Comparative analysis of different laparoscopic hysterectomy procedures

The influence of persistent bleeding after supracervical hysterectomy on depressive and anxious symptoms: a prospective bicenter study

PURPOSE

Postoperative spotting is a frequent adverse symptom after laparoscopic supracervical hysterectomy (LSH). The conical excision (eLSH) reduces the postoperative spotting rate, but data in a larger collective are still rare and inconsistent. The influence of persistent bleeding on the anxious and depressive symptoms has not been analyzed yet.

METHODS

311 patients, who underwent a laparoscopic supracervical hysterectomy with conical excision (n = 163), or with straight cervical resection (n = 148) were included. Anxious and depressive symptoms and postoperative spotting were recorded before operation, at 3 month follow-up and at 1 year follow-up in both operative groups using a validated questionnaire (German version of Hospital Anxiety and Depression Scale, HADS-D) and additional questions concerning the frequency and impact of bleeding. Statistical analysis included the impairment of bleeding as well as its impact on depressive and anxious symptoms for both groups.

RESULTS

11.5% after eLSH and 15.5% after LSH reported spotting after 1 year. Supracervical hysterectomy significantly improves depressive and anxious symptoms at 3 and at 12 month follow-up for both groups (p < 0.001) independent on residual spotting. Patients with a preoperative continuous bleeding showed a maximum benefit independent on operative method.

CONCLUSION

Laparoscopic supracervical hysterectomy has a positive effect on anxious and depressive symptoms in the short-term and intermediate-term follow-up. The conical excision of the cervical stump reduces postoperative spotting rate, but has no explicit advantage on symptoms of depression or anxiety, irrespective of residual postoperative spotting.

A new technique for supracervical hysterectomy: Anterograde vaginal subtotal hysterectomy

To review the results of a novel method of subtotal hysterectomy, called anterograde vaginal subtotal hysterectomy (AVSH), and to compare them with those of laparoscopic subtotal hysterectomy (LSH).We recruited 100 women with non-prolapsed uteruses and benign lesions of the uterus who required surgery. Of these, 60 underwent AVSH and 40 underwent LSH. Clinical data included average operation time, average volume of bleeding, postoperative anal exsufflation time, operative complications, average length of hospital stay and average hospital maintenance fee.There were no significant differences in terms of average operation time, average length of hospital stay, or operative complications between the AVSH and LSH groups. The AVSH group showed early postoperative anal exsufflation (P = .000), and had a low average hospital maintenance fee (P = .000). The AVSH group showed a higher perioperative bleeding volume than the LSH group (P = .001), which may be a result of the relatively amateur AVSH technique.AVSH is a minimally invasive, safe and feasible surgical procedure, with favorable early postoperative anal exsufflation and a low average hospital maintenance fee.

Robotic single-site supracervical hysterectomy with manual morcellation: Preliminary experience

AIM

To evaluate the feasibility, safety and peri- and postoperative outcomes of robotic single-site supracervical hysterectomy (RSSSH) for benign gynecologic disease.

METHODS

We report 3 patients who received RSSSH for adenomyosis of the uterus from November 2015 to April 2016. We evaluated the feasibility, safety and outcomes among these patients.

RESULTS

The mean surgical time was 244 min and the estimated blood loss was 216 mL, with no blood transfusion necessitated. The docking time was shortened gradually from 30 to 10 min. We spent 148 min on console operation. Manual morcellation time was also short, ranging from 5 to 10 min. The mean hospital stay was 5 d. Lower VAS pain score was also noted. There is no complication during or after surgery.

CONCLUSION

RSSSH is feasible and safe, incurs less postoperative pain and gives good cosmetic appearance. The technique of in-bag, manual morcellation can avoid tumor dissemination.

Robotic Trachelectomy After Supracervical Hysterectomy for Benign Gynecologic Disease

Background and Objectives:

A renewed interest in the supra cervical approach to hysterectomy has created a cohort of patients with a retained cervix at risk of persistent symptoms requiring a subsequent trachelectomy. The objective of this study was to evaluate the efficacy of robotic trachelectomy after a previous supracervical hysterectomy.

Methods:

This is a retrospective chart review of women who had robotic trachelectomy after supracervical hysterectomy for benign gynecologic disease from January 2009 through October 2014.

Results:

Eleven patients underwent robotic trachelectomy for benign conditions during the observed period. Prior supracervical hysterectomy had been performed for pelvic pain (8/11, 73%), abnormal uterine bleeding (7/11, 64%), and dysmenorrhea (5/11, 45%). In 10 of 11 patients, the symptoms leading to robotic trachelectomy were the same as those leading to supracervical hysterectomy. The time from hysterectomy to recurrence of symptoms ranged from 0.5 to 26 months (median, 6), whereas the time interval from previous surgery to robotic trachelectomy ranged from 1 to 57 months (median, 26). Mean age and body mass index at robotic trachelectomy were 42 ± 5.4 years and 32 ± 6.1 kg/m². Mean length of surgery was 218 ± 88 minutes (range, 100–405). There was 1 major postoperative complication involving bladder perforation and subsequent vesicovaginal fistula (VVF). Endometriosis was seen in 27% of pathologic specimens and cervicitis in another 27%; 45% showed normal tissue histology. In 6 (55%) cases, symptoms leading to trachelectomy resolved completely after surgery, and the other 5 (45%) patients reported a significant improvement.

Conclusions:

Although trachelectomy can be a challenging surgery, our experience suggests that the robotic approach may be a valuable means of achieving safe and reproducible outcomes.

Hysterectomy for benign disease: clinical practice guidelines from the French College of Obstetrics and Gynecology

OBJECTIVE

The objective of the study was to draw up French College of Obstetrics and Gynecology (CNGOF) clinical practice guidelines based on the best available evidence concerning hysterectomy for benign disease.

METHODS

Each recommendation for practice was allocated a grade, which depends on the level of evidence (clinical practice guidelines).

RESULTS

Hysterectomy should be performed by a high-volume surgeon (>10 hysterectomy procedures per year) (gradeC). Stimulant laxatives taken as a rectal enema are not recommended prior to hysterectomy (gradeC). It is recommended to carry out vaginal disinfection using povidone-iodine solution prior to hysterectomy (grade B). Antibiotic prophylaxis is recommended during hysterectomy, regardless of the surgical approach (grade B). The vaginal or laparoscopic approach is recommended for hysterectomy for benign disease (grade B), even if the uterus is large and/or the patient is obese (gradeC). The choice between these two surgical approaches depends on other parameters, such as the surgeon's experience, the mode of anesthesia, and organizational constraints (duration of surgery and medical economic factors). Vaginal hysterectomy is not contraindicated in nulliparous women (gradeC) or in women with previous cesarean section (gradeC). No specific hemostatic technique is recommended with a view to avoiding urinary tract injury (gradeC). In the absence of ovarian disease and a personal or family history of breast/ovarian carcinoma, the ovaries should be preserved in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended with a view to reducing the risk of peri- or postoperative complications (grade B).

CONCLUSION

The application of these recommendations should minimize risks associated with hysterectomy.

[Urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery on the Fallopian tube: Guidelines]

OBJECTIVES

To provide clinical practice guidelines from the French College of Obstetrics and Gynecology (CNGOF) based on the best evidence available, concerning the urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery including opportunistic salpingectomy and adnexectomy.

MATERIAL AND METHOD

Review of literature using following keywords: benign hysterectomy; urinary injury; bladder injury; ureteral injury; vesicovaginal fistula; infection; bowel injury; salpingectomy.

RESULTS

Urinary catheter should be removed before 24h following uncomplicated hysterectomy (grade B). In case of urinary catheter during hysterectomy, immediate postoperative removal is possible (grade C). No hemostasis technics can be recommended to avoid urinary injury (grade C). There is not any evidence to recommend to perform a window in the broad ligament or an ureterolysis, to put ureteral stent or a uterine manipulator in order to avoid ureteral injury. An antibiotic prophylaxis by a cephalosporin is always recommended (grade B). Mechanical bowel preparation before hysterectomy is not recommended (grade B). If there is no ovarian cyst/disease and no familial or personal history of ovarian/breast cancer, ovarian conservation is recommended in premenopausal women (grade B). In postmenopausal women, informed consent and surgical approach should be taken in account to perform a salpingo-oophorectomy. Since the association salpingectomy and hysterectomy is not assessed in the prevention of ovarian cancer, systematic bilateral salpingectomy is not recommended (expert consensus).

CONCLUSIONS

Practical application of these guidelines should decrease the prevalence of visceral complications associated with benign hysterectomy.

Laparoscopic Hysterectomies: Our 10 Years Experience in a Single Laparoscopic Center

STUDY OBJECTIVE

To evaluate the association between outcomes of laparoscopic hysterectomy with respect to clinical factors, intraoperative variants, and post-operative complications.

DESIGN

The study conducted was retrospective (Canadian Task Force Classification II-1).

SETTING

The set used in this study was a gynecological laparoscopic centre.

PATIENTS

The present study included 858 women who underwent laparoscopic hysterectomies with or without bilateral/unilateral salpingo-oophorectomy, from December 2004 to May 2014.

INTERVENTIONS

Eight hundred and sixteen patients underwent total laparoscopic hysterectomy, 14 patients underwent subtotal laparoscopic hysterectomy, 20 patients underwent laparoscopic-assisted vaginal hysterectomy, and 8 patients underwent laparoscopic radical hysterectomy with bilateral pelvic lymph node dissection.

MEASUREMENTS AND MAIN RESULTS

All surgeries were performed by the same surgeon, using the same surgical technique. The medical records were reviewed, and data were collected with respect to age, indications, type of surgery performed, intraoperative variants, and post-operative complications. Patient average age was 44.9 ± 6.2 years. Most common indication for benign TLH was leiomyoma of 54.4 %. Indications for laparoscopic radical hysterectomy were early stage endometrial cancer (n = 5) and early stage cervical cancer (n = 3). The maximum uterine size operated on was from 20-26 weeks, 4.9 % (n = 42). 9.7 % had previous abdominopelvic surgery. Fifty three % underwent unilateral/bilateral salpingo-oophorectomy. Conversion rate was 0.93 % (n = 8). The minimum and maximum operating time during the total study period was 20 min-2 h. The major complication rates were 0.9 % (n = 8). The hospital stay was not more than 2 days.

CONCLUSION

In our experience of 858 laparoscopic hysterectomies, 850 were done for benign indications, and 8 done for malignancies. TLH can be performed more safely and under vision, with less blood loss, early post-operative recovery, less post-operative infection, and less complication rate.

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

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.