EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy

Complications after benign gynecologic surgery-How are they captured in register-based research? A national register study in Sweden

INTRODUCTION

The evidence on complication rates after gynecological surgery is based on multiple types of studies, and the level of evidence is generally low. We aimed to validate the registration of complications in the Swedish National Quality Register of Gynecological Surgery (GynOp), by cross-linkage to multiple national registers.

MATERIAL AND METHODS

A national register-based study using prospectively collected data was conducted, including women who had surgery on the uterus or adnexa for benign indications from January 1, 2017, to December 31, 2020. In Sweden, complications after gynecological surgery are registered in GynOp, and if the complication has rendered any interaction with healthcare, it is also in national health registers. The GynOp register, the National Patient Register, the Prescribed Drugs Register, and the Cause of Death Register were cross-linked. Complications in GynOp and complications according to ICD10 were analyzed, as well as the cause of death if occurring within 3 months of surgery and prescription of antibiotics ≤30 days. Comparisons between the registries were descriptive.

RESULTS

During the study period 32 537 surgeries were performed, of which 26 214 (80.6%) were minimally invasive. Complications were reported in GynOp for 569 women (1.7%) at surgery, 1045 (3.2%) while admitted, and 3868 (13.7%) from discharge to 3 months after surgery. In comparison, according to the Patient Register, 2254 women (6.9%) had postoperative complications within 3 months of discharge (difference of 6.8 percentage points [95% confidence interval 6.2-7.2]). Furthermore, 4117 individuals (12.7%) had a prescription of antibiotics ≤30 days which could indicate a postoperative infection. The rates of hemorrhage, wound dehiscence, and thrombosis were comparable between GynOp and the Patient Register while diagnoses not leading to contact with specialized care had higher rates in the quality register. The coverage of complications was 79.1% in GynOp and 46.1% in the Patient Register, using the total number of complications from both registers as the denominator.

CONCLUSIONS

A higher frequency of complications is captured in GynOp than in the National Patient Register. Patient-reported outcomes assessed by a physician are beneficial in identifying complications indicating the importance of structured pre-defined follow-up over a set period.

Gynaecological cancer surveillance for women with Lynch syndrome: systematic review and cost-effectiveness evaluation

Background

Lynch syndrome is an inherited condition which leads to an increased risk of colorectal, endometrial and ovarian cancer. Risk-reducing surgery is generally recommended to manage the risk of gynaecological cancer once childbearing is completed. The value of gynaecological colonoscopic surveillance as an interim measure or instead of risk-reducing surgery is uncertain. We aimed to determine whether gynaecological surveillance was effective and cost-effective in Lynch syndrome.

Methods

We conducted systematic reviews of the effectiveness and cost-effectiveness of gynaecological cancer surveillance in Lynch syndrome, as well as a systematic review of health utility values relating to cancer and gynaecological risk reduction. Study identification included bibliographic database searching and citation chasing (searches updated 3 August 2021). Screening and assessment of eligibility for inclusion were conducted by independent researchers. Outcomes were prespecified and were informed by clinical experts and patient involvement. Data extraction and quality appraisal were conducted and results were synthesised narratively. We also developed a whole-disease economic model for Lynch syndrome using discrete event simulation methodology, including natural history components for colorectal, endometrial and ovarian cancer, and we used this model to conduct a cost-utility analysis of gynaecological risk management strategies, including surveillance, risk-reducing surgery and doing nothing.

Results

We found 30 studies in the review of clinical effectiveness, of which 20 were non-comparative (single-arm) studies. There were no high-quality studies providing precise outcome estimates at low risk of bias. There is some evidence that mortality rate is higher for surveillance than for risk-reducing surgery but mortality is also higher for no surveillance than for surveillance. Some asymptomatic cancers were detected through surveillance but some cancers were also missed. There was a wide range of pain experiences, including some individuals feeling no pain and some feeling severe pain. The use of pain relief (e.g. ibuprofen) was common, and some women underwent general anaesthetic for surveillance. Existing economic evaluations clearly found that risk-reducing surgery leads to the best lifetime health (measured using quality-adjusted life-years) and is cost-effective, while surveillance is not cost-effective in comparison. Our economic evaluation found that a strategy of surveillance alone or offering surveillance and risk-reducing surgery was cost-effective, except for path_PMS2 Lynch syndrome. Offering only risk-reducing surgery was less effective than offering surveillance with or without surgery.

Limitations

Firm conclusions about clinical effectiveness could not be reached because of the lack of high-quality research. We did not assume that women would immediately take up risk-reducing surgery if offered, and it is possible that risk-reducing surgery would be more effective and cost-effective if it was taken up when offered.

Conclusions

There is insufficient evidence to recommend for or against gynaecological cancer surveillance in Lynch syndrome on clinical grounds, but modelling suggests that surveillance could be cost-effective. Further research is needed but it must be rigorously designed and well reported to be of benefit.

Study registration

This study is registered as PROSPERO CRD42020171098.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR129713) and is published in full in Health Technology Assessment; Vol. 28, No. 41. See the NIHR Funding and Awards website for further award information.

Robotic Surgery for Severe Endometriosis: A Preliminary Comparative Study of Cost Estimation

STUDY OBJECTIVE

To compare the postoperative outcomes and the overall expenses between conventional laparoscopy and robotic surgery, in a series of consecutive patients managed for only severe endometriosis in our institute.

DESIGN

A cohort comparative study.

SETTING

Center of Excellence in Multidisciplinary Endometriosis Care.

PATIENTS

A total of 175 symptomatic patients undergoing surgery for only severe endometriosis from March 2021 to August 2022.

INTERVENTIONS

We treated patients with endometriosis involving the digestive tract such as rectum, sigmoid colon, and ileocecal junction by rectal shaving, discoid resection, or segmental resection (141 surgeries) with or without bladder (23 surgeries), sacral plexus (19 surgeries), and diaphragm involvements (14 surgeries).

MEASUREMENTS AND MAIN RESULTS

Postoperative outcomes were evaluated in terms of total surgical time (total surgical room occupancy time and total operating time), hospitalization period, postoperative complications, rehospitalization, and second surgical procedures. A statistically higher total surgical room occupancy (203 minutes vs 151 minutes) and operating time (150 minutes vs 105 minutes) were observed in the robotic group (p = .001). No differences in terms of mean hospital stay (p = .06), postoperative complications (p = .91), rehospitalization (p = .48), and secondary surgical treatment (p = .78) were identified. Concerning the cost analysis only for disposable supply, the cost of colorectal resection was totaled at 2604 euros for the laparoscopic conventional approach vs 2957 euros for the robotic approach (+352.6 euros, +14%). The cost of rectal disc excision was 1527 euros for the laparoscopic conventional approach vs 1905.85 euros (+378 euros, +25%).

CONCLUSIONS

Our study confirms the feasibility of the robotic approach for the treatment of severe endometriosis, with however a higher cost of robotic approach. Next studies should identify specific indications for robotic surgery, where technical advantages provided by the technology are followed by objective improvement of patients' outcomes.

The routes of hysterectomy: A survey of current practices amongst members of the International Society for Gynaecologic Endoscopy (ISGE)

OBJECTIVE

This study aimed to explore the current opinion on the routes of hysterectomy amongst the members of the International Society for Gynaecologic Endoscopy (ISGE), as well as the perceptions of potential barriers that inhibit gynaecologists from offering a minimally invasive hysterectomies (MIHs) to their patients.

STUDY DESIGN

An anonymous, electronic survey was designed, including the questions about the surgeon location and length of gynaecological practice, preferred approach to hysterectomy, approximate number of surgical cases performed during the year preceding the survey (2021), and potential barriers and contraindications to performing MIHs. It was validated by 12 practicing gynaecologists. Subsequently, the survey was sent to all practicing gynaecologists who are the members of the ISGE.

RESULTS

We received a response from 159 members of ISGE (29 % response rate), of which 92 % with ≥ 5 years in practice since the completion of their residency training in Gynaecology and Obstetrics. When asked about the preferred route of hysterectomy for themselves or their relatives, 59 % chose total laparoscopic hysterectomy (TLH), 19 % vaginal hysterectomy (VH), 8 % chose laparoscopically-assisted vaginal hysterectomy (LAVH) and 5 % chose total abdominal hysterectomy (TAH). However, TAH was the most performed hysterectomy procedure undertaken by the respondents in the year preceding the survey. When asked about the main obstacles to performing MIHs, more than half of the respondents highlighted insufficient training during residency and insufficient surgical experience. Only 25 % of the responders acknowledged reading the ISGE guidelines on performing vaginal hysterectomy.

CONCLUSIONS

Contrary to a full understanding of the benefits of MIHs, lack of training, as well as insufficient surgical experience and unawareness of existing evidence-based guidelines were the main reasons for the high rate of TAH among the ISGE members who participated in the study. All efforts should be directed at teaching VH and TLH techniques during residency, continuous acquisition of practical experience, and use of validated patient selection guidelines for MIH in daily clinical practice.

Vaginal Hysterectomy Compared With Laparoscopic Hysterectomy in Benign Gynecologic Conditions: A Systematic Review and Meta-analysis

OBJECTIVE

To compare surgical efficacy outcomes and complications after laparoscopic hysterectomy and vaginal hysterectomy performed for benign gynecologic conditions.

DATA SOURCES

We performed an online search in major databases, including PubMed, Scopus, Web of Science, ClinicalTrials.gov , and the Cochrane Library from 2000 until February 28, 2023.

METHODS OF STUDY SELECTION

We searched for randomized controlled trials (RCTs) that compared vaginal hysterectomy with laparoscopic hysterectomy in benign gynecologic conditions. We located 3,249 articles. After reviewing titles and abstracts, we identified 32 articles that were eligible for full-text screening. We excluded nine articles as not-RCT or not comparing vaginal hysterectomy with laparoscopic hysterectomy. Twenty-three articles were included in the final systematic review, with 22 articles included in the meta-analysis.

TABULATION, INTEGRATION, AND RESULTS

Twenty-three eligible RCTs included a total population of 2,408, with 1,105 in the vaginal hysterectomy group and 1,303 in the laparoscopic hysterectomy group. Blood loss and postoperative urinary tract infection rates were lower in the vaginal hysterectomy group than in the laparoscopic hysterectomy group (mean difference -68, 95% CI -104.29 to -31.7, P <.01, I2 =95% and odds ratio 1.73, 95% CI 0.92-3.26, P =.03, I2 =0%, respectively). Vaginal hysterectomy was associated with less total operative time, less recovery time, and greater postoperative pain on the day of surgery. Other complications, including conversion to laparotomy, visceral organ damage, or wound dehiscence, were uncommon. Because of insufficient data, we were not able to stratify by surgical indication.

CONCLUSION

Vaginal hysterectomy had a shorter total operative time and recovery time but greater postoperative pain on day of surgery compared with laparoscopic hysterectomy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42023338538.

Ice-POP: Ice Packs for Postoperative Pain: A Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate the benefit of ice packs as a supplement to standard pain management following laparoscopic hysterectomy (LH).

DESIGN

This Institutional Review Board-approved randomized controlled trial involved patients undergoing LH for benign conditions. Subjects were randomized to receive standard enhanced recovery after surgery pain management or standard enhanced recovery after surgery plus ice packs.

SETTING

Two academic tertiary care centers PATIENTS: Patients undergoing planned outpatient LH with the minimally invasive gynecologic surgery team between February 2019 and November 2020 were considered. Patients with chronic pain, current opioid use ≥1 week, or planned overnight hospitalizations were excluded. Primary outcome data were available for 51 subjects (24 control, 27 intervention).

INTERVENTIONS

Ice packs were placed on the abdomen in the operating room.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed at multiple time points throughout the study using a visual analogue scale (VAS). Opioid requirement was assessed using morphine milligram equivalent. There was no difference between the groups on any demographic variables. Morphine milligram equivalent requirements were also not different between the groups (p = .63). Postoperative day 1 (POD#1) VAS scores were not different (p = .89). Eighty-five percent of subjects reported feeling that their pain was controlled. Subjects who reported that they did not feel their pain was controlled did not use more opioids on POD#1 (p = .37), nor did they have higher POD#1 VAS scores (p = .55). Eighty-seven percent of the intervention subjects said they would use ice again, and 82.6% of them said they would recommend ice to others. There were no adverse events related to ice. All subjects were prescribed 20 tablets oxycodone and averaged 2.9 (SD 3.4) tablets used after discharge.

CONCLUSION

Ice packs are an acceptable supplement for postoperative pain control, but they do not reduce postoperative pain or opioid usage compared to standard pain management without ice packs.

Hysterectomy with a General Gynecologist vs. Gynecologic Oncologist in the Setting of Endometrial Intraepithelial Neoplasia: A Cost-Effectiveness Analysis

BACKGROUND

Standard treatment for patients with endometrial intraepithelial neoplasia (EIN) is a hysterectomy, which has a 43% risk of concomitant endometrial cancer on final pathology. General gynecologists and gynecologic oncologists perform hysterectomies; however, patients who have a hysterectomy for EIN with a general gynecologist and are found to have cancer may require a second surgery by a gynecologic oncologist to complete staging. There is current ongoing discussion regarding whether patients with EIN should be provided the option to receive the initial hysterectomy with a gynecologic oncologist.

OBJECTIVE

To better understand if patients with EIN should be initially referred to a gynecologic oncologist for treatment, we examined the cost-effectiveness of hysterectomy by general gynecologists versus gynecologic oncologists for patients with EIN.

STUDY DESIGN

We created a decision-analytic model using TreeAge Pro software to compare outcomes between patients with EIN undergoing hysterectomy by a general gynecologist versus a gynecologic oncologist. Our theoretical cohort contained 200,000 patients, an estimate of the number of individuals diagnosed with EIN each year in the United States. Outcomes included costs, quality-adjusted life years (QALYs), primary lymph node dissection (LND), secondary LND, surgical site infection, and perioperative mortality. We assumed that surgical morbidity and mortality were the same under generalist and specialist care and applied costs of travel and lost work for those seeing a gynecologic oncologist. We performed univariable sensitivity analyses as well as multivariable probabilistic sensitivity analysis to assess the model's robustness given the uncertainty of model inputs.

RESULTS

In our theoretical cohort of 200,000 patients with EIN, hysterectomy with a gynecologic oncologist was associated with a decrease in 10,811 second surgeries for LND, 87 surgical site infections, and 9 perioperative mortalities. When hysterectomy was performed by a general gynecologist, 9 fewer patients had a LND due to perioperative mortalities that occurred prior to LND with a gynecologic oncologist. Hysterectomy with a gynecologic oncologist was the dominant, cost-effective strategy as it saved $116 million and increased QALYs by 180. In our univariable analyses, hysterectomy with a gynecologic oncologist was cost-saving and increased QALYs over a wide range of probabilities and costs for LND, surgical site infection, and perioperative mortality. However, hysterectomy with a gynecologic oncologist is only a cost-effective and cost-saving saving strategy in just over 50% of multivariable simulations, demonstrating that that there is significant uncertainty in the model's cost-effectiveness.

CONCLUSIONS

In our model, hysterectomy with a gynecologic oncologist for patients with EIN was associated with cost savings and increased QALYs. Our study supports that patients undergoing hysterectomy for EIN at institutions using Mayo criteria to determine need for lymphadenectomy may benefit from surgery with a gynecologic oncologist rather than a general gynecologist to reduce costs and adverse events associated with a second surgery.

Cost effectiveness analysis of total laparoscopic hysterectomy versus total abdominal hysterectomy for uterine fibroids in Western China: a societal perspective

BACKGROUND

As a common female pelvic tumor, uterine fibroids remain the leading cause for hysterectomy in China. Hysterectomy provides a good surgical treatment of uterine fibroids, and it guarantees the removal of all uterine fibroids without lower risk of recurrence. This study compares the cost effectiveness of total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH) for women with uterine fibroids from a societal perspective.

METHODS

An economic analysis was conducted in 392 patients (TLH n = 75; TAH n = 317), including all relevant costs over a 12-month time horizon. Primary outcome was major surgical complications; secondary outcomes were postoperative discomfort symptoms and time of return to normal activities. Clinical, outcomes and costs data were collected from medical records, telephone survey and financial information system. Generalized linear models were used to assess costs and outcomes differences between the two groups. Incremental cost effectiveness ratio (ICER) was used to estimate the cost effectiveness.

RESULTS

Mean direct costs were $2,925.71 for TLH, $2,436.24 for TAH, respectively. Mean indirect costs were $1,133.22 for TLH, $1,394.85 for TAH, respectively. Incremental societal costs were $256.86 (95%CI: 249.03-264.69). Mean differences in outcome were: 4.53% (95%CI: 4.35-4.71) for major surgical complications; 6.75% (95%CI: 6.45-7.05) for postoperative discomfort symptoms; 1.27 (95%CI: 1.23-1.30) weeks for time to return to normal activities. ICER of TLH was $5,669.16 (95%CI: 5,384.76-5,955.56) per complication averted, $3,801.54 (95%CI: 3,634.81-3,968.28) per postoperative discomfort symptoms averted and $202.96 (95%CI: 194.97-210.95) per week saved to return to normal activities.

CONCLUSIONS

TLH is cost effective compared with TAH in preventing additional complications based on our estimated conservative threshold in China. The findings provide useful information for researchers to conduct further cost effectiveness analysis based on prospective study which can provide stronger and more evidence, in China. In addition, the data may be useful for Chinese health care policy-makers and medical insurance payers to make related health care decisions.

Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is common in otherwise healthy women of reproductive age, and can affect physical health and quality of life. Surgery is usually a second-line treatment of HMB. Endometrial resection/ablation (EA/ER) to remove or ablate the endometrium is less invasive than hysterectomy. Hysterectomy is the definitive treatment and can be via open (laparotomy) approach, or via minimally invasive approaches (vaginally or laparoscopically). Each approach has its own advantages and risk profile.

OBJECTIVES

To compare the effectiveness, acceptability and safety of endometrial resection or ablation versus different routes of hysterectomy (open, minimally invasive hysterectomy, or unspecified route) for the treatment of HMB.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase and PsycINFO (July 2020), and reference lists, grey literature and trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared techniques of endometrial resection/ablation with hysterectomy (by any technique) for the treatment of HMB in premenopausal women.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 10 RCTs (1966 participants) comparing EA/ER to hysterectomy (open (abdominal), minimally invasive (laparoscopic or vaginal), or unspecified (or at surgeon's discretion) route of hysterectomy). The results were rated as moderate-, low- and very low-certainty evidence. Endometrial resection/ablation versus open hysterectomy We found two trials. Women having EA/ER are probably less likely to perceive an improvement in HMB compared to women having open hysterectomy (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.84 to 0.95; 2 studies, 247 women; moderate-certainty evidence) and probably have a 13% risk of requiring further surgery for treatment failure (compared to 0 on the open hysterectomy group; 2 studies, 247 women; moderate-certainty evidence). Both treatments probably lead to similar quality of life at two years (mean difference (MD) -5.30, 95% CI -11.90 to 1.30; 1 study, 155 women; moderate-certainty evidence) and satisfaction rate at one year (RR 0.91, 95% CI 0.82 to 1.00; 1 study, 194 women; moderate-certainty evidence). There may be no difference in serious adverse events (RR 1.29, 95% CI 0.32 to 5.20; 2 studies, 247 women; low-certainty evidence). EA/ER probably reduces time to return to normal activity compared to open hysterectomy (MD -21.00 days, 95% CI -24.78 to -17.22; 1 study, 197 women; moderate-certainty evidence). Endometrial resection/ablation versus minimally invasive hysterectomy We found five trials. The proportion of women with perception of improvement in HMB at two years may be similar between groups (RR 0.97, 95% CI 0.90 to 1.04; 1 study, 79 women; low-certainty evidence). Blood loss may be higher in the EA/ER group when assessed using the Pictorial Blood Assessment Chart (MD 44.00, 95% CI 36.09 to 51.91; 1 study, 68 women; low-certainty evidence). Quality of life is probably lower in the EA/ER group compared to the minimally invasive hysterectomy group at two years according to the 36-item Short Form (SF-36) (MD -10.71, 95% CI -15.11 to -6.30; 2 studies, 145 women; moderate-certainty evidence) and Menorrhagia Multi-Attribute Scale (RR 0.82, 95% CI 0.70 to 0.95; 1 study, 616 women; moderate-certainty evidence). EA/ER probably increases the risk of further surgery for HMB compared to minimally invasive hysterectomy (RR 7.70, 95% CI 2.54 to 23.32; 4 studies, 922 women; moderate-certainty evidence) and treatments probably have similar rates of any serious adverse events (RR 0.75, 95% CI 0.35 to 1.59; 4 studies, 809 women; moderate-certainty evidence). Women with EA/ER are probably less likely to be satisfied with treatment at one year (RR 0.90, 95% CI 0.85 to 0.94; 1 study, 558 women; moderate-certainty evidence). We were unable to pool data for time to return to work or normal life because of extreme heterogeneity (99%); however, the three studies reporting this all had the same direction of effect favouring EA/ER. Endometrial resection/ablation versus unspecified route of hysterectomy We found three trials. EA/ER may lead to a lower perception of improvement in HMB compared to unspecified route of hysterectomy (RR 0.89, 95% CI 0.83 to 0.95; 2 studies, 403 women; low-certainty evidence). Although EA/ER may lead to similar quality of life using the SF-36 General Health Perception at two years' follow-up (MD -1.90, 95% CI -8.67 to 4.87; 1 study, 209 women; low-certainty evidence), the proportion of women with improvement in general health at one year may be lower (RR 0.85, 95% CI 0.77 to 0.95; 1 study, 185 women; low-certainty evidence). EA/ER probably has a risk of 5.4% of requiring further surgery for treatment failure (compared to 0 with total hysterectomy; 2 studies, 374 women; moderate-certainty evidence) and reduces the proportion of women with any serious adverse event (RR 0.21, 95% CI 0.06 to 0.80; 2 studies, 374 women; moderate-certainty evidence). Both treatments probably lead to a similar satisfaction rate at one year' follow-up (RR 0.96, 95% CI 0.88 to 1.04; 3 studies, 545 women; moderate-certainty evidence). EA/ER may lead to shorter time to return to normal activity (MD -18.90 days, 95% CI -24.63 to -13.17; 1 study, 172 women; low-certainty evidence).

AUTHORS' CONCLUSIONS

Endometrial resection/ablation (EA/ER) offers an alternative to hysterectomy as a surgical treatment for HMB. Effectiveness varies with EA/ER compared to different hysterectomy approaches. The perception of improvement in HMB with EA/ER is probably lower compared to open and unspecified route of hysterectomy, but may be similar compared to minimally invasive. Quality of life with EA/ER is probably similar to open and unspecified route of hysterectomy, but lower compared to minimally invasive hysterectomy. Further surgery for treatment failure is probably more likely with EA/ER compared to all routes of hysterectomy. Satisfaction rates also vary. EA/ER probably has a similar rate of satisfaction compared to open and unspecified route of hysterectomy, but a lower rate of satisfaction compared to minimally invasive hysterectomy. The proportion having any serious adverse event appears similar in all groups, but specific adverse events did reported difference between EA/ER and different routes. We were unable to draw conclusions about the time to return to normal activity, but the direction of effect suggests it is likely to be shorter with EA/ER.

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.

Returning to Work Following Minimally Invasive Hysterectomy

This commentary presents data collected from one patient population and reviews the literature on returning to work following minimally invasive hysterectomy (MIH). Although MIH can reduce postoperative pain, decrease hospital stays, and accelerate return to activities of daily living, it has not consistently translated into a quicker return to work (RTW) for patients. A retrospective case series was performed assessing RTW times of 31 patients following elective MIH at Mount Sinai Hospital in Toronto in 2018. The median RTW time was 21 days. Patients returned to work significantly faster when they were counselled about an expected convalescence of 2 to 4 weeks (median 16 days) compared with a more traditional 4- to 8-week recovery (median 56 days). Surgeon recommendation can strongly affect when a patient returns to work following MIH. Most patients can RTW within 2 to 3 weeks. However, recommendations should be patient-centred and consider job description.

Comparison of vaginal hysterectomy and laparoscopic hysterectomy: a systematic review and meta-analysis

BACKGROUND

There are various surgical approaches of hysterectomy for benign indications. This study aimed to compare vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) with respect to their complications and operative outcomes.

METHODS

We selected randomised controlled trials that compared VH with LH for benign gynaecological indications. We included studies published after January 2000 in the following databases: Medline, EMBASE, and CENTRAL (The Cochrane Library). The primary outcome was comparison of the complication rate. The secondary outcomes were comparisons of operating time, blood loss, intraoperative conversion, postoperative pain, length of hospital stay and duration of recuperation. We used Review Manager 5.3 software to perform the meta-analysis.

RESULTS

Eighteen studies of 1618 patients met the inclusion criteria. The meta-analysis showed no differences in overall complications, intraoperative conversion, postoperative pain on the day of surgery and at 48 h, length of hospital stay and recuperation time between VH and LH. VH was associated with a shorter operating time and lower postoperative pain at 24 h than LH.

CONCLUSIONS

When both surgical approaches are feasible, VH should remain the surgery of choice for benign hysterectomy.

Efficiency of using a vaginal drain after hysterectomy: A systematic review

Objective Hysterectomy is the second most frequently performed surgical procedure for women of reproductive age topped only by caesarean section. Hysterectomies may be associated with a significant risk of ultrasonographically detected vault haematomas in up to 59% with consequent postoperative morbidity. The aim of this systematic review was to compare women who had a vaginal drain placed intraoperatively after a hysterectomy and the impact on peri and postoperative outcomes related to vault haematomas. Study Design Electronic searches of AMED, BNI, CINAHL, EMBASE, HBE, HMIC, Medline, PsycINFO and PubMed, Cochrane register of controlled trials (CCTR), Cochrane database of systematic reviews (CDSR) CINAHL and Google scholar were performed. A systematic review and meta-analysis of studies comparing women with and without a vaginal drain after a hysterectomy and the impact on different outcomes was carried out. Results Ten studies involving 1778 women, 811 with a vaginal drain and 967 without a drain, were included in the meta-analysis. This suggests that the use of a vaginal drain after hysterectomy may significantly reduce the incidence of vault haematoma (OR 0.22, 95% CI 0.08 - 0.57) and febrile morbidity (OR 0.54, 95% CI 0.40 to 0.73), non- significantly reduce the rate of usage of antibiotics (OR 0.80, 95% CI 0.46-1.42) and makes no difference to the length of hospital stay (MD 0.12, 95% CI -0.14 to 0.38). Conclusion The use of a vaginal drain after hysterectomy could reduce the incidence of vault haematoma and febrile morbidity.

LASH in Severely Enlarged Uterine Leiomyoma: Removal of a Uterus of 4065 g

Today, even though minimally invasive approaches have become standard worldwide, large uteri are still mainly removed by means of open abdominal approaches. The present case describes the successful removal of the largest uterus ever reported (4065 g) by means of laparoscopy-assisted supracervical hysterectomy (LASH). We combined LASH with the changeover technique which allows a better access and view. We further explain how this approach allows for the safe minimally invasive removal of uteri of any size.

Two-port robotic hysterectomy: a novel approach

The objective of the study was to demonstrate a novel technique for two-port robotic hysterectomy with a particular focus on the challenging portions of the procedure. The study is designed as a technical video, showing step-by-step a two-port robotic hysterectomy approach (Canadian Task Force classification level III). IRB approval was not required for this study. The benefits of minimally invasive surgery for gynecological pathology have been clearly documented in multiple studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis and quality of life. Most gynecological surgeons require 3-5 ports for the standard gynecological procedure. Even though the minimally invasive multiport system provides an excellent safety profile, multiple incisions are associated with a greater risk for morbidity including infection, pain, and hernia. In the past decade, various new methods have emerged to minimize the number of ports used in gynecological surgery. The interventions employed were a two-port robotic hysterectomy, using a camera port plus one robotic arm, with a focus on salpingectomy and cuff closure. We describe a transvaginal and a transabdominal approach for salpingectomy and a novel method for cuff closure. The transvaginal and transabdominal techniques for salpingectomy for two-port robotic-assisted hysterectomy provide excellent tension and exposure for a safe procedure without the need for an extra port. We also describe a transvaginal technique to place the vaginal cuff on tension during closure. With the necessary set of skills on a carefully chosen patient, two-port robotic-assisted total laparoscopic hysterectomy is a feasible procedure.

Models and applications for measuring the impact of health research: update of a systematic review for the Health Technology Assessment programme

BACKGROUND

This report reviews approaches and tools for measuring the impact of research programmes, building on, and extending, a 2007 review.

OBJECTIVES

(1) To identify the range of theoretical models and empirical approaches for measuring the impact of health research programmes; (2) to develop a taxonomy of models and approaches; (3) to summarise the evidence on the application and use of these models; and (4) to evaluate the different options for the Health Technology Assessment (HTA) programme.

DATA SOURCES

We searched databases including Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and The Cochrane Library from January 2005 to August 2014.

REVIEW METHODS

This narrative systematic literature review comprised an update, extension and analysis/discussion. We systematically searched eight databases, supplemented by personal knowledge, in August 2014 through to March 2015.

RESULTS

The literature on impact assessment has much expanded. The Payback Framework, with adaptations, remains the most widely used approach. It draws on different philosophical traditions, enhancing an underlying logic model with an interpretative case study element and attention to context. Besides the logic model, other ideal type approaches included constructionist, realist, critical and performative. Most models in practice drew pragmatically on elements of several ideal types. Monetisation of impact, an increasingly popular approach, shows a high return from research but relies heavily on assumptions about the extent to which health gains depend on research. Despite usually requiring systematic reviews before funding trials, the HTA programme does not routinely examine the impact of those trials on subsequent systematic reviews. The York/Patient-Centered Outcomes Research Institute and the Grading of Recommendations Assessment, Development and Evaluation toolkits provide ways of assessing such impact, but need to be evaluated. The literature, as reviewed here, provides very few instances of a randomised trial playing a major role in stopping the use of a new technology. The few trials funded by the HTA programme that may have played such a role were outliers.

DISCUSSION

The findings of this review support the continued use of the Payback Framework by the HTA programme. Changes in the structure of the NHS, the development of NHS England and changes in the National Institute for Health and Care Excellence's remit pose new challenges for identifying and meeting current and future research needs. Future assessments of the impact of the HTA programme will have to take account of wider changes, especially as the Research Excellence Framework (REF), which assesses the quality of universities' research, seems likely to continue to rely on case studies to measure impact. The HTA programme should consider how the format and selection of case studies might be improved to aid more systematic assessment. The selection of case studies, such as in the REF, but also more generally, tends to be biased towards high-impact rather than low-impact stories. Experience for other industries indicate that much can be learnt from the latter. The adoption of researchfish^® (researchfish Ltd, Cambridge, UK) by most major UK research funders has implications for future assessments of impact. Although the routine capture of indexed research publications has merit, the degree to which researchfish will succeed in collecting other, non-indexed outputs and activities remains to be established.

LIMITATIONS

There were limitations in how far we could address challenges that faced us as we extended the focus beyond that of the 2007 review, and well beyond a narrow focus just on the HTA programme.

CONCLUSIONS

Research funders can benefit from continuing to monitor and evaluate the impacts of the studies they fund. They should also review the contribution of case studies and expand work on linking trials to meta-analyses and to guidelines.

FUNDING

The National Institute for Health Research HTA programme.

Factors for a Successful Laparoscopic Hysterectomy in Very Large Uteri

Minimally invasive hysterectomy is a standard procedure. Different approaches, as laparoscopically assisted vaginal hysterectomy, vaginal hysterectomy, and subtotal and total laparoscopic hysterectomy, have been described and evaluated by various investigations as safe and cost-effective methods. In particular, in comparison to abdominal hysterectomy, the minimally invasive methods have undoubted advantages for the patients. The main reason for a primary abdominal hysterectomy or conversion to abdominal hysterectomy during a minimal invasive approach is the uterine size. We describe our course of action in the retrospective analysis of five cases of total minimal-access hysterectomy, combining the laparoscopic subtotal hysterectomy and the vaginal extirpation of the cervix in uterine myomatosis with a uterine weight of more than 1000 grams, and discuss the factors that limit the use of laparoscopy in the treatment of big uteri. Trail Registration. The case report is registered in Research Registry under the UIN researchregistry743.

One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals

BACKGROUND

Female-to-male gender-confirmation surgery (GCS) includes removal of breasts and female genitalia and complete genital and urethral reconstruction. With a multidisciplinary approach, these procedures can be performed in one stage, avoiding multistage operations.

AIM

To present our results of one-stage sex-reassignment surgery in female-to-male transsexuals and to emphasize the advantages of single-stage over multistage surgery.

METHODS

During a period of 9 years (2007-2016), 473 patients (mean age = 31.5 years) underwent metoidioplasty. Of these, 137 (29%) underwent simultaneous hysterectomy, and 79 (16.7%) underwent one-stage GCS consisting of chest masculinization, total transvaginal hysterectomy with bilateral adnexectomy, vaginectomy, metoidioplasty, urethral lengthening, scrotoplasty, and implantation of bilateral testicular prostheses. All surgeries were performed simultaneously by teams of experienced gynecologic and gender surgeons.

OUTCOMES

Primary outcome measurements were surgical time, length of hospital stay, and complication and reoperation rates compared with other published data and in relation to the number of stages needed to complete GCS.

RESULTS

Mean follow-up was 44 months (range = 10-92). Mean surgery time was 270 minutes (range = 215-325). Postoperative hospital stay was 3 to 6 days (mean = 4). Complications occurred in 20 patients (25.3%). Six patients (7.6%) had complications related to mastectomy, and one patient underwent revision surgery because of a breast hematoma. Two patients underwent conversion of transvaginal hysterectomy to an abdominal approach, and subcutaneous perineal cyst, as a consequence of colpocleisis, occurred in nine patients. There were eight complications (10%) from urethroplasty, including four fistulas, three strictures, and one diverticulum. Testicular implant rejection occurred in two patients and testicular implant displacement occurred in one patient.

CLINICAL IMPLICATIONS

Female-to-male transsexuals can undergo complete GCS, including mastectomy, hysterectomy, oophorectomy, vaginectomy, and metoidioplasty with urethral reconstruction as a one-stage procedure without increased surgical risks and complication rates.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the largest cohort on this topic so far, with good surgical outcomes. Limitations include lack of selection or exclusion criteria and lack of other studies with a simple approach. For this reason, the technique should be studied further and compared with other techniques for female-to-male surgery before it can be recommended as an alternative procedure.

CONCLUSIONS

Through a multidisciplinary approach of experienced teams, one-stage GCS presents a safe, viable, and time- and cost-saving procedure. Complication rates do not differ from reported rates in multistage surgeries. Stojanovic B, Bizic M, Bencic M, et al. One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals. J Sex Med 2017;14:741-746.

Multidisciplinary Resection of Deeply Infiltrative Endometriosis

STUDY OBJECTIVE

To describe a multidisciplinary approach for the resection of deeply infiltrative endometriosis using the robotic platform.

DESIGN

A technical video showing a step-by-step approach for the resection of deeply infiltrative endometriosis (Canadian Task Force classification level III). Institutional review board approval was not required for this study.

SETTING

There is considerable involvement of the bowel and bladder with deeply infiltrative endometriosis [1-3]. The need for operative procedures involving multiple organs while performing a complete resection is common. The benefits of minimally invasive surgery for a gynecologic pathology have been documented in numerous studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis, and better quality of life [4-6]. We believe that deeply infiltrative endometriosis does not preclude patients from having a minimally invasive resection procedure. In this video, we describe how the robotic platform was used for a seamless transition between surgical specialties including gynecology, colorectal, and urology to ensure complete resection of endometriosis lesions involving multiple organs.

PATIENT

A 47-year-old woman with a 4-year history of severe pelvic pain, dysuria, dyspareunia, dyschezia, and dysmenorrhea failing multiple medical therapies presented to our clinic to discuss surgical options. After thorough counseling, the decision was made to proceed with definitive surgical management. Postoperatively, the patient was admitted for 2 days of postoperative inpatient care. After meeting all immediate postoperative milestones, she was discharged with an indwelling Foley catheter and instructed to follow up in the clinic with all 3 surgical specialties. At the 1-week interval, she was seen by the urology team; her indwelling catheter was removed after a cystoscopy was performed documenting adequate healing. Two weeks postoperatively, the patient was seen by the gynecology and colorectal teams and was noted to be healing adequately from the procedure. Her six-week visit was also unremarkable. She continued to follow up with the gynecology team for her yearly well-woman examinations and has been symptom free for 2 years after the surgery. She takes norethindrone daily to minimize recurrence.

INTERVENTIONS

Preoperative pelvic magnetic resonance imaging (MRI) showed bladder endometriosis and extensive rectovaginal endometriosis. We describe the multidisciplinary approach used for surgery and the procedures performed by each specialty. The urology team performed a cystoscopy preoperatively to assess for full-thickness erosions and the location of those lesions in that event. The urology team also reviewed the magnetic resonance images with the radiology team, and the endometriosis lesions were suspected to be close to the bladder trigone, keeping in mind that this finding could be overestimated given that the bladder was deflated at the time the imaging was obtained. Accordingly, at the time of surgery, the decision was made to proceed with cystoscopy and the placement of ureteral stents as a prophylactic measure. An intentional cystotomy and resection of the bladder section involved with endometriosis were performed followed by watertight closure. The trigone area of the bladder was not involved, and ureteral reimplantation was not needed in this case. The gynecology team operated second and performed an extensive dissection of the retroperitoneal space with the development of the pararectal and paravesical spaces. They also ligated the uterine artery at its origin followed by dissection of the uterovesical space, effectively reflecting the bladder off of the lower uterine segment. At this point, they proceeded with a total hysterectomy, and the specimen was removed from the pelvis through the vaginal cuff. Preoperatively, the colorectal surgeon ordered a colonoscopy to determine if full-thickness erosions were present and reviewed the magnetic resonance images with the radiology team. Based on the MRI and colonoscopy, all patients are counseled and consented for the possibility of a low anterior resection and loop ileostomy to protect the anastomosis. Based on the understanding that colorectal and gynecologic surgeries have a different approach when dissecting the pararectal space at our institution, a discussion between the 2 teams is initiated at the multidisciplinary session for surgery planning. In the case we present, the colorectal surgeon opted for the removal of the uterus before his dissection was initiated given that he dissects this space presacrally and not retroperitoneally like the gynecology counterpart. He would also benefit from the extra space for dissection with the uterus out of the pelvis. The colorectal part of the case was initiated by mobilization of the rectum and dissecting the obliterated rectovaginal space. The presacral space was then opened followed by mobilization of the rectosigmoid from its attachment. The case was concluded with full transection and reanastomosis of the rectum section involved with endometriosis. The specimen was also removed from the pelvis through the vaginal cuff.

MEASUREMENTS AND MAIN RESULTS

Complete resection of deeply infiltrative endometriosis spanning beyond the scope of 1 surgical specialty. No immediate intraoperative, perioperative, or long-term complications from surgery. Complete resolution of endometriosis symptoms.

CONCLUSION

We encourage collaborative care for planning and performing comprehensive and safe resection of deeply infiltrative endometriosis.

For U.S. Black women, shift of hysterectomy to outpatient settings may have lagged behind White women: a claims-based analysis, 2011-2013

BACKGROUND

Hysterectomy is among the most common surgeries performed on U.S. women. For benign conditions, minimally invasive hysterectomy is recommended, whenever permitted by clinical indication and previous surgery history. No study has examined whether the use of less invasive hysterectomy spread more slowly for Black women.

METHODS

We used the hysterectomy that occurs in outpatient settings as a proxy for minimally invasive hysterectomy. Using claims-based surgery data and census denominators, we calculated age-standardized rates of all hysterectomies in North Carolina from 2011 to 2013. Study participants were 41,899 women (64.6% non-Hispanic White, 28.3% non-Hispanic Black) who underwent hysterectomy for non-malignant indications. We fit Poisson models to determine whether changes in outpatient hysterectomy rates differed by Black-White race. We employed a difference-in-difference approach to control for racial differences in the severity of clinical indication. Further, we restricted to one state to minimize confounding from geographic differences in where Black and White women live.

RESULTS

From 2011 to 2013, the overall hysterectomy rate decreased from 42.3 per 10,000 women (n = 14,648) to 37.9 per 10,000 (n = 13,241) (p < 0.0001). Most hysterectomy (67.6%) occurred in outpatient settings. The inpatient rate decreased 35.2% (p < 0.0001), to 10.3 per 10,000, while the outpatient rate increased 4.6% (p < 0.01), to 27.5 per 10,000. From 2011 to 2013, Black women's outpatient rate increased 22% (p < 0.0001): from 25.8 per 10,000 to 31.5. In contrast, among White women, outpatient rates remained stable (p = 0.79): at 28.3 per 10,000 in 2013.

CONCLUSIONS

Rapid increases in outpatient hysterectomy among Black women compared to stable rates among White women indicate a race-specific catch-up phenomenon in the spread of minimally invasive hysterectomy. These results are consistent with the hypothesis that minimally invasive hysterectomy may have been adopted more slowly for Black women than their White counterparts after its introduction in the early 2000s. The persistently high rates of hysterectomy among young Black women and potentially slower adoption of minimally invasive procedures among these women highlight a potential racial disparity in women's healthcare.

Comparison of abdominal, vaginal, and laparoscopic hysterectomies in a tertiary care hospital in Turkey

AIM

The aim of this retrospective study was to assess and compare the clinical results of three hysterectomy techniques: abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH).

METHODS

A total of 2163 patients having undergone AH (n = 1226), VH (n = 426), and LH (n = 511) procedures were analyzed. The mean age, body mass index (BMI), parity, uterus weight, operation time, blood loss, duration of hospitalization, analgesic needs, intra- and postoperative complications, and indications for hysterectomy were analyzed and compared.

RESULTS

There were no differences between the groups with respect to the BMI, parity, and intra- or postoperative major and minor complications. The operation time was significantly shorter in the VH group than in the other two groups (p < 0.001), and the blood loss was significantly lower in the LH group than in the others (p < 0.001). The duration of hospitalization and analgesic needs were the shortest in the LH group (p < 0.001), while the uterus weight and previous intra-abdominal surgery rate were the lowest in the VH group (p < 0.001).

CONCLUSION(S)

Despite the fact that the LH exhibited a longer operation time than the VH, the LH was considered to be a safe and effective surgical procedure due to the lesser blood loss, hospital stay, and analgesic needs.

Implementation of Hysterectomy Pathway: Impact on Complications

OBJECTIVE

Hysterectomy is one of the most common surgical procedures in the United States. For women who need hysterectomy, it is important to ensure that minimally invasive hysterectomy procedures are used appropriately to reduce surgical complications and improve value of care. Although we previously demonstrated a reduction in total abdominal hysterectomy rates after the implementation of hysterectomy pathway treatment algorithm in 2012, this study focuses on exploring the effect of pathways implementation on surgical outcomes.

METHODS

All retrospective medical records for hysterectomy surgeries performed for benign indications at University of Pittsburgh Medical Center hospitals between the fiscal years (FY) 2012 and 2014 were identified. We analyzed the health care outcomes by route of surgery and year using Χ2 test for categorical data, and non-parametric approaches for non-normal continuous variables.

RESULTS

A total of 6,569 hysterectomies for benign indications were performed between FY 2012 and 2014. In FY 2012, 1,154 patients (59.15%) had a length of stay of 1 day or less, whereas in FY 2014 this number increased to 1,791 (74.53%; p < .0001). Within 3 years of implementing the pathway, surgical site infections had a reduction of 47%, with a considerable trend toward significance (p = .067).

CONCLUSIONS

Implementation of hysterectomy pathway has been associated with reduction of surgical complications in benign hysterectomy settings. Implementation of clinical pathways offers an opportunity for improving patient outcomes that should be investigated in various health care settings and across procedures.

Laparoscopic hysterectomy in the overweight and obese: does 3D imaging make a change?

PURPOSE

To evaluate the influence of three-dimensional (3D) high-definition (HD) visualisation in laparoscopic hysterectomy in normal weight, overweight and obese women.

METHODS

A retrospective analysis of 180 patients undergoing total laparoscopic hysterectomy (TLH: n = 90) or laparoscopic supracervical hysterectomy (LASH: n = 90) was performed. The study collective consisted of 90 women (TLH: n = 45, LASH: n = 45), who underwent laparoscopic hysterectomy with a 3D HD laparoscopic system. Ninety matched (uterine weight, previous surgeries) women with hysterectomy (TLH: n = 45, LASH: n = 45) performed by the same surgeon with conventional two-dimensional laparoscopy formed the control group. Statistical analysis was accomplished stratifying patients according to body mass index (BMI) (≤24.9, 25-29.9, ≥30.0 kg/m²). In each BMI, collective subtypes of surgery (TLH, LASH) as well as hysterectomies as a whole were analysed. Demographic data and surgical parameters were evaluated.

RESULTS

In all BMI subgroups, there were no significant differences concerning demographic parameters. Number of trocar site incisions needed was significantly less in women undergoing 3D compared to 2D laparoscopy independent of BMI. Furthermore, a significantly lower blood loss was revealed using 3D visualisation in LASH subgroups of the normal and overweight collectives. Three-dimensional laparoscopy was additionally associated with a significantly shorter duration of surgery in the TLH subgroup in overweight patients and a lower haemoglobin drop in the LASH subgroup of the obese.

CONCLUSION

The need of less trocar site incisions concerning all weight groups as well.

[Initial experience in the laparoscopic treatment of benign and malignant gynaecological diseases in the Hospital Regional de Alta Especialidad in Oaxaca]

BACKGROUND

The history of laparoscopic surgery in gynaecological diseases progressed with the advances of Semm, as well as with the development of tools, equipment, and energy that led to its development in all surgical areas, including oncology.

OBJECTIVE

To present the initial experience in the laparoscopic treatment of benign and malignant gynaecological disease in the Hospital Regional de Alta Especialidad in Oaxaca.

MATERIAL AND METHODS

An analysis was performed on a total of 44 cases, distributed into: type III radical hysterectomy for invasive cervical cancer, hysterectomy type I cervical cancer in situ, extrafascial hysterectomy for benign disease, routine endometrium, ovary and routine salpingo-oophorectomy. The variables included age, BMI, surgical time, bleeding, intraoperative and postoperative complications, conversion, hospital stay, and pathology report.

RESULTS

Hysterectomy type III; age 40.2 years, BMI 25.8kg/m², 238ml bleeding, operative time 228min, 2.6-day hospital stay, intraoperative or postoperative complications, tumour size 1.1cm, 14 lymph nodes dissected, vaginal and negative parametrical edge. Type I hysterectomy cervical cancer in situ: 51 years, BMI 23.8kg/m², 80ml bleeding, operative time 127minutes, uterus of 9cm, length of stay of 2 days, a conversion by external iliac artery injury, with bleeding of 1500ml. Routine endometrium: 50.3 years, BMI 30.3kg/m², 83ml bleeding, operative time 180minutes, uterus 12.6cm, length of stay 2.3 days, no complications.

CONCLUSION

The management of benign and malignant pelvic diseases using laparoscopy is feasible and safe, with shorter hospital stays and a prompt recovery to daily activities.

Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta-analysis

OBJECTIVE

To calculate the rates of urinary tract injury detected during and after benign gynecologic surgery. To explore the role of routine intraoperative cystoscopy and determine if it helps in reducing injuries detected postoperatively.

DATA SOURCES

We conducted a literature search for urinary tract injuries at benign gynecologic surgery in PubMed, EMBASE, ClinicalTrials.gov, and Web of Science from January 2004 to August 2014. We combined our results with a database from a previously published systematic review to include earlier studies.

METHODS OF STUDY SELECTION

A total of 79 studies met our inclusion criteria. Excluded were letters to the editor, studies involving only selective cystoscopy in higher risk patients, case reports, and reports that included injuries resulting from obstetric or oncologic procedures.

TABULATION, INTEGRATION, AND RESULTS

Data from each report were classified according to type of surgery into vaginal hysterectomy, abdominal hysterectomy, laparoscopic hysterectomy, other (nonrobotic) gynecologic and urogynecologic surgery, robotic hysterectomy, and other robotic gynecologic and urogynecologic surgery. We determined the ureteric and bladder injury rates for each surgery type from studies in which routine intraoperative cystoscopy was performed and separately from studies in which it was not performed. Intraoperatively detected rates of ureteric and bladder injury were markedly higher with routine intraoperative cystoscopy. We obtained an adjusted ureteric injury rate of 0.3% and a bladder injury rate of 0.8%. The estimated postoperative ureteric injury detection rates per 1,000 surgeries were 1.6 without routine cystoscopy and 0.7 with routine cystoscopy. Postoperative bladder injury detection rates per 1,000 surgeries were 0.8 without routine cystoscopy and 1.0 with routine cystoscopy.

CONCLUSION

Although routine cystoscopy clearly increases the intraoperative detection rate of urinary tract injuries, this systematic review of 79 mostly retrospective studies shows that it does not appear to have much effect on the postoperative injury detection rate.

A new approach to simplify surgical colpotomy in laparoscopic hysterectomy

New surgical techniques and technology have simplified laparoscopic hysterectomy and have enhanced the safety of this procedure. However, the surgical colpotomy step has not been addressed. This study evaluates the surgical colpotomy step in laparoscopic hysterectomy with respect to difficulty and duration. Furthermore, it proposes an alternative route that may simplify this step in laparoscopic hysterectomy. A structured interview, a prospective cohort study, and a problem analysis were performed regarding experienced difficulty and duration of surgical colpotomy in laparoscopic hysterectomy. Sixteen experts in minimally invasive gynecologic surgery from 12 hospitals participated in the structured interview using a 5-point Likert scale. The colpotomy in LH received the highest scores for complexity (2.8 ± 1.2), compared to AH and VH. Colpotomy in LH was estimated as more difficult than in AH (2.8 vs 1.4, p < .001). In the cohort study, 107 patients undergoing LH were included. Sixteen percent of the total procedure time was spent on colpotomy (SD 7.8 %). BMI was positively correlated with colpotomy time, even after correcting for longer operation time. No relation was found between colpotomy time and blood loss or uterine weight. The surgical colpotomy step in laparoscopic hysterectomy should be simplified as this study demonstrates that it is time consuming and is considered to be more difficult than in other hysterectomy procedures. A vaginal approach to the colpotomy is proposed to achieve this simplification.

Deprivation and poor psychosocial support are key determinants of late antenatal presentation and poor fetal outcomes--a combined retrospective and prospective study

BACKGROUND

Published guidelines emphasise the need for early antenatal care to promote maternal and neonatal health. Inadequate engagement with antenatal care is associated with adverse pregnancy outcomes including maternal death. The factors that influence the uptake and utilisation of maternity care services are poorly understood. We retrospectively explore a large maternity database of births in a large referral UK hospital to capture the socio-demographic factors that influence late pregnancy booking, and then prospectively compare the stress and social support status of consenting early and late-booking women.

METHODS

Retrospective socio-demographic and clinical outcome data on 59,487 women were collected from the maternity database record of births between 2002 and 2010 at the Jessop Wing Hospital, Sheffield UK. In a follow-on prospective survey between October 2012 and May 2013 a convenience cohort of early and late bookers for antenatal care were then studied using validated scales for fetomaternal attachment, stress and anxiety, and social support.

RESULTS

In our retrospective study, pregnancy during the teenage years, higher parity, non-white ethnic background, unemployment and smoking were significantly associated with late access to antenatal services and poor fetal outcomes (P < 0.001). However, late booking per se did not predict adverse fetal outcomes, when socio-demographic factors were accounted for. A high index of multiple deprivation (IMD) score remained independently associated with late booking when confounding factors such as ethnicity and employment status were controlled for in the model (P = 0.03). Our prospective data demonstrated that women who book late were more likely to be unmarried (OR: 3.571, 95 % CI: 1.464-8.196, p =  .005), of high parity (OR: 1.759, 95 % CI: 1.154-2.684, P = 0.009), and have lower social support than early bookers (P = 0.047).

CONCLUSIONS

Of the many complex sociocultural factors that influence the timing of maternal engagement with antenatal care, multiple deprivation and poor social support remain key factors. Improving access to prenatal care requires in-depth exploration of the relationship between maternal psychosocial health indices, social support mechanisms and engagement with antenatal care. Findings from these studies should inform interventions aimed at improving access to care.

Economic Evaluation alongside Multinational Studies: A Systematic Review of Empirical Studies

Purpose of the study

This study seeks to explore methods for conducting economic evaluations alongside multinational trials by conducting a systematic review of the methods used in practice and the challenges that are typically faced by the researchers who conducted the economic evaluations.

Methods

A review was conducted for the period 2002 to 2012, with potentially relevant articles identified by searching the Medline, Embase and NHS EED databases. Studies were included if they were full economic evaluations conducted alongside a multinational trial.

Results

A total of 44 studies out of a possible 2667 met the inclusion criteria. Methods used for the analyses varied between studies, indicating a lack of consensus on how economic evaluation alongside multinational studies should be carried out. The most common challenge appeared to be related to addressing differences between countries, which potentially hinders the generalisability and transferability of results. Other challenges reported included inadequate sample sizes and choosing cost-effectiveness thresholds.

Conclusions

It is recommended that additional guidelines be developed to aid researchers in this area and that these be based on an understanding of the challenges associated with multinational trials and the strengths and limitations of alternative approaches. Guidelines should focus on ensuring that results will aid decision makers in their individual countries.

Taxonomy for methods of resource use measurement

Resource use measures, including forms, diaries and questionnaires, are ubiquitous in trial-based economic evaluations in the UK. However, there are concerns about the accuracy of how they are described, which limits the transparency of reporting. We developed a simple and structured taxonomy for methods of resource use measurement by examining 94 resource use measures (RUMs) employed within clinical trials, conducting a descriptive synthesis of the extracted data and soliciting wider opinion during a period of consultation. The reporting of RUMs was found to be varied and inconsistent. Our new taxonomy, which considered the views of 20 consultees, requires that RUMs are reported with a description of the following: (i) the source of data (patient; patient proxy, e.g. carer, parent or guardian; observation of contemporary events; medical records; or other databases); (ii) who completes the RUM (patient or their proxy, and researcher or health care professional); (iii) how it is administered (to self [the patient], face to face or telephone); (iv) how it is recorded (form, questionnaire, log or diary); and (v) medium of recording (e.g. paper or electronically). Based on the present analysis, we have developed a taxonomy for RUMs that should result in data collection methods being described more accurately.

Total laparoscopic hysterectomy, vaginal hysterectomy and total abdominal hysterectomy using electrosurgical bipolar vessel sealing technique: a randomized controlled trial

PURPOSE

To compare total laparoscopic hysterectomy (TLH), total abdominal hysterectomy (TAH) and vaginal hysterectomy (VH) using electrosurgical bipolar vessel sealing (EBVS) technique regarding operative time, intra and postoperative complications.

METHODS

The current prospective randomized controlled clinical trial was conducted at Ain-shams University maternity Hospital, Cairo, Egypt. Ninety patients who were admitted from gynecologic outpatient clinic to undergo hysterectomy were enrolled. The study population was randomized according to type of hysterectomy done into 3 groups: group 1: VH; group 2: AH and group 3: TLH. EBVS was used in all groups. Three staff members' surgeons were also randomized to operate on the patients and they were all equally competent in all the procedures. Main outcome measures were operative time, operative blood loss, operative complications, postoperative pain assessment using the visual analogue scale (0-10), and the need for analgesics as well as the postoperative hospital stay.

RESULTS

Ninety patients were randomized to undergo VH, TAH or TLH for benign pathology using EBVS. Postoperative pain score and the need for analgesia were least in TLH compared to the other two groups, (p < 0.001). The hospital stay in TLH group was shorter than the other two groups, but there was no significant difference between VH group and TAH group with regard to hospital stay, (p < 0.001). The total operative time was shortest in the VH group (100.4 ± 35.8 min) compared to TLH (126 ± 42.7 min) and TAH (123.6 ± 44.5 min) (p = 0.033). The operative complications were more with VH and TAH groups. The blood loss was more with VH (p = 0.039).

CONCLUSION

TLH had a longer operation time, yet, less blood loss, shorter hospital stay, less postoperative pain and fewer complications, compared to TAH and VH using EBVS.

The impact of different surgical modalities for hysterectomy on satisfaction and patient reported outcomes

Background

There is an ongoing debate regarding the cost-benefit of different surgical modalities for hysterectomy. Studies have relied primarily on evaluation of clinical outcomes and medical expenses. Thus, a paucity of information on patient-reported outcomes including satisfaction, recovery, and recommendations exists.

Objective

The objective of this study was to identify differences in patient satisfaction and recommendations by approach to a hysterectomy.

Methods

We recruited a large, geographically diverse group of women who were members of an online hysterectomy support community. US women who had undergone a benign hysterectomy formed this retrospective study cohort. Self-reported characteristics and experiences were compared by surgical modality using chi-square tests. Outcomes over time were assessed with the Jonkheere-Terpstra trend test. Logistic regression identified independent predictors of patient satisfaction and recommendations.

Results

There were 6262 women who met the study criteria; 41.74% (2614/6262) underwent an abdominal hysterectomy, 10.64% (666/6262) were vaginal, 27.42% (1717/6262) laparoscopic, 18.94% (1186/6262) robotic, and 1.26% (79/6262) single-incision laparoscopic. Most women were at least college educated (56.37%, 3530/6262), and identified as white, non-Hispanic (83.17%, 5208/6262). Abdominal hysterectomy rates decreased from 68.2% (152/223) to 24.4% (75/307), and minimally invasive surgeries increased from 31.8% (71/223) to 75.6% (232/307) between 2001 or prior years and 2013 (P<.001 all trends). Trends in overall patient satisfaction and recommendations showed significant improvement over time (P<.001).There were differences across the surgical modalities in all patient-reported experiences (ie, satisfaction, time to walking, driving and working, and whether patients would recommend or use the same technique again; P<.001). Significantly better outcomes were evident among women who had vaginal, laparoscopic, and robotic procedures than among those who had an abdominal procedure. However, robotic surgery was the only approach that was an independent predictor of better patient experience; these patients were more satisfied overall (odds ratio [OR] 1.31, 95% CI 1.13-1.51) and on six other satisfaction measures, and more likely to recommend (OR 1.64, 95% CI 1.39-1.94) and choose the same modality again (OR 2.07, 95% CI 1.67-2.57). Abdominal hysterectomy patients were more dissatisfied with outcomes after surgery and less likely to recommend (OR 0.36, 95% CI 0.31-0.40) or choose the same technique again (OR 0.29, 95% CI 0.25-0.33). Quicker return to normal activities and surgery after 2007 also were independently associated with better overall satisfaction, willingness to recommend, and to choose the same surgery again.

Conclusions

Consistent with other US data, laparoscopic and robotic hysterectomy rates increased over time, with a concomitant decline in abdominal hysterectomy. While inherent shortcomings of this retrospective Web-based study exist, findings show that patient experience was better for each of the major minimally invasive approaches than for abdominal hysterectomy. However, robotic-assisted hysterectomy was the only modality that independently predicted greater satisfaction and willingness to recommend and have the same procedure again.

Cost-effectiveness of hysterectomy for benign gynecological conditions: a systematic review

The objective of this study was to assess the cost-effectiveness of hysterectomy performed for benign indications. Hysterectomy remains the most common major gynecological operation in the Western world. Rates of hysterectomy have not declined as expected with the introduction of new treatment options. Furthermore, use of laparoscopic techniques varies widely within the Nordic countries. We designed a systematic review in a University Central Hospital. The sample included all published studies regarding the cost-effectiveness of hysterectomy performed for benign indications (n = 1666). Medline, Cochrane Library, PsycINFO, CINAHL, and Nursing databases were searched. Inclusion criteria were the availability of pre- and post-intervention health-related quality of life measures (HRQoL) and data on costs. HRQoL, costs, and cost-effectiveness of treatment were the main outcome measures. Studies (n = 24) focused on treatment of symptomatic fibroids (n = 8), treatment of heavy menstrual bleeding (n = 10), various surgical techniques (n = 5) and the effect of various indications for hysterectomy (n = 2). Follow-up periods varied from 4 months to over 10 years. SF/RAND-36 or EQ-5D measures and societal cost perspective were most commonly used. Only 11 studies used individual patient data. HRQoL following hysterectomy was generally good but costs were high. The cost-effectiveness depended on indication, age, and duration of follow-up. The cost-effectiveness of hysterectomy has been surprisingly poorly studied. Conclusions are difficult to draw due to different study designs, indications, follow-up times, and HRQoL instruments used. Rates of hysterectomy have declined less than expected with the introduction of new treatment modalities. Costs of surgery are high. Laparoscopic hysterectomy seems to be the least cost-effective, although further data from original patient cohorts with long-term follow-up are needed.

Cervical Detachment Using Monopolar SupraLoop™ Electrode versus Monopolar Needle in Laparoscopic Supracervical Hysterectomy (LSH): An Interventional, Comparative Cohort Study

Objective: Currently available monopolar loop electrodes are difficult to handle in laparoscopic supracervical hysterectomy (LSH) and are entirely disposable devices, generating additional operating costs. The aim of this interventional study was the comparison of the efficiency and safety of cervical detachment with a newly developed monopolar loop electrode (SupraLoop™) with a conventional method of cervical detachment in LSH. Material and Methods: Our study sample included 1598 patients; 1070 patients that underwent LSH with cervical detachment using the monopolar SupraLoop™ (study group) and 528 patients that underwent LSH with cervical detachment using the monopolar needle (control group). We also assessed cervical detachment time and total device application and cutting time in a subgroup of 49 patients (23 patients from the study group and 26 patients from the control group). Results: Total operation time for LSH was significantly shorter among SupraLoop™ patients (93 ± 41 minutes) when compared to patients in whom cervical detachment was performed with the needle (105 ± 44 minutes) (p < 0.001). Cervical detachment time and total device application including cutting time was significantly shorter for the SupraLoop™ group (SupraLoop vs. needle; 0.12 ± 0.21 min vs. 5.1 ± 4.4 min [p < 0.001]; 2.3 ± 1.8 min vs. 5.4 ± 2.4 min [p < 0.001]). There were no major or minor complications directly related to the use of the SupraLoop™ device, whereas two intraoperative complications were directly related to the application of the monopolar needle. Conclusion: The newly developed monopolar loop electrode (SupraLoop™) is both an effective and safe instrument for cervical detachment in laparoscopic supracervical hysterectomy, and performed better than the needle, offering a significantly shorter operating time and less complications for the hysterectomy compared to the conventional method.