlation within the first 4 years of surgery (HR 0.7, 95% CI 0.7-0.8). The incidence rates per 100,000 person-years (95% CIs) for exposed vs unexposed women were 20.5 (14.3-29.5) vs 21.0 (20.6-21.5) for rectal cancer, 25.5 (18.4-35.3) vs 19.8 (19.4-20.2) for ovarian cancer, 65.0 (53.0-79.8) vs 33.1 (32.6-33.7) for endometrial cancer, 5.7 (2.8-11.3) vs 11.9 (11.6-12.2) for cervical cancer, and 19.1 (13.1-27.8) vs 13.3 (13.0-13.7) for bladder and urethra cancer.

CONCLUSION

Our results suggest that midurethral polypropylene sling surgery for SUI is not associated with an increased cancer risk later in life.

Selective progesterone receptor modulators for fertility preservation in women with symptomatic uterine fibroids

Uterine fibroids (UFs, AKA leiomyoma) are the most important benign neoplastic threat to women's health, with costs up to hundreds of billions of health care dollars worldwide. Uterine fibroids caused morbidities exert a tremendous health toll, impacting the quality of life of women of all ethnicities, especially women of color. Clinical presentations include heavy vaginal bleeding, pelvic pain, bulk symptoms, subfertility, and obstetric complications. Current management strategies heavily lean toward surgical procedures; nonetheless, the choice of treatment is generally subject to patient's age and her desire to preserve future fertility. Women with UF who desire to maintain future fertility potential face a dilemma because of the limited treatment choices that are currently available to help them achieve that goal. Recently, ulipristal acetate the first of the promising family of oral selective progesterone receptor modulators has been approved for UF treatment in Europe, Canada, and several other countries and is under review for possible approval in the USA. In this review article, we discuss recent advances in the management options against UF with a bend toward oral effective long-term treatment alternatives who are particularly suited for those seeking to preserve their future fertility potential. We also explore the transformative concept of primary and secondary UF prevention using these new anti-UF agents. We envision a remarkable shift in the management of UF in future years from surgical/invasive treatment to orally administrated options; clearly, this potential shift will require additional intense clinical research.

Patient-reported pelvic floor symptoms 5 years after hysterectomy with or without prolapse surgery

OBJECTIVE

The aim of this study was to evaluate the effect of hysterectomy with or without concomitant prolapse surgery on subject-reported pelvic floor disorders (PFD) with a 5-year follow-up.

STUDY DESIGN

This prospective longitudinal study was carried out in two Finnish central hospitals among 286 women who had undergone hysterectomy for benign reasons. The presence of urinary incontinence, urinary frequency, feeling of vaginal bulging, constipation and anal incontinence was evaluated at baseline, 1 and 5 years postoperatively. Analysis was performed on 256 (895%) patients who answered at least one of the follow-up questionnaires.

RESULTS

Hysterectomy with concomitant native tissue prolapse surgery significantly reduced urinary incontinence, urinary frequency, constipation and the feeling of vaginal bulging, and the results were maintained over the following five years. Plain hysterectomy reduced urinary frequency and the feeling of vaginal bulging but did not relieve urinary incontinence. Hysterectomy had no effect on anal incontinence. The total subsequent prolapse and/or incontinence operation rate was 2,7%, and was higher among patients who underwent hysterectomy for pelvic organ prolapse.

CONCLUSIONS

During a 5-years follow-up a hysterectomy alone or with native tissue prolapse surgery did not worsen pelvic floor disorders.

Dutch women's attitudes towards hysterectomy and uterus preservation in surgical treatment of pelvic organ prolapse

OBJECTIVE

To investigate Dutch women's attitudes and preferences towards hysterectomy or uterus preservation in surgical treatment of pelvic organ prolapse.

STUDY DESIGN

Women's attitude was assessed by a structured questionnaire in one university hospital and one non-university teaching hospital in the Netherlands. Between December 2013 and November 2014, 102 women referred with prolapse complaints, without previous prolapse surgery, responded to the questionnaire received by mail prior to gynaecological consultation. Main outcome was the preference for uterus preserving surgery versus hysterectomy. Furthermore we studied the impact of uterus preservation and hysterectomy on body image and sexual function and the importance of treatment success, risk of urinary incontinence after surgery, complication risk, recovery time, length of hospital stay, costs and the risk of developing endometrial cancer.

RESULTS

Assuming that functional and anatomical outcomes after hysterectomy and uterus preserving surgery were equal, more women expressed preference for uterus preservation (43%, 44 out of 102 women) compared to hysterectomy (27%, 27 out of 102 women). The majority of women expected a similar improvement in sexuality and body image after the two treatment modalities. Treatment success, risk for urinary incontinence after surgery and complication risk were the most important factors. Taken the future risk of endometrial cancer into account, 18% of the women preferred hysterectomy because of this risk.

CONCLUSIONS

This study demonstrated that women referred with prolapse complaints have a preference for uterus preservation in case outcomes after both interventions are expected to be equal. The majority of women expected that body image and sexual function would equally improve after both interventions.

Factors influencing the outcome of surgery for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) surgery is a common gynecological procedure. Our aim was to assess the influence of obesity and other risk factors on the outcome of anterior and posterior colporrhaphy with and without mesh.

METHODS

Data were retrieved from the Swedish National Register for Gynecological Surgery on 18,554 women undergoing primary and repeat POP surgery without concomitant urinary incontinence (UI) surgery between 2006 and 2015. Multivariate logistic regression analyses were used to identify independent risk factors for a sensation of a vaginal bulge, de novo UI, and residual UI 1 year after surgery.

RESULTS

The overall subjective cure rate 1 year after surgery was 80% (with mesh 86.4% vs 77.3% without mesh, p < 0.001). The complication rate was low, but was more frequent in repeat surgery that were mainly mesh related. The use of mesh was also associated with more frequent de novo UI, but patient satisfaction and cure rates were higher compared with surgery without mesh. Preoperative sensation of a vaginal bulge, severe postoperative complications, anterior colporrhaphy, prior hysterectomy, postoperative infections, local anesthesia, and body mass index (BMI) ≥30 were risk factors for sensation of a vaginal bulge 1 year postsurgery. Obesity had no effect on complication rates but was associated increased urinary incontinence (UI) after primary surgery. Obesity had no influence on cure or voiding status in women undergoing repeat surgery.

CONCLUSIONS

Obesity had an impact on the sensation of a vaginal bulge and the presence of UI after primary surgery but not on complications.

Relationship between hysterectomy and severity of female stress urinary incontinence

Background

Stress Urinary Incontinence (SUI) is one of the most reported health dilemmas of women suffering from lower urinary tract symptoms.

Aim

To determine the relation between hysterectomy and severity of female SUI using Valsalva Leak Point Pressure (VLPP).

Methods

This case-control study was conducted at a public urology clinic in Tehran in 2015. The study population was all female with SUI complaints who visited the clinic during 2015. We compared Valsalva leak point pressure in two groups of female SUI patients with and without hysterectomy history. The inclusion criteria were: not taking any alpha-blocker or anti-cholinergic medicines two weeks prior to the urodynamic test as well as no history of pelvic surgery or cesarean delivery in their lifetime. All qualified patients were invited to participate in the study randomly, and among them, 120 qualified patients agreed to participate by filling out the informed consent form. Data was gathered through direct interview, and double checked by patients’ medical records. All the study variables including age, BMI, delivery number, hysterectomy and UTI history were entered and analyzed by estimating ordered logistic regression and by using Stata14.1 software.

Results

The mean of VLPP was 70.17 cmH₂O in the group with hysterectomy history, and 94.55 cmH₂O in those without hysterectomy history. The difference of VLPP pressure between the two studied groups were significant (p<0.05), even after control of confounding variables. Also, the odds of severe SUI among hysterectomy group patients was 6.3 times more than no hysterectomy (OR=6.32, p<0.001).

Conclusions

Our study confirms significant relation between hysterectomy and SUI severity measured by Valsalva leak point pressure. Hysterectomy patients are more likely to suffer from more severe grades of SUI.

Anatomical complications of hysterectomy: A review

Hysterectomy is the most commonly performed gynecological procedure in the United States with three possible surgical approaches; vaginal, abdominal and laparoscopic. As with any surgical procedure, various anatomical complications can arise. These include injuries to anatomical structures such as the urinary bladder, ureter, intestines, rectum, anus, and a multitude of nervous structures. Other complications include sexual dysfunction, vaginal cuff dehiscence, and urinary incontinence. Using standard search engines, the anatomical complications of hysterectomies are reviewed. In conclusion, surgeons who perform hysterectomies or are involved with postoperative hysterectomy patients should be familiar with the possible complications of this common procedure and the steps that can be taken to help reduce the risk of those complications. Clinicians should also inform their patients of the potential complications as they can affect lifestyle and comfort. Clin. Anat. 30:946-952, 2017. © 2017 Wiley Periodicals, Inc.

Hysterectomy is not associated with de-novo urinary incontinence: A ten-year cohort study

OBJECTIVE

To determine prevalence, incidence proportion, and changes of urinary incontinence (UI) 10-13 years after hysterectomy compared to two control groups.

STUDY DESIGN

A longitudinal cohort study of 661 women with follow-up for ten years. Originally, 866 women answered a questionnaire on continence status preoperatively. Ten years postoperatively the queries were repeated in 371 with a hysterectomy, 89 with laparoscopic cholecystectomy (LC), and 201 with transcervical endometrial resection (TCRE). Significant incontinence was UI at least once a week. The main outcome measures were prevalence and incidence proportions of UI.

RESULTS

The overall prevalence of stress UI ten years after surgery was 23% compared to 12% preoperatively. Urge UI was prevalent in 12% compared to 5% preoperatively. Incidence proportions of stress UI were in hysterectomies 21%, in LC 15%, and in TCRE 18%. Similarly, incidence proportions of urge UI were in hysterectomies 11%, in LC 11%, and in TCRE 8%. No significant differences between surgical procedures were found; however, we found substantial amount of changes in continence status from continent to incontinent and vice versa in all three groups.

CONCLUSIONS

No significant difference was found after hysterectomy compared to controls in the prevalence or incidence proportions of UI after 10 years follow-up. Hysterectomy is not a risk factor of UI.

Incidence and Risk Factors of De novo Stress Urinary Incontinence after Pelvic Floor Reconstruction: A Nested Case-control Study

Background:

Some patients with pelvic organ prolapse may suffer from lower urinary tract symptoms (LUTS), especially stress urinary incontinence (SUI) named de novo SUI after pelvic floor reconstruction. This study aimed to investigate the incidence and risk factors of de novo SUI.

Methods:

This is a nested case-control study of 533 patients who underwent pelvic floor reconstruction due to pelvic organ prolapse (POP) at the Department of Gynecology in Peking University People's Hospital from January 2011 to March 2013. According to the inclusion and exclusion criteria, 401 patients were enrolled in the study with the follow-up rate of 74.8% (101 patients lost to follow-up). There were 75 patients with de novo SUI postoperatively. According to the ratio of 1:3, we ensured the number of control group (n = 225). The preoperative urinary dynamics, POP-quantification scores, and LUTS were compared between the two groups by univariate and multivariate logistic regression analyses to investigate the risk factors of de novo SUI.

Results:

The incidence of de novo SUI was 25% (75/300). Univariate analysis showed that the ratio of lower urinary tract obstruction (LUTO) before surgery in de novo SUI group was significantly higher than the control group (odds ratio [OR] = 2.1, 95% confidence interval [CI] [1.1–4.0], P = 0.022). The interaction test of LUTO and other factors displayed that Aa value was an interaction factor. With the increasing score of Aa, the incidence of de novo SUI become higher (OR = 2.1, 95% CI [1.0–3.7], P = 0.045). After multivariable adjustment, multiple regression analysis showed that LUTO was independently associated with a greater risk of de novo SUI after pelvic floor surgery (OR = 2.3, 95% CI [1.2–4.6], P = 0.013).

Conclusions:

Preoperative LUTO in patients with POP is a high-risk factor of de novo SUI, and high score of Aa-point is related to the occurrence of de novo SUI, which might be due to the outlet obstruction caused by bladder prolapse.

Effects of Hysterectomy on Pelvic Floor Disorders: A Longitudinal Study

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.

Patient-reported lower urinary tract symptoms after hysterectomy or hysteroscopy: a study from the Swedish Quality Register for Gynecological Surgery

Introduction and hypothesis

Hysterectomy is sometimes considered the cause of lower urinary tract symptoms (LUTS). We hypothesized that hysterectomy for abnormal uterine bleeding and/or symptoms of fibroids is more likely to cause LUTS than a hysteroscopic procedure for the same indications.

Methods

Two groups of women were compared: one group comprised 3,618 women who had had a hysterectomy due to abnormal uterine bleeding or symptoms of fibroids and the other group comprised 238 women who had had hysteroscopic treatment for the same indications. The main outcome measures were occurrence of LUTS before and 1 year after the surgical intervention. The frequencies of LUTS before and after surgery were compared between the groups. Binary logistic regression was used to model the odds of having postoperative urinary leakage and urgency while controlling for uterine size, surgical procedure and preoperative LUTS.

Results

There were no statistically significant differences between women after hysterectomy and after hysteroscopy in the frequencies of LUTS before or after surgery, when uterine size was comparable. However, there was a difference in the rates of de novo urinary incontinence between women with hysterectomy and women with hysteroscopy (7.6%, 95% CI 6.3–9.0, and 3.2%, 95% CI 1.6–6.5, respectively). Of the women with a large uterus, 58.6% (95% CI 51.5–65.5) reported relief of urinary incontinence and 85.5% (95% CI 82.3–88.4) reported relief of urinary urgency postoperatively.

Conclusions

Our results suggest that it is important to individualize preoperative information in women prior to hysterectomy since the outcome concerning LUTS depends on preoperative symptoms and uterine size.

Factors influencing the incidence and remission of urinary incontinence after hysterectomy

BACKGROUND

Studies on the influence of body mass index, smoking, and mode of delivery on the occurrence of urinary incontinence after hysterectomy are required to provide women with information about how these factors influence continence after a hysterectomy.

OBJECTIVE

The aim was to assess the impact of lifestyle factors such as body mass index, smoking, and delivery mode (vaginal/cesarean) on the incidence and remission of urinary incontinence after hysterectomy.

STUDY DESIGN

This was a cohort study based on pre-, per-, and postoperative (1 year) data retrieved from the Swedish National Register for Gynecological Surgery on 16,182 hysterectomies performed because of a benign indication between 2006 and 2013. Multivariable logistic regression analyses were used to identify independent risk factors for de novo urinary incontinence and postoperative remission of urinary incontinence, presented as adjusted odds ratios with 95% confidence intervals.

RESULTS

De novo urinary incontinence was reported by 8.5%, remission of urinary incontinence by 13.3%, and residual urinary incontinence by 16.1% after the hysterectomy. A body mass index ≥30 kg/m² (odds ratio, 1.63, 95% confidence interval, 1.37-1.94), having undergone a vaginal delivery (odds ratio, 1.40, 95% confidence interval, 1.14-1.86), the presence of daily urge without incontinence prior to surgery (odds ratio, 1.77, 95% confidence interval, 1.47-2.13), and a uterine weight <500 g (odds ratio, 2.46, 95% confidence interval, 1.96-3.09) were associated with an increased risk of de novo urinary incontinence. A uterine weight >300 g (odds ratio, 1.98, 95% confidence interval, 1.69-2.33), body mass index <25 kg/m² (odds ratio, 1.22, 95% confidence interval, 1.01-1.47), prolapse (odds ratio, 2.25, 95% confidence interval, 1.60-3.18), or fibroids (odds ratio, 1.33, 95% confidence interval, 1.09-1.62) as indication for surgery and the absence of daily urge without incontinence preoperatively (odds ratio, 1.51, 95% confidence interval, 1.29-1.76) were associated with an increased remission of urinary incontinence. Vaginal compared with abdominal hysterectomy was associated with a decreased remission of urinary incontinence (odds ratio, 0.70, 95% confidence interval, 0.57-0.87). There was no effect of age or smoking or a difference between total and subtotal hysterectomy with regard to de novo urinary incontinence or remission of urinary incontinence after the hysterectomy. Residual urinary incontinence and de novo urinary incontinence significantly reduced satisfaction with surgery 1 year postoperatively compared with women without urinary incontinence.

CONCLUSION

Vaginal delivery, obesity, and daily urge symptoms without incontinence prior to surgery increased de novo urinary incontinence and had a negative influence on the rate of remission of urinary incontinence after hysterectomy, which in turn influenced patients' satisfaction with surgery.

Impaired contraction and decreased detrusor innervation in a female rat model of pelvic neuropraxia

INTRODUCTION AND HYPOTHESIS

Bilateral pelvic nerve injury (BPNI) is a model of post-radical hysterectomy neuropraxia, a common sequela. This study assessed the time course of changes to detrusor autonomic innervation, smooth muscle (SM) content and cholinergic-mediated contraction post-BPNI.

METHODS

Female Sprague-Dawley rats underwent BPNI or sham surgery and were evaluated 3, 7, 14, and 30 days post-BPNI (n = 8/group). Electrical field-stimulated (EFS) and carbachol-induced contractions were measured. Gene expression was assessed by qPCR for muscarinic receptor types 2 (M2) and 3 (M3), collagen type 1α1 and 3α1, and SM actin. Western blots measured M2 and M3 protein expression. Bladder sections were stained with Masson's trichrome for SM content and immunofluorescence staining for nerve terminals expressing vesicular acetylcholine transporter (VAChT), tyrosine hydroxylase (TH), and neuronal nitric oxide synthase (nNOS).

RESULTS

Bilateral pelvic nerve injury caused larger bladders with less SM content and increased collagen type 1α1 and 3α1 gene expression. At early time points, cholinergic-mediated contraction increased, whereas EFS-mediated contraction decreased and returned to baseline by 30 days. Protein and gene expression of M3 was decreased 3 and 7 days post-BPNI, whereas M2 was unchanged. TH nerve terminals surrounding the detrusor decreased in all BPNI groups, whereas VAChT and nNOS terminals decreased 14 and 30 days post-BPNI.

CONCLUSIONS

Bilateral pelvic nerve injury increased bladder size, impaired contractility, and decreased SM and autonomic innervation. Therapeutic strategies preventing nerve injury-mediated decline in neuronal input and SM content may prevent the development of a neurogenic bladder and improve quality of life after invasive pelvic surgery.

The impact of abdominal and laparoscopic hysterectomies on women's sexuality and psychological condition

OBJECTIVE

To investigate whether there were any differences in the quality of life, sexual function, and self-esteem of patients who underwent total laparoscopic hysterectomy (TLH) (n=42) and total abdominal hysterectomy (TAH) (n=42).

MATERIALS AND METHODS

All premenopausal patients who underwent TLH or TAH because of benign uterine disorders were enrolled. The sexual function and quality of life status were assessed preoperatively and 6 months postoperatively using three standardized validated questionnaires: the Arizona Sexual Experiences Scale (ASEX), the Symptom Checklist-90-Revised (SCL-90-R), and the Rosenberg Self-Esteem Scale (RSES).

RESULTS

Preoperative ASEX, SCL-90-R and RSES scores were not different among the hysterectomy subgroups. The postoperative SCL-90-R scores were also not different among the hysterectomy subgroups. The postoperative RSES scores were significantly lower (p<0.05) than the preoperative scores for all procedures (indicating improved self-esteem) but did not differ among the groups. The postoperative ASEX scores were significantly decreased (p<0.01) as compared with the preoperative scores (indicating improved sexual function). When the average score of each item of the ASEX score was compared in both groups, significant differences were observed in sexual drive and arousal in the laparoscopy group (p<0.01).

CONCLUSION

Women undergoing TLH for benign uterine disease may have better outcomes related to certain sexual function parameters than women undergoing TAH.

Uterine Cancer After Risk-Reducing Salpingo-oophorectomy Without Hysterectomy in Women With BRCA Mutations

IMPORTANCE

The link between BRCA mutations and uterine cancer is unclear. Therefore, although risk-reducing salpingo-oophorectomy (RRSO) is standard treatment among women with BRCA mutations (BRCA+ women), the role of concomitant hysterectomy is controversial.

OBJECTIVE

To determine the risk for uterine cancer and distribution of specific histologic subtypes in BRCA+ women after RRSO without hysterectomy.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective cohort study included 1083 women with a deleterious BRCA1 or BRCA2 mutation identified from January 1, 1995, to December 31, 2011, at 9 academic medical centers in the United States and the United Kingdom who underwent RRSO without a prior or concomitant hysterectomy. Of these, 627 participants were BRCA1+; 453, BRCA2+; and 3, both. Participants were prospectively followed up for a median 5.1 (interquartile range [IQR], 3.0-8.4) years after ascertainment, BRCA testing, or RRSO (whichever occurred last). Follow up data available through October 14, 2014, were included in the analyses. Censoring occurred at uterine cancer diagnosis, hysterectomy, last follow-up, or death. New cancers were categorized by histologic subtype, and available tumors were analyzed for loss of the wild-type BRCA gene and/or protein expression.

MAIN OUTCOMES AND MEASURES

Incidence of uterine corpus cancer in BRCA+ women who underwent RRSO without hysterectomy compared with rates expected from the Surveillance, Epidemiology, and End Results database.

RESULTS

Among the 1083 women women who underwent RRSO without hysterectomy at a median age 45.6 (IQR: 40.9 - 52.5), 8 incident uterine cancers were observed (4.3 expected; observed to expected [O:E] ratio, 1.9; 95% CI, 0.8-3.7; P = .09). No increased risk for endometrioid endometrial carcinoma or sarcoma was found after stratifying by subtype. Five serous and/or serous-like (serous/serous-like) endometrial carcinomas were observed (4 BRCA1+ and 1 BRCA2+) 7.2 to 12.9 years after RRSO (BRCA1: 0.18 expected [O:E ratio, 22.2; 95% CI, 6.1-56.9; P < .001]; BRCA2: 0.16 expected [O:E ratio, 6.4; 95% CI, 0.2-35.5; P = .15]). Tumor analyses confirmed loss of the wild-type BRCA1 gene and/or protein expression in all 3 available serous/serous-like BRCA1+ tumors.

CONCLUSIONS AND RELEVANCE

Although the overall risk for uterine cancer after RRSO was not increased, the risk for serous/serous-like endometrial carcinoma was increased in BRCA1+ women. This risk should be considered when discussing the advantages and risks of hysterectomy at the time of RRSO in BRCA1+ women.