Should we perform cervix removal during hysterectomy for benign uterine disease? Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best evidence available, concerning subtotal or total hysterectomy, for benign disease.

METHODS

The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade, which depends on the quality of evidence (QE) (clinical practice guidelines).

RESULTS

Conservation of the uterine cervix is associated with an increased risk of cervical cancer (0.05 to 0.27%) and an increased risk of reoperation for cervical bleeding (QE: high). Uterine cervix removal is associated with a moderate (about 11 min) increase in operative time when hysterectomy is performed by the open abdominal route (laparotomy), but is not associated with longer operative time when the hysterectomy is performed by laparoscopy (QE: moderate). Removal of the uterine cervix is not associated with increased prevalence of short-term follow-up complications (blood transfusion, ureteral or bladder injury) (QE: low) or of long-term follow-up complications (pelvic organ prolapse, sexual disorders, urinary incontinence (QE: moderate).

CONCLUSION

Removal of the uterine cervix is recommended for hysterectomy in women presenting with benign uterine disease (Recommendation: STRONG [GRADE 1-]; the level of evidence was considered to be sufficient and the risk-benefit balance was considered to be favorable).

Bilateral Ultrasound-Guided Erector Spinae Plane Block Versus Transversus Abdominis Plane Block on Postoperative Analgesia after Total Abdominal Hysterectomy

BACKGROUND

Transversus abdominis plane (TAP) blocks provide postoperative pain relief after various abdominal surgeries. Recently, erector spinae plane (ESP) block has obtained vast attention due to its simplicity and usage in truncal procedures.

OBJECTIVES

This study aims to compare the ultrasound-guided bilateral ESP block versus bilateral TAP block on postoperative analgesia after open total abdominal hysterectomy.

STUDY DESIGN

A prospective, double-blinded, randomized, controlled, clinical trial.

SETTING

Zagazig University Hospitals.

METHODS

After ending of surgical procedure and before reversing of the muscle relaxant, 48 women were randomly allocated into 2 equal groups: erector spinae (ES) group received bilateral ultrasound-guided ESP block with 20 mL of bupivacaine 0.375% plus 5 ug/mL adrenaline (1:200000) in each side at the level of T9, and transversus abdominis (TA) group received bilateral ultrasound-guided TAP block with the same volume of bupivacaine plus adrenaline.

RESULTS

Visual Analog Scale scores at 30 minutes, 2, 4, 6, 8, 12, 16, 20, and 24 hours were statistically significantly lower in the ES group compared with the TA group. The time for requirement of first morphine was highly statistically significantly prolonged in the ES group (14.81 ± 3.52 hours) compared with the TA group (10.58 ± 2.35 hours). The total amount of morphine consumption in 24 hours postoperatively was statistically significantly decreased in the ES group; P = 0.01. Incidence of postoperative nausea and vomiting was higher but statistically insignificant in the TA group than the ES group. There were statistically significant numbers of unsatisfied patients (4) in the TA group compared with the ES group (no patient).

LIMITATIONS

Sensorial evaluation of patients was not performed because both blocks had been done under general anesthesia but did not affect outcome. Therefore we recommend further studies comparing between both blocks.

CONCLUSIONS

Bilateral ultrasound-guided ESP block provides more potent and longer postoperative analgesia with less morphine consumption than TAP block after open total abdominal hysterectomy.

KEY WORDS

Abdominal hysterectomy, transversus abdominis plane block, erector spinae plane block, postoperative analgesia.

Trends in the surgical management of malignant ovarian germcell tumors

OBJECTIVE

To evaluate trends in the surgical management of young women and pediatric patients with malignant ovarian germ cell tumors (MOGCTs) and associated survival outcomes.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database we identified patients under 40 years who underwent surgery between 1994 and 2014. The Joinpoint Regression Program was employed to investigate the presence of temporal trends and calculate average annual percent change (AAPC) rates. For analysis purposes two age groups were formed; pediatric/adolescent (≤21 yrs) and young adult (22-40 yrs). Histology was categorized into dysgerminoma, immature teratoma, yolk-sac tumor, mixed germ cell tumor and other histology. Cancer specific survival was compared using log-rank tests.

RESULTS

A total of 2238 patients were identified, with median age 21 years. Only 12.4% underwent hysterectomy. One third underwent omentectomy, and one half underwent lymphadenectomy (LND). A decrease in the rate of omentectomy (AAPC: -2.15, 95% CI: -3.4, -0.9) and hysterectomy (AAPC: -3.31, 95% CI: -6.1, -0.4) was observed. There was no change in the rate of LND (AAPC: 0.17, 95% CI: -0.7, 1.1). Pediatric patients were less likely to undergo omentectomy (30.2% vs 35.5%, p < 0.001), hysterectomy (3.5% vs 22%, p < 0.001) and LND (45.6% vs 54.7%, p < 0.001). There were no apparent survival differences according to the performance of hysterectomy, omentectomy or LND, when stratified by early (stage I) and advanced stage (II-IV), (p > 0.05).

CONCLUSIONS

Pediatric patients with MOGCTs undergo less extensive surgical staging. A trend towards less extensive surgical procedures for young women over time was observed, without an apparent detrimental effect on cancer specific survival.

Trends in Use and Effect on Survival of Simple Hysterectomy for Early-Stage Cervical Cancer

OBJECTIVE

To identify use and outcomes of simple hysterectomy compared with radical hysterectomy for women with early-stage cervical cancer.

METHODS

The National Cancer Database was used to review the cases of women with stage IA2 and IB1 (2 cm or less) cervical cancer from 2004 to 2015. Patients were classified based on whether they underwent simple or radical hysterectomy. Survival was examined after propensity score weighting.

RESULTS

Simple hysterectomy was performed in 44.6% of women with stage IA2 (n=1,530) and 35.3% of those with stage IB1 (n=3,931) tumors. Rates of simple hysterectomy increased from 37.8% to 52.7% from 2004 to 2014 for stage IA2 cancers and from 29.7% to 43.8% between 2004 and 2013 for stage IB1 cancers. For stage IA2 cancers, younger women and those treated at an academic medical center were less likely to undergo simple hysterectomy. For stage IB1 cancers, black women were more likely to undergo simple hysterectomy, and those treated at an academic medical center were less likely to undergo simple hysterectomy. After propensity score weighting, there was no association between route of hysterectomy and survival for stage IA2 cancers (hazard ratio [HR] 0.70, 95% CI 0.41-1.20, 5-year survival 95.1% for radical hysterectomy vs 97.6% for simple hysterectomy). For stage IB1 cancers, patients who underwent simple hysterectomy were at 55% increased risk of death (HR 1.55, 95% CI 1.18-2.03, and 5-year survival was 95.3% for radical hysterectomy vs 92.4% for simple hysterectomy).

CONCLUSION

Although there was no association between surgical radicality and survival for women with stage IA2 tumors, there was a 55% increase in mortality for women with stage IB1 neoplasms who underwent simple compared with radical hysterectomy. Radical hysterectomy is the treatment of choice for women with stage IB1 cervical cancer.

Next-generation sequencing reveals differentially expressed small noncoding RNAs in uterine leiomyoma

OBJECTIVE

To determine the expression profile of small noncoding RNAs (sncRNAs) in leiomyoma, which has not been investigated to date.

DESIGN

Laboratory-based investigation.

SETTING

Academic center.

PATIENT(S)

Women undergoing hysterectomy for benign indications.

INTERVENTION(S)

Next-generation sequencing and screening of an sncRNA database with confirmatory analysis by quantitative reverse-transcription polymerase chain reaction (qRT-PCR).

MAIN OUTCOME MEASURE(S)

Expression profile of sncRNAs in leiomyoma and matched myometrium.

RESULT(S)

Screening our previously determined RNA sequencing data with the sncRNA database resulted in identification of 15 small nuclear (sn) RNAs, 284 small nucleolar (sno) RNAs, 98 Piwi-interacting (pi) RNAs, 152 transfer (t) RNAs, and 45 ribosomal (r) RNAs, of which 15 snoRNAs, 24 piRNAs, 7 tRNAs, and 6 rRNAs were differentially expressed at a 1.5-fold change cutoff in leiomyoma compared with myometrium. We selected 5 snoRNAs, 4 piRNAs, 1 tRNA, and 1 rRNA that were differentially expressed and confirmed their expression in paired tissues (n = 20) from both phases of the menstrual cycle with the use of qRT-PCR. The results indicated up-regulation of the snoRNAs (SNORD30, SNORD27, SNORA16A, SNORD46, and SNORD56) and down-regulation of the piRNAs (piR-1311, piR-16677, piR-20365, piR-4153), tRNA (TRG-GCC5-1), and rRNA (RNA5SP202) expression in leiomyoma compared with myometrium (P<.05). The pattern of expression of these sncRNAs was similar to RNA sequencing analysis, with no menstrual cycle-dependent differences detected except for SNORD30. Because Argonaute 2 (AGO2) is required for sncRNA-mediated gene silencing, we determined its expression and found greater abundance in leiomyoma.

CONCLUSION(S)

Our results provide the first evidence for the differential expression of additional classes of sncRNAs and AGO2 in leiomyoma, implicating their roles as a gene regulatory mechanism.

Movement to outpatient hysterectomy for benign indications in the United States, 2008-2014

Introduction

The past decade has witnessed adoption of conservative gynecologic treatments, including minimally invasive surgery (MIS), alongside steady declines in inpatient hysterectomies. It remains unclear what factors have contributed to trends in outpatient benign hysterectomy (BH), as well as whether these trends exacerbate disparities.

Materials and methods

Retrospective cohort of 527,964 women ≥18 years old who underwent BH from 2008 to 2014. BH surgical approaches included: open/abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). Quarterly frequencies were calculated by care setting and surgical approach. We used multilevel logistic regression (MLR) using the most recent year of data (2014) to examine the influence of patient-, physician-, and hospital-level preoperative factors and surgical approaches on outpatient migration.

Results

From 2008–2014, surgical approaches for LH and RH increased, which coincided with decreases in VH and AH. Overall, a 44.2% shift was observed from inpatient to outpatient settings (P<0.0001). Among all outpatient visits MIS increased, particularly for RH (3.6% to 41.07%). We observed increases in the proportion of non-Hispanic Black and Medicaid patients who obtained MIS in 2014 vs. 2008 (P<0.001). Surgical approach (51.8%) and physician outpatient MIS experience (19.9%) had the greatest influence on predicting outpatient BH. Compared with LH, RH was associated with statistically significantly higher likelihood of outpatient BH overall (OR 1.23; 95% CI, 1.16–1.31), as well as in sub-analyses of more complex cases and hospitals that performed ≥1 RH (P<0.05).

Conclusion

From 2008–2014, rates of LH and RH significantly increased. A significant shift from inpatient to outpatient setting was observed. These findings suggest that RH may facilitate the shift to outpatient BH, particularly for patients with complexities. The adoption of MIS in outpatient settings may improve access to disadvantaged patient groups.

Trends in hysterectomy rates among women veterans in the US Department of Veterans Affairs

BACKGROUND

Prior studies demonstrate a higher prevalence of hysterectomy among veterans compared with nonveterans. While studies identify overall decreasing hysterectomy rates in the United States, none report rates of hysterectomy among women veterans. Given the increasing numbers of women veterans using Veterans Affairs health care, there is an ongoing need to ensure high-quality gynecology care. Therefore, it is important to examine current hysterectomy trends, including proportion of minimally invasive surgeries, among veterans using Veterans Affairs health care.

OBJECTIVE

Our objective was to describe hysterectomy trends and utilization of minimally invasive hysterectomy in the Veterans Affairs healthcare system.

STUDY DESIGN

This longitudinal study used Veterans Affairs clinical and administrative data from fiscal year 2008 to 2014 to identify hysterectomies provided or paid for by Veterans Affairs. Crude and age-adjusted hysterectomy rates were calculated by indication (benign or malignant), mode (abdominal, laparoscopic, vaginal, robotic assisted, unspecified), and source of care (provided vs paid for by Veterans Affairs). Mode and indication for hysterectomy were classified using International Classification of Diseases, ninth revision, codes. The distribution of hysterectomy mode in each year was calculated by indication and source of care.

RESULTS

Between fiscal year 2008 and fiscal year 2014, the total hysterectomy rate decreased from 4.0 per 1000 to 2.6 per 1000 unique women veteran Veterans Affairs users. Age-adjusted rates of abdominal hysterectomy for benign indications decreased over the study period from 1.54 per 1000 (95% confidence interval, 1.40-1.69) to 0.77 per 1000 (95% confidence interval, 0.69-0.85) for procedures provided by Veterans Affairs and 0.77 per 1,000 (95% confidence interval, 0.69-0.85) to 0.29 per 1,000 (95% confidence interval, 0.23-0.34) for those paid for by Veterans Affairs. Among hysterectomies for benign indications provided by (n = 5296) or paid for (n = 2610) by Veterans Affairs, the percentage of hysterectomies performed abdominally decreased from 67.2% to 46.8% and from 68.9% to 57.6%, respectively.

CONCLUSION

These findings suggest that gynecology care provided within Veterans Affairs has kept pace with national trends in reducing hysterectomy rates and increasing utilization of minimally invasive surgical techniques.

Uterine Morcellation: Fact and Fiction Surrounding the Recent Controversy

Minimally invasive surgery is commonly used for hysterectomies because of its many benefits over open surgery. Although small uteri can be removed whole in this approach, larger specimens must be morcellated. Power morcellation has come under scrutiny recently because of concerns that it can disseminate occult uterine sarcoma, other undiagnosed malignancies, and benign tissue. To limit uterine tissue dissemination, morcellation can be contained within a bag. In addition, a careful preoperative workup should be performed to minimize the risk of occult malignancy. New techniques that allow surgeons to offer more women a minimally invasive approach should be investigated and encouraged.

Uterine Sarcomas: The Latest Approaches for These Rare but Potentially Deadly Tumors

Uterine sarcomas are rare malignant uterine neoplasms that are responsible for a large majority of uterine cancer-associated deaths. The subtypes include leiomyosarcomas, endometrial stromal tumors, and adenosarcomas. Standard treatment includes complete surgical resection. Adjuvant treatment with chemotherapy, hormonal therapy, or radiation may be considered in patients with high-risk disease. However, because the ability of adjuvant treatment to improve overall survival in patients with uterine sarcomas is unclear, there is no standard recommendation regarding adjuvant therapy. The risk in forgoing chemotherapy is that uterine sarcomas have a tendency to develop distant recurrences. Many cytotoxic agents have been investigated in clinical trials in an attempt to identify an effective treatment that can improve the course of this disease. Adjuvant radiation appears to improve local control but has no significant impact on survival. In this review we discuss preoperative diagnosis and the role of pathology, and we summarize the current literature regarding the management of uterine sarcomas.

Trends in management of pelvic organ prolapse among female Medicare beneficiaries

OBJECTIVE

In the last decade, many new surgical treatments have been developed to achieve less-invasive approaches to prolapse management. However, limited data exist on how the patterns of care for women with pelvic organ prolapse (POP) may have changed over the last decade, and whether mesh implantation techniques have influenced the type of specific compartment repair performed. We used a national data set to analyze the temporal trends in patterns of care for women with POP.

STUDY DESIGN

Data were obtained from Public Use Files from the Centers for Medicare and Medicaid Services for a 5% random sample of national beneficiaries with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of POP from 1999 through 2009. Current Procedural Terminology, 4th Edition and International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were used to evaluate nonsurgical and surgical management trends for this cohort. Types of surgery were categorized by prolapse compartment and combinations of repairs. After 2005, when applicable codes became available, mesh or graft repairs were also analyzed.

RESULTS

Over the study time period, the number of women with a diagnosis of POP in any 1 year in our 5% sample of Medicare beneficiaries remained relatively stable (range, 21,245-23,268 per year). Rates of pessary insertion were also consistent at 11-13% over the study period. Of the women with a prolapse diagnosis, 14-15% underwent surgical repair, and there was little change over time in surgical management patterns based on compartment. Most commonly, multiple compartments were repaired simultaneously. There was a rapid increase in mesh use such that in 2009, 41% of all women who underwent surgery (5.8% of the total cohort) had mesh or graft inserted in their repair. Hysterectomy rates for prolapse decreased over time. Rates of vault suspension at the time of hysterectomy for prolapse were low; however, they showed a relative increase over time (22% in 1999 to 26% in 2009).

CONCLUSION

Patterns and rates of prolapse repairs remained relatively unchanged from 1999 through 2009, with an exception of a rapid rise in mesh use. These data suggest that the majority of mesh techniques were used for augmentation purposes only, but did not result in an increase in apical repairs performed in the United States. There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP.

[Analysis of emergency obstetric hysterectomy: the change of indications and the application of intraoperative interventions]

OBJECTIVE

To investigate the change of indications of emergency obstetric hysterectomy and the clinical application of intraoperative interventions. And to provide evidence for prevention of hysterectomy and improvement of obstetric quality.

METHODS

Clinical data were collected from 97 patients who received emergency obstetric hysterectomy at Shengjing Hospital of China Medical University between January 1st, 2004 and December 31st, 2013. The patients were divided into two groups by the time point of January 1st, 2009: the first group was cases treated between January 1st, 2004 and December 31st, 2008, while the second group was cases treated between January 1st, 2009 and December 31st, 2013. The clinical indicators, surgical indications, intraoperative interventions, and blood loss between the two groups were analyzed retrospectively.

RESULTS

(1) Incidence: 54 857 women delivered at Shengjing Hospital of China Medical University between January 1st, 2004 and December 31st, 2013. Of them, 97 patients received emergency obstetric hysterectomy, with an incidence of 0.177% (97/54 857). (2) The 17 patients delivered vaginally (18%,17/97) and 80 by caesarean section (83%,80/97). Forty-nine patients experienced repregnancy with scar uterus (51% , 49/97). About 41 patients underwent abdominal total hysterectomy (42%,41/97) and 56 received subtotal hysterectomy (58%, 56/97). (3) The number of patients were comparable between the two groups (50 vs 47; P > 0.05). (4) The main surgical indication was uterine inertia (45%, 44/97). The main causes of uterine inertia were excessive uterine tension (45%, 20/44) and placental abruption due to gestational hypertension (32%, 14/44). Of all the indications, 29 patients in the first group (58%, 29/50) and 15 patients in the second group (32%, 15/47) suffered from postpartum hemorrhage. Pathological placenta embedment occurred in 15 patients in the first group (30%, 15/50) and 25 patients in the second group (53%, 25/47). The incidences of postpartum hemorrhage due to uterine inertia or pathological placenta embedment were significantly different between the two groups (both P < 0.05), respectively. (5) In the first group, the average preoperative blood loss was (2 900±1 900) ml, and the average intraoperative amount of infused white & red blood cells was (5.9±3.5) U, with the average operation time of (2.2±1.8) hours and the average in-hospital duration of (7.8±2.3) days. In the second group, the average preoperative blood loss was (3 100± 2 200) ml, and the intraoperative amount of infused white & red blood cells was (6.2±5.2) U, with the average operation time of (2.5±2.1) hours and the average in-hospital duration of (7.9±2.9) days. There was no significant difference between the two groups in any of these indicators (P > 0.05). Postpartum hemorrhage was usually treated with uterine packing in the first group, but was preferentially treated with potent uterine contraction agents, arterial ligation, uterine balloon compression or B-Lynch suture in the second group. The therapeutic effects of these new treatments were significantly better than uterine packing (P < 0.05).

CONCLUSIONS

The incidence of emergency obstetric hysterectomy did not change significantly in the past decade. However, the indications and intraoperative interventions have changed significantly in the second five years compared with the first five years. The main surgical indications were uterine inertia and postpartum hemorrhage due to pathological placenta embedment. Therefore, strict control of caesarean section indications was important to reduce emergency obstetric hysterectomy.

Impact of a robotic surgical system on hysterectomy trends

OBJECTIVE

To determine the impact of introduction of a robotic surgical system on hysterectomy trends.

METHODS

A retrospective, cohort study using longitudinal medical records from a tertiary care community hospital was used to determine the surgical approach to hysterectomy. For the purposes of analysis, surgical approaches were categorized as robotically assisted, laparoscopic, laparotomy, vaginal, or laparoscopically assisted vaginal.

RESULTS

A total of 4,440 women underwent a hysterectomy between January 2007 and December 2012 (benign gynecology N = 3,127, gynecologic oncology N = 1,001, urogynecology N = 312). Amongst benign gynecologists, during the five years following introduction of the robotic system, the rate of hysterectomy performed via laparotomy decreased from 62.2 percent to 39.1 percent, p-value < 0.001. The rate of robotically assisted hysterectomy increased from 0.0 percent to 26.4 percent, p-value < 0.001. When subspecialties were examined, the rate of hysterectomy performed by a gynecologic oncologist via laparotomy decreased from 89.7 percent to 20.0 percent, p-value < 0.001. The rate of robotically assisted hysterectomy increased from 0.0 percent to 78.3 percent, p-value < 0.001. Amongst urogynecologists, the rate of hysterectomy performed vaginally decreased from 80.0 percent to 33.6 percent, p-value < 0.001, while the rate of robotically assisted hysterectomy increased from 0.0 percent to 54.2 percent, p-value < 0.001.

CONCLUSIONS

The percentage of robotically assisted hysterectomies has dramatically increased and is now the primary modality for performing hysterectomy amongst subspecialists.

Minimally invasive specialists and rates of laparoscopic hysterectomy

BACKGROUND AND OBJECTIVE

Despite the prevalence of hysterectomy for treatment of benign gynecologic conditions, providers nationwide have been slow to adopt minimally-invasive surgical techniques. Our objective is to investigate the impact of a department for minimally invasive gynecologic surgery (MIGS) on the rate of laparoscopic hysterectomy at an academic community hospital without robotic technology.

METHODS

This retrospective observational study included all patients who underwent hysterectomy for benign indications from January 1, 2004, through December 31, 2012. The primary outcome was route of hysterectomy: open, laparoscopic, or vaginal. Secondary outcomes of interest included length of stay and factors associated with an open procedure.

RESULTS

In 2004, only 24 (8%) of the 292 hysterectomies performed for benign conditions at Newton-Wellesley Hospital (NWH) were laparoscopic. The rate increased to more than 50% (189/365) by 2008, and, in 2012, 72% (316/439) of hysterectomies were performed via a traditional laparoscopic approach. By 2012, more than 93% (411/439) of all hysterectomies were performed in a minimally invasive manner (including total laparoscopic hysterectomy [TLH], laparoscopic supracervical hysterectomy [LSH], total vaginal hysterectomy [TVH], and laparoscopy-assisted vaginal hysterectomy [LAVH]). More than 85% of the hysterectomies at NWH in 2012 were outpatient procedures. By this time, the surgeon's preference or lack of expertise was rarely cited as a factor leading to open hysterectomy.

CONCLUSIONS

A large diverse gynecologic surgery department transformed surgical practice from primarily open hysterectomy to a majority (>72%) performed via the traditional laparoscopic route and a large majority (>93%) performed in a minimally invasive manner in less than 8 years, without the use of robotic technology. This paradigm shift was fueled by patient demand and by MIGS department surgical mentorship for generalist obstetrician/gynecologists.

Complex atypical hyperplasia of the endometrium: differences in outcome following conservative management of pre- and postmenopausal women

OBJECTIVE

To compare the safety and regression rates of conservative treatments for complex atypical hyperplasia (CAH) between pre- and postmenopausal women.

METHODS

Historical cohort study of pre- and postmenopausal women with CAH managed conservatively at one center (Royal Women's Hospital, Melbourne, Australia) between September 1999 to June 2012.

RESULTS

Of the 153 women with CAH, 92 (60%) underwent hysterectomy and the remaining 61 were managed conservatively with oral or intrauterine progestogen: 42 were premenopausal and 19 were postmenopausal. Within 12 months, 32 (76%) premenopausal women demonstrated regression of CAH and none developed endometrial cancer. In contrast, only 4 (21%) postmenopausal women showed disease regression and 4 (21%) progressed to endometrial cancer. Over a median of 24 months, 3 premenopausal women relapsed with CAH and 2 developed endometrial cancer. Four premenopausal women had successful pregnancies.

CONCLUSION

Conservative treatment with progestogen in premenopausal women with CAH leads to high regression rates within the first 12 months. In contrast, postmenopausal women have high rates of ongoing disease and cancer progression and conservative therapy should be avoided.

Trends in the national distribution of laparoscopic hysterectomies from 2003 to 2010

STUDY OBJECTIVE

The purpose of this analysis was to compare the trends in undergoing laparoscopic hysterectomy (versus abdominal or vaginal hysterectomy) based on patient age, race, median income and insurance type, from 2003 to 2010.

DESIGN

Retrospective study (Canadian Task Force classification II-3).

SETTING

National sample of hospital admissions after hysterectomy.

PATIENTS

Health Cost and Utilization Project-Nationwide Inpatient Sample database was used to review records of women who underwent hysterectomy for either menorrhagia or leiomyoma from 2003-2010.

INTERVENTION

The predicted probability of undergoing laparoscopic hysterectomy was determined for each year according to patient age, race, median income, and insurance type. The slopes of these values (i.e. the trend) was compared for each subgroup (i.e. black, white, Asian, etc.) in these categories.

MAIN RESULTS

A total of 530, 154 cases were included in this study. Total number of hysterectomies decreased by 39% from 60,364 to 36,835 from 2003 to 2010. The percent of hysterectomies that were laparoscopic increased from 11% in 2003 to 29% in 2010. All groups analyzed experienced an increase in predicted probability of undergoing a laparoscopic hysterectomy. Of all women undergoing hysterectomy, the probability of undergoing a laparoscopic hysterectomy remained highest for women who were less than 35 years old, white, with the highest median income, and with private insurance from 2003-2010. The slope was significantly greater for (1) white females versus all other races analyzed (p<0.01), (2) females in the highest income quartile versus females in the lowest income quartile (p<0.01) and (3) females with private insurance versus females with Medicaid (p<0.01) or Medicare (p<0.01).

CONCLUSIONS

There remains a gap in distribution of laparoscopic hysterectomies with regards to age, race, median income and insurance type that does not seem to be closing, despite the increased availability of laparoscopic hysterectomies.

Changes in cardiovascular risk factors by hysterectomy status with and without oophorectomy: Study of Women's Health Across the Nation

OBJECTIVES

The aim of this study was to compare the changes in risk factors for cardiovascular disease (CVD) leading up to and after hysterectomy with or without bilateral oophorectomy with the changes observed up to and after natural menopause.

BACKGROUND

Evidence suggests that hysterectomy status with or without bilateral oophorectomy might increase risk for CVD, but most studies retrospectively assess menopausal status.

METHODS

Study of Women's Health across the Nation enrolled 3,302 pre-menopausal women not using hormone therapy between 42 and 52 years of age and followed them annually for over 11 years for sociodemographic characteristics, menopausal status, surgeries, body mass index, medication use, lifestyle factors, lipids, blood pressure, insulin resistance, and hemostatic and inflammatory factors. By 2008, 1,769 women had reached natural menopause, 77 women had a hysterectomy with ovarian conservation, and 106 women had a hysterectomy with bilateral oophorectomy. Piece-wise hierarchical growth models compared these groups on annual changes in CVD risk factors before and after final menstrual period or surgery.

RESULTS

Multivariable analyses showed that annual changes in CVD risk factors did not vary by group, with few exceptions, and the significant group differences that did emerge were not in the anticipated direction.

CONCLUSIONS

Hysterectomy with or without ovarian conservation is not a key determinant of CVD risk factor status either before or after elective surgery in midlife. These results should provide reassurance to women and their clinicians that hysterectomy in midlife is unlikely to accelerate the CVD risk of women.

Hysterectomy surgery trends: a more accurate depiction of the last decade?

OBJECTIVE

The objective of the study was to describe trends in hysterectomy route at a large tertiary center.

STUDY DESIGN

We reviewed all hysterectomies performed at Magee-Womens Hospital from 2000 to 2010. This database was chosen over larger national surveys because it has been tracking laparoscopic procedures since 2000, well before laparoscopic hysterectomy International Classification of Diseases, ninth revision (ICD-9) procedure codes were developed.

RESULTS

There were 13,973 patients included who underwent hysterectomy at Magee-Womens Hospital. In 2000, 3.3% were laparoscopic (LH), 74.5% abdominal (AH), and 22.2% vaginal hysterectomy (VH). By 2010, LH represented 43.5%, AH 36.3%, VH 17.2%, and 3.0% laparoscopic converted to open (LH→AH). Hysterectomies performed for gynecological malignancy represented 24.4% of cases. The average length of stay for benign LH and VH, 1.0 ± 1.0 and 1.6 ± 1.0 days respectively, was significantly shorter than the average 3.1 ± 2.3 day stay associated with AH (P < .001). The average patient age was 46.9 ± 10.9 years for LH, 51.5 ± 12.1 years for AH, and 51.7 ± 14.1 years for VH, and over the study period there was a significant trend of increasing patient age (b1 = 0.517, 0.583, and 0.513, respectively [P < .001 for all]).

CONCLUSION

The percentage of LH increased over the last decade and by 2010 had surpassed AH. The 43.4% LH rate in 2010 is much higher than previously reported in national surveys. This likely is due to an increase in the number of laparoscopic procedures being performed over the last few years as well as the ability of our study to capture LH prior to development of appropriate ICD-9 procedure codes. Our unique ability to determine hysterectomy route, which predates appropriate coding, may provide a more accurate characterization of hysterectomy trends.

Incidence and determinants of peripartum hysterectomy in the metropolitan area of the District of Columbia

OBJECTIVE

To review the impact of the changes that have occurred in the standard of care in obstetrics and in the trend of cesarean delivery rates in recent times and factors associated with peripartum hysterectomy procedure.

STUDY DESIGN

A retrospective analysis of all cases of peripartum hysterectomies among inpatient hospitalizations at 4 major hospitals in the Washington metropolitan areas of the District of Columbia from January 1, 2000, through December 31, 2009, was conducted.

RESULTS

The total number of deliveries and postpartum hysterectomies that occurred at all 4 locations was 150,847 and 128, respectively. The rate of peripartum hysterectomies per 1,000 deliveries was 0.85. Primary and repeat cesarean deliveries, advanced maternal age, obesity, and grand multiparity have direct association with peripartum hysterectomy. Up to 80% of all cases of peripartum hysterectomy are accounted for by class III and IV hemorrhage. Peripartum hysterectomy is associated with increased prevalence of uterine atony, placenta previa, and placenta accreta.

CONCLUSION

Our results suggest that primary and repeat cesarean deliveries, advanced maternal age, obesity, and grand multiparity, uterine atony, placenta previa, and placental accreta, and class III and IV hemorrhage are independently associated with an increased risk for peripartum hysterectomy. These findings may be of concern given the increasing rate of cesarean deliveries in the District.

Total laparoscopic hysterectomy with laparoscopic uterosacral ligament suspension for the treatment of apical pelvic organ prolapse

Pelvic organ prolapse (POP) is a common problem requiring surgical correction in up to 19% of women. Abdominal sacrocolpopexy (SCP) is considered the gold standard treatment for apical POP and has been associated with lower rates of recurrent prolapse and dyspareunia compared with vaginal POP repair procedures. Total laparoscopic hysterectomy (TLH) with concurrent laparoscopic uterosacral ligament (USL) vaginal vault suspension provides a safe and effective alternative technique that has efficacy rates similar to abdominal SCP without the use of synthetic mesh. The uterosacral ligaments provide a strong supportive tissue for vaginal vault suspension that mimics the natural support system of the pelvic floor. The most challenging aspect of the TLH with laparoscopic USL suspension is laparoscopic suturing and intra/extracorporeal knot tying. Developing technologies such as robotics, automatic suturing devices, and new barbed suture materials are now providing simpler, alternative surgical techniques that will hopefully shorten operative times and increase adoption of this surgical procedure by gynecologists. With continued progress and refinement of this technique, the TLH with laparoscopic USL suspension may challenge the current standard of care for surgical treatment of POP.

Trends of myomectomy at the University of Nigeria Teaching Hospital (UNTH) Enugu Nigeria

BACKGROUND

Uterine fibroid is the commonest female genital tumour occurring within the reproductive age group, and abdominal myomectomy is the most offered surgical treatment in our environment. There is need to audit this practice in our centre so as to observe the practice pattern and outcome of myomectomies in Enugu, Nigeria.

OBJECTIVE

To audit myomectomies, the practice pattern and outcome at the University of Nigeria Teaching Hospital Enugu-Nigeria.

METHODS

A 5-year retrospective study of myomectomies performed in UNTH Enugu between January 1, 2004 and December 31, 2008. Data relating to socio-demographic characteristics, indication for surgery, intraoperative haemostatic measures, estimated blood loss, use of drain, duration of hospital stay and complications were abstracted and analyzed.

RESULT

A total of 122 abdominal myomectomies were performed and 70.5% of the patients were aged 30-39 years and 80% were nullipara. Lower abdominal swelling and discomfort were the commonest presentation and indication for the surgery. Tourniquet was used for haemostasis in 57.4% while postoperative drain was inserted in 52.6%. 24.6% received blood transfusion and the average duration of hospital stay was 8.6 days. Complications were mild, with pyrexia as the commonest complication (28.7%). There was no mortality.

CONCLUSION

Though myomectomy is safe and tolerated in our centre, a consensus practice pattern through a prospective study is required to further improve outcome.

Trends over time with commonly performed obstetric and gynecologic inpatient procedures

OBJECTIVES

To estimate trends over time in inpatient obstetric and gynecologic surgical procedures, and to estimate commonly performed obstetric and gynecologic surgical procedures across a woman's lifespan.

METHODS

Data were collected for procedures in adult women from 1979 to 2006 using the National Hospital Discharge Survey, a federal discharge dataset of U.S. inpatient hospitals, including patient and hospital demographics and International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for adult women from 1979 to 2006. Age-adjusted rates per 1,000 women were created using 1990 U.S. Census data. Procedural trends over time were assessed.

RESULTS

More than 137 million obstetric and gynecologic procedures were performed, comprising 26.5% of surgical procedures for adult women. Sixty-four percent were only obstetric and 29% were only gynecologic, with 7% of women undergoing both obstetric and gynecologic procedures during the same hospitalization. Obstetric and gynecologic procedures decreased from approximately 5,351,000 in 1979 to 4,949,000 in 2006. Both operative vaginal delivery and episiotomy rates decreased, whereas spontaneous vaginal delivery and cesarean delivery rates increased. All gynecologic procedure rates decreased during the study period, with the exception of incontinence procedures, which increased. Common procedures by age group differed across a woman's lifetime.

CONCLUSION

Inpatient obstetric and gynecologic procedures rates decreased from 1979 to 2006. Inpatient obstetric and gynecologic procedure rates are decreasing over time but still comprise a large proportion of inpatient surgical procedures for U.S. women.

LEVEL OF EVIDENCE

III.

Changing routes of hysterectomy: a cross sectional and comparative study

Hysterectomy is one of the most frequently performed major surgical procedure in women. Traditionally, the uterus has been removed either by abdominal or vaginal route. In spite of the recommendations in favor of vaginal hysterectomy majority of the hysterectomies are still done by the means of abdominal route and vaginal route is utilized mostly for prolapsed uterus. This study was done to see the current trend of routes of hysterectomy for benign condition at Kathmandu Medical College Teaching Hospital and its indication. This was a cross-sectional and comparative study done for 24 months (Jan 2008- Dec 2009). Data for the year 2009 was collected prospectively and for the year 2008 case notes of all the cases of hysterectomy was reviewed. Total 317 cases of hysterectomy were done for benign condition in KMCTH during the 2 year study period. Of the 317 cases 124 was done during the year 2008 and 193 during 2009. Three major route namely vaginal hysterectomy (VH), Abdominal Hysterectomy (AH), and Laparoscopic hysterectomy (LH) was utilized for performing hysterectomy. Major indication for hysterectomy was pelvic organ prolapse (POP) followed by abnormal uterine bleeding (AUB), and fibroid uterus during both the years. Route of hysterectomy in the cases with non prolapsed pelvic organ were AH (94.0%) and LH (6.0%) during the year 2008 and VH (6.0%), AH (76%) and LH (18.0%) during the year 2009. Major indications for hysterectomy are POP, AUB, and fibroid uterus. VH is mainly done for the cases of POP. AH is still the major route for indications other than POP. Minimally invasive approach like VH for non descent uterus and LH although is rising needs to be practiced more.

Impact of robotic surgery on obstetric-gynecologic resident training

OBJECTIVE

To compare the volume and type of surgical techniques for hysterectomies performed prior to and after the introduction of robotic surgery at our institution and to assess the potential impact on obstetric-gynecologic resident training.

STUDY DESIGN

A retrospective study examined the number and types of hysterectomies performed at our institution during the 18 months prior to, and the 18 months after, the introduction of a robotic surgical system. Procedures performed during both time periods were compared by number and percentage using the chi2 or Fisher's exact test for counts < 5.

RESULTS

A total of 903 hysterectomies were performed from July 1, 2005, to July 1, 2008. There were 444 hysterectomies in the prerobotic surgical system group and 459 hysterectomies in the postrobotic surgical system group. There was a statistically significant decrease in the number of laparoscopically assisted vaginal hysterectomies (94 vs. 36; p < 0.001) and total abdominal hysterectomies (249 vs. 203; p < 0.001) performed.

CONCLUSION

This study demonstrated a significant impact on the volume and type of surgical techniques for hysterectomies performed prior to and after the introduction of robotic surgery at our institution. This observation may have direct consequences for obstetric-gynecologic resident surgical experience.

[Surgery of the cancer of uterine neck. Past, present and future]

The evolution of the surgery of the cancer of cervix has passed for several stages. First the boarding was indisputably vaginal. Thanks to the anestesea, antibioterapia and trasfusion was produced a change that has come to our days to the abdominal route with Wertheim Meigs's intervention. From 1987 Dargent he introduced the route laparoscopica, the conservative surgery and the return to the vaginal boarding. Today the robotic surgery is imposed with the Da Vinci.

Discussion: 'Physician gender, specialty, and hysterectomy utilization' by Gretz et al

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Gretz H, Bradley WH, Zakashansky K, et al. Effect of physician gender and specialty on utilization of hysterectomy in New York, 2001-2005. Am J Obstet Gynecol 2008;199:347.e1-347.e6.

Gravid hysterectomy: a decade of experience at an academic referral center

OBJECTIVE

To evaluate the incidence of gravid hysterectomy (GH) and to examine the indications as well as risk factors and complications associated with the procedure at an academic perinatal referral center.

STUDY DESIGN

Retrospective chart review of all patients who underwent GH from 1991 to 2001. Demographics, obstetric history, delivery information, complications and outcome were analyzed.

RESULTS

There were 34 GHs out of 19,491 deliveries (1.74/1000). The preoperative indications were hemorrhage associated with atony (32.4%), placenta accreta (20.6%) and uncontrolled bleeding (17.6%). Of the patients, 87.5% were parous and 53.1% had previous cesarean section. GH was performed prior to viability in 3. GH followed cesarean delivery in 24 (68.6%). Uterine and/or hypogastric artery ligation were performed in 11 (32.4%). Postoperative complications included surgical re-exploration for recurrent hemorrhage in 5, transfusion of blood products in 30, disseminated intravascular coagulopathy in 15, prolonged (> 24 hours) ventilation in 10 and admission to the SICU for prolonged intensive care in 12. There were 2 maternal deaths (5.9%). A significant rise in GH rate from 1/800 to 1/299 occurred over the past 5 years despite constant cesarean rates (chi2, p < 0.05).

CONCLUSION

Rates of GH increased over the period examined. Placenta accreta associated with previous cesarean section is the predominant risk factor for GH.

Caesarean section in countries of the Eastern Mediterranean Region

This paper reviews global data on caesarean section (CS) focusing on Eastern Mediterranean Region (EMR) countries for which data could be obtained. CS rates in the EMR tend to average around 10%. The data, however, are often not representative of the whole country, being mostly hospital rather than community based. Global and regional CS trends, determinants, and outcomes are presented. Controversies and consensus over the indications for CS are reviewed. The cost of rising CS rates, women's involvement in decision-making, the role of health workers, data quality and legal aspects are highlighted, with discussion of the aim of reducing unduly high CS rates and promoting high-quality maternity care.

Hysterectomy surveillance in the United States, 1997 through 2005

BACKGROUND

To identify patterns and trends in hysterectomy from 1997 through 2005.

MATERIAL/METHODS

Analyses are based on hysterectomy prevalence data from the Behavior Risk Factor Surveillance System, hysterectomy incidence data from the National Hospital Discharge Survey, and population estimates from the US Census Bureau.

RESULTS

Hysterectomy rates significantly decreased 1.9% per year between 1997 and 2005 (-0.5% for ages 18-44, -3.1% for ages 45-64, and -5.0% for ages 65 years and older). The estimated annual decrease in rates was significant in the Northeast (-2.9%), Northwest (-1.7%), and South (-2.6%), but not in the West. For hysterectomies performed among women ages 18-44 years, the percentage in 1997-98 compared with 2004-05 resulting from leiomyoma (fibroids) decreased (31.4% vs. 26.9%), from uterine bleeding increased (14.6% vs. 25.2%), from endometriosis decreased (17.3% in vs. 16.2%), and from pain increased (10.4% vs. 11.7%); the most common procedure, total abdominal hysterectomy, decreased (65.0% vs. 60.5%), the second most common procedure, vaginal hysterectomy, decreased (32.0% vs. 30.7%), and the third most common procedure, subtotal hysterectomy, increased (1.6% in 1997-98 and 7.5% in 2004-05). Decreases in hysterectomy rates occurred for most of the reproductive health conditions resulting in hysterectomy. Exceptions included pain and bleeding in the age group 18-44 and bleeding in the age group 45-64. An increase occurred in subtotal abdominal hysterectomy rates in each of the age groups.

CONCLUSIONS

Continued monitoring of hysterectomy rates provides an indication of female reproductive health and how women are being treated for selected reproductive problems.

Nerve-sparing radical hysterectomy in cervical cancer: Evolution of concepts

OBJECTIVES

This paper reviews the evolution of concepts concerning the nerve-sparing radical hysterectomy (NSRH) in cervical cancer.

METHODS

Research studies published between 1991 and 2006 were reviewed.

RESULTS

Significant progress has been made in understanding the neuroanatomy and the neurophysiology of autonomic pelvic plexus. The ideal surgical management of cervical cancer patients should be tailored on the basis of prognostic factors and quality of life. Within the discussion concerning the optimal level of radicality of hysterectomy, which is still controversial, the new concept of NSRH has to be considered in order to reduce morbidity without compromising the oncological disease control. Surgical strategies have been developed to spare the autonomic functions with promising results.

CONCLUSIONS

To date, there is a growing body of data about NSRH in cervical cancer. However, there is not yet a consensus concerning to which part of uterine support ligaments a NS approach should be directed.

[Hemostatic hysterectomy in modern obstetrics]

Haemostatic hysterectomies have been performed for the first time in the XIXth century to reduce the increased maternal mortality and associated morbidity. In Romania the main cause of death through direct obstetrical risk (DOR) is the haemorrhagic syndrome, with a value of 45% of the total number of deaths in the last 15 -16 years, a lot higher then the world average of 25% as evaluated by OMS. Among the deaths due to hemorrhagic syndrome 43% is held by antepartum haemorrhage (placenta praevia, utero-placental apoplexy) and 42% by postpartum haemorrhage.

RESULTS

In the past 15 years (1990 - 2005) there have been studied 53,870 births, out of which only 60 have had haemostatic hysterectomy, representing 0.11% of the total number of births. The prevalence of haemostatic hysterectomy is only 1 in every 883 births as a result of surgical teams' efforts to preserve the uterus. The placental pathology (30%) is responsible for most of haemostatic hysterectomy indications. Out of 60 cases under study, none ended with maternal death, while 11 cases ended with fetal death (intrapartum or postpartum).

CONCLUSIONS

Morbidity and maternal death can be reduced by effective prenatal care, by identifying high risk patients and by the possibility of caesarean section. Haemostatic hysterectomy remains, in essence, a life saving procedure!

Influence of hysterectomy on long-term fracture risk

OBJECTIVE

To assess long-term fracture risk after hysterectomy, with or without oophorectomy.

DESIGN

Population-based, cohort study.

SETTING

Olmsted County, Minnesota.

PATIENT(S)

Women residing in Olmsted County (n = 9,258) who underwent hysterectomy in 1965-2002, compared to an equal number of age- and sex-matched community controls.

INTERVENTION(S)

Observational study of the effect of hysterectomy for various indications on subsequent fractures.

MAIN OUTCOME MEASURE(S)

Fractures of any type, and at osteoporotic sites (e.g., hip, spine, or wrist) alone, as assessed by electronic review of inpatient and outpatient diagnoses in the community.

RESULT(S)

Compared with controls, there was a significant increase (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.13-1.29) in overall fracture risk among the women with a hysterectomy, but osteoporotic fracture risk was not elevated (HR, 1.09; 95% CI, 0.98-1.22). Most hysterectomy indications were associated with fractures generally, although these were not often statistically significant. Only operations for a uterine prolapse were associated with osteoporotic fractures (HR, 1.33; 95% CI, 1.01-1.74). Oophorectomy was not an independent predictor of fracture risk (HR, 1.0; 95% CI, 0.98-1.15).

CONCLUSION(S)

Hysterectomy does not appear to pose much long-term risk for fractures, but the association of fractures with surgery for uterine prolapse deserves further attention.

Changes in rates of hysterectomy and uterine conserving procedures for treatment of uterine leiomyoma

OBJECTIVE

The purpose of this study was to investigate treatment of uterine leiomyoma by hysterectomy and uterine conserving procedures (UCPs).

STUDY DESIGN

Data from Kaiser Permanente Northern California members undergoing hysterectomy, myomectomy, uterine artery embolization (UAE) and endometrial ablation (EA) for uterine leiomyoma from 1997-2003 were collected. Statistical analysis included trend tests and survival analysis.

RESULTS

Hysterectomy rates for leiomyoma decreased significantly from 2.13 per 1000 to 1.91 (P < .0001). Rates for myomectomy (.4-.37) and EA (.26-.27) remained stable (P = .17 and .26, respectively), whereas rates for UAE increased significantly from < .01-.24 (P < .0001). The combined rates for hysterectomy and UCPs remained stable at 2.79 (P = .95). Rate of hysterectomy after UCP increased over time, and at 6 years reached 11.5%, 17.7%, and 7.9% for EA, UAE, and myomectomy, respectively.

CONCLUSION

Whereas rate of hysterectomy for leiomyoma decreased, total rate of invasive treatment remained stable. Increase in rate of UAE had the greatest impact on treatment, possibly replacing hysterectomy.

Decreasing utilization of hysterectomy: a population-based study in Olmsted County, Minnesota, 1965-2002

OBJECTIVE

The purpose of this study was to assess temporal trends for hysterectomy among Olmsted County, Minnesota women.

STUDY DESIGN

Using the Rochester Epidemiology Project database, we identified all county residents undergoing a hysterectomy in 1965-2002. Temporal changes in the utilization (incidence) rate, type, diagnostic indications, and age at surgery were assessed.

RESULTS

Between 1965 and 2002, 6152 women had a hysterectomy alone, whereas 3126 women had, in addition, a pelvic floor repair; the age-adjusted utilization rate for hysterectomy alone and for combined procedures declined (P < .0001) by 13% and 63%, respectively. Except for subjects aged 75-85 years, this decline affected every age group. The distribution of vaginal (56%) and abdominal (44%) procedures differed across indications. Uterine leiomyomata, precancerous conditions, and genital prolapse accounted for 28%, 23%, and 12% of all procedures, respectively.

CONCLUSION

Among community women, the utilization rate, age distribution, and indications for a hysterectomy changed substantially between 1965 and 2002.

Changing hysterectomy technique from open abdominal to laparoscopic: New trend in Oslo, Norway

STUDY OBJECTIVE

To evaluate the change in hysterectomy technique.

DESIGN

Retrospective study (Canadian Task Force classification XXX).

SETTING

University tertiary referring center in Norway.

PATIENTS

A total of 1963 women treated with hysterectomy over a 5-year period in Oslo.

INTERVENTIONS

The operative records and techniques were investigated in all treated patients.

MEASUREMENTS AND MAIN RESULTS

A total of 1963 hysterectomies were performed from 2001 through 2005. The operative patient records were investigated with the main focus on indication for surgery and the technique used in the operative procedure. In 2001, 62 (17.7%) laparoscopic hysterectomies were performed, while 256 (73.1%) of the hysterectomies were done with laparotomy. The operative technique has gradually changed during the last 5 years. In 2005, 220 (53.5%) of the surgical procedures were laparoscopic, 177 (43.1%) were done by laparotomy, while the vaginal approach in all these years was less than 10%.

CONCLUSION

From 2001 to 2005, a trend shift of the operative technique has been observed in Oslo, increasing the endoscopic hysterectomy rate from approximately 18% to 54%. During the same time, enlarged uteri with myomas equivalent to 10 to 12 weeks' gestation and endometrial cancer were more often treated by laparoscopic hysterectomy instead of open abdominal hysterectomy. With modern equipment and trained staff, more routine hysterectomies can be managed with laparoscopy.

Hysterectomy in the 21st Century: Different Approaches, Different Challenges

The final decision to perform a certain method of hysterectomy customarily mirrors experience and level of comfort with a particular surgical approach in the context of the patient's condition and indication for surgery. Given the morbidity and recovery associated with a laparotomic incision, every effort should be made to avoid abdominal hysterectomy. The best available evidence points to the advantage of the vaginal approach over other methods of hysterectomy for benign conditions. Regrettably, the state of education in residency programs is not providing a level of surgical competency to meet this charge. Whenever vaginal surgery is not an option, laparoscopically assisted hysterectomy offers the best alternative. Although the promises of supracervical hysterectomy have yet to be demonstrated, laparoscopic supracervical hysterectomy may offer the least morbid alternative to vaginal hysterectomy.

The Evolution of Uterine Surgery

Although described in antiquity, the real dawn of uterine surgery was in the mid-19th century when hysterectomy was occasionally performed vaginally, usually for cancer or prolapse. Then, as now, women experienced symptoms of bleeding and pain emanating from the uterus, and when severe and debilitating, brave surgeons and patients sometimes explored hysterectomy as an alternative. Abdominal hysterectomy mortality rates in the mid-1850s were extremely high, but reduced drastically in the early to mid-20th century. By the 1950s, total hysterectomy supplanted supracervical techniques, largely as a method for preventing carcinoma of the cervix. Surgical alternatives to hysterectomy started in the 1930s with abdominal myomectomy and the first publication of nonhysteroscopic endometrial ablation from Germany, but by the end of the 20th century, included a plethora of techniques including laparoscopic, hysteroscopic, and interventional radiologic approaches. The advent of early detection of, and even prevention of, preinvasive cervical neoplasia, has led to a reevaluation of the need for total hysterectomy in many patients. In the early years of the millennium, targeted leiomyoma therapy was under development with a range of energy sources including cryogenic and radiofrequency probes, as well as focused ultrasound, targeted and controlled by magnetic resonance imaging.

Hysterectomy Rates for Benign Indications

OBJECTIVE

To investigate the annual rates, types, and indications for hysterectomies performed for benign disease in Kaiser Permanente Northern California from 1994 to 2003.

METHODS

All women, 20 years or age or older, who were undergoing hysterectomy for benign indications in Kaiser Permanente Northern California from 1994 to 2003 were identified. We analyzed hysterectomy rates by type, indication, and age group. Changes over time were analyzed with the Cochran-Armitage test for linear trend.

RESULTS

From 1994 to 2003, there were 32,321 hysterectomies performed for benign indications. Hysterectomy rates showed a significant decline, from 4.01 per 1,000 women in 1994 to 3.41 per 1,000 women in 2003 (P for trend < .001). The relative proportions of all hysterectomies performed as laparoscopically assisted vaginal hysterectomy (LAVH) peaked at 13.0% in 1995 and then steadily declined to 3.9% in 2003 (P for trend < .001), whereas the relative proportion of subtotal abdominal hysterectomy increased from 6.9% in 1994 to 20.8% in 2003 (P for trend < .001). Hysterectomy rates declined 11.2% for uterine leiomyoma (relative risk [RR] 0.89, 95% confidence interval [CI] 0.83-0.95), 33.1% for endometriosis (RR 0.67, 95% CI 0.59-0.76), and 18.6% for uterine prolapse (RR 0.81, 95% CI 0.72-0.92). The relative proportion performed for uterine leiomyoma was consistently greater than for all other indications combined.

CONCLUSION

The rates of hysterectomy for benign indications are decreasing. The type of hysterectomy changed significantly, with LAVH performed less frequently and subtotal abdominal hysterectomy increasing in popularity. Uterine leiomyoma remains the most common indication for benign hysterectomy.

LEVEL OF EVIDENCE

II-2.

Obstetric hysterectomy: changing trends over 20 years in a multiethnic high risk population

The aim of this study was to determine the demographics, indication and complications of emergency postpartum hysterectomy in a multiethnic high-risk obstetric population and to assess if there is a change in trend between 1983 and 2003. Eighteen women underwent postpartum hysterectomies in the 20 year period (prevalence 0.028%) and there were two maternal deaths. Overall, 77% of the postpartum hysterectomies were performed for intractable haemorrhage following caesarean section (CS). There is a statistically significant threefold increase (Mann-Whitney test, p=0.007) in the prevalence of emergency postpartum hysterectomies between 1994 and 2003 as compared to the previous 10 years between 1983 and 1993 despite the introduction of new pharmacological agents and conservative surgical techniques. Subtotal abdominal hysterectomy appears to be the procedure of choice in the more recent 10 years (60% of cases between 1994 and 2003 compared to 25% of cases between 1983 and 1993). Previous Caesarean section, advancing maternal age, abnormal placentation (including placenta praevia) appear to be risk factors for postpartum hysterectomy. Women of black African origin appear to be more at risk for hysterectomy compared to women of other ethinicity.

Utilization of diagnostic studies in the pretreatment evaluation of invasive cervical cancer in the United States: results of intergroup protocol ACRIN 6651/GOG 183

PURPOSE

To review the current utilization of diagnostic tests prescribed by the International Federation of Gynecology and Obstetrics (FIGO) clinical staging guidelines in the pretreatment work-up of invasive cervical cancer, and to compare the data with those of previous patterns of care studies.

PATIENTS AND METHODS

This interdisciplinary American College of Radiology Imaging Network/Gynecologic Oncology Group prospective clinical trial was conducted between March 1, 2000, and November 11, 2002. Twenty-five participating institutions, all from the United States, enrolled a total of 208 patients. Only patients scheduled for surgery with biopsy-confirmed cervical cancer of clinical FIGO stage IB or higher were eligible. The patterns of care data analysis was based on 197 patients who met all inclusion criteria. The conventional FIGO-recommended tests used for pre-enrollment FIGO clinical stage classification were at the discretion of the treating physician; overall frequency of use was tabulated for each test.

RESULTS

Use of cystoscopy (8.1%) and sigmoidoscopy or proctoscopy (8.6%) was significantly lower than in 1988 to 1989 (P < .0001 in each instance). Intravenous urography was used in only 1% of patients as compared with 42% in 1988 to 1989 and 91% in 1983. No patient included in the data analysis had barium enema or lymphangiography. Only 26.9% of patients had examination under anesthesia for FIGO clinical staging.

CONCLUSION

There is a large discrepancy between the diagnostic tests recommended by FIGO and the actual tests used for cervical cancer staging, suggesting a need to reassess the relevance of the FIGO guidelines to current clinical practice in the United States.

Hysterectomy: evolution and trends

Hysterectomy was mentioned in Greek manuscripts 2000 years ago, but there is no proof that it was performed. Early--usually fatal--attempts at vaginal hysterectomy are recorded from the 16th century. The origins of vaginal and abdominal hysterectomy are traced from the 19th century after the pioneering work of Langenbeck and Clay. Advances in anaesthesia, blood transfusion, antibiotics and surgical technique led to hysterectomy becoming the second most common operation in women. In the first part of the 20th century subtotal abdominal hysterectomy was standard, but by the 1950s this was replaced by total abdominal hysterectomy. There has been a recent, albeit minor, resurgence of interest in subtotal hysterectomy. The development of laparoscopic assisted hysterectomy in the 1990s has, ironically, led to the re-emergence of standard vaginal hysterectomy as the method of choice for most cases of benign gynaecological disease requiring hysterectomy. At the start of the 21st century there are signs that alternatives to hysterectomy-such as hysteroscopic surgery, uterine fibroid embolization, and the levonorgestrel intrauterine device-are leading to a reduction in hysterectomy rates.

Radical hysterectomy: past, present, and future

After an analysis of 3,441 radical hysterectomies performed in our department, we found, after modification of the operative technique in 1983, the more lateral the excision the less the recurrence rate. The recurrence rate for Stage 1b-2a and Stage 2b patients comparing the years before 1983 to the years after decreased to 12.4% from 15.7% (158/1,006 vs 268/2,163; p = 0.009) in Stage 1b-2a and 24.6% from 55.8% (38/68 vs 47/191; p = 0.0007) in Stage 2b, respectively. With the modern trend of aspiring for an easier lifestyle, most physicians practice earlier. Therefore only very few physicians study radical hysterectomy. As the skill of surgery needs a longer period of education and training, it may only interest physicians who work with medical professionals as part of a team at a medical center. In the future, we should provide gynecological residents not only with a training program using the classic textbooks, but also with different points of view on changes and developments in radical hysterectomy. We hope to promote an attitude of offering patients access to different choices and opportunities of therapy. Radical hysterectomy is in fact a treatment option for patients with bulky cervical lesions and Stage 2b in particular.

Extent of radical hysterectomy: evolving emphasis

OBJECTIVE

As with other oncologic operations, the indications for and the technique of radical hysterectomy for cervical cancer has changed considerably since its initial conception in the late 19th century. This paper reviews the evolution of concepts concerning the extent of radical hysterectomy for cervical cancer.

METHODS

A Medline literature search was performed through looking for articles published in the English language that related to radical hysterectomy for cervical cancer. Specific subjects that were searched included technique, morbidity, and histopathologic assessment of the parametria.

RESULTS

Initial emphasis on local control and potential long-term survival gradually shifted to reduction of mortality and serious morbidity. Early refinements directed attention to the regional lymph nodes, definition of prognostic factors, and determination of the population of patients best suited for the operation. During the mid to late 20th century, a better understanding of regional and local prognostic factors helped clarify the role of adjuvant treatment following radical hysterectomy. By the mid 20th century, the mortality and serious morbidity rates had fallen substantially, and attention turned to reduction of other types of morbidity, especially urinary bladder voiding dysfunction. Reduction of much of the serious morbidity (urinary fistulas) and voiding dysfunction has been related to modifications of the extent of radical hysterectomy. Specific nerve-sparing techniques now have been described. However, maintaining full radicality continues to be emphasized at some centers.

CONCLUSION

The current primary operative approaches to stage 1B cervical cancer include full radical hysterectomy, modified radical hysterectomy followed by adjuvant therapy in selected patients, radical hysterectomy with nerve-sparing, and individualization of surgical management. Studies are needed which further elucidate the significance of parametrial micrometastases, further define and refine broadly feasible nerve-sparing techniques, and more accurately preoperatively identify low and high risk cervical tumors. Optimally, these studies will remove adjuvant treatment as a confounding variable.