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Vila Rabell M, Barri Soldevila P. Papel de la histerectomía en el sangrado uterino anormal. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2022.100815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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2
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Quality of Life after Risk-Reducing Hysterectomy for Endometrial Cancer Prevention: A Systematic Review. Cancers (Basel) 2022; 14:cancers14235832. [PMID: 36497314 PMCID: PMC9736914 DOI: 10.3390/cancers14235832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Risk-reducing hysterectomy (RRH) is the gold-standard prevention for endometrial cancer (EC). Knowledge of the impact on quality-of-life (QoL) is crucial for decision-making. This systematic review aims to summarise the evidence. METHODS We searched major databases until July 2022 (CRD42022347631). Given the paucity of data on RRH, we also included hysterectomy as treatment for benign disease. We used validated quality-assessment tools, and performed qualitative synthesis of QoL outcomes. RESULTS Four studies (64 patients) reported on RRH, 25 studies (1268 patients) on hysterectomy as treatment for uterine bleeding. There was moderate risk-of-bias in many studies. Following RRH, three qualitative studies found substantially lowered cancer-worry, with no decision-regret. Oophorectomy (for ovarian cancer prevention) severely impaired menopause-specific QoL and sexual-function, particularly without hormone-replacement. Quantitative studies supported these results, finding low distress and generally high satisfaction. Hysterectomy as treatment of bleeding improved QoL, resulted in high satisfaction, and no change or improvements in sexual and urinary function, although small numbers reported worsening. CONCLUSIONS There is very limited evidence on QoL after RRH. Whilst there are benefits, most adverse consequences arise from oophorectomy. Benign hysterectomy allows for some limited comparison; however, more research is needed for outcomes in the population of women at increased EC-risk.
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Beckenbodeninsuffizienz und Sexualität aus gynäkologischer Sicht. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00552-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Utama BI. A case report of modified Porro caesarean hysterectomy on mother with hemorrhagic shock and severe anemia due to placental abruption. Int J Surg Case Rep 2021; 79:135-137. [PMID: 33460885 PMCID: PMC7817426 DOI: 10.1016/j.ijscr.2020.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Modified Porro caesarean hysterectomy is an operation technique that is used in management of emergency obstetric complication in the presence of life threatening hemorrhage. This technique was developed by Eduardo Porro in 1876 consisting of uterine corpus amputation after caesarean section and suturing of the cervical stump into the abdominal wall incision. CASE A G6P4, 44-year-old woman with 30-31 weeks of gestation referred presented with heavy vaginal bleeding since 8 h. She was unconscious, her vital sign: Blood Pressure 90/70mmhg. Obstetric examination revealed fundal height corresponding to 26 weeks gestation, single fetus with transverse lie with hand presentation, fetal heart didn't found. Per vaginal examination showed cervical dilation of 4 cm, ongoing heavy bleeding from canalis cervicalis. Arm was felt on vaginal toucher. Her hemoglobin was 6.3g/dL. Emergency caesarean section was planned. After the peritoneum was opened, hematoma in the uterus was found and the blood pressure dropped to 60/30 the team was decided to perform modified Porro caesarean hysterectomy, hysterectomy was performed without delivering the baby. Patient was hospitalized for 4 days before discharged. CONCLUSION The primary concern of modified Porro cesarean hysterectomy is to save the mother by shorten the operation and stop the bleeding quickly.
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Affiliation(s)
- Bobby Indra Utama
- Obstetric and Gynecology Department, Andalas University, Indonesia; Reksoediwiryo Soldier Hospital, Padang, Indonesia.
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Cooper K, Breeman S, Scott NW, Scotland G, Hernández R, Clark TJ, Hawe J, Hawthorn R, Phillips K, Wileman S, McCormack K, Norrie J, Bhattacharya S. Laparoscopic supracervical hysterectomy compared with second-generation endometrial ablation for heavy menstrual bleeding: the HEALTH RCT. Health Technol Assess 2020; 23:1-108. [PMID: 31577219 DOI: 10.3310/hta23530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is a common problem that affects many British women. When initial medical treatment is unsuccessful, the National Institute for Health and Care Excellence recommends surgical options such as endometrial ablation (EA) or hysterectomy. Although clinically and economically more effective than EA, total hysterectomy necessitates a longer hospital stay and is associated with slower recovery and a higher risk of complications. Improvements in endoscopic equipment and training have made laparoscopic supracervical hysterectomy (LASH) accessible to most gynaecologists. This operation could preserve the advantages of total hysterectomy and reduce the risk of complications. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of LASH with second-generation EA in women with HMB. DESIGN A parallel-group, multicentre, randomised controlled trial. Allocation was by remote web-based randomisation (1 : 1 ratio). Surgeons and participants were not blinded to the allocated procedure. SETTING Thirty-one UK secondary and tertiary hospitals. PARTICIPANTS Women aged < 50 years with HMB. Exclusion criteria included plans to conceive; endometrial atypia; abnormal cytology; uterine cavity size > 11 cm; any fibroids > 3 cm; contraindications to laparoscopic surgery; previous EA; and inability to give informed consent or complete trial paperwork. INTERVENTIONS LASH compared with second-generation EA. MAIN OUTCOME MEASURES Co-primary clinical outcome measures were (1) patient satisfaction and (2) Menorrhagia Multi-Attribute Quality-of-Life Scale (MMAS) score at 15 months post randomisation. The primary economic outcome was incremental cost (NHS perspective) per quality-adjusted life-year (QALY) gained. RESULTS A total of 330 participants were randomised to each group (total n = 660). Women randomised to LASH were more likely to be satisfied with their treatment than those randomised to EA (97.1% vs. 87.1%) [adjusted difference in proportions 0.10, 95% confidence interval (CI) 0.05 to 0.15; adjusted odds ratio (OR) from ordinal logistic regression (OLR) 2.53, 95% CI 1.83 to 3.48; p < 0.001]. Women randomised to LASH were also more likely to have the best possible MMAS score of 100 (68.7% vs. 54.5%) (adjusted difference in proportions 0.13, 95% CI 0.04 to 0.23; adjusted OR from OLR 1.87, 95% CI 1.31 to 2.67; p = 0.001). Serious adverse event rates were low and similar in both groups (4.5% vs. 3.6%). There was a significant difference in adjusted mean costs between LASH (£2886) and EA (£1282) at 15 months, but no significant difference in QALYs. Based on an extrapolation of expected differences in cost and QALYs out to 10 years, LASH cost an additional £1362 for an average QALY gain of 0.11, equating to an incremental cost-effectiveness ratio of £12,314 per QALY. Probabilities of cost-effectiveness were 53%, 71% and 80% at cost-effectiveness thresholds of £13,000, £20,000 and £30,000 per QALY gained, respectively. LIMITATIONS Follow-up data beyond 15 months post randomisation are not available to inform cost-effectiveness. CONCLUSION LASH is superior to EA in terms of clinical effectiveness. EA is less costly in the short term, but expected higher retreatment rates mean that LASH could be considered cost-effective by 10 years post procedure. FUTURE WORK Retreatment rates, satisfaction and quality-of-life scores at 10-year follow-up will help to inform long-term cost-effectiveness. TRIAI REGISTRATION Current Controlled Trials ISRCTN49013893. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 53. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kevin Cooper
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Suzanne Breeman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Neil W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - T Justin Clark
- Birmingham Women's NHS Foundation Trust, Birmingham Women's Hospital, Birmingham, UK
| | - Jed Hawe
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Robert Hawthorn
- NHS Greater Glasgow and Clyde, Southern General Hospital, Glasgow, UK
| | - Kevin Phillips
- Hull and East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Kirsty McCormack
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Edinburgh, UK
| | - Siladitya Bhattacharya
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK.,Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Cooper K, Breeman S, Scott NW, Scotland G, Clark J, Hawe J, Hawthorn R, Phillips K, MacLennan G, Wileman S, McCormack K, Hernández R, Norrie J, Bhattacharya S. Laparoscopic supracervical hysterectomy versus endometrial ablation for women with heavy menstrual bleeding (HEALTH): a parallel-group, open-label, randomised controlled trial. Lancet 2019; 394:1425-1436. [PMID: 31522846 PMCID: PMC6891255 DOI: 10.1016/s0140-6736(19)31790-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/21/2019] [Accepted: 07/12/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Heavy menstrual bleeding affects 25% of women in the UK, many of whom require surgery to treat it. Hysterectomy is effective but has more complications than endometrial ablation, which is less invasive but ultimately leads to hysterectomy in 20% of women. We compared laparoscopic supracervical hysterectomy with endometrial ablation in women seeking surgical treatment for heavy menstrual bleeding. METHODS In this parallel-group, multicentre, open-label, randomised controlled trial in 31 hospitals in the UK, women younger than 50 years who were referred to a gynaecologist for surgical treatment of heavy menstrual bleeding and who were eligible for endometrial ablation were randomly allocated (1:1) to either laparoscopic supracervical hysterectomy or second generation endometrial ablation. Women were randomly assigned by either an interactive voice response telephone system or an internet-based application with a minimisation algorithm based on centre and age group (<40 years vs ≥40 years). Laparoscopic supracervical hysterectomy involves laparoscopic (keyhole) surgery to remove the upper part of the uterus (the body) containing the endometrium. Endometrial ablation aims to treat heavy menstrual bleeding by destroying the endometrium, which is responsible for heavy periods. The co-primary clinical outcomes were patient satisfaction and condition-specific quality of life, measured with the menorrhagia multi-attribute quality of life scale (MMAS), assessed at 15 months after randomisation. Our analysis was based on the intention-to-treat principle. The trial was registered with the ISRCTN registry, number ISRCTN49013893. FINDINGS Between May 21, 2014, and March 28, 2017, we enrolled and randomly assigned 660 women (330 in each group). 616 (93%) of 660 women were operated on within the study period, 588 (95%) of whom received the allocated procedure and 28 (5%) of whom had an alternative surgery. At 15 months after randomisation, more women allocated to laparoscopic supracervical hysterectomy were satisfied with their operation compared with those in the endometrial ablation group (270 [97%] of 278 women vs 244 [87%] of 280 women; adjusted percentage difference 9·8, 95% CI 5·1-14·5; adjusted odds ratio [OR] 2·53, 95% CI 1·83-3·48; p<0·0001). Women randomly assigned to laparoscopic supracervical hysterectomy were also more likely to have the best possible MMAS score of 100 than women assigned to endometrial ablation (180 [69%] of 262 women vs 146 [54%] of 268 women; adjusted percentage difference 13·3, 95% CI 3·8-22·8; adjusted OR 1·87, 95% CI 1·31-2·67; p=0·00058). 14 (5%) of 309 women in the laparoscopic supracervical hysterectomy group and 11 (4%) of 307 women in the endometrial ablation group had at least one serious adverse event (adjusted OR 1·30, 95% CI 0·56-3·02; p=0·54). INTERPRETATION Laparoscopic supracervical hysterectomy is superior to endometrial ablation in terms of clinical effectiveness and has a similar proportion of complications, but takes longer to perform and is associated with a longer recovery. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Kevin Cooper
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK.
| | - Suzanne Breeman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Neil W Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK; Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Justin Clark
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jed Hawe
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Robert Hawthorn
- NHS Greater Glasgow and Clyde, Southern General Hospital, Glasgow, UK
| | - Kevin Phillips
- Hull and East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Cottingham, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Kirsty McCormack
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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7
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Aleixo GF, Fonseca MCM, Bortolini MAT, Brito LGO, Castro RA. Pelvic floor symptoms 5 to 14 years after total versus subtotal hysterectomy for benign conditions: a systematic review and meta-analysis. Int Urogynecol J 2018; 30:181-191. [DOI: 10.1007/s00192-018-3811-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/29/2018] [Indexed: 12/16/2022]
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8
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Tahlak MA, Abdulrahman M, Hubaishi NM, Omar M, Cherifi F, Magray S, Carrick FR. Emergency peripartum hysterectomy in the Dubai health system: A fifteen year experience. Turk J Obstet Gynecol 2018; 15:1-7. [PMID: 29662708 PMCID: PMC5894529 DOI: 10.4274/tjod.55492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/07/2017] [Indexed: 12/01/2022] Open
Abstract
Objective: To determine the incidence, demographic data, risk factors, indications, outcome and complications of emergency peripartum hysterectomy (EPH) performed in two major tertiary care hospitals in Dubai, and to compare the results with the literature. Materials and Methods: The records of all women who underwent EPH from January 2000 to December 2015 in two major tertiary care hospitals in Dubai were accessed and reviewed. Maternal characteristics, hysterectomy indications, outcomes, and postoperative complications were recorded using descriptive statistics to describe the cohort. Results: There were 79 EPH out of 168.293 deliveries, a rate of 0.47/1000 deliveries. The most common indications for hysterectomy were abnormal placentation (previa and/or accreta) and uterine atony. The majority of hysterectomies were subtotal (70%). The complications were dominated by massive transfusion, urinary tract injuries, one case of maternal death, and one case of neonatal death. Conclusion: The main indication for EPH was abnormal placentation in scarred uterus and uterine atony. The major method of prevention of EPH is to assess women’s risks and to reduce the number of cesarean section deliveries, by limiting the rate of primary cesareans. This is challenging in the United Arab Emirates (UAE) where the culture is for high gravidity and high parity. Recommendations to act to reduce primary and repeated cesareans should be included on the national agenda in UAE.
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Affiliation(s)
- Muna Abdulrazzaq Tahlak
- Dubai Health Authority, Latifa Women and Children Hospital, Clinic of Obstetrics and Gynegology Dubai, United Arab Emirates
| | - Mahera Abdulrahman
- Dubai Health Authority, Clinic of Medical Education, Dubai, United Arab Emirates
| | - Nawal Mahmood Hubaishi
- Dubai Health Authority, Dubai Hospital, Clinic of Obstetrics and Gynegology, Dubai, United Arab Emirates
| | - Mushtaq Omar
- Dubai Health Authority, Latifa Women and Children Hospital, Clinic of Obstetrics and Gynegology Dubai, United Arab Emirates
| | - Fatima Cherifi
- Dubai Health Authority, Dubai Hospital, Clinic of Obstetrics and Gynegology, Dubai, United Arab Emirates
| | - Shazia Magray
- Dubai Health Authority, Latifa Women and Children Hospital, Clinic of Obstetrics and Gynegology Dubai, United Arab Emirates
| | - Frederick Robert Carrick
- Bedfordshire Centre for Mental Health Research in Association with University of Cambridge, Department of Neurology and Senior Research, Cambridge, United Kingdom.,Harvard Medical School-Harvard Macy Institute, Clinic of Nevrology, Boston, USA.,Carrick Institute, Cape Canaveral, Clinic of Nevrology, Florida, USA
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9
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Ramdhan RC, Loukas M, Tubbs RS. Anatomical complications of hysterectomy: A review. Clin Anat 2017; 30:946-952. [PMID: 28762535 DOI: 10.1002/ca.22962] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/26/2017] [Indexed: 01/23/2023]
Abstract
Hysterectomy is the most commonly performed gynecological procedure in the United States with three possible surgical approaches; vaginal, abdominal and laparoscopic. As with any surgical procedure, various anatomical complications can arise. These include injuries to anatomical structures such as the urinary bladder, ureter, intestines, rectum, anus, and a multitude of nervous structures. Other complications include sexual dysfunction, vaginal cuff dehiscence, and urinary incontinence. Using standard search engines, the anatomical complications of hysterectomies are reviewed. In conclusion, surgeons who perform hysterectomies or are involved with postoperative hysterectomy patients should be familiar with the possible complications of this common procedure and the steps that can be taken to help reduce the risk of those complications. Clinicians should also inform their patients of the potential complications as they can affect lifestyle and comfort. Clin. Anat. 30:946-952, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Rebecca C Ramdhan
- Department of Anatomical Sciences, St. George's University, Grenada, West Indies.,Seattle Science Foundation, Seattle, Washington
| | | | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, Grenada, West Indies.,Seattle Science Foundation, Seattle, Washington
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10
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Kruse AR, Jensen TD, Lauszus FF, Kallfa E, Madsen MR. Changes in incontinence after hysterectomy. Arch Gynecol Obstet 2017; 296:783-790. [PMID: 28756528 DOI: 10.1007/s00404-017-4481-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/25/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Information about the perioperative incontinence following hysterectomy is limited. To advance the postoperative rehabilitation further we need more information about qualitative changes in incontinence, fatigue and physical function of patients undergoing hysterectomy. METHODS 108 patients undergoing planned hysterectomy were compared pre- and postoperatively. In a sub-study of the prospective follow-up study the changes in incontinence, postoperative fatigue, quality of life, physical function, and body composition were evaluated preoperatively, 13 and 30 days postoperatively. Sample size calculation indicated that 102 women had to be included. The incontinence status was estimated by a Danish version of the ICIG questionnaire; further, visual analogue scale, dynamometer for hand grip, knee extension strength and balance were applied. Work capacity was measured ergometer cycle together with lean body mass by impedance. Quality of life was assessed using the SF-36 questionnaire. Patients were examined preoperatively and twice postoperatively. RESULTS In total 41 women improved their incontinence after hysterectomy and 10 women reported deterioration. Preoperative stress incontinence correlated with BMI (r = 0.25, p < 0.01) and urge incontinence with age (r = 0.24, p < 0.02). Further, improvement after hysterectomy in stress incontinence was associated with younger age (r = 0.20, p < 0.04). Improvement in urge incontinence was positively associated with BMI (r = 0.22, p = 0.02). A slight but significant loss was seen in lean body mass 13 and 30 days postoperatively. CONCLUSIONS Hysterectomy was not significantly associated with the risk of incontinence; in particular, when no further vaginal surgery is performed. Hysterectomy may even have a slightly positive effect on incontinence and de-novo cure.
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Affiliation(s)
- Anne Raabjerg Kruse
- Gynecology Department, Herning Hospital, Gl. Landevej 61, 7400, Herning, Denmark
| | | | - Finn Friis Lauszus
- Gynecology Department, Herning Hospital, Gl. Landevej 61, 7400, Herning, Denmark.
| | - Ervin Kallfa
- Gynecology Department, Herning Hospital, Gl. Landevej 61, 7400, Herning, Denmark
| | - Mogens Rørbæk Madsen
- Surgical Research Unit, Department of Surgery, Herning Hospital, Gl. Landevej 61, 7400, Herning, Denmark
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Moen M. Hysterectomy for Benign Conditions of the Uterus: Total Abdominal Hysterectomy. Obstet Gynecol Clin North Am 2017; 43:431-40. [PMID: 27521877 DOI: 10.1016/j.ogc.2016.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Hysterectomy is the most common major gynecologic procedure. Although alternatives to hysterectomy result in fewer procedures performed annually, and the use of endoscopic techniques and vaginal hysterectomy have resulted in a lower percentage performed by the open abdominal route, certain pelvic disorders require abdominal hysterectomy. Preoperative evaluation with informed consent and surgical planning are essential to select appropriate candidates. Prophylactic antibiotics, thromboprophylaxis, attention to surgical technique, and enhanced recovery protocols should be used to provide optimal outcomes.
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Affiliation(s)
- Michael Moen
- Obstetrics and Gynecology, Chicago Medical School, Rosalind Franklin University, 3333 Green Bay Road, North Chicago, IL 60064, USA.
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12
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Matsuo K, Machida H, Takiuchi T, Garcia-Sayre J, Yessaian AA, Roman LD. Prognosis of women with apparent stage I endometrial cancer who had supracervical hysterectomy. Gynecol Oncol 2017; 145:41-49. [PMID: 28215841 DOI: 10.1016/j.ygyno.2017.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/02/2017] [Accepted: 02/02/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine characteristics and survival outcomes of women with apparent early-stage endometrial cancer who had a supracervical hysterectomy. METHODS The Surveillance, Epidemiology, and End Results Program was used to identify women with presumed stage I endometrial cancer who underwent supracervical hysterectomy between 1983 and 2012. Propensity score matching was performed to adjust background difference between supracervical hysterectomy (n=1,339) and total hysterectomy (n=110,523) cases. Endometrial cancer-specific survival (CSS) was examined by multivariable analysis expressed with adjusted-hazard ratio [HR] and 95% confidence interval [CI]. RESULTS Supracervical hysterectomy was independently associated with younger age, low-grade disease, and small tumor size on multivariable analysis (all, P<0.001). After propensity score matching, supracervical hysterectomy remained an independent prognostic factor for decreased CSS compared to total hysterectomy (10-year rates, 91.0% versus 94.9%, adjusted-HR 1.72, 95%CI 1.20-2.47, P=0.003). Among women who received postoperative radiotherapy, 10-year CSS rates were similar between supracervical and total hysterectomy cases (84.7% versus 80.3%, P=0.40). Contrary, in the absence of postoperative radiotherapy, women undergoing supracervical hysterectomy had a significantly lower 10-year CSS rate compared to those undergoing total hysterectomy (92.1% versus 97.2%, P<0.001). Moreover, with lack of lymphadenectomy, supracervical hysterectomy was associated with decreased CSS compared to those who had total hysterectomy (91.6% versus 94.3%, P=0.018) but had similar CSS rates with lymphadenectomy (92.7% versus 91.8%, P=0.91). CONCLUSION Although rarely performed, supracervical hysterectomy is associated with decreased survival outcome among women with apparent stage I endometrial cancer supporting the importance of avoiding this procedure in women with or at risk of endometrial cancer.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Hiroko Machida
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Tsuyoshi Takiuchi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Jocelyn Garcia-Sayre
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Annie A Yessaian
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
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13
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Is cervix removal associated with patient-centered outcomes of pain, dyspareunia, well-being and satisfaction after laparoscopic hysterectomy? Arch Gynecol Obstet 2014; 291:371-6. [DOI: 10.1007/s00404-014-3420-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
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14
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Wilczyński M, Cieślak J, Malinowski A. Supracervical hysterectomy - the vaginal route. Wideochir Inne Tech Maloinwazyjne 2014; 9:207-12. [PMID: 25097688 PMCID: PMC4105678 DOI: 10.5114/wiitm.2014.41633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/22/2013] [Accepted: 10/11/2013] [Indexed: 11/17/2022] Open
Abstract
Removal of the cervix during hysterectomy is not mandatory. There has been no irrefutable evidence so far that total hysterectomy is more beneficial to patients in terms of pelvic organ function. The procedure that leaves the cervix intact is called a subtotal hysterectomy. Traditional approaches to this surgery include laparoscopic and abdominal routes. Vaginal total hysterectomy has been proven to present many advantages over the other approaches. Therefore, it seems that this route should also be applied in the case of subtotal hysterectomy. We present 9 cases of patients who underwent subtotal hysterectomy performed through the vagina for benign gynecological diseases.
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Affiliation(s)
- Miłosz Wilczyński
- Department of Surgical, Endoscopic and Oncologic Gynecology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Jarosław Cieślak
- Department of Surgical, Endoscopic and Oncologic Gynecology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Andrzej Malinowski
- Department of Surgical, Endoscopic and Oncologic Gynecology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
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Rosati M, Bramante S, Bracale U, Pignata G, Azioni G. Efficacy of laparoscopic sacrocervicopexy for apical support of pelvic organ prolapse. JSLS 2013; 17:235-44. [PMID: 23925017 PMCID: PMC3771790 DOI: 10.4293/108680813x13654754535115] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Laparoscopic sacrocervicopexy appears to be an effective option for sexually active women with pelvic organ prolapse. Background and Objectives: To evaluate the efficacy of laparoscopic sacrocervicopexy for apical support in sexually active patients with pelvic organ prolapse. Methods: One-hundred thirty-five women with symptomatic prolapse of the central compartment (Pelvic Organ Prolapse Quantitative [POP-Q] stage 2) underwent laparoscopic sacrocervicopexy. The operating physicians used synthetic mesh to attach the anterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory with subtotal hysterectomy. Anterior and posterior colporrhaphy was performed when necessary. The patients returned for follow-up examinations 1 month after surgery and then over subsequent years. On follow-up a physician evaluated each patient for the recurrence of genital prolapse and for recurrent or de novo development of urinary or bowel symptoms. We define “surgical failure” as any grade of recurrent prolapse of stage II or more of the POP-Q test. Patients also gave feedback about their satisfaction with the procedure. Results: The mean follow-up period was 33 months. The success rate was 98.4% for the central compartment, 94.2% for the anterior compartment, and 99.2% for the posterior compartment. Postoperatively, the percentage of asymptomatic patients (51.6%) increased significantly (P < .01), and we observed a statistically significant reduction (P < .05) of urinary urge incontinence, recurrent cystitis, pelvic pain, dyspareunia, and discomfort. The present study showed 70.5% of patients stated they were very satisfied with the operation and 18.8% stated high satisfaction. Conclusion: Laparoscopic sacrocervicopexy is an effective option for sexually active women with pelvic organ prolapse.
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Affiliation(s)
- Maurizio Rosati
- Department of Obstetrics and Gynecology, Santo Spirito Hospital, Pescara, Italy
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Laparoscopic supracervical hysterectomy (LSH) versus total laparoscopic hysterectomy (TLH): an implementation study in 1,952 patients with an analysis of risk factors for conversion to laparotomy and complications, and of procedure-specific re-operations. Arch Gynecol Obstet 2013; 288:1329-39. [PMID: 23775263 DOI: 10.1007/s00404-013-2921-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 05/02/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE To compare laparoscopic supracervical hysterectomy (LSH) with total laparoscopic hysterectomy (TLH) with regard to relevant surgical parameters and risk factors of conversion to laparotomy and complications. METHODS This prospective, open, single-center, interventional study included women with benign gynecologic disease who underwent standardized LSH or TLH. The techniques were compared for conversion rate and mean operating time, hemoglobin drop, hospital stay, and complication rates using descriptive statistics and standard non-parametric statistical tests. Risk factors of conversion and complications were identified by logistic regression analysis. RESULTS During January 2003 to December 2010, 1,952 women [mean age (SD): 47.5 (7.2) years] underwent LSH [1,658 (84.9%)] or TLH [294 (15.1%)], mostly (>70%) for uterine fibroids. Significant differences in surgical parameters were observed for conversion rate (LSH/TLH: 2.6/6.5%), mean operating time [87 (34)/103 (36) min], hemoglobin drop [1.3 (0.8)/1.6 (1.0) g/dL], and hospital stay [4.3 (1.5)/4.9 (2.8) days]. Overall intraoperative (0.2/0.7%) and long-term (>6 weeks) post-operative (0.8/1.7%) complication rates did not differ significantly, but the short-term LSH complication rate was significantly lower (0.6 vs. 4.8%). Spotting (LSH, 0.2%) and vaginal cuff dehiscence (TLH, 0.7%) were long-term method-specific complications. Logistic regression showed that uterine weight and extensive adhesiolysis were significant factors for conversion while previous surgery, age, and BMI were not. Major risk factors of short-term complications were age, procedure (LSH/TLH), and extensive adhesions. CONCLUSIONS Both procedures proved effective and were well tolerated. LSH performed better than TLH regarding most outcome measures. LSH is associated with very low rates of re-operation and spotting.
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Unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH): an analysis of 1,584 LASH cases. Arch Gynecol Obstet 2012; 287:455-62. [PMID: 23053310 DOI: 10.1007/s00404-012-2559-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Accepted: 09/06/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of this research was to identify the rate of unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH) and describe the therapy regime. METHODS The research is based on a retrospective chart analysis of patients undergoing a simple hysterectomy in the gynecological endoscopy department of a general hospital in Germany. RESULTS 2,577 simple hysterectomies conducted between March 2005 and March 2010 were sub-classified in different types of hysterectomies (vaginal-, abdominal-, total-, abdominal supracervical hysterectomy, LAVH, and LASH). This study focuses on the LASH sub-group of 1,584 patients and does not make any comparisons to other operative approaches. Out of the 1,584 patients, 87.8 % (n = 1,391) received preoperative screening to exclude dysplasia or malignancy based on the policy of the German Association for gynecology and obstetrics (DGGG). The screening includes cytology (Pap-smear) and preoperative ultrasound of the uterus or dilatation and curettage (d&c). Unexpected malignancies were found in 0.25 % (n = 4) of the patients pre-screened according to DGGG protocol. Out of the four malign patients, two had endometrial cancer. Two patients had leiomyosarcoma. CONCLUSION The study shows that there is a small probability of unexpected malignancies even in correctly pre-screened patients for LASH procedures. Yet in the short-term (28-52 months), malign patients remain recurrence free after treatment. LASH is therefore a good procedure for assumed benign disease.
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Health Concerns That Affect Female Sexuality. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012. [DOI: 10.1016/s1701-2163(16)35357-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mesh erosion following abdominal sacral colpopexy in the absence and presence of the cervical stump. Int Urogynecol J 2012; 24:113-8. [PMID: 22717784 DOI: 10.1007/s00192-012-1845-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Accepted: 05/20/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We compared the role of abdominal sacral colpopexy (ASCP) with concomitant supracervical hysterectomy to ASCP alone in patients with prior hysterectomy in the prevention of mesh erosion. MATERIALS AND METHODS We performed a retrospective chart review of 277 consecutive patients who underwent ASCP with one surgeon. Patients were separated into two groups based on the presence of a uterus at the time of surgery. Group A comprised195 patients with a uterus who underwent ASCP and concomitant supracervical hysterectomy; group B comprised 82 patients with prior total hysterectomy who underwent ASCP. The outcome measures included peri- and postoperative findings, complications, and surgical success. Data were analyzed by t test and chi-square test using SPSS software. RESULTS No significant difference was found between groups during surgery in terms of anesthesia type, total operative time, and estimated intraoperative blood loss. At mean postoperative follow-up of 7-8 months, there was no difference between groups in terms of de novo urinary symptoms, recurrent vaginal-wall prolapse, or dyspareunia and Pelvic Organ Prolapse Quantification (POP-Q) point C examination. Sling erosion was observed in four (4.2 %) patients in group A versus none in group B. Apical mesh erosion was diagnosed in one patient in group A (0.5 %) and two (2.4 %) patients in group B. These differences were not statistically significant. CONCLUSION Concomitant supracervical hysterectomy with ASCP was associated with a low incidence of mesh erosion and had the same intraoperative course and postoperative outcome as ASCP with previous hysterectomy.
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Benson AD, Kramer BA, Wayment RO, Schwartz BF. Supracervical robotic-assisted laparoscopic sacrocolpopexy for pelvic organ prolapse. JSLS 2011; 14:525-30. [PMID: 21605516 PMCID: PMC3083043 DOI: 10.4293/108680810x12924466008006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Supracervical robotic-assisted laparoscopic sacrocolpopexy was found to be an effective repair of apical vaginal defects in patients with pelvic organ prolapse who had not undergone previous hysterectomy. Background: Supracervical robotic-assisted laparoscopic sacrocolpopexy (SRALS) is a new surgical treatment for pelvic organ prolapse that secures the cervical remnant to the sacral promontory. We present our initial experience with SRALS in the same setting as supracervical robotic-assisted hysterectomy (SRAH). Methods: Women with vaginal vault prolapse and significant apical defects as defined by a Baden-Walker score of ≥3 who had not undergone hysterectomy were offered SRALS in combination with SRAH. A chart review was performed to analyze operative and perioperative data. Outcome data also included patients who underwent robotic-assisted laparoscopic sacrocolpopexy (RALS) without any other procedure. Results: Thirty-three patients underwent RALS, including 12 patients who underwent SRALS. All SRALS were performed following SRAH in the same setting. The mean follow-up for the RALS and SRALS patients was 38.4 months and 20.7 months, respectively. One patient in the RALS group had an apical recurrence. There were no recurrences in the SRALS group. Conclusions: SRALS is effective for repair of apical vaginal defects in patients with significant pelvic organ prolapse who have not undergone previous hysterectomy. Complications are few and recurrences rare in short- and medium-term follow-up. Greater follow-up and numbers are needed to further establish the role of this procedure.
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Affiliation(s)
- Aaron D Benson
- Division of Urology, Southern Illinois University, Springfield, Illinois 62794-9665, USA
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Schmidt T, Eren Y, Breidenbach M, Fehr D, Volkmer A, Fleisch M, Rein DT. Modifications of Laparoscopic Supracervical Hysterectomy Technique Significantly Reduce Postoperative Spotting. J Minim Invasive Gynecol 2011; 18:81-4. [DOI: 10.1016/j.jmig.2010.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 09/23/2010] [Accepted: 09/30/2010] [Indexed: 11/25/2022]
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Thomas B, Magos A. Subtotal hysterectomy and myomectomy - vaginally. Best Pract Res Clin Obstet Gynaecol 2010; 25:133-52. [PMID: 21185235 DOI: 10.1016/j.bpobgyn.2010.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 10/22/2010] [Accepted: 11/02/2010] [Indexed: 11/28/2022]
Abstract
Vaginal subtotal (or supracervical) hysterectomy and vaginal myomectomy are elegant procedures rarely carried out by the average gynaecologist. Both techniques, however, are easily learned, and in view of the proven advantages of vaginal surgery over abdominal or laparoscopic approaches, they are worthy of a wider application. Subtotal hysterectomy may be preferred to excision of the entire uterus in certain circumstances, and may be carried out vaginally. Vaginal myomectomy allows for a more thorough myomectomy and stronger uterine repair than a laparoscopic procedure, as well as avoiding abdominal wounds. It may represent the optimal approach where fibroids are favourably sited. We first set out the case for subtotal hysterectomy and then describe the development of vaginal subtotal hysterectomy and vaginal myomectomy. We discuss the evidence supporting their use and indications, and then describe techniques for both vaginal procedures.
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Affiliation(s)
- Benjamin Thomas
- Minimally Invasive Therapy Unit and Endoscopy Training Centre, University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK
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Maina WC, Morris EP. Management of women requesting subtotal hysterectomy. MENOPAUSE INTERNATIONAL 2010; 16:152-5. [PMID: 21156852 DOI: 10.1258/mi.2010.010038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Subtotal hysterectomy (SH), which is also referred to as supracervical hysterectomy, is a common gynaecological procedure in which the uterus is removed and the cervix is retained. There is continuing debate about the advantages and disadvantages of SH compared with total abdominal hysterectomy. Persistent vaginal bleeding and the need for continued cervical screening appear to be the main disadvantages of SH. The procedure is often combined with removal of the ovaries. Women should be counselled appropriately prior to removal of their ovaries. Following an internal audit of practice of hormone replacement therapy (HRT) prescription within our own unit, we discovered that there were inconsistencies in the prescription of HRT following SH which led us to investigate this matter further. We concluded that evidence is lacking to guide HRT prescription following SH and bilateral oophorectomy and propose content that can help produce guidelines for the counselling of women prior to SH and prescription of HRT.
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Affiliation(s)
- William C Maina
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital, Colney Lane, Norfolk NR18 0XF, UK.
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Trends in Various Types of Surgery for Hysterectomy and Distribution by Patient Age, Surgeon Age, and Hospital Accreditation: 10-Year Population-Based Study in Taiwan. J Minim Invasive Gynecol 2010; 17:612-9. [DOI: 10.1016/j.jmig.2010.04.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 04/12/2010] [Accepted: 04/23/2010] [Indexed: 11/18/2022]
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Hysterectomy-a comparison of approaches. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:353-9. [PMID: 20539807 DOI: 10.3238/arztebl.2010.0353] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 10/05/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND The advantages and disadvantages of the various surgical techniques for hysterectomy are currently a topic of debate, with particular controversy over leaving the cervix in situ in the laparoscopic supracervical hysterectomy (LASH) procedure. METHODS In a retrospective single-center study, medical history and clinical characteristics were compared in patients who had undergone hysterectomy for benign disease in the period 2002-2008 at the Department of Obstetrics and Gynecology, Erlangen University Hospital. Postoperative satisfaction and the frequency of secondary operations for prolapse or incontinence in women with surgery between 2002 and 2007 were surveyed by means of a questionnaire. RESULTS The longest hospital stay was observed after abdominal hysterectomy (AH; 10 days), followed by vaginal hysterectomy (VH; 7.8 days) and laparoscopy-assisted vaginal hysterectomy (LAVH; 7.2 days). The shortest stays in hospital were seen after LASH (5.9 days) and total laparoscopic hysterectomy (TLH; 5.7 days). The shortest operating time was noted with VH (87 min) and the longest with LAVH (122 min). The lowest rates of blood loss were with LASH (1.38 g/dL) and TLH (1.51 g/dL). The highest rate of postoperative complications occurred after AH (8.9%). No differences were found in relation to postoperative satisfaction or surgery for prolapse or incontinence. CONCLUSION No postoperative benefits were found for leaving the cervix in situ when performing LASH. However, this was not a controlled randomized study.
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Long-Term Outcomes of the Total or Supracervical Hysterectomy (TOSH) Trial. Female Pelvic Med Reconstr Surg 2010; 16:49-57. [PMID: 22229107 DOI: 10.1097/spv.0b013e3181cec343] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND: Participants in the multi-center, randomized Total or Supracervical Hysterectomy (TOSH) trial showed within-group improvement in pelvic floor symptoms 2 years post-surgery and no differences between supracervical (SCH) versus total hysterectomy (TAH). This study describes longer term outcomes from the largest recruiting site. STUDY DESIGN: Questionnaires addressing pelvic symptoms, sexual function, and health-related quality of life were administered. Linear models and McNemar's test were utilized. RESULTS: Thirty-seven participants (69%) responded (19 TAH, 18 SCH); mean follow up was 9.1±0.7 years. No between-group differences emerged in urinary incontinence, voiding dysfunction, pelvic prolapse symptoms and overall health related quality of life (HRQOL). Within-group analysis showed significant improvement in the ability to have and enjoy sex (P = 0.002) and in the SF-36 physical component summary score (P = 0.03) among women randomized to TAH. CONCLUSION: 9 years after surgery, TOSH participants continue to experience improvement and show no major between-group differences in lower urinary tract or pelvic floor symptoms conferring no major benefit of SCH over TAH.
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van Evert JS, Smeenk JMJ, Dijkhuizen FPHLJ, de Kruif JH, Kluivers KB. Laparoscopic subtotal hysterectomy versus laparoscopic total hysterectomy: a decade of experience. ACTA ACUST UNITED AC 2009; 7:9-12. [PMID: 20234836 PMCID: PMC2837242 DOI: 10.1007/s10397-009-0529-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 09/21/2009] [Indexed: 10/26/2022]
Abstract
At present, there are only few data on the surgical outcomes of laparoscopic hysterectomy (LH). Up till now, it has been unclear whether there is a difference in number of complications among the subcategories of laparoscopic total hysterectomy and laparoscopic subtotal hysterectomy (LSH). Therefore, we have performed a retrospective analysis to evaluate the peri- and postoperative outcomes in women undergoing LSH versus LH. This multi-centre retrospective cohort study (Canadian Task Force classification II-2) was conducted in multi-centres (two teaching hospitals and one university medical centre) in the Netherlands, all experienced in minimally invasive gynaecology. In a multi-centre retrospective cohort study we compared the long-term outcomes of laparoscopic subtotal hysterectomy and laparoscopic total hysterectomy (including laparoscopic assisted vaginal hysterectomy, laparoscopic hysterectomy and total laparoscopic hysterectomy). All laparoscopic hysterectomies from the last 10 years (January 1998 till December 2007) were included. Patient characteristics, intra- and postoperative complications, operating time and duration of hospital stay were recorded. The minimum follow-up was 6 months. A total of 390 cases of laparoscopic hysterectomies were included in the analysis: 192 laparoscopic subtotal hysterectomies and 198 laparoscopic total hysterectomies. Patient characteristics such as age and parity were equal in the groups. The overall number of short-term and long-term complications was comparable in both groups: 17% and 15%. Short-term complications (bleeding, fever) were 3% in the LSH group and 12% in the LH group. Long-term complications were (tubal prolapse and cervical stump reoperations) 15% in the LSH group and 3% in the LH group. Laparoscopic subtotal hysterectomy as compared with the different types of laparoscopic total hysterectomy is associated with more long-term postoperative complications, whereas laparoscopic total hysterectomy is associated with more short-term complications.
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Warren L, Ladapo JA, Borah BJ, Gunnarsson CL. Open Abdominal versus Laparoscopic and Vaginal Hysterectomy: Analysis of a Large United States Payer Measuring Quality and Cost of Care. J Minim Invasive Gynecol 2009; 16:581-8. [DOI: 10.1016/j.jmig.2009.06.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 06/16/2009] [Accepted: 06/18/2009] [Indexed: 10/20/2022]
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Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009:CD003677. [PMID: 19588344 DOI: 10.1002/14651858.cd003677.pub4] [Citation(s) in RCA: 344] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically. OBJECTIVES To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists. SELECTION CRITERIA Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included. DATA COLLECTION AND ANALYSIS Independent selection of trials and data extraction were employed following Cochrane guidelines. MAIN RESULTS There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures. AUTHORS' CONCLUSIONS Because of equal or significantly better outcomes on all parameters, VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH however the length of the surgery increases as the extent of the surgery performed laparoscopically increases. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.
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Affiliation(s)
- Theodoor E Nieboer
- Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Johan de Wittlaan, Arnhem, Netherlands, 80 6828 WJ
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Comparison of total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH) in women with uterine leiomyoma. Eur J Obstet Gynecol Reprod Biol 2009; 144:76-9. [DOI: 10.1016/j.ejogrb.2009.02.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 01/13/2009] [Accepted: 02/04/2009] [Indexed: 11/30/2022]
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Lucot JP, Coulon C, Collinet P, Cosson M, Vinatier D. Thérapeutique chirurgicale des pathologies fonctionnelles. ACTA ACUST UNITED AC 2008; 37 Suppl 8:S398-404. [DOI: 10.1016/s0368-2315(08)74780-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 2008; 116:492-500. [PMID: 19016683 DOI: 10.1111/j.1471-0528.2008.01966.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the complication rate after laparoscopic total hysterectomy and laparoscopic subtotal hysterectomy (LASH) in case of benign disease. DESIGN All complications were prospectively recorded at the time of surgery and analysed retrospectively. SETTING University hospital. POPULATION Among 4505 hysterectomies performed by the same team using the same techniques between 1990 and 2006, 3190 were performed by laparoscopy, 906 by the vaginal route and 409 by laparotomy. METHODS Laparoscopic hysterectomies, defined as laparoscopic subtotal hysterectomy (LASH) and total laparoscopic hysterectomy [laparoscopy-assisted vaginal hysterectomy (LAVH) switched to total laparoscopic hysterectomy (TLH) in 2000], were compared with vaginal and abdominal hysterectomies. MAIN OUTCOME MEASURES AND RESULTS Since the early 1990s, the number of laparoscopic procedures has continued to grow, while the number of abdominal and vaginal procedures has decreased. Both minor complications (fever >38.5 degrees C after 2 days, bladder incision of <2 cm and iatrogenic adenomyosis) and major complications (haemorrhage, vesicoperitoneal fistula, ureteral injury, rectal perforation or fistula) have been observed during the surgical procedure itself and postoperatively. In the LASH group (n = 1613), the minor complication rate was 0.99% (n = 16) and the major complication rate 0.37% (n = 6). In the total laparoscopic hysterectomy (LAVH/TLH) group (n = 1577), the minor complication rate was 1.14% (n = 18) and the major complication rate 0.51% (n = 8). In the vaginal hysterectomy group (n = 906), minor and major complication rates were 0.77% (n = 7) and 0.33% (n = 3), respectively. In the abdominal hysterectomy group (n = 409), minor and major complication rates were 0.73% (n = 3) and 0.49% (n = 2), respectively. CONCLUSION The results from our series of 4505 women clearly show that, in experienced hands, laparoscopic hysterectomy is not associated with any increase in major complication rates.
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Affiliation(s)
- O Donnez
- Department of Gynecology, Université Catholique de Louvain, Brussels, Belgium
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Fialkow M, Symons RG, Flum D. Reoperation for urinary incontinence. Am J Obstet Gynecol 2008; 199:546.e1-8. [PMID: 18639207 DOI: 10.1016/j.ajog.2008.04.047] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Revised: 03/17/2008] [Accepted: 04/30/2008] [Indexed: 11/20/2022]
Abstract
OBJECTIVE(S) The objective of the study was to describe the rate and associated factors of reoperation for urinary incontinence. STUDY DESIGN A cohort study using Washington state hospitalization records from 1987 to 2005 of inpatient urinary incontinence surgeries. The cumulative reoperation rate was estimated for the entire cohort and by procedure. Cox regression was used to estimate the hazard of reoperation. RESULTS A total of 41,705 women underwent either a sling or retropubic colposuspension (Burch); 1895 underwent reoperation for urinary incontinence (8.6%; 95% confidence interval, 7.8-9.5%), a rate of 5.5 per 1000 woman-years. Women undergoing Burch had a lower reoperation rate than those undergoing slings (4.2 vs 6.7 per 1000 woman-years; P < .001). Concomitant hysterectomy was associated with a lower reoperation rate for Burch and sling repairs (5.4-2.9 and 7.7-4.2 per 1000 woman-years). CONCLUSION(S) Reoperation for urinary incontinence occurs commonly in the general population. The variable reoperation rate observed should be further investigated, given current trends toward increased Sling use.
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Affiliation(s)
- Michael Fialkow
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
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First Experience of a Modified Device for Excision of the Endocervix in a Reverse Cone during Laparoscopic Supracervical Hysterectomy. J Minim Invasive Gynecol 2008; 15:624-6. [DOI: 10.1016/j.jmig.2008.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 05/13/2008] [Accepted: 06/07/2008] [Indexed: 11/22/2022]
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Lieng M, Qvigstad E, Istre O, Langebrekke A, Ballard K. Long-term outcomes following laparoscopic supracervical hysterectomy. BJOG 2008; 115:1605-10. [PMID: 18752588 DOI: 10.1111/j.1471-0528.2008.01854.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Evaluation of long-term outcomes following laparoscopic supracervical hysterectomy (LSH). DESIGN Retrospective postal questionnaire. SETTING Norwegian university teaching hospital. POPULATION A total of 315 consecutive patients. METHODS A questionnaire sent to all patients who underwent a LSH during 2004 and 2005. MAIN OUTCOME MEASURES Persistent vaginal bleeding and pelvic pain, patient acceptability of such symptoms and patient satisfaction following LSH. RESULTS A total of 240 women (78%) completed the questionnaire. About 24% reported experiencing vaginal bleeding up to 3 years following their hysterectomy, although this was rated as minimal in 90% of cases, resulting in a mean bothersome score of 1.1 (SD 2.0) on a 10-point visual analogue scale (VAS). Women operated on by less experienced surgeons were more likely to report vaginal bleeding following surgery (P = 0.02). About 74% of women reported having menstrual pain prior to surgery, with a mean score of 6.8 (SD 2.1) (10-point VAS). Up to 3 years following surgery, 38% continued to experience menstrual pain, although this was significantly less intense with a mean score of 3.5 (SD 2.2) (P < 0.01). While all women reported a decrease in the amount of pain experienced following the hysterectomy, those having a hysterectomy because of endometriosis reported significantly higher levels of menstrual/cyclical pain after surgery compared with women who had a hysterectomy for other reasons (P < 0.01). Ninety per cent of women reported being satisfied with their surgery. CONCLUSION Although vaginal bleeding and pelvic pain are frequently observed following LSH, these symptoms are significantly reduced and patient satisfaction is high.
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Affiliation(s)
- M Lieng
- Department of Gynaecology and Obstetrics, Ullevål University Hospital, Oslo, Norway.
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Rosenblatt PL, Chelmow D, Ferzandi TR. Laparoscopic sacrocervicopexy for the treatment of uterine prolapse: a retrospective case series report. J Minim Invasive Gynecol 2008; 15:268-72. [PMID: 18439495 DOI: 10.1016/j.jmig.2008.01.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 12/28/2007] [Accepted: 01/09/2008] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE To evaluate apical support in patients desiring uterine preservation with pelvic organ prolapse who underwent laparoscopic sacrocervicopexy. DESIGN Retrospective case series report (Canadian Task Force classification III). SETTING Academic community teaching hospital. PATIENTS Forty consecutive women who underwent laparoscopic sacrocervicopexy. INTERVENTIONS Synthetic mesh was used to attach the distal uterosacral ligaments and posterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory. MEASUREMENTS AND MAIN RESULTS Pelvic organ prolapse quantification system measurements were used and apical support was evaluated using point C. Mean C was -1.13 (+9 to -4) preoperatively, -5.28 (-3 to -13) at 6 weeks postoperatively, -5.26 (-3 to -8) at 6 months postoperatively, and -4.84 (-3 to -7) at 1 year postoperatively. CONCLUSION Laparoscopic sacrocervicopexy is an effective option for women with pelvic organ prolapse who desire uterine preservation.
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Robert M, Soraisham A, Sauve R. Postoperative urinary incontinence after total abdominal hysterectomy or supracervical hysterectomy: a metaanalysis. Am J Obstet Gynecol 2008; 198:264.e1-5. [PMID: 18199420 DOI: 10.1016/j.ajog.2007.09.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Revised: 07/14/2007] [Accepted: 09/19/2007] [Indexed: 01/08/2023]
Abstract
OBJECTIVE A metaanalysis of randomized trials was conducted to evaluate if the type of hysterectomy, total abdominal hysterectomy or supracervical hysterectomy, has an impact on the development of urinary incontinence. STUDY DESIGN We searched MEDLINE, EMBASE, CINAHL, Biological Abstract, and the Cochrane Library up to February 2007; abstracts at major meetings and bibliographies of retrieved articles were scanned. A fixed effect model was used to calculate summary relative risk estimates and 95% confidence intervals (CIs). RESULTS Analysis showed no statistical difference in the risk of developing stress or urge urinary incontinence in women who underwent supracervical hysterectomy compared with women who underwent total abdominal hysterectomy (relative risk, 1.3; 95% CI, 0.94-1.78; P = 0.16 and relative risk, 1.37; 95% CI, 0.77-2.46; P = .25). CONCLUSION There is no statistical evidence of a different risk for developing either stress or urge urinary incontinence after a supracervical hysterectomy or a total hysterectomy.
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Affiliation(s)
- Magali Robert
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada.
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Abstract
Various methods exist to destroy the endometrium as a treatment for menorrhagia. This chapter discusses the rationale, evidence, indications, and long-term safety and efficacy of the current techniques. It also discusses endometrial ablation in the context of its clinical utility in comparison with the existing alternative treatments.
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Affiliation(s)
- Paul McGurgan
- School of Womens and Infants Health, University of West Australia, c/o King Edward's Memorial Hospital, Subiaco, Perth, WA, Australia.
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Endometrial vaporization of the cervical stump employing an office hysteroscope and bipolar technology. J Minim Invasive Gynecol 2007; 14:767-9. [DOI: 10.1016/j.jmig.2007.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Revised: 05/29/2007] [Accepted: 06/01/2007] [Indexed: 11/20/2022]
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Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study. Lancet 2007; 370:1494-9. [PMID: 17964350 DOI: 10.1016/s0140-6736(07)61635-3] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hysterectomy for benign indications has been associated with an increased risk for lower-urinary-tract sequela, but results have been inconclusive. We aimed to establish the risk for stress-urinary-incontinence surgery after hysterectomy for benign indications. METHODS We did a nationwide, population-based, cohort study from 1973 to 2003 in Sweden. We identified our population from the Swedish Inpatient Registry. We selected 165 260 women who had undergone hysterectomy (exposed cohort) and a control group of 479 506 individuals who had not had this procedure (unexposed cohort), matched by year of birth and county of residence. In both cohorts, occurrence of stress-urinary-incontinence surgery was established from the Swedish Inpatient Registry. Hazard ratios with 95% CIs were calculated by Cox's proportional-hazards regression. FINDINGS During the 30-year observational period, the rate of stress-urinary-incontinence surgery per 100,000 person-years was 179 (95% CI 173-186) in the exposed cohort versus 76 (73-79) in the unexposed cohort. Correspondingly, individuals in the exposed cohort were at increased risk for stress-urinary-incontinence surgery compared with those in the unexposed cohort (hazard ratio 2.4; 95% CI 2.3-2.5), irrespective of surgical technique. Risk for stress-urinary-incontinence surgery varied slightly with time of follow-up: the highest overall risk was recorded within 5 years of surgery (2.7; 2.5-2.9) and the lowest risk was seen after an observation period of 10 years or more (2.1, 1.9-2.2). INTERPRETATION Hysterectomy for benign indications, irrespective of surgical technique, increases the risk for subsequent stress-urinary-incontinence surgery. Women should be counselled on associated risks related to hysterectomy, and other treatment options should be considered before surgery.
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Affiliation(s)
- Daniel Altman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
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Owusu-Ansah R, Gatongi D, Chien PFW. Health technology assessment of surgical therapies for benign gynaecological disease. Best Pract Res Clin Obstet Gynaecol 2006; 20:841-79. [PMID: 17145485 DOI: 10.1016/j.bpobgyn.2006.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This chapter summarises the evidence of the benefits and harm of surgical therapies for benign gynaecological disease. We have limited the discussion in this chapter to three gynaecological conditions - menorrhagia, endometriosis and benign ovarian tumours - with a further section on the different surgical approaches for performing a hysterectomy for menorrhagia due to dysfunctional uterine bleeding and pelvic masses such as fibroids and benign adnexal masses. The currently available evidence suggests that there is little to choose between the four first-generation endometrial destruction techniques - laser ablation, transcervical resection of endometrium, vaporisation ablation and rollerball ablation - in terms of clinical efficacy and patient satisfaction. There is a paucity of evidence with regards to the comparison of the different second-generation endometrial-destruction techniques but current evidence suggests that bipolar radiofrequency ablation is more effective than thermal balloon ablation for treating menorrhagia. Overall, the second-generation techniques are at least as effective as first-generation methods but are easier to perform and can be done under local rather than general anaesthesia in some circumstances. Hysteroscopic endometrial ablation is an alternative to hysterectomy and should be offered to women with menorrhagia because of its high satisfaction rates, shorter operation time, shorter hospital stay, earlier recovery and reduced postoperative complications; hysterectomy remains the surgical option of choice for women with intractable menorrhagia despite repeated endometrial ablations and for those who do not wish under any circumstances to continue to have menstrual bleeding. The combined use of laparoscopic laser ablation, adhesiolysis and uterine nerve ablation has been shown to have a beneficial effect on pelvic pain associated with mild to moderate endometriosis. Current evidence also supports the use of laparoscopic treatment of minimal and mild endometriosis to improve the on-going pregnancy and live birth rate in infertile patients. The current available evidence suggests that the laparoscopic approach is superior to laparotomy for the surgical management of benign ovarian cysts. It results in less postoperative pain and a shorter postoperative hospital stay; it also costs less. With regards to the surgical approach for performing a hysterectomy for menorrhagia and benign pelvic masses, vaginal hysterectomy should be performed over laparoscopic and abdominal hysterectomy when possible. Where it is not possible to perform the hysterectomy vaginally, then laparoscopic hysterectomy can be employed instead of abdominal hysterectomy to avoid a laparotomy scar. There appears to be no significant advantage in performing a subtotal hysterectomy instead of the total removal of the uterine corpus and cervix.
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Lethaby A, Shepperd S, Cooke I, Farquhar C. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev 2000:CD000329. [PMID: 10796528 DOI: 10.1002/14651858.cd000329] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) or menorrhagia is an important cause of ill health in women. Surgical treatment of HMB often follows failed or ineffective medical therapy and the definitive treatment is hysterectomy but this is a major surgical procedure with significant physical and emotional complications and social and economic costs. A number of less invasive surgical techniques (e.g. endometrial resection and laser ablation) have been developed with the purpose of removing the entire thickness of the endometrium. The benefits claimed for these therapies are reduced trauma and post-operative complications to the woman, reduced need for a general anaesthetic, direct cost savings to the health service due largely to a shift from inpatient to day case treatment and indirect cost savings to society as women return more quickly to their usual activities. However, endometrial hysteroscopic techniques are not always completely successful and additional surgical treatment is required in a proportion of cases. Although initially the resource and patient costs of these techniques are much cheaper than the cost of hysterectomy, the need for re treatment at a later stage may reduce the cost differential. Thus, the effectiveness of these techniques to improve a woman's perception of her own wellbeing long term has yet to be confirmed. OBJECTIVES The objective of this review is to compare endometrial destruction techniques with hysterectomy by any means for the treatment of heavy menstrual bleeding (HMB). SEARCH STRATEGY Electronic searches for relevant randomised controlled trials of the Cochrane Menstrual Disorders and Sub fertility Group Register of Trials, MEDLINE, EMBASE, PsychLIT, Current Contents, Biological Abstracts, Social Sciences Index and CINAHL were performed. Attempts were also made to identify trials from citation lists of review articles and hand searching. In most cases, the first or corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA The inclusion criteria were randomised comparisons of endometrial destruction techniques with hysterectomy by any means for the treatment of heavy menstrual bleeding in premenopausal women. DATA COLLECTION AND ANALYSIS Five RCTs were identified that fulfilled the inclusion criteria for this review. For two trials, a number of publications were identified which assessed different outcomes and different follow up time points for the same patients. The reviewers extracted the data independently and odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes were estimated from the data. Outcomes analysed included improvement in menstrual blood loss, satisfaction, change in quality of life, duration of surgery and hospital stay, time to return to work, adverse events and requirement for repeat surgery because of failure of the initial surgical treatment. MAIN RESULTS There was a significant advantage in favour of hysterectomy in the improvement in HMB and satisfaction rates (up to 4 years post surgery) compared with endometrial destruction techniques. Although many quality of life scales reported no differences between surgery groups, there was some evidence of a greater improvement in general health for hysterectomy patients. Duration of surgery, hospital stay and recovery time were all shorter following endometrial destruction. Most adverse events, both major and minor, were significantly more likely after hysterectomy and before discharge from hospital. After discharge from hospital, the only difference that was reported for this group was a higher rate of infection. Repeat surgery because of failure of the initial treatment, either endometrial ablation or hysterectomy, was more likely after endometrial destruction than hysterectomy. (ABSTRACT TRUNCATED)
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Affiliation(s)
- A Lethaby
- Department of Obstetrics and Gynaecology, University of Auckland, 2nd Floor, National Women's Hospital, Claude Road, Epsom, Auckland, New Zealand.
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