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Norrbom C, Osler M, Krabbe-Sørensen M, Rasmussen SC, Carlsen SE, Nilas L, Settnes A, Løkkegaard ECL. Risk of Bowel Obstruction After Hysterectomy for Benign Indication According to Surgical Method in Denmark, 1984-2013. J Minim Invasive Gynecol 2024; 31:855-869.e6. [PMID: 38942232 DOI: 10.1016/j.jmig.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 06/13/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024]
Abstract
STUDY OBJECTIVE To estimate the risk of bowel obstruction (BO) after hysterectomy for benign indications depending on the surgical method (abdominal, vaginal, or laparoscopic) and identify risk factors for adhesive BO. DESIGN A national registry-based cohort. SETTING Danish hospitals during the period 1984-2013. PATIENTS Danish women who underwent hysterectomy for benign indications (N = 125 568). INTERVENTIONS Abdominal hysterectomies were compared with vaginal hysterectomies, laparoscopic hysterectomies, and minimally invasive (vaginal and laparoscopic) hysterectomies. MEASUREMENTS AND MAIN RESULTS The incidence of BO according to the surgical method was compared using Cox proportional hazard regression. The covariates included were the time period, age, concomitant operations, previous abdominal surgery or disease, and socioeconomic factors. In a subanalysis (n = 35 712 women) of the period 2004-2013, detailed information from the Danish Hysterectomy Database enabled the inclusion of patient-, surgery-, and complication-related covariates. The overall crude incidence of BO was 17.4 of 1000 hysterectomies (2196 incident cases). The 10-year cumulative incidence of BO differed among the surgical routes (abdominal, 1.7%; laparoscopic, 1.4%; and vaginal, 0.9%). In multiple-adjusted analyses, the risk of BO was higher after abdominal hysterectomy than after vaginal (hazard ratio 1.64 [95% confidence interval, 1.39-1.93]) and minimally invasive (vaginal or laparoscopic) hysterectomy (hazard ratio 1.54 [1.33-1.79]). Additional pre-existing risk factors for BO at the time of hysterectomy were increased age, low education, low income, smoking, high American Society of Anesthesiologists comorbidity score, history of infertility, abdominal infection, and previous abdominal surgery (apart from cesarean section), penetrating lesions in abdominal organs, or operative adhesiolysis. Perioperative risk factors at the time of hysterectomy included concomitant removal of the ovaries, adhesiolysis, blood transfusion, readmission, and overall presence of perioperative complications. CONCLUSION Abdominal hysterectomy is associated with a 54% higher risk of BO than minimally invasive (laparoscopic or vaginal) hysterectomy.
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Affiliation(s)
- Christina Norrbom
- Department of Obstetrics and Gynecology, North Zealand Hospital Hillerød, Hillerød, Denmark (Dr. Norrbom, Mr. Rasmussen, Mr. Carlsen, Dr. Settnes, and Dr. Løkkegaard); Department of Clinical Medicine (Drs. Norrbom, Nilas, Settnes, and Løkkegaard) and Section of Epidemiology
| | - Merete Osler
- Department of Public Health (Dr. Osler); University of Copenhagen, Copenhagen, Denmark, Center for Clinical Research and Disease Prevention, Frederiksberg and Bispebjerg Hospitals, Denmark, Frederiksberg, Denmark (Dr. Osler)
| | | | - Steen C Rasmussen
- Department of Obstetrics and Gynecology, North Zealand Hospital Hillerød, Hillerød, Denmark (Dr. Norrbom, Mr. Rasmussen, Mr. Carlsen, Dr. Settnes, and Dr. Løkkegaard)
| | - Sif E Carlsen
- Department of Obstetrics and Gynecology, North Zealand Hospital Hillerød, Hillerød, Denmark (Dr. Norrbom, Mr. Rasmussen, Mr. Carlsen, Dr. Settnes, and Dr. Løkkegaard)
| | - Lisbeth Nilas
- Department of Clinical Medicine (Drs. Norrbom, Nilas, Settnes, and Løkkegaard) and Section of Epidemiology
| | - Annette Settnes
- Department of Obstetrics and Gynecology, North Zealand Hospital Hillerød, Hillerød, Denmark (Dr. Norrbom, Mr. Rasmussen, Mr. Carlsen, Dr. Settnes, and Dr. Løkkegaard); Department of Clinical Medicine (Drs. Norrbom, Nilas, Settnes, and Løkkegaard) and Section of Epidemiology
| | - Ellen C L Løkkegaard
- Department of Obstetrics and Gynecology, North Zealand Hospital Hillerød, Hillerød, Denmark (Dr. Norrbom, Mr. Rasmussen, Mr. Carlsen, Dr. Settnes, and Dr. Løkkegaard); Department of Clinical Medicine (Drs. Norrbom, Nilas, Settnes, and Løkkegaard) and Section of Epidemiology.
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Shoukry A, Yousri M. Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature. BMC Womens Health 2024; 24:500. [PMID: 39256764 PMCID: PMC11384712 DOI: 10.1186/s12905-024-03326-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 08/21/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Despite being a highly debated issue, subtotal or supracervical hysterectomy (SCH) is still considered a safe and effective treatment for women with benign gynecological lesions. Benign and malignant cervical diseases have been reported after SCH, with fibroids being the most frequently diagnosed lesions in the excised cervical stump. Recurrence of cervical disease after SCH usually presents with vaginal bleeding, pelvic mass, or abdominal pain; moreover, it may necessitate reoperation and resection of the cervical stump or trachelectomy. Trachelectomy is known to be a difficult surgical procedure that may be associated with significant intra- and post-operative morbidity. CASE PRESENTATION We presented here a case of a 41-year-old nulliparous woman with a pelvic mass related to the cervical stump presented 2 years after subtotal hysterectomy, performed due to interactable abnormal uterine bleeding, which was attributed to a multiple fibroid uterus. Six years ago, she complained of pelvic pain, excessive vaginal discharge, and spotting. A transvaginal sonography and magnetic resonance imaging with contrast were performed, which revealed a 10.2 × 7.6 × 6.5 cm heterogeneous pelvic mass with irregular borders and marked vascularity on color Doppler. Surgical exploration and resection of the mass with cervical stump excision were performed. Histopathology confirmed the diagnosis of cervical stump multiple benign leiomyomata with no atypical features. CONCLUSION Recurrence or De novo development of leiomyomata and other cervical lesions might occur after supracervical or subtotal hysterectomy; thus, thorough pre-operative counseling for women requesting a SCH regarding the pros and cons of the procedure compared with total hysterectomy should be optimized. Meticulous follow-up, including the continuation of routine cervical cytological smears, is mandatory for patients with a retained cervix.
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Affiliation(s)
- Ahmed Shoukry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Mahmoud Yousri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Hong CX, O'Leary M, Horner W, Schmidt PC, Harvie HS, Kamdar NS, Morgan DM. Decreasing Utilization of Vaginal Hysterectomy in the United States: An Analysis by Candidacy for Vaginal Approach. Int Urogynecol J 2024:10.1007/s00192-024-05908-y. [PMID: 39240369 DOI: 10.1007/s00192-024-05908-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 08/01/2024] [Indexed: 09/07/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to assess trends in hysterectomy routes by patients who are likely and unlikely candidates for a vaginal approach. METHODS We performed a retrospective cohort study of patients who underwent vaginal, abdominal, or laparoscopic/robotics-assisted laparoscopic hysterectomy between 2017 and 2020 using the National Surgical Quality Improvement Program database. Patients undergoing hysterectomy for a primary diagnosis of benign uterine pathology, dysplasia, abnormal uterine bleeding, or pelvic floor disorders were eligible for inclusion. Patients who were parous, had no history of pelvic or abdominal surgery, and had a uterine weight ≤ 280 g on pathology were considered likely candidates for vaginal hysterectomy based on an algorithm developed to guide the surgical approach. Average annual changes in the proportion of likely vaginal hysterectomy candidates and route of hysterectomy were assessed using logistic regression. RESULTS Of the 77,829 patients meeting the inclusion criteria, 13,738 (17.6%) were likely vaginal hysterectomy candidates. Among likely vaginal hysterectomy candidates, the rate of vaginal hysterectomy was 34.5%, whereas among unlikely vaginal hysterectomy candidates, it was 14.1%. The overall vaginal hysterectomy rate decreased -1.2%/year (p < 0.01). This decreasing trend was nearly twice as rapid among likely vaginal hysterectomy candidates (-1.9%/year, p < .01) compared with unlikely vaginal hysterectomy candidates (-1.1%/year, P < 0.01); the difference in trends was statistically significant (p < 0.01). CONCLUSIONS The rate of vaginal hysterectomy performed for eligible indications decreased between 2017 and 2020 in a national surgical registry. This negative trend was more pronounced among patients who were likely candidates for vaginal hysterectomy based on favorable parity, surgical history, and uterine weight.
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Affiliation(s)
- Christopher X Hong
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Michael O'Leary
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Payton C Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, Division of Urogynecology, Perelman School of Medicine, Philadelphia, PA, USA
| | - Neil S Kamdar
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Daniel M Morgan
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
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Barba M, Cola A, De Vicari D, Melocchi T, Gili MA, Frigerio M. Enhanced recovery after surgery (ERAS) in prolapse repair: A prospective study on pre-emptive uterosacral/cervical block. Int J Gynaecol Obstet 2024; 166:1240-1246. [PMID: 38516832 DOI: 10.1002/ijgo.15483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre-emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery. METHODS This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively. RESULTS We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180). CONCLUSIONS For the first time, we demonstrated the impact of pre-emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics.
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Affiliation(s)
- Marta Barba
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alice Cola
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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Garzon S, Caliò A, Ferrari FA, Iannicello CQ, Zorzato PC, Bosco M, Piazzola E, Martignoni G, Laganà AS, Mariani A, Uccella S. Uterine perivascular epithelioid cell tumors (PEComa) and the accuracy of proposed classification systems in predicting the malignant versus non-malignant behavior. Gynecol Oncol 2024; 188:35-43. [PMID: 38905754 DOI: 10.1016/j.ygyno.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/08/2024] [Accepted: 06/11/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE To compare the accuracy of available classification systems (Folpe, modified Folpe, Bennet, and Schoolmester) in predicting the behavior of uterine Perivascular Epithelioid Cell tumors (PEComas). METHODS We reviewed the pathology registry to identify all uterine PEComas treated at our center. We conducted a systematic literature review searching electronic databases from inception to November 2023. We included all references reporting at least one case of uterine PEComa; cases associated with tuberous sclerosis complex were excluded. Patient-level data were extracted by identified records. Survival analysis was used to assess the accuracy of all proposed classification systems to classify uterine PEComas as malignant versus non-malignant. RESULTS Six uterine PEComas were treated at our center. The literature search identified 101 uterine PEComas from 32 studies. Eighty-five out of 107 PEComas (28 studies and our series) reported enough follow-up data and details to apply all four classifications. The modified Folpe classification demonstrated the highest hazard ratio (HR) for relapse (HR:8.63; 95% confidence interval [CI] 2.06-36.1) and death due to PEComa (HR:6.8, 95%CI:0.89-51.6) for malignant versus non-malignant PEComas. Changing the cut-off of PEComa size to ≥8 cm and mitotic figures per 50 high power fields to ≥5, the HR for recurrence lowered (HR:6.26; 95% CI 2.20-17.80), but HR for death increased (HR:10.3; 95% CI 1.35-77.80). CONCLUSIONS The modified Folpe classification was the most accurate in predicting the PEComa behavior. Changing the cut-off of PEComa size and number of mitotic figures may improve the accuracy in predicting death due to disease.
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Affiliation(s)
- Simone Garzon
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy.
| | - Anna Caliò
- Section of Pathology, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Filippo Alberto Ferrari
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Cesare Quintino Iannicello
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Pier Carlo Zorzato
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Mariachiara Bosco
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Elena Piazzola
- Section of Pathology, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Guido Martignoni
- Section of Pathology, Department of Diagnostic and Public Health, University of Verona, Verona, Italy; Department of Pathology, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Andrea Mariani
- Department of Gynecology and Obstetrics, Mayo Clinic, Rochester, MN, USA
| | - Stefano Uccella
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Guan X, Yang Q, Lovell DY. Assessing Feasibility and Outcomes of Robotic Single Port Transvaginal NOTES(RSP-vNOTES) Hysterectomy: A Case Series. J Minim Invasive Gynecol 2024:S1553-4650(24)00364-9. [PMID: 39222841 DOI: 10.1016/j.jmig.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 08/19/2024] [Accepted: 08/28/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To demonstrate the feasibility and short-term outcomes of Robot-Assisted Single Port vaginal NOTES (RSP-vNOTES) for total hysterectomy, with or without endometriosis resection for all stages. DESIGN Retrospective case series. SETTING Single academic tertiary care hospital in Houston, Texas, USA. PARTICIPANTS 28 adult women with chronic pelvic pain who underwent RSP-vNOTES hysterectomy, with or without endometriosis resection. INTERVENTIONS Hysterectomy with or without excision of endometriosis via single-port robot-assisted vNOTES platform (Intuitive Da Vinci SP Platform). MAIN RESULTS 28 patients with a mean age of 40.1 years (range 24.0-54.0 years), mean BMI 28.5 kg/m2 (range 19.5-48.4 kg/m2), underwent RSP-vNOTES from November 11, 2023 to May 7, 2024. Five (17.9%) patients underwent solely a hysterectomy, while 23 (82.1%) patients underwent additional endometriosis resection; 28.6% with stage I, 25.0% stage II, 7.1% stage III, and 21.4% with stage IV. Mean total operative time was 188.7 minutes (range 135.0-427.0 minutes), with robot dock time of 2.9 minutes (range 1.0-10.0 minutes), robot console time of 97.3 minutes (range 51.0-221.0 minutes), and hysterectomy time of 55.3 minutes (range 24.0-170.0 minutes). Estimated blood loss averaged 32.1 mL (range 25.0-50.0mL). One case required a mini-laparotomy as the irregularly-shaped 1668g fibroid uterus was unable to be removed vaginally. Complications included one case of vaginal cuff cellulitis and one case of urinary tract infection. CONCLUSION Our findings indicate that RSP-vNOTES, a novel single-port surgical approach, presents a promising alternative surgical platform in vaginal surgeries.
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Affiliation(s)
- Xiaoming Guan
- Division of Minimally Invasive Gynecologic surgery, Baylor College of Medicine, Houston, Texas, U.S.A..
| | - Qiannan Yang
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Daniel Y Lovell
- Division of Minimally Invasive Gynecologic surgery, Baylor College of Medicine, Houston, Texas, U.S.A
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Palacios-Helgeson LK, Premkumar A, Wong JMK, Gould CH, Cahn MA, Osmundsen BC. A National Database Study on Racial Disparities in Route of Hysterectomy with a Surrogate Control for Uterine Size: A Proposed Quality Metric for Benign Indications. J Minim Invasive Gynecol 2024:S1553-4650(24)00302-9. [PMID: 39002659 DOI: 10.1016/j.jmig.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 07/01/2024] [Accepted: 07/08/2024] [Indexed: 07/15/2024]
Abstract
STUDY OBJECTIVE To investigate the association between race and route of hysterectomy among patients undergoing hysterectomy for abnormal uterine bleeding (AUB) in the absence of uterine myoma disease and excluding malignancy. DESIGN A cross-sectional cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and National Ambulatory Surgical databases to compare abdominal to minimally invasive routes of hysterectomy. SETTING Hospitals and hospital-affiliated ambulatory surgical centers participating in the Healthcare Cost and Utilization Project in 2019. PATIENTS A total of 75 838 patients who had undergone hysterectomy for AUB, excluding uterine myoma and malignancy. INTERVENTIONS n/a MEASUREMENTS AND MAIN RESULTS: Of the 75 838 hysterectomies performed for AUB in the absence of uterine myomas and malignancy, 10.1% were performed abdominally and 89.9% minimally invasively. After adjusting for confounders, Black patients were 38% more likely to undergo abdominal hysterectomy compared to White patients (OR 1.38, CI 1.12-1.70 p = .002). Black race, thus, is independently associated with open surgery. CONCLUSION Despite excluding uterine myomas as a risk factor for an abdominal route of hysterectomy, Black race remained an independent predictor for abdominal versus minimally invasive hysterectomy, and Black patients were found to undergo a disproportionately higher rate of abdominal hysterectomy compared to White patients.
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Affiliation(s)
- Leslie K Palacios-Helgeson
- Department of Obstetrics and Gynecology (Drs. Palacios-Helgeson, Gould, and Osmundsen), Legacy Health System, Portland, OR.
| | - Ashish Premkumar
- Department of Obstetrics and Gynecology (Dr. Premkumar), University of Chicago, Chicago, IL
| | - Jacqueline M K Wong
- Department of Obstetrics and Gynecology (Dr. Wong), Oregon Health & Science University, Portland, OR
| | - Claire H Gould
- Department of Obstetrics and Gynecology (Drs. Palacios-Helgeson, Gould, and Osmundsen), Legacy Health System, Portland, OR
| | - Megan A Cahn
- Legacy Research Institute (Dr. Cahn), Legacy Health System, Portland, OR
| | - Blake C Osmundsen
- Department of Obstetrics and Gynecology (Drs. Palacios-Helgeson, Gould, and Osmundsen), Legacy Health System, Portland, OR
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Mamik MM, Kim-Fine S, Yang L, Sharma V, Gala R, Aschkenazi S, Sheyn D, Howard D, Walter AJ, Kudish B, Balk EM, Antosh DD. Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review. Obstet Gynecol 2024; 144:40-52. [PMID: 38743951 DOI: 10.1097/aog.0000000000005607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/14/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint. DATA SOURCES PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible. METHODS OF STUDY SELECTION This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy. TABULATION, INTEGRATION, AND RESULTS The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss. CONCLUSION Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021233300.
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Affiliation(s)
- Mamta M Mamik
- Albert Einstein College of Medicine, Bronx, New York; University of Calgary, Calgary, Alberta, Canada; Northwestern Medicine, Chicago, Illinois; Ochsner Clinical School, Jefferson, Louisiana; Waukesha Memorial Hospital, Waukesha, Wisconsin; University Hospitals, Cleveland, Ohio; Rutgers New Jersey Medical School, Newark, New Jersey; Kaiser Permanente, Roseville, California; Florida State University, Tallahassee, Florida; Brown University School of Public Health, Providence, Rhode Island; and Houston Methodist Hospital, Houston, Texas
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Vannuccini S, Petraglia F, Carmona F, Calaf J, Chapron C. The modern management of uterine fibroids-related abnormal uterine bleeding. Fertil Steril 2024; 122:20-30. [PMID: 38723935 DOI: 10.1016/j.fertnstert.2024.04.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/21/2024]
Abstract
Uterine fibroids (UFs) are the most common female benign pelvic tumors, affecting >60% of patients aged 30-44 years. Uterine fibroids are asymptomatic in a large percentage of cases and may be identified incidentally using a transvaginal ultrasound or a magnetic resonance imaging scan. However, in approximately 30% of cases, UFs affect the quality of life and women's health, with abnormal uterine bleeding and heavy menstrual bleeding being the most common complaints, along with iron deficiency (ID) and ID anemia. Medical treatments used for UFs-related abnormal uterine bleeding include symptomatic agents, such as nonsteroidal antiinflammatory drugs and tranexamic acid, and hormonal therapies, including combined oral contraceptives, gonadotropin-releasing hormone agonists or antagonists, levonorgestrel intrauterine systems, selective progesterone receptor modulators, and aromatase inhibitors. Nevertheless, few drugs are approved specifically for UF treatment, and most of them manage the symptoms. Surgical options include fertility-sparing treatments, such as myomectomy, or nonconservative options, such as hysterectomy, especially in perimenopausal women who are not responding to any treatment. Radiologic interventions are also available: uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound, and radiofrequency ablation. Furthermore, the management of ID and ID anemia, as a consequence of acute and chronic bleeding, should be taken into account with the use of iron replacement therapy both during medical treatment and before and after a surgical procedure. In the case of symptomatic UFs, the location, size, multiple UFs, or coexistent adenomyosis should guide the choice with a shared decision-making process, considering long- and short-term treatment goals expected by the patient, including pregnancy desire or wish to preserve the uterus independently of reproductive goals.
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Affiliation(s)
- Silvia Vannuccini
- Division of Obstetrics and Gynecology, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy.
| | - Felice Petraglia
- Division of Obstetrics and Gynecology, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Francisco Carmona
- Department of Obstetrics and Gynecology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Joaquim Calaf
- Hospital Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Charles Chapron
- Département de Gynécologie, Obstétrique et Médecine de la Reproduction, Faculté de Santé, Faculté de Médicine Paris Centre, Centre Hospitalier Universitaire (CHU), Université Paris-Cité, Paris, France
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10
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Sonkusare A, Dixit P. Comparative Analysis of Total Laparoscopic Hysterectomy Versus Non-descent Vaginal Hysterectomy for Benign Uterine Pathologies in Women: A Systematic Review. Cureus 2024; 16:e62846. [PMID: 39036204 PMCID: PMC11260428 DOI: 10.7759/cureus.62846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/23/2024] Open
Abstract
Hysterectomy, which can be conducted through abdominal or vaginal routes, is one of the most common gynecological procedures performed worldwide. When the patient is not able to undergo a vaginal hysterectomy due to contraindications involving a narrow pelvis or endometriosis and technical difficulties, laparoscopic removal of the uterus is the recommended method over abdominal hysterectomy. Additionally, the type of surgery depends on the expertise of the surgeon. Therefore, this systematic review aimed to evaluate different measures related to total laparoscopic (TLH) versus non-descent vaginal hysterectomy (NDVH) in women with benign uterine pathologies. ScienceDirect, PubMed, and Google Scholar databases were searched from 2019 to 2023 for a literature review using keywords including "Non-descent Vaginal Hysterectomy," AND "Total Laparoscopic Hysterectomy," AND "Benign Uterine Pathologies." This systematic review includes five studies based on the selection criteria. The data were extracted and a quality assessment of the studies was performed. The review concluded that NDVH has an advantage over TLH as a scarless surgery performed in a very short period and with minimum blood loss with fewer complications and in terms of cost-effectiveness. However, the postoperative parameters and satisfaction with the TLH technique were better than the NDVH technique, but the procedure was much more time-consuming and needed laparoscopic surgical expertise. The duration of hospitalization in NDVH and TLH was nearly the same. Furthermore, both techniques could be employed for salpingo-oophorectomy or when there are adnexal masses and adhesions present; however, TLH may be the best course of action.
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Affiliation(s)
- Abhishek Sonkusare
- Department of Obstetrics and Gynaecology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, IND
| | - Prachi Dixit
- Department of Obstetrics and Gynaecology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, IND
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11
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Donmez EE, Elci E, Elci G. Total vNOTES hysterectomy versus conventional total laparoscopic hysterectomy in virgin transgender men. MINIM INVASIV THER 2024; 33:163-170. [PMID: 38353421 DOI: 10.1080/13645706.2024.2309960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/08/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND AND AIM Comparison of the applicability, safety, and surgical outcomes of total vaginal NOTES hysterectomy (TVNH) using natural orifice transluminal endoscopic surgery, which is considered a natural orifice surgery for hysterectomy with bilateral salpingo-oophorectomy (HBSO) in virgin transgender men, with conventional total laparoscopic hysterectomy (TLH). MATERIAL AND METHODS A retrospective cohort study was conducted between 2019 and 2021. The results of transgender male individuals who underwent HBSO operations using TVNH (n = 21) were compared with those who underwent operations using TLH (n = 62). RESULTS TVNH was performed in 21 individuals, while TLH was performed in 62 individuals. Patients in the TVNH approach group had a longer operation duration than those in the TLH group (p = .001). Patients in the TVNH group experienced less pain at two hours (5 ± 1.56), six hours (4 ± 1.57), 12 h (2 ± 0.91), and 24 h (1 ± 0.62) postoperatively (p = .001). The postoperative hospitalization duration was shorter in the TVNH group (1.6 ± 1.01) than in the TLH group (2.9 ± 0.5) (p = .001). CONCLUSIONS For the HBSO operation of female-to-male transgender individuals, TVNH, which is completely endoscopically performed, can be preferred and safely conducted as an alternative surgical method to conventional laparoscopy.
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Affiliation(s)
- Emin Erhan Donmez
- Department of Gynecology Oncology, Koc University Faculty of Medicine, Istanbul, Turkey
| | - Erkan Elci
- Department of Obstetrics and Gynecology, Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Gulhan Elci
- Department of Obstetrics and Gynecology, University of Healty Sciences Sancaktepe Training and Research Hospital, Istanbul, Turkey
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12
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Srinivas T, Lulseged B, Mirza Aghazadeh Attari M, Borahay M, Weiss CR. Patient Characteristics Associated With Embolization Versus Hysterectomy for Uterine Fibroids: A Systematic Review and Meta-Analysis. J Am Coll Radiol 2024; 21:729-739. [PMID: 38191081 DOI: 10.1016/j.jacr.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION Black and underinsured women in the United States are more likely than their counterparts to develop uterine fibroids (UFs) and experience more severe symptoms. Uterine artery embolization (UAE), a uterine-sparing therapeutic procedure, is less invasive than the common alternative, open hysterectomy. To determine whether demographic disparities persist in UF treatment utilization, we reviewed patient characteristics associated with UAE versus hysterectomy for UF among studies of US clinical practices. METHODS A systematic literature review was conducted via PubMed, Embase, and CINAHL (PROSPERO CRD42023455051), yielding 1,350 articles (January 1, 1995, to July 15, 2023) that outlined demographic characteristics of UAE compared with hysterectomy. Two readers screened for inclusion criteria, yielding 13 full-text US-based comparative studies specifying at least one common demographic characteristic. Random effects meta-analysis was performed on the data (STATA v18.0). Egger's regression test was used to quantify publication bias. RESULTS Nine (138,960 patients), four (183,643 patients), and seven (312,270 patients) studies were analyzed for race, insurance status, and age as predictors of treatment modality, respectively. Black race (odds ratio = 3.35, P < .01) and young age (P < .05) were associated with UAE, whereas private insurance (relative to Medicare and/or Medicaid) was not (odds ratio = 1.06, P = .52). Between-study heterogeneity (I2 > 50%) was detected in all three meta-analyses. Small-study bias was detected for age but not race or insurance. CONCLUSIONS AND IMPLICATIONS Knowledge of demographic characteristics of patients with UFs receiving UAE versus hysterectomy is sparse (n = 13 studies). Among these studies, which seem to be racially well distributed, Black and younger women are more likely to receive UAE than their counterparts.
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Affiliation(s)
- Tara Srinivas
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Mohammad Mirza Aghazadeh Attari
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Vascular and Interventional Radiology, the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mostafa Borahay
- Associate Professor of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Director of the Division of General Gynecology & Obstetrics, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Clifford R Weiss
- Division of Vascular and Interventional Radiology, the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland; Director of the Johns Hopkins HHT Center of Excellence and Professor of Radiology and Radiological Science, Baltimore, Maryland.
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13
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Milman T, Maeda A, Swift BE, Bouchard-Fortier G. Predictors and outcomes of same day discharge after minimally invasive hysterectomy in gynecologic oncology within the National Surgical Quality Improvement Program database. Int J Gynecol Cancer 2024; 34:602-609. [PMID: 38097349 DOI: 10.1136/ijgc-2023-004970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE To assess trends over time of same day discharge after minimally invasive hysterectomy in oncology, identify perioperative factors influencing same day discharge, and evaluate 30 day postoperative morbidity. METHODS A retrospective cohort of elective minimally invasive hysterectomies performed for gynecologic oncologic indications between January 2013 and December 2021 was identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Clinical and surgical characteristics, length of stay, and 30 day postoperative complications were captured. Clinical and surgical factors affecting same day discharge rate and impact of same day discharge on postoperative outcomes were evaluated using χ2 tests and logistic regression. RESULTS Patients undergoing minimally invasive hysterectomy (n=32 823) had a same day discharge rate of 34.5% over the 9 year period, increasing from 15.5% in 2013 to 55.1% in 2021. The rate of patients discharged on postoperative day 1 decreased from 76.4% to 41.4% over this period. On multivariable analysis, same day discharge decreased with: age 70-79 years (odds ratio (OR) 0.80) and ≥80 years (OR 0.42); body mass index 40-49.9 kg/m2 (OR 0.89) and ≥50 kg/m2 (OR 0.67); patient comorbidities, including hypertension (OR 0.85), chronic steroid use (OR 0.74), bleeding disorder (OR 0.54), anemia (OR 0.89), and hypoalbuminemia (OR 0.76); and surgical time >90th percentile (OR 0.40) (all p<0.05). Lymphadenectomy did not impact the same day discharge rate (unadjusted OR 1.03, p=0.22). Same day discharge had no effect on 30 day postoperative composite morbidity (OR 0.91, p=0.20), and was associated with fewer readmissions (OR 0.75, p=0.005). Age 70-79 years (OR 1.07, p=0.435) and age ≥80 years (OR 1.11, p=0.504) did not increase postoperative morbidity. However, body mass index categories 40-49.9 kg/m2 (OR 1.28, 95% CI 1.08 to 1.51) and ≥50 kg/m2 (OR 1.60, 95% CI 1.27 to 2.01) were associated with greater 30 day composite morbidity. CONCLUSION In this study, same day discharge following minimally invasive hysterectomy for oncologic indications was safe, and rates are rising among all age and body mass index categories. Quality improvement initiatives are needed at oncology centers to promote early discharge after minimally invasive gynecologic oncology surgery.
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Affiliation(s)
- Tal Milman
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Azusa Maeda
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health System, Toronto, Ontario, Canada
| | - Brenna E Swift
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Geneviève Bouchard-Fortier
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health System, Toronto, Ontario, Canada
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Balgobin S, Balk EM, Porter AE, Misal M, Grisales T, Meriwether KV, Jeppson PC, Doyle PJ, Aschkenazi SO, Miranne JM, Hobson DT, Howard DL, Mama S, Gupta A, Antosh DD. Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review. Obstet Gynecol 2024; 143:524-537. [PMID: 38301255 DOI: 10.1097/aog.0000000000005522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/07/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures. DATA SOURCES We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022. METHODS OF STUDY SELECTION Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated. TABULATION, INTEGRATION, AND RESULTS The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity. CONCLUSION Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022327490.
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Affiliation(s)
- Sunil Balgobin
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, the Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, and the Division of Urogynecology, Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio; the Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, California; the Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico; the Woman's Center for Advanced Pelvic Surgery, Phoenix, Arizona; the Departments of Obstetrics and Gynecology and Urology, School of Medicine & Dentistry, University of Rochester, Rochester, New York; the Department of Obstetrics and Gynecology, Medical College of Wisconsin, Waukesha, Wisconsin; the Division of Urogynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; the Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan; the Department of Obstetrics, Gynecology, and Reproductive Health, Rutgers New Jersey Medical School, Newark, and the Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University, Camden, New Jersey; and the Division of Female Pelvic Medicine & Reconstructive Surgery, University of Louisville Health, Louisville, Kentucky
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15
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Lerner V, Stuart AE, Baekalandt J. Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Deconstructed: Expanding Minimally Invasive Gynecologic Surgeons' Toolbox. J Gynecol Surg 2024; 40:78-99. [PMID: 38690154 PMCID: PMC11057779 DOI: 10.1089/gyn.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Background The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines. Methods This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field. Results The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials. Conclusions vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).
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Affiliation(s)
- Veronica Lerner
- Department of Obstetrics & Gynecology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, USA
| | - Andrea E Stuart
- Department of Obstetrics and Gynaecology, Institution of Clinical Sciences, Lund University, Lund, Sweden
- Department of Obstetrics and Gynaecology, Helsingborg Hospital, Sweden
| | - Jan Baekalandt
- Department of Gynaecologic Oncology, Imelda Hospital, Bonheiden, Belgium
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Inocencio-Diaz JJ, Liang FJ, Boyanovsky BB. Laparoscopic-Assisted Vaginal Hysterectomy With Dense Bladder Adhesions and Absent Cervix: A Case Report With a Descriptive Video of the Entire Procedure. Cureus 2024; 16:e57482. [PMID: 38707153 PMCID: PMC11068215 DOI: 10.7759/cureus.57482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 05/07/2024] Open
Abstract
Hysterectomy is one of the most frequently performed surgical procedures in the United States. Hysterectomy for benign gynecological reasons can be performed through several approaches: abdominal, laparoscopic, laparoscopically assisted vaginal, robotic-assisted, and vaginal natural orifice hysterectomy. The choice of approach is strongly influenced by factors such as previous procedures, safety, and recovery process. Currently, vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy (LAVH), assisted vaginal hysterectomy, and robotic-assisted vaginal hysterectomy are considered minimally invasive approaches with multiple benefits to the patient such as less trauma, shorter operative time, and shorter postoperative period. However, in patients with pelvic adhesions, adhesions within the abdominal cavity, especially omental adhesions to the abdominal wall, and adhesions between the uterus and the bladder caused by multiple cesarian sections or prior surgery on the cervix, these minimally invasive approaches are problematic. In this report, we describe in detail our approach to LAVH in a patient with severe abdominal adhesions and an absent cervix. We believe that our approach is safe and relatively fast compared to an open abdominal procedure and, therefore, it may help gynecologic surgeons-in-training nationwide.
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Affiliation(s)
- Jerrelyn J Inocencio-Diaz
- Department of Clinical Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA
- Clinical Sciences, Southern California Permanente Medical Group., Pasadena, USA
| | - Felice J Liang
- Department of Clinical Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA
| | - Boris B Boyanovsky
- Department of Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, Ivins, USA
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Zhang C, Liu D, Zhang Q, Li Q, He L, Lin Y, Ge H. A case control study of vNOTES hysterectomy with the da Vinci surgical system and conventional vNOTES hysterectomy. Medicine (Baltimore) 2024; 103:e37323. [PMID: 38457540 PMCID: PMC10919455 DOI: 10.1097/md.0000000000037323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/10/2024] Open
Abstract
The aim of the case control study was to compare surgical outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy with the da Vinci surgical system (dVSS) and conventional vNOTES. A case control study was performed on 25 cases in our hospital. Patients (n = 8) who underwent vNOTES hysterectomy with dVSS were selected to compare with the control group (n = 17) consisted of patients who underwent conventional vNOTES. Patients in the 2 groups underwent different operations respectively, and no case was transferred to transabdominal laparoscopy. In the conventional vNOTES group, 1 patient happened intraoperative hemorrhage of about 1000 mL, and was treated with blood transfusion, and the other one of vNOTES hysterectomy with dVSS had poor incision healing within 1 month after surgery. The other patients had no intraoperative and postoperative complications. The difference of pain scores on the first day (P = .006) and the third day (P = .045) after the 2 surgical methods differed significantly. No statistical differences were observed in operation time, median hospital stay, blood loss, decreased hemoglobin 3 days after surgery, and postoperative white blood cell count. vNOTES hysterectomy with dVSS is safe and feasible, and can achieve the same effect as the conventional vNOTES hysterectomy. And this method may alleviate the pain of patients.
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Affiliation(s)
- Chengling Zhang
- Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Dandan Liu
- Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qiang Zhang
- Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qiaoqiao Li
- Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li He
- Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yonghong Lin
- Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Huisheng Ge
- Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Jiamset I, Uttraporn P, Suphasynth Y. Comparative outcomes between transvaginal endoscopic hysterectomy and total laparoscopic hysterectomy in patients with benign uterine disease: A single-center, retrospective, cohort, interrupted time-series study. Int J Gynaecol Obstet 2024; 164:1080-1085. [PMID: 37731329 DOI: 10.1002/ijgo.15144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES To compare the surgical outcomes of total laparoscopic hysterectomy (TLH) and transvaginal endoscopic hysterectomy (TVEH) for benign uterine diseases. METHODS This retrospective, cohort, interrupted time-series study included patients who underwent TLH between January 2013 and September 2016 and TVEH between October 2016 and June 2020. Median difference regression was used to compare the hospital length of stay (LOS) and operative time between the groups. Risk difference regression was used to analyze the proportion of patients who developed postoperative fever or vaginal stump infection. RESULTS Of the total 171 patients enrolled, 101 and 70 underwent TVEH and TLH, respectively. The mean ages of patients in the TVEH and TLH groups were 46.49 and 46.17 years, respectively. No conversion was observed. Ureteric injury occurred in one patient in the TVEH group, whereas there was no organ injury in any of the patients in the TLH group. Compared with those in the TLH group, patients in the TVEH group had a significantly shorter median operative time, shorter hospital LOS, lower morphine use, and lower postoperative febrile morbidity rates. However, no significant difference was observed in the rate of vaginal stump infection between the groups. CONCLUSION Given the shorter operative time, shorter hospital LOS, less febrile morbidity, and lower morphine use in patients with TVEH than in those with TLH, TVEH should be considered as an alternative hysterectomy procedure for benign uterine diseases.
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Affiliation(s)
- Ingporn Jiamset
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pawara Uttraporn
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Yuthasak Suphasynth
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Pfeuti CK, Makai G. Gynecologic Surgical Subspecialty Training Decreases Surgical Complications in Benign Minimally Invasive Hysterectomy. J Minim Invasive Gynecol 2024; 31:250-257. [PMID: 38151094 DOI: 10.1016/j.jmig.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 12/29/2023]
Abstract
STUDY OBJECTIVE To evaluate the impact of gynecologic subspecialty training on surgical outcomes in benign minimally invasive hysterectomies (MIHs) while accounting for surgeon volume. DESIGN Retrospective cohort study of patients who underwent an MIH between 2014 and 2017. SETTING Single community hospital system. PATIENTS Patients were identified via Current Procedural Terminology codes for MIH: vaginal, laparoscopic, or robotic. Exclusion criteria included a gynecologic cancer diagnosis or concomitant major procedure at the time of hysterectomy. One thousand six hundred thirty-one patients underwent a benign MIH performed by a gynecologic generalist or a subspecialist in minimally invasive gynecologic surgery, urogynecology and pelvic reconstructive surgery, or gynecologic oncology; 125 hysterectomies were vaginal, 539 were conventional laparoscopic, and 967 were robotic. MEASUREMENTS AND MAIN RESULTS Surgical outcomes, including intraoperative complications, operative outcomes, and postoperative readmissions and reoperations, were compared between generalists and subspecialists and were stratified by surgeon volume status, with high-volume (HV) defined as performing 12 or more hysterectomies annually. Odds ratios for the primary outcome, Clavien-Dindo Grade III complications (which included visceral injuries, conversions, and reoperations within 90 days), were calculated to evaluate the impact of subspecialty training while accounting for surgeon volume status. Of 1631 MIHs, 855 (52.4%) were performed by generalists and 776 (47.6%) by subspecialists. HV generalists performed 618 (37.9%) of MIHs, and 237 (14.5%) were performed by low-volume generalists. All subspecialists were HV surgeons; 38.1% of generalists were HV. The odds ratio of a Clavien-Dindo Grade III complication was 0.39 (0.25-0.62) for hysterectomies performed by subspecialists compared to HV generalists after adjusting for potential confounding variables (p <.001). Subspecialists and HV surgeons had significantly lower incidences of visceral injuries, transfusions, blood loss over 500 mL, and conversions compared with generalists and low-volume surgeons, respectively. CONCLUSION Both subspecialty training and high surgeon volume status are associated with a lower risk of surgical complications in benign MIH. Subspecialty training is associated with a reduction in surgical complications even after accounting for surgeon volume.
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Affiliation(s)
- Courtney Kay Pfeuti
- Department of Obstetrics and Gynecology, ChristianaCare, Newark, Deleware (all authors).
| | - Gretchen Makai
- Department of Obstetrics and Gynecology, ChristianaCare, Newark, Deleware (all authors)
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Paily VP, Raj Girijadevi R, K Shefeek S. Salpingo-Oophorectomy During Non-Descent Vaginal Hysterectomy Using the Paily Vaginal Oophorectomy Clamp. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102281. [PMID: 37951573 DOI: 10.1016/j.jogc.2023.102281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 11/14/2023]
Abstract
We conducted a 6-year prospective surgical case series study at a tertiary care centre in South India to evaluate the safety and efficacy of the novel Paily Vaginal Oophorectomy Clamp and its unique application technique during non-descent vaginal hysterectomy requiring salpingo-oophorectomy. The Paily Vaginal Oophorectomy Clamp's reversed blade design allows direct and secure grasping of the infundibulopelvic ligament as there is no intervening tissue near the joint, reducing the risk of slippage. In contrast, while using conventional clamps such as Heaney's, infundibulopelvic slippage occurs due to the presence of tissue between blades near the joint. A demonstration video is provided (Video).
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Affiliation(s)
- Vakkanal Paily Paily
- Department of Obstetrics and Gynaecology, Rajagiri Hospital, Kochi, Kerala, India.
| | - Raji Raj Girijadevi
- Department of Obstetrics and Gynaecology, Rajagiri Hospital, Kochi, Kerala, India
| | - Suhail K Shefeek
- Department of Obstetrics and Gynaecology, Rajagiri Hospital, Kochi, Kerala, India
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Förster CE, Calabretti I, Gubser L, Schötzau A, Fellmann-Fischer B, Heinzelmann-Schwarz V, Zwimpfer TA. Comparison of different suture techniques for laparoscopic vaginal cuff closure. Sci Rep 2024; 14:4860. [PMID: 38418580 PMCID: PMC10901882 DOI: 10.1038/s41598-024-55586-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/26/2024] [Indexed: 03/01/2024] Open
Abstract
Laparoscopic hysterectomy is a commonly performed procedure. However, one high-risk complication is vaginal cuff dehiscence. Currently, there is no standardization regarding thread material or suturing technique for vaginal cuff closure. Therefore, this study aimed to compare extracorporeal and intracorporeal suturing techniques for vaginal cuff closure using a pelvic trainer model. Eighteen experts in laparoscopic surgery performed vaginal cuff closures with interrupted sutures using intracorporeal knotting, extracorporeal knotting and continuous, unidirectional barbed sutures. While using an artificial tissue suturing pad in a pelvic trainer, experts performed vaginal cuff closure using each technique according to block randomization. Task completion time, tension resistance, and the number of errors were recorded. After completing the exercises, participants answered a questionnaire concerning the suturing techniques and their performance. Experts completed suturing more quickly (p < 0.001, p < 0.001, respectively) and with improved tension resistance (p < 0.001, p < 0.001) when using barbed suturing compared to intracorporeal and extracorporeal knotting. Furthermore, the intracorporeal knotting technique was performed faster (p = 0.04) and achieved greater tension resistance (p = 0.023) compared to extracorporeal knotting. The number of laparoscopic surgeries performed per year was positively correlated with vaginal cuff closure duration (p = 0.007). Barbed suturing was a time-saving technique with improved tension resistance for vaginal cuff closure.
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Affiliation(s)
- Christiane E Förster
- Department of Gynecological Oncology, University Hospital Basel, 4056, Basel, Switzerland
| | | | - Laura Gubser
- Medical Faculty, University of Basel, 4056, Basel, Switzerland
| | - Andreas Schötzau
- Department of Gynecological Oncology, University Hospital Basel, 4056, Basel, Switzerland
| | | | | | - Tibor A Zwimpfer
- Department of Gynecological Oncology, University Hospital Basel, 4056, Basel, Switzerland.
- Cancer Research, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia.
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22
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Hurni Y, Fung H, Simonson C, Serio MD, Lachat R, Bodenmann P, Seidler S, Huber D. Impact of Uterine Weight and Shape on vNOTES Hysterectomy: Analysis of 238 Consecutive Cases. J Minim Invasive Gynecol 2024; 31:115-122. [PMID: 37981263 DOI: 10.1016/j.jmig.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
STUDY OBJECTIVE To compare the perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies for different uterine weights and shapes. DESIGN Observational study. SETTING Swiss teaching hospital. PATIENTS Women who underwent vNOTES hysterectomy for benign conditions between May 2020 and July 2023 (N = 238). Patients were divided into 4 subgroups depending on uterus weight and shape. Uteri weighting <280 g were classified as type 0. Uteri weighting ≥280 g were categorized as type 1 (no vascular pedicle displacement), type 2 (cranial displacement of adnexal vascular pedicles), and type 3 (displacement of uterine arteries). INTERVENTIONS All women underwent vNOTES hysterectomies. We compared perioperative outcomes for the 4 subgroups. MEASUREMENT AND MAIN RESULTS We classified 168 patients (70.6%) as uterus type 0, 33 patients (13.9%) as type 1, 24 patients (10.1%) as type 2, and 13 patients (5.4%) as type 3. Mean uterine weight was 135.8 ± 59.5 g in type 0, 398.0 ± 167.3 g in type 1, 603.5 ± 217.9 g in type 2, and 661.7 ± 281.6 g in type 3. Operative time in type 0 (65.1 ± 30.9 minutes) and type 1 (65.1 ± 24.0 minutes) was shorter than in type 2 (102.3 ± 60.0 minutes) and type 3 (115.2 ± 40.3 minutes). Blood losses were more significant in type 2 (158.5 ± 212.0 mL) and type 3 (158.5 ± 110.7 mL) than in type 0 (85.6 ± 113.5 mL). No difference in the rate of total complications among groups was observed (8.3%, 3.0%, 12.5%, and 15.4% in types 0, 1, 2, and 3, respectively). CONCLUSION The displacement of the vascular pedicles seems associated with longer operative time and more blood loss and could represent a marker for technical difficulty in vNOTES hysterectomy. However, it does not influence the perioperative complication rate.
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Affiliation(s)
- Yannick Hurni
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber).
| | - Helen Fung
- Faculty of Medicine, University of Geneva, Geneva, Switzerland (Ms. Fung)
| | - Colin Simonson
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Marcello Di Serio
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Régine Lachat
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Pauline Bodenmann
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Stéphanie Seidler
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber)
| | - Daniela Huber
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland (Drs. Hurni, Simonson, Di Serio, Lachat, Bodenmann, Seidler, and Huber); Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland (Dr. Huber)
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23
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Burger KA, Robison EH, Nekkanti S, Hundley AF, Hudson CO. Perioperative Outcomes for Same- Versus Next-Day Discharge After Benign Vaginal Hysterectomy. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:89-97. [PMID: 37882048 DOI: 10.1097/spv.0000000000001403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
IMPORTANCE While same-day discharge (SDD) after laparoscopic hysterectomy is well supported, studies for vaginal hysterectomy (VH) are lacking. OBJECTIVE The aim of the study was to compare 30-day complications for SDD versus next-day discharge (NDD) after benign VH. STUDY DESIGN This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019. Vaginal hysterectomy with or without urogynecology procedures was identified by Current Procedural Terminology codes. The primary outcome was 30-day composite complications of SDD versus NDD after VH. Secondary outcomes compared reoperations rates, time to and reasons for reoperation, and complications between the groups. Composite complications included death, major infection or wound complication, thromboembolism, transfusion, cardiopulmonary complication, renal insufficiency/failure, stroke, or reoperation. Unadjusted and adjusted odds ratios were determined using univariate and multivariate analysis. RESULTS Of 24,277 people included, 4,073 (16.8%) were SDD, which were more likely to be younger ( P < 0.001), less likely to have hypertension (23.4 vs 18.3%, P < 0.0001) or diabetes (4.5 vs 3.3%, P = 0.001), and had shorter surgical procedures (100.7 ± 47.5 vs 111.2 ±57.5 minutes, P < 0.0001). There was no difference in composite complications after SDD versus NDD and this remained true in multivariate analysis (2.0 vs 2.3%, P = 0.30, SDD; adjusted odds ratio, 0.9; 95% confidence interval, 0.7-1.1). There was no difference in reoperation rates (0.9 vs 0.9%, P = 0.94) or reasons for reoperation. Time to first complication was shorter for SDD versus NDD (11 vs 13 days, P = 0.47). CONCLUSION In our cohort of low-risk patients, SDD after VH with or without urogynecology procedures did not have an increased odds of 30-day composite complications.
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Affiliation(s)
| | | | - Silpa Nekkanti
- From the Division of Female Pelvic Medicine and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Andrew F Hundley
- From the Division of Female Pelvic Medicine and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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24
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Kahveci AC, Dooley MJ, Johnson J, Mund AR. Are There Racial Disparities in Perioperative Pain? A Retrospective Study of a Gynecological Surgery Cohort. J Perianesth Nurs 2024; 39:82-86. [PMID: 37855762 PMCID: PMC10873002 DOI: 10.1016/j.jopan.2023.06.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE The purpose of this study was to examine whether racial disparities exist in immediate postoperative pain scores and intraoperative analgesic regimens in a single surgical cohort. DESIGN A single-center, retrospective analysis. METHODS This retrospective study of a single surgical cohort was conducted via chart review of the existing electronic health record. A total of 203 patients who underwent minimally invasive hysterectomy were included in the analysis. Three initially reviewed patient records were excluded from the final analysis due to the small size of their racial cohorts (two Asian or Pacific Islander and one Native American). The White patients (n = 103) and Black patients (n = 100) were compared for differences in pain scores in the postanesthesia care unit (PACU). The patients' intraoperative analgesic regimens were also compared. FINDINGS There were no significant differences between races in the postoperative pain scores in the PACU or in the analgesia administered by the anesthesia provider intraoperatively. CONCLUSIONS In this specific population, there was no evidence of racial disparities in postoperative pain or intraoperative analgesia administration. Further research is needed to understand the unique factors of the perioperative period, to see if the absence of disparities in this study is repeated in other cohorts, and to mitigate any disparities that are found.
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Affiliation(s)
- Allyson C Kahveci
- Department of Anesthesiology, Virginia Commonwealth University Health, Richmond, VA.
| | - Mary J Dooley
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Jada Johnson
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | - Angela R Mund
- College of Health Professions, Medical University of South Carolina, Charleston, SC
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25
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Assaf W, Wattad A, Ali-Saleh M, Shalabna E, Lavie O, Abramov Y. Evaluation of blood type as a potential risk factor for hemorrhage during vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol 2024; 293:91-94. [PMID: 38134609 DOI: 10.1016/j.ejogrb.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/24/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To examine the association between the O blood type and bleeding tendency in patient undergoing vaginal hysterectomy. METHODS This was a retrospective cohort study including all women who had undergone vaginal hysterectomy at our institution between January 2015 and September 2020. All women underwent blood type and complete blood count testing pre- and post-operatively. The estimated intraoperative blood loss, the need for blood transfusion, pre- and postoperative hemoglobin and hematocrit measurements and surgical data were recorded for all patients. Patients with known coagulopathies or those taking antithrombotic medications were excluded from the study. Statistical analysis was performed using student t, χ2, Fischer exact, and ANOVA tests as well as a stepwise logistic regression model. RESULTS The study included 106 patients (35.2 %) with O and 195 patients (64.8 %) with non-O (i.e., A, B or AB) blood types. The O blood type was significantly associated with a higher risk for moderate blood loss (defined as a pre- to postoperative Hb or HCT drop >2gr or >6 %, respectively) (p = 0.012), but not with severe (defined as a Hb or HCT drop of >3gr or >9 %, respectively) perioperative bleeding, nor with the need for blood transfusion. CONCLUSION The O blood type was found to be significantly associated with moderate but not with severe intraoperative bleeding during and following vaginal hysterectomy.
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Affiliation(s)
- Wisam Assaf
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Technion University, Rappaport Faculty of Medicine, Haifa, Israel.
| | - Aya Wattad
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Technion University, Rappaport Faculty of Medicine, Haifa, Israel
| | - Mais Ali-Saleh
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Technion University, Rappaport Faculty of Medicine, Haifa, Israel
| | - Eiman Shalabna
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Technion University, Rappaport Faculty of Medicine, Haifa, Israel
| | - Ofer Lavie
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Technion University, Rappaport Faculty of Medicine, Haifa, Israel
| | - Yoram Abramov
- Department of Obstetrics and Gynecology, Lady Davis Carmel Medical Center, Technion University, Rappaport Faculty of Medicine, Haifa, Israel
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26
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Burnett AF, Pitman TC, Baekelandt JF. vNOTES (vaginal natural orifice transluminal surgery) gynecologic procedures in morbidly and super-morbidly obese women: five year experience. Arch Gynecol Obstet 2024; 309:565-570. [PMID: 37880384 DOI: 10.1007/s00404-023-07250-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 10/01/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE To analyze our experience with vNOTES gynecologic procedures in women with morbid and super morbid obesity to determine feasibility and compare outcomes with standard minimally invasive techniques. METHODS Gynecologic procedures performed by three surgeons on women with a body mass index (BMI) ≥ 40 kg/m2 from 2017 to 2023. A subset of women with a BMI ≥ 50 kg/m2 was also analyzed. RESULTS 103 women with a BMI ≥ 40 kg/m2 were identified (Class IV), 19 of whom had a BMI ≥ 50 kg/m2 (Class V). For the entire population the mean BMI was 45.7 kg/m2 (40-62). 29 women were nulliparous and 23 had at least one prior cesarean delivery. 51 had no prior abdominal surgery. The procedures performed were hysterectomy and removal of adnexae in 77 patients, hysterectomy alone in six, adnexal surgery alone in nine, and hysterectomy with adnexectomy and lymph nodes in five. Two surgeries were converted to laparoscopy and five to laparotomy. Average surgical time was 87 min (30-232). Average blood loss was 82 mL (10-400). Mean uterine weight was 206 g (29-2890). 53 procedures were performed as outpatient, 44 had overnight observation, four had a length of stay of 2 days, one each for 4 days and 5 days. The laparoscopies occurred in one patient with an obliterated cul-de-sac and in one patient for lymph node removal. The laparotomies occurred for adnexal adhesions in one, bleeding in two, a cystotomy in one requiring urology consultation, and an obliterated cul-de-sac One patient developed a postoperative vaginal cuff hematoma not requiring intervention. CONCLUSION vNOTES gynecologic procedures are feasible in this high-risk population and may result in shorter recovery times and fewer complications than standard laparoscopy or transvaginal surgery. What does this study add to the clinical work: VNOTES approach is feasible in morbidly obese women and may have distinct advantages over conventional laparoscopic, vaginal or open techniques.
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Affiliation(s)
- Alexander F Burnett
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 793, Little Rock, Arkansas, 72205, USA.
| | - Thomas C Pitman
- Baptist Medical Group Desoto Women's Consultants, Core Faculty, Baptist Memorial Hospital OB/GYN, Residency, Memphis, TN, USA
| | - Jan F Baekelandt
- Division of Gynecologic Oncology, Imelda Hospital, Bonheiden, Belgium
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27
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mei Y, He L, Li Y, Zhang C, Hou Q, Lin Y. Transvaginal natural Orifical transluminal Endoscopy for sacrocolpopexy: A case series report. Heliyon 2024; 10:e23606. [PMID: 38192848 PMCID: PMC10772630 DOI: 10.1016/j.heliyon.2023.e23606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/10/2024] Open
Abstract
Background To describe the surgical technique and operative outcomes of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for sacrocolpopexy with or without robotic surgical system in patients with pelvic organ prolapse (POP). Methods Patients with POP undergoing traditional transvaginal natural orifice transluminal endoscopic surgery (TV-NOTES) or robotic transvaginal natural orifice transluminal endoscopic surgery (RV-NOTES) for sacrocolpopexy performed by one surgeon from Sep 2020 to Jan 2023 in our hospital were included in this study. The baseline demographics and operative outcomes were collected and analyzed. In addition, some surgical skills were presented. The operative outcomes of V-NOTES for sacrocolpopexy performed by three beginners were also presented. Results Eight patients who underwent TV-NOTES, and two patients who underwent RV-NOTES were included in this study. The mean operative time was 180 ± 49 min, and the estimated blood loss was 107 ± 82 ml for these ten cases. Particularly, the operative time of the two patients who underwent RV-NOTES was 275 and 132 min, while the estimated blood loss (EBL) was 100 and 50 ml respectively. During the follow-up period, no mesh exposure and recurrence were observed. In addition, five cases of TV-NOTES for sacrocolpopexy by beginners were all successfully completed. Conclusion Both TV-NOTES and RV-NOTES appeared to be feasible and safe for sacrocolpopexy.
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Affiliation(s)
| | | | - Yan Li
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Chengling Zhang
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Qiannan Hou
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Yonghong Lin
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
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28
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Kim JH, Choi HY, Park YH, Kim SH, Chae HD, Lee SR. A new knotless parametrial tissue ligation technique for safe total laparoscopic hysterectomy. Obstet Gynecol Sci 2024; 67:120-131. [PMID: 38104531 DOI: 10.5468/ogs.23179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVE Parametrial tissue ligation during total laparoscopic hysterectomy (TLH) is important in large uteri with large vessels. METHODS A retrospective study was performed at Asan Medical Center for comparing TLH performed with a new knotless parametrial tissue ligation method and conventional laparoscopic-assisted vaginal hysterectomy (LAVH) from March 2019 to August 2021. For TLH, after anterior colpotomy, the parametrial tissue was ligated by anchoring the suture and making a loop in one direction three times using 1-0 V-LocTM 180 (Covidien, Mansfield, MA, USA) suture. Subsequently, the cranial part of the loop was cut using an endoscopic device. RESULTS A total of 119 and 178 patients were included in the TLH and LAVH groups, respectively. The maximal diameter of the uterus was larger in the TLH group (106.29±27.16 cm) than in the LAVH group (99.00±18.92 cm, P=0.01). The change in hemoglobin (Hb) level was greater in the LAVH group than in the TLH group (P<0.001). The weight of the removed uterus was greater in the TLH group than in the LAVH group (431.95±394.97 vs. 354.94±209.52 g; P=0.03). However, when the uterine weight was >1,000 g, the operative times and change in Hb levels were similar between the two groups. In both groups, no ureteral complications occurred during or after surgery. CONCLUSION Knotless parametrial tissue ligation using 1-0 V-LocTM 180 suture in TLH can be safely applied, even in cases with large uteri, without increased risks of ureteral injury or uterine bleeding.
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Affiliation(s)
- Ju Hee Kim
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hea Yeon Choi
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Hee Park
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Hoon Kim
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Dong Chae
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sa Ra Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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29
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Anderson D, Garcia K, Fang W, Dueñas-Garcia O. Feasibility of opportunistic salpingectomy at the time of a vNOTES hysterectomy: A retrospective cohort. Int J Gynaecol Obstet 2023; 163:1026-1027. [PMID: 37661708 DOI: 10.1002/ijgo.15085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
SynopsisThe vNOTES approach has a high feasibility of performing a salpingectomy at the time of a hysterectomy.
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Affiliation(s)
- Dylan Anderson
- Department of Obstetrics and Gynecology, West Virginia University School of Medicine, West Virginia, Morgantown, USA
| | - Katerina Garcia
- Department of Obstetrics and Gynecology, West Virginia University School of Medicine, West Virginia, Morgantown, USA
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, West Virginia, Morgantown, USA
| | - Omar Dueñas-Garcia
- Department of Obstetrics and Gynecology, West Virginia University School of Medicine, West Virginia, Morgantown, USA
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30
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Wang EB, Chang S, Bossa D, Rosero EB, Kho KA. Association between Endometriosis and Surgical Complications among Benign Hysterectomies. J Minim Invasive Gynecol 2023; 30:990-998. [PMID: 37709129 DOI: 10.1016/j.jmig.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023]
Abstract
STUDY OBJECTIVE To investigate the effect of endometriosis on perioperative outcomes in patients undergoing hysterectomy for benign disease. DESIGN A retrospective cohort study. SETTING The American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS A total of 127 556 hysterectomies performed for benign gynecologic indications INTERVENTIONS: Differences in the primary outcomes were compared between patients with and without endometriosis after adjustment for group differences in covariates using inverse probability of treatment weighting approach. MEASURES AND MAIN RESULTS Of the 127 556 hysterectomies identified, 19 618 (15.4%) had a diagnosis of endometriosis. Patients with endometriosis were younger with a lower prevalence of chronic comorbidities but had higher rates of concurrent pelvic inflammatory disease and previous abdominal operations. The incidence of postoperative complications was higher in patients with endometriosis (9.9% vs 8.1%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.17-1.34). The incidence of 30-day mortality (0.1% vs 0.03%; OR, 1.98; 95% CI, 0.69-5.65) and reoperations (1.50% vs 1.36%; OR, 1.18; 95% CI, 0.98-1.42) were not different in patients with and without endometriosis. CONCLUSION Postoperative complications are more likely in hysterectomies involving endometriosis than those without endometriosis, likely owing to anatomic distortion incurring increased surgical complexity. Patients and surgeons should be aware of the increased risk of complications and plan for mitigating these increased risks before and during surgery for suspected endometriosis.
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Affiliation(s)
- Emily B Wang
- Department of Obstetrics and Gynecology (Drs. Wang, Chang, Bossa, and Kho)
| | - Stephanie Chang
- Department of Obstetrics and Gynecology (Drs. Wang, Chang, Bossa, and Kho).
| | - Deina Bossa
- Department of Obstetrics and Gynecology (Drs. Wang, Chang, Bossa, and Kho)
| | - Eric B Rosero
- Department of Anesthesiology and Pain Management (Dr. Rosero), University of Texas Southwestern Medical Center, Dallas, TX
| | - Kimberly A Kho
- Department of Obstetrics and Gynecology (Drs. Wang, Chang, Bossa, and Kho)
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31
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Pham NK, Jalloul RJ, Chen HY, Hui M, Leon MG. Venous Thromboembolism After Abdominal and Minimally Invasive Large Specimen Hysterectomy. J Minim Invasive Gynecol 2023; 30:884-889. [PMID: 37422052 DOI: 10.1016/j.jmig.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023]
Abstract
STUDY OBJECTIVE To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population. DESIGN Retrospective cohort study (Canadian Task Force Classification II2) of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States. SETTING National Surgical Quality Improvement Program Database. PATIENTS Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into 4 groups according to uterine weight: <100 g, 100-249 g, 250 g-499 g, and specimens ≥500 g. INTERVENTIONS Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index, smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight. MEASUREMENTS AND MAIN RESULTS A total of 122,418 hysterectomies occurring between 2014 and 2019 were included in our study, of which 28,407 (23.2%) patients underwent abdominal, 75,490 (61.7%) laparoscopic, and 18,521 (15.1%) vaginal hysterectomy. The overall rate of VTE in patients with large specimen hysterectomies (≥500 g) was 0.64%. After multivariable adjustment, there was no significant difference in the odds of VTE between uterine weight groups. Only 30% of the surgeries with uterine weight above 500 g were performed with minimally invasive surgical routes. Patients who underwent minimally invasive hysterectomy had lower odds of VTE via laparoscopic (adjusted odds ratio [aOR] 0.62; confidence interval [CI]: 0.48-0.81) and vaginal (aOR 0.46; CI: 0.31-0.69) routes compared to laparotomy. Prolonged operative time (>120 min) was associated with increased odds of VTE (aOR 1.86; CI:1.51-2.29). CONCLUSION The occurrence of VTE after a benign large specimen hysterectomy is rare. The odds of VTE is higher with longer operative times and lower with minimally invasive approaches, even for markedly enlarged uteri.
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Affiliation(s)
- Nguyen K Pham
- Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs. Pham, Jalloul, Hui, and Leon).
| | - Randa J Jalloul
- Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs. Pham, Jalloul, Hui, and Leon)
| | - Han-Yang Chen
- School of Public Health (Dr. Chen), McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Mason Hui
- Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs. Pham, Jalloul, Hui, and Leon)
| | - Mateo G Leon
- Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs. Pham, Jalloul, Hui, and Leon)
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Yang Y, Gu S, Sang WL, Liu W, Wu SF. Technical, ergonomic and cognitive learning methodology in transumbilical single-port laparoscopic hysterectomy. Int J Gynaecol Obstet 2023; 163:158-166. [PMID: 37254585 DOI: 10.1002/ijgo.14883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/09/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVE We introduced learning curves on a detailed step protocol and ergonomic aspect to determine key surgical points in transumbilical single-port laparoscopic hysterectomy (TSPLH) and to popularize both technical and cognitive methodology on laparoendoscopic single-site surgery (LESS). MATERIALS AND METHODS A retrospective analysis of 87 TSPLH procedures was conducted by a single surgeon in three learning stages. Technical, ergonomic, and cognitive steps were introduced, and surgical outcomes were analyzed. RESULTS Key production points in TSPLH include developing a clear retroperitoneal space, maintaining appropriate strength and direction with a vaginal manipulator, coagulating the uterine artery, and applying an improved vaginal stump suturing method. Technical factors included instrument domination, hand-eye coordination, and alternating hand functions. Ergonomic techniques focused on shoulder, elbow, arm, wrist, and finger movements, range of motion, muscle power, continuous forces, and flexibility. Improved cognitive factors such as confidence, decision-making, and communication were also observed. CONCLUSIONS The study aimed to form methodological education on TSPLH and LESS and benefit more surgeons. The detailed production and key ergonomic points will help guide self-learning and education.
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Affiliation(s)
- Ye Yang
- Obstetrics and Gynecology Department, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Song Gu
- Trauma Center, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Lin Sang
- Orthopedics Department, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Liu
- Educational Department, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Su Fang Wu
- Obstetrics and Gynecology Department, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Balagna SJ, Boyd C, Arnold DE, Wagner CA, Veronikis DK, Short M, Butler J, Marquart S. Implementing a Bundle to Improve Surgical Site Infection Rates for Patients Undergoing Nonvaginal-Approach Hysterectomy at a Midwestern Teaching Hospital. AORN J 2023; 118:240-248. [PMID: 37750800 DOI: 10.1002/aorn.13999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 09/27/2023]
Abstract
Accrediting organizations, third-party payers, and patients review the surgical site infection (SSI) rates of health care organizations. Infection preventionists collaborate with perioperative personnel to decrease SSI rates; they also monitor and report SSI information to national organizations. The standard infection ratio is a comparison of the observed number of SSIs to the predicted number of SSIs based on national benchmark data. Leaders of a midwestern teaching hospital convened an interdisciplinary team (eg, surgeons, perioperative leaders, infection preventionists) to address a standard infection ratio after hysterectomies that was greater than 1.0. The team reviewed national guidelines and published articles on decreasing SSIs (including recommendations for vaginal preparation) before developing and implementing a hysterectomy-specific bundle for SSI prevention. The rate of SSIs decreased 68% after the implementation of the bundle. Perioperative personnel at this facility continue to use the bundle and infection preventionists monitor and report compliance with the bundle's elements.
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Thigpen B, Connell P, Erfani H, Koythong T, Sunkara S, Guan X. Robotic-assisted vaginal natural orifice transluminal endoscopic surgery versus robotic-assisted single-site port for benign hysterectomy: a comparison of surgical outcomes. J Robot Surg 2023; 17:2487-2494. [PMID: 37523047 DOI: 10.1007/s11701-023-01680-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
The objective of this study is to evaluate the surgical outcomes for robotic-assisted vaginal natural orifice transluminal endoscopic surgery (R-VNOTES) hysterectomy versus robotic-assisted single-site port (RSSP) hysterectomy when performed for benign indications. This is a retrospective chart review in an academic tertiary setting. 404 patients underwent hysterectomy for benign indications. R-VNOTES hysterectomy and RSSP hysterectomy were performed by a single minimally invasive gynecologic surgeon from January 2015 to August 2022. The primary outcome of our study was total operative time (minutes). Secondary outcomes included estimated blood loss (mL), length of hospital stay (days), and postoperative pain score. Other intraoperative and postoperative surgical complications were also compared. 159 patients underwent R-VNOTES hysterectomy, and 269 patients underwent RSSP hysterectomy. Median length of surgery (minutes) demonstrated a statistically significant shorter operative time in the R-VNOTES hysterectomy group when compared to the RSSP hysterectomy group, (132 min versus 146 min, respectively, p = 0.0001). Additionally, patients in the R-VNOTES hysterectomy group experienced decreased postoperative pain levels at week 1 (6 versus 7, respectively, p = 0.01) and week 3 (1.5 versus 2.5, respectively, p = 0.01) after surgery. There were no statistically significant differences between the two groups when comparing length of hospital stay, estimated blood loss, and weight of the uterus. There was no difference in rates of urinary tract infection, blood transfusion, bowel injury, readmission, reoperation, conversion, deep surgical site infection, and venous thromboembolism between both groups. However, there was a higher rate of superficial SSI in the RSSP hysterectomy group (0.6% versus 4.5%, respectively, p = 0.03). When compared to RSSP hysterectomy, R-VNOTES hysterectomy is safe and feasible, as both approaches have comparable surgical outcomes. Patients undergoing R-VNOTES hysterectomy had shorter length of surgery, decreased postoperative pain, and lower rates of superficial surgical site infections.
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Affiliation(s)
- Brooke Thigpen
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Phillip Connell
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Hadi Erfani
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Tamisa Koythong
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Sowmya Sunkara
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA
| | - Xiaoming Guan
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F1020, Houston, TX, 77030, USA.
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Baracy MG, Kerl A, Hagglund K, Fennell B, Corey L, Aslam MF. Trends in surgical approach to hysterectomy and perioperative outcomes in Michigan hospitals from 2010 through 2020. J Robot Surg 2023; 17:2211-2220. [PMID: 37280406 DOI: 10.1007/s11701-023-01631-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/21/2023] [Indexed: 06/08/2023]
Abstract
The objective of this study was to determine the trends in surgical approach to hysterectomy over the last decade and compare perioperative outcomes and complications. This retrospective cohort study used clinical registry data from the Michigan Hospitals that participated in Michigan Surgical Quality Collaborative (MSQC) from January 1st, 2010 through December 30th, 2020. A multigroup time series analysis was performed to determine how surgical approach to hysterectomy [open/TAH, laparoscopic (TLH/LAVH), and robotic-assisted (RA)] has changed over the last decade. Abnormal uterine bleeding, uterine fibroids, chronic pelvic pain, pelvic organ prolapse, endometriosis, pelvic mass, and endometrial cancer were the most common indications for hysterectomy. The open approach to hysterectomy declined from 32.6 to 16.9%, a 1.9-fold decrease, with an average decline of 1.6% per year (95% CI - 2.3 to - 0.9%). Laparoscopic-assisted hysterectomies decreased from 27.2 to 23.8%, a 1.5-fold decrease, with an average decrease of 0.1% per year (95% CI - 0.7 to 0.6%). Finally, the robotic-assisted approach increased from 38.3 to 49.3%, a 1.25-fold increase, with an average of 1.1% per year (95% CI 0.5 to 1.7%). For malignant cases, open procedures decreased from 71.4 to 26.6%, a 2.7-fold decrease, while RA-hysterectomy increased from 19.0 to 58.7%, a 3.1-fold increase. After controlling for the confounding variables age, race, and gynecologic malignancy, RA hysterectomy was found to have the lowest rate of complications when compared to the vaginal, laparoscopic and open approaches. Finally, after controlling for uterine weight, black patients were twice as likely to undergo an open hysterectomy compared to white patients.
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Affiliation(s)
- Michael G Baracy
- Department of Obstetrics and Gynecology, Ascension St. John Hospital, 22101 Moross Rd, Detroit, MI, 48236, USA.
| | - Alexis Kerl
- Department of Family Medicine, Ascension St. John Hospital, Detroit, MI, 48236, USA
| | - Karen Hagglund
- Department of Biomedical Investigations and Research, Ascension St. John Hospital, Detroit, MI, 48236, USA
| | - Brian Fennell
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, 48202, USA
| | - Logan Corey
- Department of Gynecologic Oncology, Wayne State University, Detroit, MI, 48202, USA
| | - Muhammad Faisal Aslam
- Department of Female Pelvic Medicine and Reconstructive Surgery, Ascension St. John Hospital, Detroit, MI, 48236, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
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Xu P, Zhao Z, Tian Y, Li Y, Liu Y, Ji M. A retrospective analysis of robot-assisted total hysterectomy by transvaginal natural orifice transluminal endoscopic surgery. Heliyon 2023; 9:e19207. [PMID: 37662750 PMCID: PMC10474405 DOI: 10.1016/j.heliyon.2023.e19207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023] Open
Abstract
Objective The present study aimed to explore the feasibility and safety of robot-assisted total hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Methods In this study, the clinical data of 37 patients who underwent da Vinci robot-assisted total hysterectomy by vNOTES between September 1, 2019 and March 31, 2022 at the Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, China were retrospectively analyzed. Clinical characteristics, operative postoperative complications, surgical outcomes, and postoperative pain scores were collected and analyzed. Results The average age of the patients included in the study was 47.43 ± 4.44 years. The body mass index (BMI) was calculated using the formula BMI = body weight (kg)/height2 (m2). The average BMI was 23.16 ± 2.72 kg/m2. Among the 37 patients, 30 patients underwent total hysterectomy and bilateral salpingectomy, of which 11 patients underwent ovarian cystectomy simultaneously. Among these 11 patients, three had bilateral ovarian cysts and eight had unilateral ovarian cysts, with the largest cyst diameter measuring 8 cm. The remaining seven patients underwent total hysterectomy and bilateral salpingo-oophorectomy. The average operative time was 86.19 ± 17.83 min, and the estimated intraoperative blood loss was 24.46 ± 15.40 mL, with no intraoperative complications reported. The time to the first postoperative exhaust was 18.51 ± 6.63 h, and the average postoperative length of hospital stay was 3.81 ± 1.05 days. The postoperative visual analog scale (VAS) pain scores were 5.30 ± 0.91 at 24 h after surgery, 3.30 ± 0.70 at 36 h after surgery, and 1.14 ± 0.92 at 48 h after surgery. Only one patient experienced a fever exceeding 38.5 °C, which resolved after receiving antibiotic treatment. Conclusion The use of the da Vinci robot-assisted total hysterectomy by vNOTES demonstrated safety and offers several advantages. These include reduced surgical trauma, an aesthetic incision, decreased pain, and shorter duration of postoperative exhaust time and hospital stay. These benefits contribute to accelerated postoperative rehabilitation.
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Affiliation(s)
- Penglin Xu
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, PR China
| | - Zhao Zhao
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, PR China
| | - Yanpeng Tian
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, PR China
| | - Yue Li
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, PR China
| | - Yafen Liu
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, PR China
| | - Mei Ji
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, PR China
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Pickett CM, Seeratan DD, Mol BWJ, Nieboer TE, Johnson N, Bonestroo T, Aarts JW. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2023; 8:CD003677. [PMID: 37642285 PMCID: PMC10464658 DOI: 10.1002/14651858.cd003677.pub6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH). OBJECTIVES To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS We searched the following databases (from their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies. AUTHORS' CONCLUSIONS Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.
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Affiliation(s)
- Charlotte M Pickett
- Department of Obstetrics and Gynecology, University of California San Diego, La Jolla, California, USA
| | - Dachel D Seeratan
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | | | - Neil Johnson
- Obstetrics & Gynaecology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Tijmen Bonestroo
- Department of Obstetrics and Gynecology, Rijnstate Hospital, Arnhem, Netherlands
| | - Johanna Wm Aarts
- Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, Netherlands
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Robinson WR, Mathias JG, Wood ME, Anderson LG, Howard AG, Carey ET, Nicholson WK, Carey TS, Myers ER, Stürmer T, Doll KM. Ethnoracial Differences in Premenopausal Hysterectomy: The Role of Symptom Severity. Obstet Gynecol 2023; 142:350-359. [PMID: 37473411 PMCID: PMC10351903 DOI: 10.1097/aog.0000000000005225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/13/2023] [Accepted: 03/10/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To evaluate whether greater symptom severity can explain higher hysterectomy rates among premenopausal non-Hispanic Black compared with White patients in the U.S. South rather than potential overtreatment of Black patients. METHODS Using electronic health record data from 1,703 patients who underwent hysterectomy in a large health care system in the U.S. South between 2014 and 2017, we assessed symptom severity to account for differences in hysterectomy rates for noncancerous conditions among premenopausal non-Hispanic Black, non-Hispanic White, and Hispanic patients. We used Poisson generalized linear mixed modeling to estimate symptom severity (greater than the 75th percentile on composite symptom severity scores of bleeding, bulk, or pelvic pain) as a function of race-ethnicity. We calculated prevalence ratios (PRs). We controlled for factors both contra-indicating and contributing to hysterectomy. RESULTS The overall median age of non-Hispanic White (n=1,050), non-Hispanic Black (n=565), and Hispanic (n=158) patients was 40 years. The White and Black patients were mostly insured (insured greater than 95%), whereas the Hispanic patients were often uninsured (insured 58.9%). White and Black patients were mostly treated outside academic medical centers (nonmedical center: 63.7% and 58.4%, respectively); the opposite was true for Hispanic patients (nonmedical center: 34.2%). Black patients had higher bleeding severity scores compared with Hispanic and White patients (median 8, 7, and 4 respectively) and higher bulk scores (median 3, 1, and 0, respectively), but pain scores differed (median 3, 5, and 4, respectively). Black and Hispanic patients were disproportionately likely to have severe symptoms documented on two or more symptoms (referent: not severe on any symptoms) (adjusted PR [Black vs White] 3.02, 95% CI 2.29-3.99; adjusted PR [Hispanic vs White] 2.61, 95% CI 1.78-3.83). Although Black and Hispanic patients were more likely to experience severe symptoms, we found no racial and ethnic differences in the number of alternative treatments attempted before hysterectomy. CONCLUSION We did not find evidence of overtreatment of Black patients. Our findings suggest potential undertreatment of Black and Hispanic patients with uterine-sparing alternatives earlier in their disease progression.
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Affiliation(s)
- Whitney R Robinson
- Division of Women's Community and Population Health, Department of Obstetrics and Gynecology, Duke University School of Medicine, the Margolis Center for Health Policy, Duke University, and the Duke-UNC Alzheimer's Disease Research Center, Durham, the Department of Epidemiology and the Department of Biostatistics, Gillings School of Global Public Health, the Carolina Population Center, and the Department of Obstetrics and Gynecology and the Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of Prevention and Community Health, George Washington Milken Institute of Public Health, Washington, DC; and the Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington
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Katon JG, Bossick A, Carey C, Christy A, Doll K, Gatsby E, Gray KE, Lynch KE, Moy E, Owens S, Washington DL, Callegari LS. Racial Disparities in Uterine Fibroid Treatment Among Veterans Using VA Health Care. Womens Health Issues 2023; 33:405-413. [PMID: 37105835 DOI: 10.1016/j.whi.2023.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 03/10/2023] [Accepted: 03/24/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Uterine fibroids are common, nonmalignant tumors that disproportionately impact Black patients. We aimed to examine Black and White differences in receipt of any treatment and type of first treatment in the Department of Veterans Affairs, including effect modification by severity as approximated by anemia. METHODS We used Department of Veterans Affairs administrative data to identify 5,041 Black and 3,206 White veterans with symptomatic uterine fibroids, identified by International Classification of Diseases, 9th edition, Clinical Modification, codes, between fiscal year 2010 and fiscal year 2012 and followed in the administrative data through fiscal year 2018 for outcomes. Outcomes included receipt of any treatment, hysterectomy as first treatment, and fertility-sparing treatment as first treatment. We stratified all analyses by age (<45, ≥45 years old), used generalized linear models with a log link and Poisson error distribution, included an interaction term between race and anemia, and used recycled predictions to estimate adjusted percentages for outcomes. RESULTS There was evidence of effect modification by anemia for receipt of any treatment but not for any other outcomes. Across age and anemia sub-groups, Black veterans were less likely to receive any treatment than White veterans. Adjusted racial differences were most pronounced among veterans with anemia (<45 years, Black-White difference = -10.3 percentage points; 95% confidence interval, -15.9 to -4.7; ≥45 years, Black-White difference = -20.3 percentage points; 95% confidence interval, -27.8 to -12.7). Across age groups, Black veterans were less likely than White veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment. CONCLUSIONS We identified significant Black-White disparities in receipt of treatment for symptomatic uterine fibroids. Additional research that centers the experiences of Black veterans with uterine fibroids is needed to inform strategies to eliminate racial disparities in uterine fibroid care.
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Affiliation(s)
- Jodie G Katon
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington.
| | - Andrew Bossick
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Henry Ford Healthcare System, Detroit, Michigan
| | - Cathea Carey
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington
| | - Alicia Christy
- Office of Women's Health, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Kemi Doll
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Elise Gatsby
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Kristen E Gray
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Kristine E Lynch
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah; Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ernest Moy
- U.S. Department of Veterans Affairs, Office of Health Equity, Washington, District of Columbia
| | - Shanise Owens
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
| | - Donna L Washington
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Lisa S Callegari
- U.S. Department of Veterans Affairs (VA) Puget Sound Healthcare System, Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development (HSR&D), Seattle, Washington; Department of Health Systems and Population Health, University of Washington, Seattle, Washington; Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
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Alkatout I, Mazidimoradi A, Günther V, Salehiniya H, Allahqoli L. Total or Subtotal Hysterectomy for the Treatment of Endometriosis: A Review. J Clin Med 2023; 12:jcm12113697. [PMID: 37297893 DOI: 10.3390/jcm12113697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/07/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE The purpose of the review was to evaluate and compare outcomes after total or subtotal hysterectomy in women with endometriosis or adenomyosis. METHODS We searched four electronic databases: Medline (PubMed), Scopus, Embase, and Web of Science (WoS). The first aim of the study was to compare outcomes after total and subtotal hysterectomy in women with endometriosis, and the second aim was to compare the two procedures in women with adenomyosis. Publications that reported short- and long-term outcomes after total and subtotal hysterectomy were included in the review. The search was not subject to any limitation in terms of time or method. RESULTS After screening 4948 records, we included 35 studies published from 1988 to 2021; the studies were based on various methodologies. With regard to the first aim of the review, we found 32 eligible studies and divided these into the following four categories: postoperative short- and long-term outcomes, recurrence of endometriosis, quality of life and sexual function, and patient satisfaction after total or subtotal hysterectomy in women with endometriosis. Five investigations were deemed eligible for the second aim of the review. No differences were seen in terms of postoperative short- and long-term outcomes after subtotal or total hysterectomy in women with endometriosis or adenomyosis. CONCLUSIONS Preservation or removal of the cervix in women with endometriosis or adenomyosis appears to have no effect on short- or long-term outcomes, recurrence of endometriosis, quality of life and sexual function, or patient satisfaction. Nevertheless, we lack randomized blinded controlled trials on these aspects. Such trials will be needed to enhance our comprehension of both surgical approaches.
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Affiliation(s)
- Ibrahim Alkatout
- Kiel School of Gynaecological Endoscopy, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| | - Afrooz Mazidimoradi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz 7134814336, Iran
| | - Veronika Günther
- Kiel School of Gynaecological Endoscopy, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| | - Hamid Salehiniya
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand 9717853577, Iran
| | - Leila Allahqoli
- Midwifery Department, Ministry of Health and Medical Education, Tehran 1467664961, Iran
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Johnson M, Carreño PK, Lutgendorf MA, Brown JE, Velosky AG, Highland KB. Hysterectomy inequities between black and white patients in the US military health system: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2023; 286:52-60. [PMID: 37209523 DOI: 10.1016/j.ejogrb.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/02/2023] [Accepted: 05/08/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE To evaluate multicomponent aspects of hysterectomy-related care in the US Military Health System including the probability of open hysterectomy (versus vaginal or laparoscopic hysterectomy), probability of having a length of stay > 1 day, and discharge milligram morphine equivalent dose (MED). Analyses sought to identify the presence and strength of healthcare inequities between Black and white patients. METHODS In this retrospective cohort study, records of patients (N = 11,067) ages 18-65 years enrolled in TRICARE who underwent a hysterectomy between January 2017 to January 2021 in US military treatment facilities (direct care) or civilian facilities (purchased care) were included. Graphic representations illustrated provider and facility variation. Generalized additive mixed models (GAMMs) evaluated inequities across outcomes. Sensitivity analyses included only direct care receipt and added a random effect for the facility. RESULTS There was significant variation in provider use of open versus vaginal or laparoscopic hysterectomies, as well as provider and facility discharge MED. The GAMMs indicated Black patients were more likely to receive an open hysterectomy [log(OR) -0.54, (95 %CI -0.65, -0.43), p < 0.001] and have a length of stay > 1 day [log(OR) 0.18, (95 %CI 0.07, 0.30), p = 0.002], but had similar discharge MED [-2 mg (95% CI -7 mg, 3 mg), p = 0.51], relative to white patients. Patients receiving care in purchased care, relative to direct care, were more likely to receive a vaginal or laparoscopic hysterectomy [log(OR) 0.28, (95 %CI 0.17, 0.38), p = 0.002] and received approximately 21 mg lower discharge MED (95 %CI 16-26 mg less, p < 0.001), but were more likely to have a hospital stay > 1 day [log(OR) 0.95, (95 %CI 0.83, 0.1.10), p < 0.001]. Additional gynecological conditions (e.g., uterine fibroids) and prescription receipt were associated with some, but not all outcomes. CONCLUSION Improving timely care receipt, especially for uterine fibroids, increasing access to vaginal and laparoscopic hysterectomies, and reducing unwarranted variation in discharge MED could improve care quality and equity in the US Military Health System.
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Affiliation(s)
- Monnique Johnson
- School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Patricia K Carreño
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Monica A Lutgendorf
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Jill E Brown
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Alexander G Velosky
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD 20817, United States; Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
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Messingschlager C, Ferrando CA, Chang OH. Intention matters: Success rate of bilateral salpingo-oophorectomy at the time of vaginal hysterectomy for pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol 2023; 283:54-58. [PMID: 36773471 DOI: 10.1016/j.ejogrb.2023.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/23/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study was to determine the incidence of successful bilateral salpingo-oophorectomy at the time of vaginal hysterectomy for pelvic organ prolapse and to evaluate associated factors and success rate over time. STUDY DESIGN This was a retrospective chart review of all women who underwent vaginal hysterectomy for pelvic organ prolapse who were consented for bilateral salpingo-oophorectomy "if possible" and "including extraordinary measures" between 2014 and 2019 at a tertiary medical center. Baseline demographic data along with prolapse stage, operative findings, operative time, and complications were recorded. Univariate analysis using the Pearson's chi-square test, the student's t-test or Mann Whitney U test when appropriate and multivariable logistic regression was performed to determine predictors of successful vaginal bilateral salpingo-oophorectomy. RESULTS A total of 453 eligible patients were included. 420 patients (92.7 %) were consented for bilateral salpingo-oophorectomy "if possible" and 33 patients (7.3 %) were consented for "including extraordinary measures". The success rate of vaginal bilateral salpingo-oophorectomy in all patients was 57.9 % (n = 262). Of the patients consented for extraordinary measures, the success rate was 93.9 % (n = 31), compared to a success rate of 55 % (n = 231) in the "if possible" group. A concurrent posterior repair was found to have higher odds of successful bilateral salpingo-oophorectomy (adjOR 1.75 [95 % CI = 1.17-2.61]). Successful bilateral salpingo-oophorectomy extended operative time by 14 min (154 min vs 140 min, p < 0.001). Compared to patients in the unsuccessful group, the successful group had a higher proportion of the following indications: a family history of ovarian cancer, personal breast cancer history or patient request for definitive removal. CONCLUSION When the pre-operative intention to perform bilateral salpingo-oophorectomy at the time of vaginal hysterectomy for pelvic organ prolapse is high, the success rate is nearly 40% higher when compared to an opportunistic procedure. This suggests that success is closely linked to the surgeon's determination to complete this procedure vaginally.
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Affiliation(s)
- Cory Messingschlager
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Cecile A Ferrando
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Olivia H Chang
- Division of Female Urology, Pelvic Reconstructive Surgery & Voiding Dysfunction. Department of Urology, University of California Irvine, Irvine, CA, United States.
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Katon JG, Plowden TC, Marsh EE. Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context. Fertil Steril 2023; 119:355-363. [PMID: 36682686 PMCID: PMC9992263 DOI: 10.1016/j.fertnstert.2023.01.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Uterine fibroids and endometriosis are 2 of the leading causes of morbidity among reproductive-aged women. There are significant racial disparities in disease prevalence, incidence, age of onset, and treatment profile in fibroids. The data on endometriosis are less clear. OBJECTIVE To conduct a systematic review of racial disparities in prevalence of uterine fibroids and endometriosis in the United States and summarize the literature on these 2 highly prevalent benign gynecologic conditions using a framework that explicitly incorporates and acknowledges the social, structural, and political contexts as a root cause of racial disparities between Black and White women. EVIDENCE REVIEW A systematic review regarding racial disparities in prevalence of fibroids and endometriosis was conducted separately. Two separate searches were conducted in PubMed to identify relevant original research manuscripts and prior systematic reviews regarding racial disparities in uterine fibroids and endometriosis using standardized search terms. In addition, we conducted a structured literature search to provide social, structural, and political context of the disparities. FINDINGS A systematic review of the literature indicated that the prevalence of uterine fibroids was consistently higher in Black than in White women with the magnitude of the difference varying depending on population and case definition. Prevalence of endometriosis varied considerably depending on the base population and case definition, but was the same or lower among Black vs. White women. As a result of the social, structural, and political context in the United States, Black women disproportionately experience a range of exposures across the life course that may contribute to their increased uterine fibroid incidence, prevalence, and severity of uterine fibroids. However, data suggest no racial difference in the incidence of endometriosis. Nevertheless, Black women with fibroids or endometriosis experience worse clinical and surgical outcomes than their White counterparts. CONCLUSION AND RELEVANCE Racial disparities in uterine fibroids and endometriosis can be linked with differential exposures to suspected etiologic agents, lack of adequate access to health care, including highly skilled gynecologic surgeons, and bias and discrimination within the health care system. Eliminating these racial disparities will require solutions that address root causes of health disparities through policy, education and programs to ensure that all patients receive culturally- and structurally-competent care.
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Affiliation(s)
- Jodie G Katon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Torie C Plowden
- Division of Reproductive Endocrinology and Infertility, Department of Gynecologic Surgery and Obstetrics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Erica E Marsh
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan.
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Disparities in Benign Gynecologic Surgical Care. Clin Obstet Gynecol 2023; 66:124-131. [PMID: 36657049 DOI: 10.1097/grf.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A person's health is not only affected by their disease states, but also the quality of care and posttreatment sequelae. Research shows that disparities exist in benign gynecologic surgery access to care, techniques, and perioperative outcomes. Surgical education, pathways that emphasize minimally invasive approaches, and patient-centered care that recognizes historical influences on patient perspectives are critical to dampening these disparities.
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Chang OH, Tewari S, Yao M, Walters MD. Who Places High Value on the Uterus? A Cross-sectional Survey Study Evaluating Predictors for Uterine Preservation. J Minim Invasive Gynecol 2023; 30:131-136. [PMID: 36332820 DOI: 10.1016/j.jmig.2022.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE To determine predictors for placing high value on the uterus in patients who no longer desire fertility. The secondary objective was to identify reasons for placing high value on the uterus. DESIGN Cross-sectional survey study. SETTING Three hospitals within a large healthcare system in the United States. PATIENTS New patients ≥45 years old seeking care for benign gynecologic conditions, including abnormal uterine bleeding, uterine myomas, pelvic organ prolapse, endometriosis, or pelvic pain. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was the summative score of the validated Value of Uterus (VALUS) instrument for measuring value placed on the uterus and the validated visual analog scale with the question "how important is it to you to keep your uterus when you have a gynecologic condition?" A total of 163 surveys were returned for analysis (79.2%). Using the VALUS cutoff, 64 patients (45.7%) were considered to have low value for their uterus (VALUS score <14), whereas 76 patients (54.3%) were considered to have high value for their uterus (VALUS score ≥14). The adjusted odds of placing high value for the uterus was 5.06 times higher among those who wanted to be sexually active in the future than those who do not desire to be sexually active (95% confidence interval, 1.55-16.52, p = .01). Patients who are sexually active have 3.94 higher adjusted odds of placing high value on the uterus than those who are not sexually active and do not desire to be (95% confidence interval, 1.36-11.43; p = .01). Race, religion, and personal history of cancer were not statistically significant. CONCLUSION Patients who highly value the uterus were highly motivated by the desire to be sexually active. Nonwhite race, religion, and personal history of cancer were not predictors for placing high value on uterine preservation.
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Affiliation(s)
- Olivia H Chang
- Division of Female Urology, Pelvic Reconstructive Surgery and Voiding Dysfunction, Department of Urology, University of California Irvine (Dr. Chang), Orange, CA.
| | - Surabhi Tewari
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University (Ms. Tewari), Cleveland Clinic, Cleveland, Ohio
| | - Meng Yao
- Quantitative Health Sciences, Cleveland Clinic (Mr. Yao), Cleveland, Ohio
| | - Mark D Walters
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute (Dr. Walters), Cleveland Clinic, Cleveland, Ohio
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Kobylianskii A, Murji A, Matelski JJ, Adekola AB, Shapiro J, Shirreff L. Surgeon Gender and Performance Outcomes for Hysterectomies: Retrospective Cohort Study. J Minim Invasive Gynecol 2023; 30:108-114. [PMID: 36332819 DOI: 10.1016/j.jmig.2022.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/05/2022] [Accepted: 10/26/2022] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE To evaluate whether there are differences in several performance metrics between male and female surgeons for hysterectomies. DESIGN Multicenter retrospective cohort study. We matched surgeries performed by female surgeons to those by male surgeons using a propensity score and compared outcomes by gender after adjusting for years in practice and fellowship training. SETTING A total of 6 hospitals (3 academic, 3 community) in Ontario, Canada, between July 2016 and December 2019. PATIENTS All consecutive patients. INTERVENTIONS Hysterectomy. MEASUREMENTS AND MAIN RESULTS Primary outcome was a composite of any complication or return to emergency room (ER) within 30 days. Secondary outcomes were grade II or greater complications, return to ER, and operative time. We included 2664 hysterectomies performed by 77 surgeons. After propensity matching, 963 surgeries performed by females were compared with 963 performed by males. There were no differences in the primary (relative risk [RR], 0.92; 95% confidence interval [CI], 0.71-1.20; p = .56) or secondary outcomes of grade II or greater complication (RR, 1.01; 95% CI, 0.71-1.45; p = .96) or return to ER (RR, 0.81; 95% CI, 0.55-1.20; p = .30). However, surgeries performed by males were 24.72 minutes shorter (95% CI, 18.09-31.34 minutes; p <.001). Entire cohort post hoc regression analysis confirmed these findings. E-value analysis indicated that it is unlikely for an unmeasured confounder to undo the observed difference. CONCLUSION Although complication and readmission rates are similar, male surgeons may have a shorter operating time than female surgeons for hysterectomies, which may have implications for health systems and inequalities in surgeon renumeration.
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Affiliation(s)
| | - Ally Murji
- Department of Obstetrics and Gynecology, University of Toronto; Department of Obstetrics and Gynecology, Mount Sinai Hospital
| | - John J Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | | | - Jodi Shapiro
- Department of Obstetrics and Gynecology, University of Toronto; Department of Obstetrics and Gynecology, Mount Sinai Hospital
| | - Lindsay Shirreff
- Department of Obstetrics and Gynecology, University of Toronto; Department of Obstetrics and Gynecology, Mount Sinai Hospital.
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Zachomitros F, Tsakiridis I, Peitsidis N, Michos G, Dagklis T, Kalogiannidis I. Hemoperitoneum due to spontaneous bleeding from a smooth muscle tumor of uncertain malignant potential: A rare case report. Int J Surg Case Rep 2023; 103:107910. [PMID: 36736227 PMCID: PMC9925965 DOI: 10.1016/j.ijscr.2023.107910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/29/2023] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Smooth muscle tumors of uncertain malignant potential (STUMPs) are uncommon tumors representing an extremely rare cause of hemoperitoneum. CASE PRESENTATION We report a case of a 48-year-old Caucasian, premenopausal woman that presented in the emergency department with acute abdominal pain. There was no remarkable past medical and surgical history except from a known uterine leiomyoma. The ultrasound and the computed tomography imaging showed an intraperitoneal fluid collection and a heterogenous uterine mass. The patient underwent emergent exploratory laparotomy; a subserosal uterine tumor was identified with an actively bleeding vessel on its surface. The uterine lesion was completely excised and the histopathology set the diagnosis of a STUMP. After consultation on the significance of this finding with the patient, an abdominal total hysterectomy and bilateral salpingo-oophorectomy were scheduled and performed and the subsequent histopathology detected no malignancy. CLINICAL DISCUSSION This case demonstrates that a STUMP may be a rare cause of acute intraperitoneal bleeding. Careful evaluation of clinical history, imaging findings and, if needed, surgical exploration are important for the diagnosis, while appropriate follow-up is also of major importance for the management of these rare tumors. CONCLUSION We presented an extremely rare case of hemoperitoneum due to spontaneous bleeding from a STUMP. From an oncological perspective, this case poses a diagnostic, management and follow-up challenge.
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Affiliation(s)
| | - Ioannis Tsakiridis
- Third Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Greece.
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Mei Y, He L, Zhang Q, Chen Y, Zheng J, Xiao X, Lin Y. The comparison of gasless and traditional robot-assisted transvaginal natural orifice transluminal endoscopic surgery in hysterectomy. Front Med (Lausanne) 2023; 10:1117158. [PMID: 36936202 PMCID: PMC10019594 DOI: 10.3389/fmed.2023.1117158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Study objective To describe the surgical technique and compare the operative outcomes of gasless and traditional robot-assisted transvaginal natural orifice transluminal endoscopic surgery (GR-vNOTES vs. TR-vNOTES) in hysterectomy. Methods The patients undergoing hysterectomy via GR-vNOTES or TR-vNOTES between February 2020 and January 2022 in our hospital were included. Clinical data regarding patient demographics, operative time, blood loss, complications, and postoperative hospital stays were collected and analyzed. Results Five cases underwent hysterectomy via GR-vNOTES, and nine cases via TR-vNOTES. The baseline demographics and operative outcomes were not significantly different in GR-vNOTES and TR-vNOTES groups. There was no conversion to multiport robotic laparoscopy, conventional laparoscopy or laparotomy. No complications were seen in both groups, except two cases had fever postoperatively in the TR-vNOTES group. For those with early stage cervical/endometrial cancer, no recurrence or metastasis was observed in the follow-up of six months. Conclusion Both GR-vNOTES and TR-vNOTES were feasible and safe for hysterectomy. GR-vNOTES was a promising alternative to TR-vNOTES in hysterectomy.
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Bruno M, Legge F, Gentile C, Carone V, Stabile G, Di Leo F, Ludovisi M, Di Florio C, Guido M. Risk Assessment Model for Complications in Minimally Invasive Hysterectomy: A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010234. [PMID: 36612556 PMCID: PMC9819802 DOI: 10.3390/ijerph20010234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 06/01/2023]
Abstract
Objective: To estimate the rate of intra-operative and postoperative complications, and to define the risk of 30-day major postoperative complications (Clavien-Dindo > 2) according to the presence of one of 10 different variables of minimally invasive (MI) hysterectomy; and then to create a risk assessment model easily applicable in clinical practice. Methods: A single center single arm retrolective study. Data of consecutive patients who have undergone MI hysterectomy for gynaecologic disorders between May 2018 and April 2021 were analyzed. Perioperative surgical outcomes, occurrence of intra- and postoperative complications, and readmissions within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major postoperative complications. Results: Over the study period, 445 patients were included in the study. The majority of patients developed a minor event, while major complications (grade III) were required in 14 patients. None of the patients showed a grade IV or V complication. Univariate analysis was performed on patients who had developed intra- or postoperative complications from those who did not experience complications. Body mass index (BMI) (p-value 0.045) and surgeon’s experience (p-value 0.015) were found to be associated with a different surgery time. Regarding major postoperative complications, a statistically significant association was found for the variables: BMI (p-value 0.006), previous abdominal surgery (p-value 0.015), and surgeon’s experience (p-value 0.035) in the univariate analysis. Also in the multivariate analysis, the risk of major postoperative complications was higher in these three different variables. BMI, previous surgery, and surgeon’s experience were inserted in a reproducible risk assessment model in order to stratify the risk of major postoperative complications. Conclusions: We proposed a risk assessment model including factors not previously considered in the literature: the standardization of the surgical technique, the surgeon’s experience, the best MI approach (laparoscopy or robot-assisted), and previous abdominal surgery are crucial tools to consider. Further prospective studies with a larger population sample are needed to validate these preliminary evaluations for patients undergoing MI hysterectomy.
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Affiliation(s)
- Matteo Bruno
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Francesco Legge
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Cosimo Gentile
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Vito Carone
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Guglielmo Stabile
- Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Department of Obstetrics and Gynaecology, 34137 Trieste, Italy
| | - Federico Di Leo
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Manuela Ludovisi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Christian Di Florio
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Maurizio Guido
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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Carey CM, Katon JG, Bossick AS, Gray KE, Doll KM, Christy AY, Callegari LS. Uterine Weight as a Modifier of Black/White Racial Disparities in Minimally Invasive Hysterectomy Among Veterans with Fibroids in the Veterans Health Administration. Health Equity 2022; 6:909-916. [PMID: 36636115 PMCID: PMC9811843 DOI: 10.1089/heq.2022.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Uterine fibroids are the most common indication for hysterectomy. Minimally invasive hysterectomy (MIH) confers lower risk of complications and shorter recovery than open surgical procedures; however, it is more challenging to perform with larger fibroids. There are racialized differences in fibroid size and MIH rates. We examined the role of uterine size in black-white differences in MIH among Veterans in the Department of Veterans Affairs (VA). Methods Using VA clinical and administrative data, we conducted a cross-sectional study among black and white Veterans with fibroids who underwent hysterectomy between 2012 and 2014. We abstracted postoperative uterine weight from pathology reports as a proxy for uterine size. We used a generalized linear model to estimate the association between race and MIH and tested an interaction between race and postoperative uterine weight (≤250 g vs. >250 g). We estimated adjusted marginal effects for racial differences in MIH by postoperative uterine weight. Results The sample included 732 Veterans (60% black, 40% white). Postoperative uterine weight modified the association of race and MIH (p for interaction=0.05). Black Veterans with postoperative uterine weight ≤250 g had a nearly 12-percentage point decrease in MIH compared to white Veterans (95% CI -23.1 to -0.5), with no difference by race among those with postoperative uterine weight >250 g. Discussion The racial disparity among Veterans with small fibroids who should be candidates for MIH underscores the role of other determinants beyond uterine size. To eliminate disparities in MIH, research focused on experiences of black Veterans, including pathways to treatment and provider-patient interactions, is needed.
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Affiliation(s)
- Cathea M. Carey
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington, USA
| | - Jodie G. Katon
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington, USA.,Address correspondence to: Jodie G. Katon, PhD, MS, Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, 1660 South Columbian Way, S-152, Seattle, WA 98108, USA.
| | - Andrew S. Bossick
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA.,Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Kristen E. Gray
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington, USA.,Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
| | - Kemi M. Doll
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Alicia Y. Christy
- Women's Health Services, Veterans Administration, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Lisa S. Callegari
- Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, U.S. Department of Veterans Affairs, VA Puget Sound Healthcare System, Seattle, Washington, USA.,Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
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