Does the uterine cervix become abnormally reinnervated after subtotal hysterectomy and what is the association with future trachelectomy?

Total or Subtotal Hysterectomy for the Treatment of Endometriosis: A Review

OBJECTIVE

The purpose of the review was to evaluate and compare outcomes after total or subtotal hysterectomy in women with endometriosis or adenomyosis.

METHODS

We searched four electronic databases: Medline (PubMed), Scopus, Embase, and Web of Science (WoS). The first aim of the study was to compare outcomes after total and subtotal hysterectomy in women with endometriosis, and the second aim was to compare the two procedures in women with adenomyosis. Publications that reported short- and long-term outcomes after total and subtotal hysterectomy were included in the review. The search was not subject to any limitation in terms of time or method.

RESULTS

After screening 4948 records, we included 35 studies published from 1988 to 2021; the studies were based on various methodologies. With regard to the first aim of the review, we found 32 eligible studies and divided these into the following four categories: postoperative short- and long-term outcomes, recurrence of endometriosis, quality of life and sexual function, and patient satisfaction after total or subtotal hysterectomy in women with endometriosis. Five investigations were deemed eligible for the second aim of the review. No differences were seen in terms of postoperative short- and long-term outcomes after subtotal or total hysterectomy in women with endometriosis or adenomyosis.

CONCLUSIONS

Preservation or removal of the cervix in women with endometriosis or adenomyosis appears to have no effect on short- or long-term outcomes, recurrence of endometriosis, quality of life and sexual function, or patient satisfaction. Nevertheless, we lack randomized blinded controlled trials on these aspects. Such trials will be needed to enhance our comprehension of both surgical approaches.

Optimal Management of Endometriosis and Pain

The pathophysiology of endometriosis-associated pain involves inflammatory and hormonal alterations and changes in brain signaling pathways. Although medical treatment can provide temporary relief, most patients can achieve long-term sustained pain relief when it is combined with surgical intervention. Owing to its complexity, there is an ongoing debate about how to optimally manage endometriosis-associated pain. We believe optimal management for this condition requires: 1) possible egg preservation in affected young patients with and without endometriomas; 2) preoperative medical suppression to inhibit ovulation and to avoid removal of functional cysts that might look like endometriomas; and 3) postoperative hormonal suppression to decrease recurrence, but this treatment should be modified according to disease severity, symptoms, and fertility goals.

Identifying Preoperative Factors Associated with Nonresponders in Women Undergoing Comprehensive Surgical Treatment for Endometriosis

STUDY OBJECTIVE

To examine whether existing quality of health outcome measures can be used to predict or have an association with nonresponse surgery for endometriosis.

DESIGN

Retrospective cohort study.

SETTINGS

Single endometriosis referral center.

PATIENTS

Women (n = 198) undergoing surgery for endometriosis.

INTERVENTIONS

Validated health questionnaires and visual analogue scales.

MEASUREMENTS AND MAIN RESULTS

Patients were given validated health questionnaires, including Endometriosis Health Profile 30, Gastrointestinal Quality of Life Index, EuroQol-5, Hospital Anxiety and Depression Scale, preoperatively and at 12 months after full surgical excision of endometriosis. Visual analogue scales were also used that measured dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain. Surgical management was dependent on severity of disease. Superficial disease was treated by laparoscopic peritoneal excision or laser ablation. Deep infiltrating disease involving the bowel was excised completely together with laparoscopic bowel surgery (shave, disc, or segmental resection) with/without concomitant total hysterectomy and bilateral salpingo-oophorectomy. Nonresponders were defined as women who failed to demonstrate an improvement in pain scores 12 months postoperatively. We examined preoperative and postoperative questionnaires, visual analogue scores, and other variables such as age at onset of symptoms, type of surgery, and the presence of postoperative complications comparing responder and nonresponder women to identify the factors associated with nonresponse. Of 102 women treated for superficial endometriosis, 25 (24.51%) were nonresponders. No factors were associated with nonresponse at 12 months. Of 96 women treated for severe endometriosis involving the bowel, 10 (10.41%) were nonresponders. Nonresponders had significantly less preoperative pain (p = .031) and feeling of control (p = .015) than responders. There was no association between nonresponders and women who underwent a hysterectomy with bilateral salpingo-oophorectomy or those with complications. Radical bowel surgery (resection) was associated with nonresponders.

CONCLUSION

Minimal preoperative factors are associated with nonresponse for women having surgery for endometriosis. The severity of pain experienced by women with endometriosis may be used to predict their response to surgery.

Pain relief procedures before high-dose-rate brachytherapy for non-surgical treatment of cervix cancer

Cervical cancer (CC) is a neoplasm with great potential for prevention, but it is still an important public health problem in most developing countries. No significant difference is found in the literature between intracavitary high-dose-rate (HDR) and low-dose-rate (LDR) brachytherapy, when considering overall, disease specific, and recurrence-free survivals. Cervical dilatation is mandatory for the insertion of intra-uterine tandems for CC intracavitary brachytherapy. Pain and discomfort may eventually be the limiting factors of the procedure, sometimes leading to unsatisfactory results in terms of adequate position of the applicator set. In this paper, we critically reviewed the current sedation and anesthetic options for comfort and safety procedures when performing intracavitary brachytherapy.