1
|
Baffour Awuah G, Schauberger G, Klug SJ, Tanaka LF. An age-period-cohort analysis of hysterectomy incidence trends in Germany from 2005 to 2019. Sci Rep 2024; 14:15110. [PMID: 38956303 PMCID: PMC11220048 DOI: 10.1038/s41598-024-66019-8] [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: 11/03/2023] [Accepted: 06/26/2024] [Indexed: 07/04/2024] Open
Abstract
Recent studies show declining trends in hysterectomy rates in several countries. The objective of this study was to analyse hysterectomy time trends in Germany over a fifteen-year period using an age-period-cohort approach. Using an ecological study design, inpatient data from Diagnoses Related Group on hysterectomies by subtype performed in Germany from 2005 to 2019 were retrieved from the German Statistical Office. Descriptive time trends and age-period-cohort analyses were then performed. A total of 1,974,836 hysterectomies were performed over the study period. The absolute number of hysterectomies reduced progressively from 155,680 (365 procedures/100,000 women) in 2005 to 101,046 (257 procedures/100,000 women) in 2019. Total and radical hysterectomy decreased by 49.7% and 44.2%, respectively, whilst subtotal hysterectomy increased five-fold. The age-period-cohort analysis revealed highest hysterectomy rates in women aged 45-49 for total and subtotal hysterectomy with 608.63 procedures/100,000 women (95% CI 565.70, 654.82) and 151.30 procedures/100,000 women (95% CI 138.38, 165.44) respectively. Radical hysterectomy peaked later at 65-69 years with a rate of 40.63 procedures/100,000 women (95% CI 38.84, 42.52). The risk of undergoing total or radical hysterectomy decreased over the study period but increased for subtotal hysterectomy. Although, overall hysterectomy rates have declined, subtotal hysterectomy rates have increased; reflecting changes in clinical practice largely influenced by the availability of uterus-sparing options, evolving guidelines and introduction of newer surgical approaches.
Collapse
Affiliation(s)
- Gifty Baffour Awuah
- Chair of Epidemiology, TUM School of Medicine and Health, Technical University of Munich, Georg-Brauchle-Ring 56, 80992, Munich, Germany.
| | - Gunther Schauberger
- Chair of Epidemiology, TUM School of Medicine and Health, Technical University of Munich, Georg-Brauchle-Ring 56, 80992, Munich, Germany
| | - Stefanie J Klug
- Chair of Epidemiology, TUM School of Medicine and Health, Technical University of Munich, Georg-Brauchle-Ring 56, 80992, Munich, Germany
| | - Luana Fiengo Tanaka
- Chair of Epidemiology, TUM School of Medicine and Health, Technical University of Munich, Georg-Brauchle-Ring 56, 80992, Munich, Germany
| |
Collapse
|
2
|
Wang Z, Liu C, Zhang Z, Deng Y, Xiao M, Zhang Z, Dekker A, Wang S, Liu Y, Qian L, Zhang Z, Traverso A, Feng Y. Real-time auto-segmentation of the ureter in video sequences of gynaecological laparoscopic surgery. Int J Med Robot 2023:e2604. [PMID: 38115728 DOI: 10.1002/rcs.2604] [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: 08/30/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Ureteral injury is common during gynaecological laparoscopic surgery. Real-time auto-segmentation can assist gynaecologists in identifying the ureter and reduce intraoperative injury risk. METHODS A deep learning segmentation model was crafted for ureter recognition in surgical videos, utilising 3368 frames from 11 laparoscopic surgeries. Class activation maps enhanced the model's interpretability, showing its areas. The model's clinical relevance was validated through an End-User Turing test and verified by three gynaecological surgeons. RESULTS The model registered a Dice score of 0.86, a Hausdorff 95 distance of 22.60, and processed images in 0.008 s on average. In complex surgeries, it pinpointed the ureter's position in real-time. Fifty five surgeons across eight institutions found the model's accuracy, specificity, and sensitivity comparable to human performance. Yet, artificial intelligence experience influenced some subjective ratings. CONCLUSIONS The model offers precise real-time ureter segmentation in laparoscopic surgery and can be a significant tool for gynaecologists to mitigate ureteral injuries.
Collapse
Affiliation(s)
- Zhixiang Wang
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Radiation Oncology (Maastro), GROW-School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Chongdong Liu
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhen Zhang
- Department of Radiation Oncology (Maastro), GROW-School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Yupeng Deng
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Meizhu Xiao
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhiqiang Zhang
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Andre Dekker
- Department of Radiation Oncology (Maastro), GROW-School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Shuzhen Wang
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yujiang Liu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - LinXue Qian
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhenyu Zhang
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Alberto Traverso
- Department of Radiation Oncology (Maastro), GROW-School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ying Feng
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
3
|
Karaca İ, Demirayak G, Öztürk E, Adıyeke M, Hamdi İnan A, Karaca SY. Facilitating method for removal of the large uterus after laparoscopic hysterectomy: Vaginal vault vertical incision. J Gynecol Obstet Hum Reprod 2023; 52:102530. [PMID: 36587738 DOI: 10.1016/j.jogoh.2022.102530] [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: 10/09/2022] [Revised: 12/25/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND In patients with a large uterus, an important part of the laparoscopic hysterectomy operation time is the phase of removing the uterus from the abdomen.The development of techniques that will shorten the morcellation time is the key to reducing the total operation time. AIM To evaluate the effect of vaginal cuff vertical incision in accelerating removal of the large uterus in laparoscopic hysterectomy. METHODS This study was performed with patients who underwent total laparoscopic hysterectomy. In the study group, a vertical incision was performed in the middle of the posterior vaginal stump before the vaginal removal of the larger uterus (weighing more than 500 g). The control group consisted of patients who underwent vaginal morcellation after conventional colpotomy. Patients in both groups were matched in terms of uterine weights +/-50 g and the same vaginal morcellation technique was applied to all patients. RESULTS In patients who underwent a vertical incision procedure, the time to remove the uterus from the abdomen (17.55±2.53 min vs 26.62±4.72 min, p<0.001) and the total operation time (130.81±12.83 min vs.143.29±13, 15 min, p = 0.001) was statistically significantly less than the patients without vertical incision. There was no difference between the groups in terms of intraoperative complications, drop in hemoglobin levels, time to flatus, postoperative 6th,24th hour visual analog score and length of hospital stay. CONCLUSIONS The vertical incision procedure reduces the time to remove the large uterus from the abdomen after laparoscopic hysterectomy and, accordingly, the total operation time. This procedure may be the preferred method before vaginal morcellation, especially in large uterus.
Collapse
Affiliation(s)
- İbrahim Karaca
- Department of Obstetrics and Gynecology, İzmir Bakircay University, İzmir, Turkey
| | - Gökhan Demirayak
- Department of Obstetrics and Gynecology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Emine Öztürk
- Department of Obstetrics and Gynecology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Adıyeke
- Department of Obstetrics and Gynaecology, Health Sciences University Tepecik Education and Research Hospital, Izmir, Turkey
| | - A Hamdi İnan
- Department of Obstetrics and Gynaecology, Health Sciences University Tepecik Education and Research Hospital, Izmir, Turkey
| | - Suna Yıldırım Karaca
- Department of Obstetrics and Gynaecology, Health Sciences University Tepecik Education and Research Hospital, Izmir, Turkey.
| |
Collapse
|
4
|
Cooley JJP, Maguire FB, Morris CR, Parikh-Patel A, Abrahão R, Chen HA, Keegan THM. Cervical Cancer Stage at Diagnosis and Survival among Women ≥65 Years in California. Cancer Epidemiol Biomarkers Prev 2023; 32:91-97. [PMID: 36620897 PMCID: PMC9833840 DOI: 10.1158/1055-9965.epi-22-0793] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/13/2022] [Accepted: 10/31/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Through adequate screening and follow-up, cervical cancer can be prevented or detected at early-stage (stage I), which is related to excellent survival. Current guidelines recommend discontinuing screening for women ≥65 years with history of normal Pap and/or HPV tests, potentially leaving this age group vulnerable. This study examined late-stage disease in a population-based cohort. METHODS Using California Cancer Registry data, we identified 12,442 patients ages ≥21 years with a first primary cervical cancer diagnosed during 2009-2018. Proportions of late-stage disease (stages II-IV) and early- and late-stage 5-year relative survival are presented by the age group. Among patients ages ≥65 years, multivariable logistic regression estimated associations of sociodemographic and clinical characteristics with late-stage cervical cancer. RESULTS Nearly one fifth of patients (n = 2,171, 17.4%) were ≥65 years. More women ages ≥65 years (71%) presented with late-stage disease than younger women (48% in patients ages <65). Late-stage 5-year relative survival was lower for women ≥65 years (23.2%-36.8%) compared with patients <65 (41.5%-51.5%). Characteristics associated with late-stage cervical cancer in women ≥65 years included older age [odds ratio (OR), 1.02; 95% confidence interval (CI), 1.01-1.04; each year], non-adenocarcinoma histologic subtypes, and comorbidities (OR, 1.59; 95% CI, 1.21-2.08). CONCLUSIONS There remains a significant burden of advanced cervical cancer in women ≥65. IMPACT Efforts should be made to better understand how the current screening paradigm is failing women of 65 years and older. Future work should focus on determining past screening history, lapses in follow-up care, and non-invasive testing approaches.
Collapse
Affiliation(s)
- Julianne J. P. Cooley
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California
| | - Frances B. Maguire
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California
| | - Cyllene R. Morris
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California
| | - Arti Parikh-Patel
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, California
| | - Renata Abrahão
- Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, CA,Center for Healthcare Policy and Research, University of California Davis Health, Sacramento, CA
| | - Hui A. Chen
- University of California Davis Comprehensive Cancer Center, Department of Gynecology Oncology
| | - Theresa H. M. Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, CA
| |
Collapse
|
5
|
Schneyer RJ, Greene NH, Wright KN, Truong MD, Molina AL, Tran K, Siedhoff MT. The Impact of Race and Ethnicity on Use of Minimally Invasive Surgery for Myomas. J Minim Invasive Gynecol 2022; 29:1241-1247. [PMID: 35793780 DOI: 10.1016/j.jmig.2022.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE To determine whether minimally invasive surgery (MIS) for uterine myomas is used differentially based on race and ethnicity. DESIGN Retrospective cohort study. SETTING Quaternary care academic hospital in the United States. PATIENTS Patients undergoing hysterectomy or myomectomy for uterine myomas between March 15, 2015, and March 14, 2020 (N = 1311). Cases involving correction of pelvic organ prolapse, malignancy, peripartum hysterectomy, or combined procedures with nongynecologic specialties were excluded. Racial/ethnic composition of the study population was 40.0% non-Hispanic white (white), 27.9% non-Hispanic black (black), 14.0% Hispanic, 13.7% non-Hispanic Asian (Asian), and 4.3% non-Hispanic American Indian/Alaska Native/Pacific Islander/Other. INTERVENTIONS Hysterectomy, myomectomy. MEASUREMENTS AND MAIN RESULTS Of the 1311 cases, 35.9% were minimally invasive hysterectomy, 16.4% abdominal hysterectomy, 35.6% minimally invasive myomectomy, and 12.1% abdominal myomectomy. MIS rates were 94.7% among fellowship-trained minimally invasive gynecologic surgery subspecialists, 44.2% among obstetrics and gynecology specialists, and 46.8% among gynecologic oncologists. There were disparities in surgeon type based on race/ethnicity, with 59.8% of white patients having undergone surgery with a minimally invasive gynecologic surgery subspecialist vs 44.0% of black patients and 45.7% of Hispanic patients. Black and Hispanic patients were less likely to undergo MIS overall vs white patients (adjusted odds ratio [aOR] 0.33, 95% confidence interval [CI] 0.22-0.48 and aOR 0.44, 95% CI 0.28-0.72, respectively). Black and Hispanic patients undergoing hysterectomy were less likely than white patients to undergo MIS (aOR 0.33, 95% CI 0.21-0.51 and aOR 0.35, 95% CI 0.20-0.60, respectively). There were no significant differences in rates of MIS based on race/ethnicity for myomectomies nor differences in major or minor complications by race/ethnicity overall. CONCLUSION At a quaternary care institution, black and Hispanic patients were significantly less likely than white patients to undergo MIS for uterine myomas, particularly for hysterectomy.
Collapse
Affiliation(s)
- Rebecca J Schneyer
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Schneyer, Greene, and Molina), Los Angeles, California.
| | - Naomi H Greene
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Schneyer, Greene, and Molina), Los Angeles, California
| | - Kelly N Wright
- Division of Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center (Drs. Wright, Truong, and Siedhoff), Los Angeles, California
| | - Mireille D Truong
- Division of Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center (Drs. Wright, Truong, and Siedhoff), Los Angeles, California
| | - Andrea L Molina
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Schneyer, Greene, and Molina), Los Angeles, California
| | - Kevin Tran
- David Geffen School of Medicine at UCLA (Dr. Tran), Los Angeles, California
| | - Matthew T Siedhoff
- Division of Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center (Drs. Wright, Truong, and Siedhoff), Los Angeles, California
| |
Collapse
|
6
|
Wright JD, Chen L, Melamed A, Clair CMS, Hou JY, Khoury-Collado F, Gockley A, Accordino M, Hershman DL, Xu X. Containment Bag Use Among Women Who Undergo Hysterectomy With Laparoscopic Power Morcellation. Obstet Gynecol 2022; 140:371-380. [PMID: 35926199 DOI: 10.1097/aog.0000000000004886] [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: 01/31/2022] [Accepted: 05/19/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To estimate trends in use of laparoscopic power morcellators in women undergoing minimally invasive hysterectomy and to examine use of containment systems in these patients in relation to safety guidance from the U.S. Food and Drug Administration (FDA). METHODS We examined data that were recorded in the Premier Healthcare Database from patients who underwent laparoscopic supracervical hysterectomy from 2010 to 2018. Patients were stratified based on use of laparoscopic power morcellators. The cohort was further stratified as either pre-FDA guidance (2010 quarter 1-2014 quarter 1) or post-FDA guidance (2014 quarter 2-2018 quarter 2). Interrupted time series analyses were performed to determine the effect of FDA guidance on the use of laparoscopic power morcellators and containment bags. RESULTS Among 67,115 patients, laparoscopic power morcellator use decreased from 66.7% in 2013 quarter 4 to 13.3% by 2018 quarter 2. The likelihood of laparoscopic power morcellator use decreased by 9.5% for each quarter elapsed in the post-FDA warning period (risk ratio [RR] 0.91, 95% CI 0.90-0.91). Containment bag use rose from 5.2% in 2013 quarter 4 to 15.2% by 2018 quarter 2. The likelihood of containment bag use increased by 3% for each quarter elapsed in the post-FDA warning period (RR 1.03, 95% CI 1.02-1.05). Among women who had laparoscopic power morcellator use, uterine cancers or sarcomas were identified in 54 (0.17%) before the FDA guidance compared with seven (0.12%) after the guidance ( P =.45). Containment bags were used in 11.1% of women with uterine cancers or sarcomas before the FDA guidance compared with 14.3% after the guidance ( P =.12). The perioperative complication rate was 3.3% among women who had laparoscopic power morcellator use without a containment bag compared with 4.5% ( P =.001) in those with a containment bag (aRR 1.35, 95% CI 1.12-1.64). CONCLUSION Use of laparoscopic power morcellators has decreased over time. Containment bag use increased after the FDA's 2014 guidance; however, most procedures employing laparoscopic power morcellators are still performed without a containment bag.
Collapse
Affiliation(s)
- Jason D Wright
- Columbia University College of Physicians and Surgeons, the Joseph L. Mailman School of Public Health, Columbia University, the Herbert Irving Comprehensive Cancer Center, and NewYork-Presbyterian Hospital, New York, New York; and Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Protopapas A, Vlachos DE, Kathopoulis N, Grigoriadis T, Zacharakis D, Athanasiou S, Chatzipapas I. Total laparoscopic hysterectomy in patients with deep endometriosis: Different technical and postoperative considerations, in comparison with a procedure performed for other benign indications. Taiwan J Obstet Gynecol 2022; 61:216-222. [PMID: 35361379 DOI: 10.1016/j.tjog.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Total laparoscopic hysterectomy (TLH) may be indicated in patients with deep infiltrative endometriosis (DIE) to treat severe chronic pelvic pain symptoms, recurrences, or co-existing uterine disease. This study discusses the challenges and specific operative and postoperative considerations in patients submitted to TLH and excision of DIE, in comparison with those undergoing a procedure for other benign indications. MATERIALS AND METHODS Patients undergoing TLH and excision of DIE were included (N = 18, group 1). These were matched with cases, treated with TLH for other benign indications during the same period (2010-2019), at a 2:1 ratio (N = 36, group 2). The two groups were compared with regards to their characteristics, and intraoperative and postoperative data, including operative time, estimated blood loss (EBL), hospital stays, and rates of complications. RESULTS In group 1, median DIE nodule size was 2.5 cm (range: 1.3-4.2). Simple hysterectomy was performed in 10, and a more extended procedure in 8 cases. All nodules were removed from the bowel wall using the shaving technique. Average EBL was significantly higher (p = .027), and duration of surgery and hospital stays longer (p = .003, and p = .0001, respectively), in group 1 vs. group 2. The rates of long-term (L-T) complications were higher in group 1 but not to a significant level (p = .087). Analysis within the DIE group showed that operative time was significantly related to nodule size, type of hysterectomy (p = .021), presence of adenomyosis (p = .041), uterine size ≥12weeks (p = .039), and the occurrence of L-T complications (p = .016). Increasing nodule size and an extended procedure (p = .005) increased significantly the EBL, which had also a significant effect on the risk of L-T complications (p = .006). CONCLUSIONS TLH in DIE patients is a different, complex and potentially more dangerous procedure compared with TLH for other benign indications. Thorough knowledge of retroperitoneal anatomy, a clear operative plan, and excellent laparoscopic skills are necessary for concomitant radical excision of lesions, with low rates of adverse events.
Collapse
Affiliation(s)
- Athanasios Protopapas
- 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, Faculty of Medicine, Greece.
| | - Dimitrios-Euthymios Vlachos
- 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, Faculty of Medicine, Greece
| | - Nikolaos Kathopoulis
- 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, Faculty of Medicine, Greece
| | - Themistoklis Grigoriadis
- 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, Faculty of Medicine, Greece
| | - Dimitrios Zacharakis
- 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, Faculty of Medicine, Greece
| | - Stavros Athanasiou
- 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, Faculty of Medicine, Greece
| | - Ioannis Chatzipapas
- 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, Faculty of Medicine, Greece
| |
Collapse
|
8
|
Xu X, Desai VB, Schwartz PE, Gross CP, Lin H, Schymura MJ, Wright JD. Safety Warning about Laparoscopic Power Morcellation in Hysterectomy: A Cost-Effectiveness Analysis of National Impact. WOMEN'S HEALTH REPORTS 2022; 3:369-384. [PMID: 35415718 PMCID: PMC8994439 DOI: 10.1089/whr.2021.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/09/2022]
Abstract
Background: Following a 2014 safety warning (that laparoscopic power morcellation may increase tumor dissemination if patients have occult uterine cancer), hysterectomy practice shifted from laparoscopic to abdominal approach. This avoided morcellating occult cancer, but increased perioperative complications. To inform the national impact of this practice change, we examined the cost-effectiveness of hysterectomy practice in the postwarning period, in comparison to counterfactual hysterectomy practice had there been no morcellation warning. Materials and Methods: We constructed a decision tree model to simulate relevant outcomes over the lifetime of patients in the national population undergoing hysterectomy for presumed benign indications. The model accounted for both hysterectomy- and occult cancer-related outcomes. Probability-, cost-, and utility weight-related input parameters were derived from analysis of the State Inpatient Databases, State Ambulatory Surgery and Services Databases, data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry, and published literature. Results: With an estimated national sample of 353,567 adult women, base case analysis showed that changes in hysterectomy practice after the morcellation warning led to a net gain of 867.15 quality-adjusted life years (QALYs), but an increase of $19.54 million in costs (incremental cost-effectiveness ratio = $22,537/QALY). In probabilistic sensitivity analysis, the practice changes were cost-effective in 54.0% of the simulations when evaluated at a threshold of $50,000/QALY, which increased to 70.9% when evaluated at a threshold of $200,000/QALY. Conclusion: Hysterectomy practice changes induced by the morcellation warning are expected to be cost-effective, but uncertainty in parameter values may affect the cost-effectiveness results.
Collapse
Affiliation(s)
- Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vrunda B. Desai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- CooperSurgical, Inc., Trumbull, Connecticut, USA
| | - Peter E. Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Haiqun Lin
- Division of Nursing Science, Rutgers University School of Nursing, Newark, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Newark, New Jersey, USA
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, New York, USA
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| |
Collapse
|
9
|
What We Know about the Long-Term Risks of Hysterectomy for Benign Indication-A Systematic Review. J Clin Med 2021; 10:jcm10225335. [PMID: 34830617 PMCID: PMC8622061 DOI: 10.3390/jcm10225335] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/02/2021] [Accepted: 11/06/2021] [Indexed: 12/29/2022] Open
Abstract
Hysterectomy is the most common treatment option in women with uterine fibroids, providing definitive relief from the associated burdensome symptoms. As with all surgical interventions, hysterectomy is associated with risk of complications, short-term morbidities, and mortality, all of which have been described previously. However, information on the potential long-term risks of hysterectomy is only recently becoming available. A systematic literature review was performed to identify studies published between 2005 and December 2020 evaluating the long-term impact of hysterectomy on patient outcomes. A total of 29 relevant studies were identified. A review of the articles showed that hysterectomy may increase the risk of cardiovascular events, certain cancers, the need for further surgery, early ovarian failure and menopause, depression, and other outcomes. It is important to acknowledge that the available studies examine possible associations and hypotheses rather than causality, and there is a need to establish higher quality studies to truly evaluate the long-term consequences of hysterectomy. However, it is of value to consider these findings when discussing the benefits and risks of all treatment options with patients with uterine fibroids to allow for preference-based choices to be made in a shared decision-making process. This is key to ensuring that patients receive the treatment that best meets their individual needs.
Collapse
|
10
|
Neis F, Reisenauer C, Kraemer B, Wagner P, Brucker S. Retrospective analysis of secondary resection of the cervical stump after subtotal hysterectomy: why and when? Arch Gynecol Obstet 2021; 304:1519-1526. [PMID: 34453213 PMCID: PMC8553675 DOI: 10.1007/s00404-021-06193-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/14/2021] [Indexed: 12/26/2022]
Abstract
Purpose The rates of hysterectomy are falling worldwide, and the surgical approach is undergoing a major change. To avoid abdominal hysterectomy, a minimally invasive approach has been implemented. Due to the increasing rates of subtotal hysterectomy, we are faced with the following questions: how often does the cervical stump have to be removed secondarily, and what are the indications? Methods This was a retrospective, single-centre analysis of secondary resection of the cervical stump conducted from 2004 to 2018. Results Secondary resection of the cervical stump was performed in 137 women. Seventy-four percent of the previous subtotal hysterectomy procedures were performed in our hospital, and 26% were performed in an external hospital. During the study period, 5209 subtotal hysterectomy procedures were performed at our hospital. The three main indications for secondary resection of the cervical stump were prolapse (31.4%), spotting (19.0%) and cervical dysplasia (18.2%). Unexpected histological findings (premalignant and malignant) after subtotal hysterectomy resulted in immediate (median time, 1 month) secondary resection of the cervical stump in 11 cases. In four patients, the indication was a secondary malignant gynaecological disease that occurred more than 5 years after subtotal hysterectomy. The median time between subtotal hysterectomy and secondary resection of the cervical stump was 40 months. Secondary resection of the cervical stump was performed vaginally in 75.2% of cases, laparoscopically in 20.4% of cases and abdominally in 4.4% of cases. The overall complication rate was 5%. Conclusion Secondary resection of the cervical stump is a rare surgery with a low complication rate and can be performed via the vaginal or laparoscopic approach in most cases. The most common indications are prolapse, spotting and cervical dysplasia. If a secondary resection of the cervical stump is necessary due to symptoms, 66.6% will be performed within the first 6 years after subtotal hysterectomy.
Collapse
Affiliation(s)
- Felix Neis
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany.
| | - Christl Reisenauer
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany
| | - Bernhard Kraemer
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany
| | - Philipp Wagner
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany
| | - Sara Brucker
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany
| |
Collapse
|
11
|
Outcomes of Women Undergoing Excision of the Retained Cervix After Supracervical Hysterectomy. Obstet Gynecol 2021; 137:831-836. [PMID: 33831922 DOI: 10.1097/aog.0000000000004360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/11/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize the indications for and complication rates of excision of the retained cervix after supracervical hysterectomy. METHODS We performed a retrospective cohort study of women undergoing excision of the retained cervix after supracervical hysterectomy in the 2010-2014 National Inpatient Sample. International Classification of Diseases, Ninth Revision codes were used to identify indication for the procedure and surgical complications. We weighted the hospital-level data to obtain nationwide estimates of patient characteristics, surgical complications, and length of stay. RESULTS Nationwide, 1,140 women underwent excision of the retained cervix after hysterectomy. Their mean age was 49 years, and the majority were White and privately insured. Leiomyomas were the most commonly coded indication (35%, 95% CI 29-42), followed by prolapse (14%, 95% CI 9-18). Eighteen percent (95% CI 13.0-23.1) were performed for malignancy, including 5.3% (95% CI 2.3-8.2) for cervical cancer. Only 11.5% (95% CI 7.3-15.6) of cases were performed laparoscopically. The overall complication rate was high (38%, 95% CI 32-45), particularly for bleeding complications (26%, 95% CI 20-31) and transfusion (15%, 95% CI 11-20). Gastrointestinal complication rates were second highest (8%, 95% CI 5-12); ileus was the most common gastrointestinal complication (7.0%, 95% CI 3.7-10.4). The median length of stay was 2 days (range 0-34). CONCLUSION Women who undergo excision of the retained cervix after supracervical hysterectomy experience high rates of complications, the most common of which was bleeding. Patient counseling regarding removal of the cervix at the time of hysterectomy should include this information.
Collapse
|
12
|
Abstract
Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.
Collapse
Affiliation(s)
- Lior Levy
- Gynaecological Endoscopy and Endometriosis Surgery, Department of Obstetrics and Gynaecology Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Jim Tsaltas
- Gynaecological Endoscopy and Endometriosis Surgery, Department of Obstetrics and Gynaecology Monash Health, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
13
|
Le X, Dogan NU, Favero G, Köhler C. Cervical stump necrosis after laparoscopic supracervical hysterectomy: successful management by laparoscopic approach. J Int Med Res 2021; 49:3000605211020697. [PMID: 34187211 PMCID: PMC8258770 DOI: 10.1177/03000605211020697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Persistent bleeding from the remaining cervix after laparoscopic supracervical hysterectomy (LSH) is normally related to the presence of residual functioning endometrial tissue. However, postoperative significant vaginal hemorrhage caused by cervical necrosis following LSH is relatively rare. A 39-year-old nulligravida was admitted to the emergency department with hypovolemic shock after LSH performed in another hospital for treatment of uterine fibroids 18 days previously. Following hemodynamic stabilization and mechanical tamponade of the bleeding uterine cervix, laparoscopic simple trachelectomy was carried out and antibiotics were administered. The patient developed no surgical or clinical complications and was discharged 4 days after surgery. Histologic examination revealed extensive areas of tissue necrosis and no signs of malignancy. Stump necrosis and accompanying bleeding are rare but serious complications of LSH. Infection is an important component of this entity and should be treated. Endoscopic management of this condition appears to be feasible and safe.
Collapse
Affiliation(s)
- Xin Le
- Gynecological Minimal Invasive Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China.,Department of Special Operative and Oncologic Gynecology, Asklepios Hospital Altona, Germany
| | - Nasuh Utku Dogan
- Department of Special Operative and Oncologic Gynecology, Asklepios Hospital Altona, Germany.,Department of Gynecology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Giovanni Favero
- Department of Special Operative and Oncologic Gynecology, Asklepios Hospital Altona, Germany
| | - Christhardt Köhler
- Department of Special Operative and Oncologic Gynecology, Asklepios Hospital Altona, Germany
| |
Collapse
|
14
|
Xu X, Desai VB, Wright JD, Lin H, Schwartz PE, Gross CP. Hospital variation in responses to safety warnings about power morcellation in hysterectomy. Am J Obstet Gynecol 2021; 224:589.e1-589.e13. [PMID: 33359176 DOI: 10.1016/j.ajog.2020.12.1207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/17/2020] [Accepted: 12/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes. OBJECTIVE This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy. STUDY DESIGN This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions. RESULTS Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72). CONCLUSION Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.
Collapse
Affiliation(s)
- Xiao Xu
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT.
| | - Vrunda B Desai
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Medical Affairs, CooperSurgical, Inc, Trumbull, CT
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Haiqun Lin
- Division of Nursing Science, School of Nursing, Rutgers University, Newark, NJ
| | - Peter E Schwartz
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Cary P Gross
- Internal Medicine, Yale School of Medicine, New Haven, CT; Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT
| |
Collapse
|
15
|
Cui MH, Zhang XW, Zhao LP, Liu SY, Jia Y. Disseminated ovarian granulosa cell tumor after laparoscopic surgery: Two case reports. Medicine (Baltimore) 2021; 100:e25176. [PMID: 33847615 PMCID: PMC8052061 DOI: 10.1097/md.0000000000025176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/25/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Granulosa cell tumors (GCT) have an incidence of 0.6 to 0.8/100,000. Short-term relapsed ovarian GCT is extremely rare. Herein, this report aims to present 2 rare cases of disseminated ovarian GCT and analyze the causes of recurrence. PATIENT CONCERNS The 2 patients presented with abdominal pain. DIAGNOSIS Both the patients were diagnosed with relapsed ovarian GCT (IIIc stage) in the adult type. INTERVENTIONS The 2 patients had a medical history of surgery for ovarian GCT by using laparoscopic with power morcellators (LPM). They experienced relapsed ovarian GCT postoperatively. Subsequently, they received a repeated operation through a laparotomy approach. Numerous malignant metastasis neoplasms were detected at the port-sites. Then, tumor resection was performed. OUTCOMES The postoperative pathologies of both case 1 and case 2 reported ovarian GCT (IIIc stage) in adult type. The 2 patients presented disease-free survival for more than 33 months follow-up period. LESSONS The application of LPM may be a risk factor of disseminated ovarian GCT. However, laparoscopic surgery is still an optimal treatment strategy for ovarian tumors. Besides, gynecologists should comply with the tumor-free principle during surgery.
Collapse
|
16
|
Ebner F, de Gregorio N, Lato C, Ohly V, Janni W, Spohrs J, Jerg-Bretzke L, Walter S. Choosing a Surgical Access Point for Hysterectomy: A Paradigm Shift Over a 10-Year Span. Front Med (Lausanne) 2020; 7:569895. [PMID: 33324658 PMCID: PMC7724105 DOI: 10.3389/fmed.2020.569895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/28/2020] [Indexed: 01/24/2023] Open
Abstract
Background: When choosing a surgical procedure for a hysterectomy, doctors and patients have various options in terms of the multiple surgical access points available. The aim of this study was to descriptively analyze developments concerning the surgical access point selected over the past 10 years at Ulm University Hospital, (south) Germany, assess the variables associated with the surgical method and explore any potential significant correlations that influence these surgical access routes. Explicitly, we wished to investigate whether the approval of ulipristal acetate and the warning issued by the Food and Drug Administration (FDA) in connection with its use changed existing trends. Material and Methods: This monocentric study retrospectively assessed data from all patients who underwent a hysterectomy due to a benign disease or endometrial cancer from January 2007 until December 2016. Results: Of the benign indications considered, myomas and descensus genitalis occurred most frequently (49.5 and 30.6%, respectively). The percentage of abdominal procedures declined from 61.4 to 13.4% between 2007 and 2016 for all hysterectomies, whilst it increased from 4.1 to 69.7% for laparoscopic hysterectomies. The rate of vaginal hysterectomies increased to 45.5% until 2013 and declined in the years afterwards. Laparoscopic assisted vaginal hysterectomies were comparatively rare. The trends in terms of surgical routes were similar for endometrial cancer. During the observation period, the share of abdominal hysterectomies fell from 100 to 11.3%, whilst the share of laparoscopic hysterectomies increased from 0 to 86.6%. The other two procedures were less frequently used. Use of the laparoscopic hysterectomy procedure also increased significantly after the FDA's 2014 warning. Ulipristal acetate may have tended to influence the process. Conclusion: Contrary to the national decrease in hysterectomy numbers, the annual number of hysterectomies at Ulm University Hospital remained stable during the observation period. Nevertheless, there was a clear shift in the preferred surgical routes for hysterectomy.
Collapse
Affiliation(s)
- Florian Ebner
- Department of Gynaecology, Helios Amper-Hospital Dachau, Dachau, Germany
- Department of Gynaecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Niko de Gregorio
- Department of Gynaecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Christiane Lato
- Department of Gynaecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Valerie Ohly
- Department of Gynaecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Wolfgang Janni
- Department of Gynaecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - Jennifer Spohrs
- Medical Psychology Division, Department of Psychosomatic Medicine and Psychotherapy, Ulm University Hospital, Ulm, Germany
| | - Lucia Jerg-Bretzke
- Medical Psychology Division, Department of Psychosomatic Medicine and Psychotherapy, Ulm University Hospital, Ulm, Germany
| | - Steffen Walter
- Medical Psychology Division, Department of Psychosomatic Medicine and Psychotherapy, Ulm University Hospital, Ulm, Germany
| |
Collapse
|
17
|
Unanticipated Uterine and Cervical Malignancy in Women Undergoing Hysterectomy for Uterovaginal Prolapse. Female Pelvic Med Reconstr Surg 2020; 27:e549-e554. [PMID: 33208657 DOI: 10.1097/spv.0000000000000990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study aimed to determine the prevalence of unanticipated uterine cancer and cervical cancer in women undergoing hysterectomy for uterovaginal prolapse. METHODS Using data from the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program, we identified adult women who underwent a hysterectomy with a concurrent procedure for uterovaginal prolapse. Patients who underwent a radical hysterectomy or had other procedures or diagnoses suggestive of preoperatively suspected or known gynecologic cancer were excluded. Our outcome measures were pathology-confirmed diagnoses of uterine cancer and cervical cancer. Bivariate statistical tests and multivariable logistic regression were used to identify patient characteristics associated with the likelihood of having unanticipated uterine cancer. RESULTS Among 9,687 patients meeting the sample eligibility criteria (median age, 60 years), 51 (0.53%; 95% confidence interval, 0.39%-0.69%) had a diagnosis of uterine cancer. Forty-three (84.3%) were stage I-IB. Multivariable logistic regression showed that older age (adjusted odds ratio, 2.75; 95% confidence interval, 1.47-5.51, for age >60 vs 41-60 years) and uterine weight greater than 250 g (adjusted odds ratio, 4.34; 95% confidence interval, 1.48-10.79) were associated with a significantly higher likelihood of having unexpected uterine malignancy. In addition, in a subsample of 7,908 patients who underwent a total hysterectomy, 7 (0.09%; 95% confidence interval, 0.04%-0.18%) had a diagnosis of cervical cancer. CONCLUSIONS The risk of unexpected uterine cancer and cervical cancer in women undergoing hysterectomy for uterovaginal prolapse was relatively low but should be appropriately considered when counseling patients desiring uterine- or cervix-sparing procedures.
Collapse
|
18
|
Carrubba AR, Jijon AJ, Heckman MG, Brushaber DE, Chen AH, Dinh TA, Destephano CC. Association of uterine dimensions and route of contained morcellation following laparoscopic hysterectomy. MINERVA GINECOLOGICA 2020; 72:316-324. [PMID: 32677775 DOI: 10.23736/s0026-4784.20.04602-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to determine if uterine dimensions on preoperative imaging are associated with route of contained morcellation during laparoscopic hysterectomy. METHODS This is a prospective cohort study of patients undergoing laparoscopic hysterectomy and requiring morcellation for specimen extraction from March 2017 through August 2019. A contained extraction system was inserted and manual morcellation was performed vaginally, abdominally, or via a combination of both methods in cases of failed vaginal extraction. RESULTS A total of 47 patients were treated. Median age was 47 (range 38-70). Morcellation was performed vaginally for 29 patients (61.7%), abdominally for 13 patients (27.7%), and via combined approach for 5 patients (10.6%). The combined group had the highest frequency of patients who were black (vaginal: 24%, abdominal: 31%, combined: 100%; P=0.005), the longest median total operating time (vaginal: 167 minutes, abdominal: 183 minutes, combined: 268 minutes; P=0.006) and the longest median time of uterine morcellation (vaginal: 14 minutes, abdominal: 37 minutes, combined: 85 minutes; P<0.001). There was strong evidence of a positive correlation with time of uterine morcellation for both largest uterine diameter (Spearman's r: 0.62, P<0.001) and uterine volume (Spearman's r: 0.70, P<0.001). These associations remained consistent after multivariable linear regression models that were adjusted for route of morcellation, hysterectomy type, and BMI (both P<0.001). CONCLUSIONS Larger uterine dimensions are associated with increased total operating and morcellation times. Uterine size and volume on preoperative imaging were not associated with route of morcellation, but there was a trend towards failed vaginal extraction when uterine dimensions exceeded 16 centimeters.
Collapse
Affiliation(s)
- Aakriti R Carrubba
- Department of Gynecologic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA -
| | - Alfredo J Jijon
- Department of Gynecologic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Danielle E Brushaber
- Division of Biomedical Statistics and Informatics, Mayo Clinic Florida, Rochester, MN, USA
| | - Anita H Chen
- Department of Gynecologic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Tri A Dinh
- Department of Gynecologic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | | |
Collapse
|
19
|
Abstract
Fibroid tissue extraction during hysterectomy and myomectomy has become increasingly controversial. A wave of research has tried to clarify difficult questions around the prevalence of occult malignancies, the effect of morcellation on cancer outcomes, proper informed consent, and surgical options for tissue extraction. This review examines the history of these controversies and discusses tissue extraction techniques and continued areas of debate in the field.
Collapse
|
20
|
Singh S, Bougie O. HEALTH for heavy menstrual bleeding: real-world implications. Lancet 2019; 394:1390-1392. [PMID: 31522847 DOI: 10.1016/s0140-6736(19)32086-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Sukhbir Singh
- Department of Obstetrics and Gynecology, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada.
| | - Olga Bougie
- Department of Obstetrics and Gynaecology, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| |
Collapse
|
21
|
Rising From the Ashes: Minimally Invasive Surgery in the Wake of Power Morcellation. Obstet Gynecol 2019; 134:225-226. [PMID: 31348208 DOI: 10.1097/aog.0000000000003386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|