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

Mastering nonobstetric surgery in pregnancy: Insights, guidelines evaluation, and point-by-point discussion

For surgeons and clinicians, nonobstetric surgery during pregnancy has certain difficulties and considerations. In order to aid in decision-making in these situations, this manuscript offers a thorough review of the guidelines currently in place from renowned obstetric and surgical societies, such as the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians & Gynecologists, and others. Using AGREE II-S methodology, a comprehensive analysis of guidelines reveals differences in recommendations for anesthetics, surgical procedures, imaging modalities, and thromboembolic prophylaxis. Furthermore, a thorough discussion of strategic surgical planning is provided, covering aspects such as patient positioning, trocar placement, pneumoperitoneum generation, and thromboembolic risk management. The publication highlights that in order to maximize the results for both the mother and the fetus after nonobstetric surgery performed during pregnancy, a multidisciplinary approach and evidence-based decision-making are essential.

VaNoLaH trial: a study protocol-a multinational randomised controlled trial including two identical substudies comparing vaginal versus vNOTES (vaginal natural orifice transluminal surgery) hysterectomy or laparoscopic versus vNOTES hysterectomy

INTRODUCTION

Hysterectomy is one of the most common surgeries performed in women. Minimally invasive methods are on the rise globally as they have been shown to decrease surgical morbidity compared with abdominal hysterectomy. Hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) is the latest innovation. It combines the vaginal approach and endoscopy via the vagina. Large pragmatic randomised controlled trials (RCTs) are lacking comparing outcomes after vNOTES, vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH).

METHODS

Multicentre pragmatic RCT aiming to recruit 1000 women aged 18-75 years undergoing hysterectomy for benign disease. The RCT includes two identical substudies (groups A and B). If VH is considered safe and feasible, the patient will be randomised within group A (VH vs vNOTES). If VH is not considered safe or feasible, patients will be randomised within group B (LH vs vNOTES).

ANALYSIS

Primary outcome is the proportion of women leaving the hospital within 12 hours after surgery. Secondary outcomes are hospitalisation time, conversion rates, duration of the surgical procedure, intraoperative complications, postoperative complications and readmission.

ETHICS AND DISSEMINATION

The Ethical Board Committee at Imelda Hospital, Bonheiden, Belgium, has approved the research protocol 230704 (principal investigator). Before including patients, all centres will require local or national ethical approval. The results of the study will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05971875.

Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis

The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: - 0.144 [- 0.21, - 0.08], p < 0.0001; R/V WMD: - 0.39 [- 0.70, - 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.

Long-Term Health Consequences After Ovarian Removal at Benign Hysterectomy : A Nationwide Cohort Study

BACKGROUND

More evidence is needed to substantiate current recommendations about removing ovaries during hysterectomy for benign conditions.

OBJECTIVE

To compare long-term outcomes in women with and without bilateral salpingo-oophorectomy (BSO) during hysterectomy for benign conditions.

DESIGN

Emulated target trial using data from a population-based cohort.

SETTING

Women in Denmark aged 20 years or older during 1977 to 2017.

PARTICIPANTS

142 985 women with hysterectomy for a benign condition, 22 974 with BSO and 120 011 without.

INTERVENTION

Benign hysterectomy with or without BSO.

MEASUREMENTS

The primary outcomes were overall hospitalization for cardiovascular disease (CVD), overall cancer incidence, and all-cause mortality through December 2018.

RESULTS

Compared with women without BSO, women with BSO who were younger than 45 years at surgery had a higher 10-year cumulative risk for hospitalization for CVD (risk difference [RD], 1.19 percentage points [95% CI, 0.09 to 2.43 percentage points]). Women with BSO had a higher 10-year cumulative risk for cancer for ages 45 to 54 years (RD, 0.73 percentage point [CI, 0.05 to 1.38 percentage points]), 55 to 64 years (RD, 1.92 percentage points [CI, 0.69 to 3.25 percentage points]), and 65 years or older (RD, 2.54 percentage points [CI, 0.91 to 4.25 percentage points]). Women with BSO had higher 10-year mortality in all age groups, although the differences were statistically significant only for ages 45 to 54 years (RD, 0.79 percentage point [CI, 0.27 to 1.30 percentage points]). The mortality at 20 years was inconsistent with that at 10 years in women aged 65 years or older.

LIMITATION

Age was a proxy for menopausal status.

CONCLUSION

The authors find that these results support current recommendations for conserving ovaries in premenopausal women without a high risk for ovarian cancer and suggest a cautious approach in postmenopausal women.

PRIMARY FUNDING SOURCE

The Danish Cancer Society's Scientific Committee and the Mermaid Project.

Preemptive local analgesia at vaginal hysterectomy: a systematic review

INTRODUCTION AND HYPOTHESIS

We conducted a systematic review of the effectiveness of local preemptive analgesia for postoperative pain control in women undergoing vaginal hysterectomy.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched systematically to identify eligible studies published through September 25, 2019. Only randomized controlled trials and systematic reviews addressing local preemptive analgesia compared to placebo at vaginal hysterectomy were considered. Data were extracted by two independent reviewers. Results were compared, and disagreement was resolved by discussion. Forty-seven studies met inclusion criteria for full-text review. Four RCTs, including a total of 197 patients, and two SRs were included in the review.

RESULTS

Preemptive local analgesia reduced postoperative pain scores up to 6 h and postoperative opioid requirements in the first 24 h after surgery.

CONCLUSION

Preemptive local analgesia at vaginal hysterectomy results in less postoperative pain and less postoperative opioid consumption.

Iatrogenic Ureteral Injuries Associated with Gynecological and Surgical Procedures: Our Experience About 18 Cases and Literature Review

Aim

To describe the epidemiological aspects, etiology and outcome of iatrogenic ureteral injury repair at the urology division of Souro Teaching Hospital of Bobo Dioulasso (Burkina-Faso).

Patients and Methods

This was a retrospective descriptive study of consecutive patients with iatrogenic ureteric injuries who were referred and managed in the urology division of Souro Sanou Teaching Hospital (Bobo-Dioulasso) from January 2012 to December 2017. Variables studied were age, the time at the diagnosis, the causative event, the method of repair, and the outcome of the management.

Results

The mean age was 37.72±3.5 years coming from the rural population in most cases. The mean time at the diagnosis was 15 days. The injuries were due to gynecologic surgeries with hysterectomy (66%) and caesarian section (33%). Ureteric reimplantation with anti-reflux system was performed in seventeen patients. The rate of treatment success was 94% and the postoperative course was uneventful for all the patients.

Conclusion

Iatrogenic ureteric lesions at the department of urology of Sanou Sourou teaching hospital of Bobo Dioulasso were mainly caused by gynecologic and obstetric surgeries like hysterectomy and caesarian section.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of bupivacaine injection to trocar sites on postoperative pain following laparoscopic hysterectomy: Results from a prospective, multicentre, double-blind randomized controlled trial

OBJECTIVES

Laparoscopic surgery has numerous advantages over open surgery in view of postoperative pain. In this context, to elevate its benefits and patient satisfaction, different pain management interventions have been used so far. This study aimed to evaluate the effect of bupivacaine injection to trocar sites following laparoscopic hysterectomy for the management of postoperative pain.

STUDY DESIGN

In this study, patients were randomized into two groups (56 cases; 52 controls). A single injection of bupivacaine (0.5 %, 5 mg/mL) was introduced to trocar sites under subcutaneous tissue at a dose of 4 ml for the umbilicus and 2 ml for each 5-mm ancillary trocar site in the study group. No bupivacaine was administered to the control group. The primary aim was to measure differences in 2 -h postoperative numerical rating scale (NRS) pain scores between the two groups. The secondary aims were to evaluate differences between 1-, 4-, 6-, 24- and 48 -h postoperative NRS pain scores, surgical complications, estimated blood loss, duration of operation and analgesic consumption.

RESULTS

The number of postoperative rescue doses of analgesics was found to be lower in the study group compared to the control group (median of 2 vs. 4; p < 0.01). The 1-, 4-, 6-, 24- and 48-hour postoperative NRS pain scores were also found to be lower in the study group compared to the control group (p < 0.01 at each follow-up). The mean duration of surgery and uterus removal, as well as the estimated blood loss, were not significantly different between the two groups.

CONCLUSIONS

The present study suggests that bupivacaine injection to trocar sites is an effective and safe method for reducing pain following laparoscopic hysterectomy.

Evidence-based practical guidelines of the International Society for Gynecologic Endoscopy (ISGE) for vaginal hysterectomy

OBJECTIVE

The study was established by the International Society for Gynecologic Endoscopy (ISGE) to provide evidence-based recommendations in the steps that should be undertaken in successfully performing a vaginal hysterectomy for a non-prolapsed uterus.

MATERIAL AND METHODS

The ISGE Task Force for vaginal hysterectomy for the non-prolapsed uterus defined key clinical questions regarding the surgical technique, which led the Medline/PubMed and the Cochrane Database literature search. Identified pertinent articles, published in English from 1997 to 2019, were analysed. The available information was graded by the level of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group approach. The recommendations were developed through multiple cycles of literature analysis and expert discussion.

RESULTS

Six recommendations were established: 1. A circular incision at the level of cervico-vaginal junction is recommended (grade IC). 2. The posterior peritoneum should be opened first (grade IC). 3. Clamping and cutting the uterosacral and cardinal ligaments before or after getting access into anterior peritoneum is recommended (grade IC). 4. Routine closure of the peritoneum during vaginal hysterectomy is not recommended (grade IB). 5. Vertical or horizontal closure of the vaginal vault following vaginal hysterectomy is recommended (grade IC). 6. To insert a vaginal plug following vaginal hysterectomy is not recommended (grade IB).

CONCLUSION

Vaginal hysterectomy for a non-prolapsed uterus should be the preferential route for removing the uterus when hysterectomy is indicated. The ISGE provides evidence-based practical guidelines on how vaginal hysterectomy for non-prolapsed uterus should be undertaken. All efforts should be directed in teaching the surgical technique of vaginal hysterectomy during residency.

Regional variation of hysterectomy for benign uterine diseases in Switzerland

Background

Hysterectomy is the last treatment option for benign uterine diseases, and vaginal hysterectomy is preferred over more invasive techniques. We assessed the regional variation in hysterectomy rates for benign uterine diseases across Switzerland and explored potential determinants of variation.

Methods

We conducted a population-based analysis using patient discharge data from all Swiss hospitals between 2013 and 2016. Hospital service areas (HSAs) for hysterectomies were derived by analyzing patient flows. We calculated age-standardized mean procedure rates and measures of regional variation (extremal quotient [EQ], highest divided by lowest rate) and systematic component of variation [SCV]). We estimated the reduction in the variance of crude hysterectomy rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, cultural/socioeconomic factors, burden of disease, and density of gynecologists.

Results

Overall, 40,211 hysterectomies from 54 HSAs were analyzed. The mean age-standardized hysterectomy rate was 298/100,000 women (range 186–456). While the variation in overall procedure rate was moderate (EQ 2.5, SCV 3.7), we found a very high procedure-specific variation (EQ vaginal 5.0, laparoscopic 6.3, abdominal 8.0; SCV vaginal 17.5, laparoscopic 11.2, abdominal 16.9). Adjusted for procedure year, demographic, cultural, and sociodemographic factors, a large share (64%) of the variance remained unexplained (vaginal 63%, laparoscopic 85%, abdominal 70%). The main determinants of variation were socioeconomic/cultural factors. Burden of disease and the density of gynecologists was not associated with procedure rates.

Conclusions

Switzerland has a very high regional variation in vaginal, laparoscopic, and abdominal hysterectomy for benign uterine disease. After adjustment for potential determinants of variation including demographic factors, socioeconomic and cultural factors, burden of disease, and the density of gynecologists, two thirds of the variation remain unexplained.

[Impact of the LACC study. A SFOG survey]

INTRODUCTION

The LACC (Laparoscopic Approach to Cervical Cancer Trial) study, released in 2018, described oncological findings in favour of open surgery compared to the minimally invasive pathway in the management of early stage cervical cancers. Our aim was to assess the impact of this study on surgical practices in France.

METHOD

Online questionnaire, consisting of 13 questions addressed to gynecology oncology french society (SFOG) surgeons.

RESULTS

Forty questionnaires were collected. The median annual number of radical hysterectomy was 5 (0-20). Prior to the study, 92.5 % of cervical cancer patients had radical hysterectomy by minimally invasive surgery. In case of laparoscopy or robot, the uterine manipulator was used in 67.6 % and the colpotomy was performed intra-abdominally (78.4 %). After the LACC study, 60 % changed their practice. Open surgery was favored by 75 % of those who modified their practice. Among those continuing to perform minimally invasive surgeries, the manipulator and the intracorporeal colpotomy were discontinued. One-third of surgeons have changed their surgical practice for endometrial cancer in parallel.

CONCLUSION

The results of the LACC study led to a change in surgical practices with an increase in open surgery and a stop in the use of the uterine manipulator and the laparoscopic/robotic intracorporeal colpotomy in the surgical management of early stage of cervical cancer.

Achieving high value in the surgical approach to hysterectomy

Value-based care, best clinical outcome relative to cost, is a priority in correcting the high costs for average clinical outcomes of health care delivery in the United States. Hysterectomy represents the most common and identifiable nonobstetric major surgical procedure among women. Surgical approaches to hysterectomy in the United States have changed in recent decades. For benign indications, clinical evidence identifies the superiority of vaginal hysterectomy over all other routes. These conclusions rest on clinical outcomes; however, cost differentials also exist across hysterectomy approaches, with the vaginal approach consistently incurring the lowest overall costs. Taken together, vaginal hysterectomy has the highest value, whereas the robotic (given high costs) and abdominal approaches (given less favorable clinical outcomes) have less value. Traditional laparoscopic hysterectomy holds an intermediate value. Increasing the use of high-value hysterectomy approaches can be achieved by adopting multimodal strategies, with changes in the payment models being the most important.

Opportunistic prophylactic salpingectomy for prevention of ovarian cancer: What do national societies advise?

OBJECTIVE

To determine how many FIGO (International Federation of Obstetrics and Gynecology) member societies have statements regarding opportunistic (incidental, prophylactic, risk-reducing) salpingectomy at the time of benign gynecologic surgery and to categorize statements as positive, negative or ambivalent.

STUDY DESIGN

The websites of the 130 FIGO member societies were searched for statements on opportunistic salpingectomy. We looked for separate statements and statements embedded in other documents such as clinical guidelines as well as statements by national societies of gynecologic oncology. If nothing was found on the websites we contacted societies by Email or fax.

RESULTS

As of early 2018, 13 FIGO member societies representing 14 countries have statements regarding opportunistic salpingectomy. Nine were separate, stand-alone statements, four were embedded in other documents. Nine of the 13 statements (from Canada, Finland, U.S.A., Great Britain, Australia and New Zealand, Denmark, Austria, Turkey, and Japan) support consideration of opportunistic salpingectomy in appropriate women and four (from Germany, Sweden, Norway, and France) are ambivalent; there are no statements recommending against opportunistic salpingectomy.

CONCLUSION

In 2018 only a small minority of FIGO members have statements on opportunistic prophylactic salpingectomy. These statements are ambivalent or supportive, none is negative.

Systematic review of the limited evidence for different surgical techniques at benign hysterectomy: A clinical guideline initiated by the Danish Health Authority

Hysterectomy for benign gynecological conditions is a common operation that has developed extensively through the last 20 years. Methods and surgical techniques vary throughout the regions in Denmark as well as internationally. Consequently, the Danish Health Authority initiated a national clinical guideline on the subject based on a systematic review of the literature. A guideline panel of seven gynecologists formulated the clinical questions for the guideline. A search specialist performed the comprehensive literature search. The guideline panel reviewed the literature and rated the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Finally, the panel weighted the evidence and formulated the clinical recommendations. Based on the limited available literature and the corresponding quality of evidence according to GRADE, the guideline panel gave the following recommendations: ↓ Subtotal hysterectomy should only be preferred over total hysterectomy after careful consideration because there are documented disadvantages such as persistent cyclic vaginal bleeding (⊕ΟΟΟ). ↑ Consider vaginal hysterectomy rather than conventional laparoscopic hysterectomy for non-prolapsed uteri when feasible (⊕ΟΟΟ). ↓ Robot-assisted laparoscopic hysterectomy should only be preferred over conventional laparoscopic hysterectomy after careful consideration because the beneficial effect is uncertain and because of the longer operating time (⊕⊕ΟΟ). ↑ Consider concomitant bilateral salpingectomy at the time of hysterectomy if the procedure is not considered to increase the risk of complications significantly (⊕ΟΟΟ). ↑ Consider vaginal vault suspension to the cardinal and the uterosacral ligaments when performing hysterectomy for non-prolapsed uteri (⊕ΟΟΟ). Though supporting evidence is missing, the guideline panel emphasizes that it is good practice not to morcellate uteri with presumed fibroids inside the peritoneal cavity (√). The recommendations serve as professional advice in specific clinical situations. The implementation of the guideline in Denmark will be monitored through the national Danish Hysterectomy and Hysteroscopy Database.

Rates and Routes of Hysterectomy for Benign Indications in Austria 2002 - 2014

INTRODUCTION

Rates and routes of hysterectomy have implications for quality, costs and training. This study analyzed rates of benign hysterectomy and surgical approaches for benign hysterectomy in Austria from 2002 to 2014.

MATERIAL AND METHODS

This was a population-based retrospective observational study of coding data from all acute care hospitals (public and private) in Austria. Main outcome measures were numbers of women undergoing hysterectomy for benign indications in Austria per year and the route of hysterectomy for benign indications.

RESULTS

The number of benign hysterectomies performed per year declined from 10 675 in 2002 to 7747 in 2014, a decline of 27%. The use of vaginal hysterectomy was stable (53% and 47%, respectively). Use of laparoscopic techniques increased (5% in 2002, 32% in 2014) whereas use of abdominal hysterectomy decreased (41% and 20%, respectively).

CONCLUSIONS

Numbers of benign hysterectomies performed per year in Austria declined substantially between 2002 and 2014. Use of vaginal hysterectomy was stable at about 50%, whereas increased use of laparoscopic techniques was associated with lower rates of open hysterectomy.

Case report of ovarian torsion mimicking ovarian cancer as an uncommon late complication of laparoscopic supracervical hysterectomy

Laparoscopic supracervical hysterectomy (LSH) is an example of a partial hysterectomy, performed due to benign gynaecological complaints. Better endoscopic instruments and operational techniques have led to a great reduction in the number of abdominal hysterectomies. It is believed that LSH is a safe and minimally invasive hysterectomy technique. The Cochrane Database meta-analysis proves the benefits of minimally invasive surgery compared with abdominal gynaecological surgery, including decreased pain, surgical-site infections and hospital stay, quicker return to activity, and fewer postoperative adhesions. According to recent publications, the overall complication rate of all hysterectomy methods is about 1-4.5%. Adnexal torsion is a correlated complication. About 3-5% of patients undergoing emergency surgery due to pelvic pain are diagnosed with this condition. It may be the cause of acute abdomen and correlated symptoms such as vomiting, nausea, or severe pain.

To the best of our knowledge a case of asymptomatic, delayed ovarian torsion mimicking ovarian tumour has not been reported so far. In the presented case, torsion successfully imitated neoplastic process as both ROMA score and IOTA ‘simple rules’ indicated a malignancy with high degree of probability. This case demonstrates that, if ovarian tumour is detected in the postoperative period, a torsion of ovarian pedicle should be taken into consideration as it may mimic malignant neoplasm.