Size matters in planning hysterectomy approach

Hysterectomy Techniques and Outcomes for Benign Large Uteri: A Systematic Review

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.

Correlation between Pelvic Diameter and Different Surgical Procedures for Exogenous Cervical Leiomyoma

Objectives

The objective of the study was to investigate the clinical value of pelvic diameter in the evaluation of surgical difficulty and selection of the best surgical plan for exogenous cervical leiomyomas.

Materials and Methods

Sixty-five patients with exogenous cervical leiomyomas admitted to our hospital from 2012 to 2021 were enrolled. All patients underwent pelvic magnetic resonance imaging examination before surgery and received surgical treatment within 1 week. Relevant clinical data were collected. According to the surgical approach, they were divided into two groups: the laparoscopic group and the laparotomy group. The clinical significance of the pelvic diameter line in the surgical selection of exogenous cervical leiomyomas was discussed by retrospective analysis of the correlation between the pelvic diameter line and the collected clinical indicators.

Results

There was no significant difference in tumor location and pelvic diameter between the two groups (P > 0.05). However, there was a significant difference in tumor diameter and the ratio of tumor diameter line to pelvic diameter line (P < 0.05). In addition, the laparoscopic group underwent more myomectomy than hysterectomy and lost more blood during operation (P < 0.05). The postoperative index showed that patients in the laparotomy group had a higher proportion of full of cellular leiomyoma, higher postoperative temperature, and longer postoperative exhaust time (P < 0.05).

Conclusion

The ratio of the tumor diameter line to the pelvic diameter line is correlated with the surgical plan selection of exogenous cervical leiomyomas, which may be used to evaluate the surgical difficulty of these patients and the selection of the suitable surgical plan.

A Comparison between Total Abdominal Hysterectomy versus Total Laparoscopic Hysterectomy

Objectives

To compare the operative and postoperative outcomes of total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH).

Materials and Methods

In this retrospective comparative study, we reviewed all hysterectomies performed in the Al-Karak Governmental Hospital in Al-Karak, Jordan, from September 2018 to July 2022. We enrolled 129 patients who underwent hysterectomy. The patients were divided into the TLH (n = 39) and TAH (n = 90) groups. Patient data were accessed through hospital records and analyzed using SPSS 25.0.

Results

The most common indication for TLH was uterine fibroid, and that for TAH was abnormal uterine bleeding, although the specimen weights were comparable. There was no significant between-group difference in the patient's demographics. Although the TLH group had longer operative time, the hospital stay was shorter and there were no reported cases of wound infection. The estimated blood loss was significantly lower in the TLH group than in the TAH group, but there was no difference between the two groups in terms of blood transfusion requirement and postoperative hemoglobin level.

Conclusion

TLH and TAH had comparable overall outcomes in the Al-Karak Governmental Hospital. However, TLH was superior to TAH in terms of blood loss, and patients with TLH recovered faster without postoperative wound infection.

Operative Complications and Outcomes Comparing Small and Large Uterine Weight in Case of Laparoscopic Hysterectomy for a Benign Indication

Study Objective: This study was performed to evaluate the association between uterine weight and operative outcomes in women undergoing laparoscopic hysterectomy for a benign indication.

Methods: This is a secondary analysis of a randomized trial with data collected prospectively and retrospectively. The data of 159 women undergoing laparoscopic hysterectomy for a benign indication were analyzed. Women were divided in two groups according to the postoperative uterine weight: small uterus group (<250 grams) and large uterus group (≥250 grams). Operative complications were compared between the two groups. Operative outcomes (need for uterine morcellation, operative duration, estimated blood loss), postoperative pain, and hospital length of stay were also analyzed.

Main Results: Operative complications were not significantly different between the two groups (37% in the large uterus group versus 41% in the small uterus group). Operative outcomes showed a significantly increased use of uterine morcellation in the large uterus group (61% in the large uterus group versus 10% in the small uterus group). The operative duration was 150 min in the small uterus group and 176 min in the large uterus group, which corresponds to an increase of 17% in the large uterus group. The mean pain score on the day of surgery was identical in both groups (VAS pain score 5), but significantly in favor of the large uterus group on day 1 postoperatively (VAS pain score 4 in the small uterus group and 3 in the large uterus group). There was no statistical difference between groups in the mean hospital stay (62 ± 37 hours in the small uterus group versus 54 ± 21 hours in the large uterus group). In terms of surgical indication, the small uterus group comprised more patients with endometriosis/adenomyosis (36%) and the large uterus group more patients with leiomyoma (93%).

Conclusion: The results from this study show that, even if a large uterine weight is associated with increased uterine morcellation requirement and operative duration, a laparoscopic approach is safe and does not increase operative complications nor pain and/or length of hospital stay in women undergoing hysterectomy for a benign indication.

Effects of Total Abdominal Hysterectomy and Total Laparoscopic Hysterectomy on Urinary Tract Dysfunction

Objectives:

The aim of this study is to compare the urinary tract dysfunction rates of total abdominal hysterectomy (TAH) and total laparoscopic hysterectomy.

Materials and Methods:

Turkish patients who underwent TAH and laparoscopic hysterectomy were invited to participate in this study. In this study, 140 patients were examined who underwent hysterectomy in gynecology clinic between 2013 and 2018. The post residual urine volumes of patients were measured in the preoperative period and 8^th week of the postoperative period as urodynamic evaluation (with office cystometry and Q tip test). Statistical analysis was performed using Kruskal–Wallis Mann–Whitney U test by using SPSS 22.0 statistical program.

Results:

No statistical significance (P > 0.05) was found between age, parity, menopause, and obesity in our patients who underwent TAH and laparoscopic hysterectomy with high postvoid residual values in the postoperative period.

Conclusion:

In this study, no statistical significance was found between the hysterectomy techniques on urinary tract dysfunction. It can be said that laparoscopy should be more preferable in correctly selected patients for minimal dysfunctional complications.

Predictors of the cost of hysterectomy for benign indications

INTRODUCTION

Hysterectomy is a commonly performed procedure with widely variable costs. As gynecologists divert from invasive to minimally invasive approaches, many factors come into play in determining hysterectomy cost and efforts should be sought to minimize it. Our objective was to identify the predictors of hysterectomy cost.

MATERIALS AND METHODS

This was a retrospective cohort study where women who underwent hysterectomy for benign conditions at the University of Texas Medical Branch from 2009 to 2016 were identified. We obtained and analyzed demographic, operative, and financial data from electronic medical records and the hospital finance department.

RESULTS

We identified 1,847 women. Open hysterectomy was the most frequently practiced (35.8 %), followed by vaginal (23.7 %), laparoscopic (23.6 %), and robotic (16.9 %) approaches. Multivariate regression demonstrated that hysterectomy charges can be significantly predicted from surgical approach, patient's age, operating room (OR) time, length of stay (LOS), estimated blood loss, insurance type, fiscal year, and concomitant procedures. Charges increased by $3,723.57 for each day increase in LOS (P <0.001), by $76.02 for each minute increase in OR time (P <0.001), and by $48.21 for each one-year increase in age (P 0.037). Adjusting for LOS and OR time remarkably decreased the cost of open and robotic hysterectomy, respectively when compared with the vaginal approach.

CONCLUSION

Multiple demographic and operative factors can predict the cost of hysterectomy. Healthcare providers, including gynecologists, are required to pursue additional roles in proper resource management and be acquainted with the cost drivers of therapeutic interventions. Future efforts and policies should target modifiable factors to minimize cost and promote value-based practices.

Abdominal Supracervical Hysterectomy With Bilateral Salpingo-Oophorectomy as the Surgical Approach for a 22-Week Uterus With Incidental Endometrial Polyp Focal Atypia

A 49-year-old perimenopausal female presented with abnormal uterine bleeding (AUB) and chronic lower abdominal pain with associated urinary urgency. The patient elected to have an abdominal supracervical hysterectomy with bilateral salpingo-oophorectomy for a large, symptomatic fibroid uterus. Preoperative ultrasounds revealed a uterine size of 22 x 20 x 17 cm and a 15.9 x 13 x 9 x 9.2 cm subserosal fibroid occupying the majority of the fundus and body of the uterus. Under general anesthesia, abdominal supracervical hysterectomy and bilateral salpingo-oophorectomy with a midline vertical incision were completed. Pathology reported a uterus with multiple leiomyomata as well as endometrial polyps with focal atypical endometrial hyperplasia and squamous metaplasia. Overall, the uterine corpus with one attached adnexa weighed 3433 g and was 25.8 x 20.3 x 15cm. Choice of surgical approach in a hysterectomy depends upon clinical circumstances, the surgeon's technical expertise, and patient preference. Although minimally invasive hysterectomies via vaginal and laparoscopic approaches are now preferred due to decreased hospitalization stays and postoperative recovering times, individualized treatment plans for patients should be considered depending on uterine size and the possibility of not achieving adequate exposure, which may lead to complications. As this case presents, an abdominal hysterectomy is an important option for certain patients where the use of other approaches could pose significant risk.