Prevention and Management of Hysterectomy Complications

Psychological Outcomes and Quality of Life After Hysterectomy for Benign Diseases: A Prospective Cohort Study

Background Hysterectomy is a common surgical procedure performed for benign gynecological diseases. While the physical benefits have been extensively studied, less attention has been given to its impact on psychological well-being and overall quality of life (QoL). This study aimed to assess the psychological outcomes and QoL before and after hysterectomy for benign diseases. Methodology This prospective cohort study included women undergoing hysterectomy for benign diseases at Ibn El Jazzar Hospital in Kairouan, Tunisia. The study was conducted from January 2, 2020, to December 31, 2021. We used the Short-Form-36 Health Survey (SF-36) to evaluate the QoL and the Hospital Anxiety and Depression Scale (HADS) to assess psychological outcomes preoperatively and after six months. Data entry and analysis were performed using SPSS version 26 (IBM Corp., Armonk, NY, USA) with the significance level (p) set to 0.05. Results Of 84 assessed patients, 60 were included. Following the hysterectomy, there were improvements in QoL and psychological outcomes across all domains, regardless of whether total or subtotal hysterectomy was performed. The mean HADS score for anxiety decreased from 12.57 to 8.77 after hysterectomy and from 14.83 to 9.57 for depression. Moreover, the median SF-36 total score increased from 29.81 to 68.1. We found no statistically significant difference between the two groups in all assessed outcomes. Conclusions Hysterectomy for benign conditions, whether total or subtotal, positively impacted symptoms of depression and anxiety, as well as the overall QoL for patients. A thorough preoperative psychiatric assessment is recommended to address and support mental health outcomes in these patients. Future research should consider a larger multicenter approach for a broader application of findings.

FIGO best practice guidance in surgical consent

Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.

Applying graph theory to improve the quality of scientific evidence from textual information: Neural injuries after gynaecologic pelvic surgery for genital prolapse and urinary incontinence

AIMS

To provide the overall rate for all types of neurologic iatrogenic injuries during urogynaecologic surgery from textual data.

METHODS

Systematic research focused on complications of gynaecologic surgery and neurologic injuries in abstracts. Keywords concerning complications (cluster A), unspecific; neurologic issues (cluster B); surgery (generic words) (cluster C); specific gynaecologic operations (cluster D); and specific gynaecologic operations for pelvic organ prolapse and urinary incontinence (cluster E) were extracted. Associations among clusters of keywords were assessed by using multiple runs of text-mining software Semantic Brand Score (SBS, https://semanticbrandscore.com/#primary). Association scores were converted into probabilities. The rate of neurologic complications in urogynaecologic surgery was calculated ("a priori" probability) by applying Bayes' theorem. Textual estimates of neurological injuries in urogynaecologic surgery are 0.035554 (95% confidence intervals 0.019607-0.0515001; no quantitative data were found). To test if the probability calculated on textual information was the same as quantitative data reports ("a posteriori" probability), the rate of neurologic complication of all gynaecologic surgery was calculated using a meta-analytics approach and was compared with the textual analysis value.

RESULTS

The rate of neurologic complications in gynaecologic surgery after meta-analytic data synthesis has been 0.016489 (95% confidence intervals 0.012163-0.022320), which is equal to the textual estimate (0.016889, 95% confidence intervals 0.019607-0.051501). Therefore, 0.035554 is a reliable likelihood to observe a neurologic complication in urogynaecologic surgery.

CONCLUSION

Iatrogenic nerve injuries in urogynaecologic surgery are higher than whole gynaecologic surgery. Text-mining software SBS and probability conversion can provide reliable answers from overall scholars' opinions on unsolved clinical questions when better evidence is lacking.

Prophylaxis Effect of Metronidazole Vaginal Gel in Decreasing the Risk of Surgical Site Infections after Elective Hysterectomy

Objective

Infections are an important cause of morbidity and mortality after hysterectomy. Here, we aimed to investigate and evaluate the beneficial effects of metronidazole vaginal gel on the rate of surgical site infections in women undergoing elective abdominal hysterectomy.

Methods

This is a randomized prospective, double-blind controlled clinical trial performed in 2020 in Isfahan on 108 candidates for elective hysterectomy. At the beginning of the study, we completed a checklist of the patient's characteristics (patient age, body mass index [BMI], and history of medical conditions such as diabetes, hypertension, anemia, and immune deficiency) and the cause of hysterectomy. All patients were randomized into two groups. The first group received a lubricant vaginal gel single dosage, and the second group received a 0.75% metronidazole vaginal gel single dosage the night before surgery. Patients were visited up to 6 weeks after surgery, and the frequency of infection at the surgical site was determined.

Findings

The rates of infection were lower in patients who received metronidazole vaginal gel (5.8%) compared to the control group (11.6%) (P = 0.03). Patients with an estimated blood loss volume of more than 500 mL had higher rates of infection (13.46%) compared to patients with a bleeding volume of fewer than 500 mL (1.9%) (P = 0.001). We also found that patients with diabetes (13.5%) and patients with BMI more than 30 kg/m2(13.5%) had higher rates of infection compared to patients without diabetes (5.8%) and patients with BMI <30 kg/m2 (11.5%) (P = 0.001 for both). Patients with higher hospitalization duration had higher infection rates (P = 0.009).

Conclusion

Administration of a single dosage of metronidazole vaginal gel before abdominal hysterectomy may reduce surgical site infection and have clinical values.

Risk factors for postoperative pelvic floor dysfunction in patients with cervical cancer: evidences for management strategies

Background

It’s necessary to evaluate the potential risk factors for postoperative pelvic floor dysfunction (PFD) in patients with cervical cancer, to provide insights into the treatment and nursing care of cervical cancer.

Methods

Our study was a case-control study design. Patients who underwent radical cervical cancer surgery in our hospital from January 2018 to January 2020 were included. We selected the patients with benign uterine lesions after hysterectomy at the same time as the control group. The patient characteristics of two groups were retrospectively compared and analyzed. Multiple logistic regression analyses were conducted to identify the potential risk factors.

Results

A total of 247 patients were included. The duration of surgery, estimated blood loss, duration of urinary catheter, and length of hospital stay in cervical cancer group were significantly more than that of control group (all P<0.05). The incidence of postoperative PFD was 63.93%. There were significant differences in the age, postoperative constipation, number of deliveries, duration of urinary catheter between PFD and no PFD patients (all P<0.05). Age ≥45y (OR 4.39, 1.05–9.83), duration of urinary catheter ≥7d (OR 4.31, 1.22–8.05), postoperative constipation (OR 3.17, 1.07–5.89) and number of deliveries ≥2 (OR 2.75, 1.22–5.43) were the risk factors for postoperative PFD in patients with cervical cancer.

Conclusions

Early measures targeted on those risk factors should be implemented for the prophylaxis of PFD.

Venous Thromboembolism After Blood Transfusions in Women Undergoing Hysterectomy for Non-Malignant Indications: A Retrospective Cohort Study

OBJECTIVE

To quantify the effect of blood transfusion on the risk of venous thromboembolism (VTE) among women undergoing hysterectomy for non-malignant indications.

METHODS

A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was conducted. Women who underwent hysterectomy for non-malignant indications between 2011 and 2016 were identified using the Current Procedural Terminology and Internationally Classification of Diseases codes. The primary outcome was development of VTE. Data on patient demographics and perioperative variables were obtained. Pair-wise comparison using χ² tests were performed to compare women with and without VTE. Multivariable logistic regression was performed to adjust for potential confounders and identify independent predictors of VTE.

RESULTS

Between 2011 and 2016, 169 593 women underwent hysterectomy for non-malignant indications. The overall incidence of VTE was 0.32%. Patient characteristics associated with VTE included obesity and higher American Society of Anesthesiologists (ASA) status. Associated operative factors included abdominal surgery, blood transfusion, and prolonged operative time (P < 0.05 for all). Following adjustment for potential confounders, abdominal hysterectomy was associated with greater odds of VTE than laparoscopic or vaginal approaches (adjusted odds ratio [aOR] 1.81; 95% CI 1.48-2.21 and aOR 2.31; 95% CI 1.62-3.28, respectively). Greater odds of VTE were also observed with OR time >150 minutes (aOR 1.88; 95% CI 1.46-2.42), ASA class ≥III (aOR 1.53; 95% CI 1.05-2.26), and intra- and postoperative transfusion (aOR 2.65; 95% CI 1.78-3.95 and aOR 2.98; 95% CI 1.95-4.55, respectively).

CONCLUSION

The risk of VTE is low in women undergoing hysterectomy for non-malignant indications. Blood transfusion was associated with the highest risk of VTE.

The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective

Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.

Experiencia de pacientes sometidas a histerectomía laparoscópica en el Hospital Universitario San José de Popayán entre 2014 y 2018

Introducción. La histerectomía es un procedimiento común en la práctica ginecológica para el manejo de condiciones benignas y malignas. En la actualidad, se ha demostrado que el abordaje mínimamente invasivo es mejor que la cirugía abierta, ya que presenta menos complicaciones intraoperatorias y posoperatorias.Objetivo. Describir la experiencia de pacientes sometidas a histerectomía laparoscópica entre 2014 y 2018 en el Hospital Universitario San José de Popayán Empresa Social del Estado.Materiales y métodos. Estudio observacional descriptivo de serie de casos que incluyó 36 pacientes intervenidas entre enero de 2014 y abril de 2018. Se evaluaron variables sociodemográficas y clínicas. Para medir el grado de satisfacción posoperatoria y la calidad de vida se realizó una encuesta telefónica.Resultados. La edad promedio de las entrevistadas fue 45 años, el tiempo quirúrgico promedio fue 124 minutos, la tasa de complicaciones intraoperatorias fue 2.78% (n=1) y la estancia hospitalaria promedio fue 1.3 días. Los principales diagnósticos preoperatorios fueron carcinoma in situ (28%) y leiomiomatosis (17%). En cuanto al grado de satisfacción, el 92% refirió mejoría en la calidad de vida y el 64% manifestó tener una recuperación posoperatoria rápida.Conclusión. Para la población estudiada, la histerectomía laparoscópica fue un procedimiento seguro con una baja tasa de complicaciones y un alto grado de satisfacción posoperatoria.

Time Intervals Between Prior Cervical Conization and Posterior Hysterectomy Influence Postoperative Infection in Patients with Cervical Intraepithelial Neoplasia or Cancer

Background

This study was conducted to observe the influence of different time intervals between prior cervical conization and posterior hysterectomy on postoperative infection in female patients with cervical intraepithelial neoplasia or cancer.

Material/Methods

Medical records of 170 patients who underwent hysterectomy following cervical conization between November 2010 and September 2016 at the Zhenjiang 4^th Hospital were reviewed. According to the interval between hysterectomy and cervical conization, patients were classified into 1–2-week, 4–5-week, and 6-week groups. The outcomes of 46 patients who underwent conization with iodoform gauze inside the vagina were observed.

Results

The total postoperative infection rate after hysterectomy was 25.3% (43/170). The expression levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and high mobility group box 1 (HMGB1) in the cervical secretions and tissues were found to gradually increase, peaking at 2 weeks after conization, then significantly decreasing 3–6 weeks onwards. Compared with the 1–2-week group, the 4–5-week and 6-week groups exhibited significantly lower infection rates (2/42, 4.8%, 4–5-week group; 0%, 0/33, 6-week group; vs. 41/95, 43.2%, 1–2-week group; p<0.001). In the 1–2-week group in particular, the postoperative infection rate after laparoscopic hysterectomy was significantly higher than the rate after abdominal hysterectomy (21/35, 60% vs. 20/60, 33%, p=0.0177). In addition, the vaginal and cervical wound infection rates after conization in patients treated with iodoform were significantly lower than the rates in those without iodoform treatment (p<0.05).

Conclusions

Hysterectomy should be performed at least 4 weeks after conization. Treatment with iodoform would be beneficial.

Multidetector CT of expected findings and complications after hysterectomy

Abstract

Indicated to manage a variety of disorders affecting the female genital tract, hysterectomy represents the second most common gynaecological operation after caesarean section. Performed via an open, laparoscopic or vaginal approach, hysterectomy is associated with non-negligible morbidity and occasional mortality. Iatrogenic complications represent a growing concern for gynaecologists and may result in prolonged hospitalisation, need for interventional procedures or repeated surgery, renal impairment and malpractice claims. As a result, radiologists are increasingly requested to investigate patients with suspected complications after hysterectomy. In the vast majority of early postoperative situations, multidetector CT represents the ideal modality to comprehensively visualise the surgically altered pelvic anatomy and to consistently triage the varied spectrum of possible injuries. This pictorial review provides an overview of current indications and surgical techniques, illustrates the expected CT appearances after recent hysterectomy, the clinical and imaging features of specific complications such as lymphoceles, surgical site infections, haemorrhages, urinary tract lesions and fistulas, bowel injury and obstruction. Our aim is to increase radiologists’ familiarity with normal post-hysterectomy findings and with post-surgical complications, which is crucial for an appropriate choice between conservative, interventional and surgical management.

Teaching points

• Hysterectomy via open, laparoscopic or vaginal route is associated with non-negligible morbidity.

• Multiplanar CT imaging optimally visualises the surgically altered pelvic anatomy.

• Familiarity with early post-hysterectomy CT and expected findings is warranted.

• Complications encompass surgical site infections, haemorrhages, bowel injury and obstruction.

• Urological complications include ureteral leakage, bladder injury, urinomas and urinary fistulas.

Peripheral Nerve Injury during Abdominal-Pelvic Surgery: Analysis of the National Surgical Quality Improvement Program Database

Peripheral nerve injury (PNI) is a rare but preventable complication of surgery. We sought to assess whether the use of minimally invasive surgery (MIS) affects the occurrence of PNI. Using the American College of Surgeons National Surgical Quality Improvement Program database, we examined rates of PNI among patients undergoing appendectomy, hysterectomy, colectomy, or radical prostatectomy between 2005 and 2012. We assessed the effect of MIS, as compared with open surgery, on PNI occurrence using logistic regression. Among 297,532 patients, of whom 175,884 (59.1%) underwent MIS, the rate of PNI was 0.03 per cent. Forty-four patients treated using MIS had PNI (0.03%) as compared with 63 who underwent open surgery (0.05%; P = 0.0002). There was a significant decrease in the proportion of surgeries resulting in PNI (P < 0.0001) over time. In univariate analysis, MIS was associated with a decreased occurrence of PNI (odds ratio 0.48, 95% confidence interval 0.33–0.71), but this became nonsignificant on multivariable analysis (odds ratio 0.71, 95% confidence interval 0.47–1.09). Increased operative time and smoking status were the only factors independently associated with an increased risk of PNI on multivariable analysis. MIS techniques during common abdominal-pelvic surgeries do not appear to increase the risk of PNI. Prolonged operative time and smoking are independently associated with an increased risk of PNI. Quality improvement initiatives to increase awareness of PNI and identify patients at increased risk of this preventable complication should be considered.

Study comparing 3 hour and 24 hour post-operative removal of bladder catheter and vaginal pack following vaginal surgery: a randomised controlled trial

BACKGROUND

Traditional practice after vaginal hysterectomy was to keep the vaginal pack and urinary catheter for 24 hours post operatively. But there were studies that prolonged cathterisation was associated with urinary infection. So this study was conducted to compare the post operative outcome when the urinary catheter and vaginal pack were removed after 3 hours and after 24 hours after surgery.

METHODS

The study was done in the Department of Obstetrics and Gynecology, in a tertiary teaching institute of South India from September 2008 to March 2010. It was a randomised controlled trial involving 200 women undergoing vaginal surgery, who were randomly assigned to 2 groups - catheter and vaginal pack were removed either in 3 h in study group or were removed in 24 h in control group. The outcome of the study were vaginal bleeding, urinary retention, febrile morbidity, and urinary infection.

RESULTS

There was no significant difference between the study and control groups with respect to vaginal bleeding (0 and 1%, p = 1), urinary retention (9 and 4%, p = 0.15), febrile morbidity (7 and 4%, p = 0.35), and urinary infection (26% in each group, p = 1.0).

CONCLUSION

Keeping the urinary catheter and vaginal pack for 24 h following vaginal surgery does not offer any additional benefit against removing them after 3 h.

Effects of salpingectomy during abdominal hysterectomy on ovarian reserve: a randomized controlled trial

Background

The aim of this study was to investigate the effect of salpingectomy on ovarian function by measuring AMH.

Methods

This study was a balanced, single-center, double-blind, randomized, controlled trial in Ruin Tan Arash Hospital, Tehran, between May 2013 and November 2014. A total of 30 patients undergoing elective abdominal hysterectomy were randomized into two groups, 15 with salpingectomy and 15 without salpingectomy. The primary objective of this study was to compare mean difference of anti-Mullerian hormone (AMH) between two groups. The secondary outcomes measured were follicle-stimulating hormone (FSH), operative time, and blood loss.

Results

Serum AMH levels decreased at 3 months after hysterectomy in all patients (pre AMH 1.32 ± (0.91); post AMH 1.05 ± (0.88), P < 0.001), the salpingectomy group (pre AMH 1.44 ± (0.94); post AMH 1.13 ± (0.86), P < 0.001), and no salpingectomy group (pre AMH 1.2 ± (0.9); post AMH 0.97 ± (0.92), P < 0.001). The rate of decline of AMH levels after surgery did not differ between the two groups (25% (17–33%) vs. 26% (15–36%), P = 0.23) among the women with salpingectomy versus without salpingectomy, respectively. There was no difference in the mean operative time (mean difference 0.33, 95% CI − 22.21 to 22.86, P < 0.92), mean blood loss (mean difference − 0.66, 95% CI − 15.8 to 14.46, P < 0.97), and post FSH (mean difference 0.34, 95% CI − 1.2 to 1.88, P < 0.65) between both groups.

Conclusions

Salpingectomy with abdominal hysterectomy is a safe treatment that does not have a deleterious effect on ovarian reserve.

Trial registration

Iranian Registry of Clinical Trials, IRCT2014123118866N4 (www.IRCT.ir)

Antibiotic prophylaxis for elective hysterectomy

BACKGROUND

Elective hysterectomy is commonly performed for benign gynaecological conditions. Hysterectomy can be performed abdominally, laparoscopically, or vaginally, with or without laparoscopic assistance. Antibiotic prophylaxis consists of administration of antibiotics to reduce the rate of postoperative infection, which otherwise affects 40%-50% of women after vaginal hysterectomy, and more than 20% after abdominal hysterectomy. No Cochrane review has systematically assessed evidence on this topic.

OBJECTIVES

To determine the effectiveness and safety of antibiotic prophylaxis in women undergoing elective hysterectomy.

SEARCH METHODS

We searched electronic databases to November 2016 (including the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Studies (CRSO), MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as clinical trials registers, conference abstracts, and reference lists of relevant articles.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing use of antibiotics versus placebo or other antibiotics as prophylaxis in women undergoing elective hysterectomy.

DATA COLLECTION AND ANALYSIS

We used Cochrane standard methodological procedures.

MAIN RESULTS

We included in this review 37 RCTs, which performed 20 comparisons of various antibiotics versus placebo and versus one another (6079 women). The quality of the evidence ranged from very low to moderate. The main limitations of study findings were risk of bias due to poor reporting of methods, imprecision due to small samples and low event rates, and inadequate reporting of adverse effects. Any antibiotic versus placebo Vaginal hysterectomyModerate-quality evidence shows that women who received antibiotic prophylaxis had fewer total postoperative infections (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.19 to 0.40; five RCTs, N = 610; I2 = 85%), less urinary tract infection (UTI) (RR 0.58, 95% CI 0.43 to 0.77; eight RCTs, N = 1790; I2 = 44%), fewer pelvic infections (RR 0.28, 95% CI 0.20 to 0.39; 11 RCTs, N = 2010; I2 = 57%), and fewer postoperative fevers (RR 0.43, 95% CI 0.34 to 0.54; nine RCTs, N = 1879; I2 = 48%) than women who did not receive such prophylaxis. This suggests that antibiotic prophylaxis reduces the average risk of postoperative infection from about 34% to 7% to 14%. Whether this treatment has led to differences in rates of other serious infection remains unclear (RR 0.20, 95% CI 0.01 to 4.10; one RCT, N = 146; very low-quality evidence).Data were insufficient for comparison of adverse effects. Abdominal hysterectomyWomen who received antibiotic prophylaxis of any class had fewer total postoperative infections (RR 0.16, 95% CI 0.06 to 0.38; one RCT, N = 345; low-quality evidence), abdominal wound infections (RR 0.64, 95% CI 0.45 to 0.92; 11 RCTs, N = 2434; I2 = 0%; moderate-quality evidence), UTIs (RR 0.39, 95% CI 0.29 to 0.51; 11 RCTs, N = 2547; I2 = 26%; moderate-quality evidence), pelvic infections (RR 0.50, 95% CI 0.35 to 0.71; 11 RCTs, N = 1883; I2 = 11%; moderate-quality evidence), and postoperative fevers (RR 0.60, 95% CI 0.51 to 0.70; 11 RCTs, N = 2581; I2 = 51%; moderate-quality evidence) than women who did not receive prophylaxis, suggesting that antibiotic prophylaxis reduces the average risk of postoperative infection from about 16% to 1% to 6%. Whether this treatment has led to differences in rates of other serious infection remains unclear (RR 0.44, 95% CI 0.12 to 1.69; two RCTs, N = 476; I2 = 29%; very low-quality evidence).It is unclear whether rates of adverse effects differed between groups (RR 1.80, 95% CI 0.62 to 5.18; two RCTs, N = 430; I2 = 0%; very low-quality evidence). Head-to-head comparisons between antibiotics Vaginal hysterectomyWe identified four comparisons: cephalosporin versus penicillin (two RCTs, N = 470), cephalosporin versus tetracycline (one RCT, N = 51), antiprotozoal versus lincosamide (one RCT, N = 80), and cephalosporin versus antiprotozoal (one RCT, N = 78). Data show no evidence of differences between groups for any of the primary outcomes, except that fewer cases of total postoperative infection and postoperative fever were reported in women who received cephalosporin than in those who received antiprotozoal.Only one comparison (cephalosporin vs penicillin; two RCTs, N = 451) yielded data on adverse effects and showed no differences between groups. Abdominal hysterectomyWe identified only one comparison: cephalosporin versus penicillin (N = 220). Data show no evidence of differences between groups for any of the primary outcomes. Adverse effects were not reported. Combined antibiotics versus single antibiotics Vaginal hysterectomyWe identified three comparisons: cephalosporin plus antiprotozoal versus cephalosporin (one RCT, N = 78), cephalosporin plus antiprotozoal versus antiprotozoal (one RCT, N = 78), and penicillin plus antiprotozoal versus penicillin (one RCT, N = 230). Data were unavailable for most outcomes, including adverse effects. We found no evidence of differences between groups, except that fewer women receiving cephalosporin with antiprotozoal received a diagnosis of total postoperative infection, UTI, or postoperative fever compared with women receiving antiprotozoal. Abdominal hysterectomyWe identified one comparison (penicillin plus antiprotozoal vs penicillin only; one RCT, N = 230). Whether differences between groups occurred was unclear. Adverse effects were not reported. Comparison of cephalosporins in different regimensSingle small trials addressed dose comparisons and provided no data for most outcomes, including adverse effects. Whether differences between groups occurred was unclear. No trials compared route of administration.The quality of evidence for all head-to-head and dose comparisons was very low owing to very serious imprecision and serious risk of bias related to poor reporting of methods.

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis appears to be effective in preventing postoperative infection in women undergoing elective vaginal or abdominal hysterectomy, regardless of the dose regimen. However, evidence is insufficient to show whether use of prophylactic antibiotics influences rates of adverse effects. Similarly, evidence is insufficient to show which (if any) individual antibiotic, dose regimen, or route of administration is safest and most effective. The most recent studies included in this review were 14 years old at the time of our search. Thus findings from included studies may not reflect current practice in perioperative and postoperative care and may not show locoregional antimicrobial resistance patterns.

Effects of the morbid obesity and skin incision choices on surgical outcomes in patients undergoing total abdominal hysterectomy

OBJECTIVE

This study aimed to evaluate the effect of obesity on surgical outcomes in patients who underwent gynecologic surgery.

MATERIALS AND METHODS

In total, we evaluated 132 patients who underwent total abdominal hysterectomy with or without salpingo-oophorectomy for benign gynecologic procedures at our tertiary referral gynaecology clinic.

RESULTS

The non-morbid obese group [body mass index (BMI) <40 kg/m²] included 94 patients, and the morbid obese group (BMI ≥40 kg/m²) included 38 patients. The perioperative outcomes of the groups were compared. The mean operative time was significantly longer for morbid obese patients than non-morbid obese patients (p<0.05). Estimated blood loss, the need for blood transfusion, postoperative hemoglobin values, and the need for an intraabdominal drain were similar between the groups. Early and late postoperative complications were significantly more frequent in the morbid obese group than the other group (p<0.05, for each). Early postoperative complications in patients who underwent vertical skin incision were significantly more frequent than in patients who underwent pfannenstiel incision (p<0.05). Late complications were comparable between the two types of skin incision.

CONCLUSION

Morbid obesity significantly increases the mean operative times and the postoperative complication rates of abdominal hysterectomy operations.

Recovery 3 and 12 months after hysterectomy: epidemiology and predictors of chronic pain, physical functioning, and global surgical recovery

Chronic postsurgical pain (CPSP) is 1 important aspect of surgical recovery. To improve perioperative care and postoperative recovery knowledge on predictors of impaired recovery is essential. The aim of this study is to assess predictors and epidemiological data of CPSP, physical functioning (SF-36PF, 0-100), and global surgical recovery (global surgical recovery index, 0-100%) 3 and 12 months after hysterectomy for benign indication.A prospective multicenter cohort study was performed. Sociodemographic, somatic, and psychosocial data were assessed in the week before surgery, postoperatively up to day 4, and at 3- and 12-month follow-up. Generalized linear model (CPSP) and linear-mixed model analyses (SF-36PF and global surgical recovery index) were used. Baseline data of 468 patients were collected, 412 (88%) patients provided data for 3-month evaluation and 376 (80%) patients for 12-month evaluation.After 3 and 12 months, prevalence of CPSP (numeric rating scale ≥ 4, scale 0-10) was 10.2% and 9.0%, respectively, SF-36PF means (SD) were 83.5 (20.0) and 85.9 (20.2), global surgical recovery index 88.1% (15.6) and 93.3% (13.4). Neuropathic pain was reported by 20 (5.0%) patients at 3 months and 14 (3.9%) patients at 12 months. Preoperative pain, surgery-related worries, acute postsurgical pain on day 4, and surgery-related infection were significant predictors of CPSP. Baseline level, participating center, general psychological robustness, indication, acute postsurgical pain, and surgery-related infection were significant predictors of SF-36PF. Predictors of global surgical recovery were baseline expectations, surgery-related worries, American Society of Anesthesiologists classification, type of anesthesia, acute postsurgical pain, and surgery-related infection.Several predictors were identified for CPSP, physical functioning, and global surgical recovery. Some of the identified factors are modifiable and optimization of patients' preoperative pain status and psychological condition as well as reduction of acute postsurgical pain and surgery-related infection may lead to improvement of outcome.

Medical Therapies for Uterine Fibroids - A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials

Background

Uterine fibroids are common, often symptomatic and a third of women need repeated time off work. Consequently 25% to 50% of women with fibroids receive surgical treatment, namely myomectomy or hysterectomy. Hysterectomy is the definitive treatment as fibroids are hormone dependent and frequently recurrent. Medical treatment aims to control symptoms in order to replace or delay surgery. This may improve the outcome of surgery and prevent recurrence.

Purpose

To determine whether any medical treatment can be recommended in the treatment of women with fibroids about to undergo surgery and in those for whom surgery is not planned based on currently available evidence.

Study Selection

Two authors independently identified randomised controlled trials (RCT) of all pharmacological treatments aimed at the treatment of fibroids from a list of references obtained by formal search of MEDLINE, EMBASE, Cochrane library, Science Citation Index, and ClinicalTrials.gov until December 2013.

Data Extraction

Two authors independently extracted data from identified studies.

Data Synthesis

A Bayesian network meta-analysis was performed following the National Institute for Health and Care Excellence—Decision Support Unit guidelines. Odds ratios, rate ratios, or mean differences with 95% credible intervals (CrI) were calculated.

Results and Limitations

A total of 75 RCT met the inclusion criteria, 47 of which were included in the network meta-analysis. The overall quality of evidence was very low. The network meta-analysis showed differing results for different outcomes.

Conclusions

There is currently insufficient evidence to recommend any medical treatment in the management of fibroids. Certain treatments have future promise however further, well designed RCTs are needed.