Morbidity of 10 110 hysterectomies by type of approach

LAparoscopic Versus Abdominal hysterectomy (LAVA): protocol of a randomised controlled trial

INTRODUCTION

There is uncertainty about the advantages and disadvantages of laparoscopic hysterectomy compared with abdominal hysterectomy, particularly the relative rate of complications of the two procedures. While uptake of laparoscopic hysterectomy has been slow, the situation is changing with greater familiarity, better training, better equipment and increased proficiency in the technique. Thus, a large, robust, multicentre randomised controlled trial (RCT) is needed to compare contemporary laparoscopic hysterectomy with abdominal hysterectomy to determine the safest and most cost-effective technique.

METHODS AND ANALYSIS

A parallel, open, non-inferiority, multicentre, randomised controlled, expertise-based surgery trial with integrated health economic evaluation and an internal pilot with an embedded qualitative process evaluation. A within trial-based economic evaluation will explore the cost-effectiveness of laparoscopic hysterectomy compared with open abdominal hysterectomy. We will aim to recruit 3250 women requiring a hysterectomy for a benign gynaecological condition and who were suitable for either laparoscopic or open techniques. The primary outcome is major complications up to six completed weeks postsurgery and the key secondary outcome is time from surgery to resumption of usual activities using the personalised Patient-Reported Outcomes Measurement Information System Physical Function questionnaire. The principal outcome for the economic evaluation is to be cost per QALY at 12 months' postsurgery. A secondary analysis is to be undertaken to generate costs per major surgical complication avoided and costs per return to normal activities.

ETHICS AND DISSEMINATION

The study was approved by the West Midlands-Edgbaston Research Ethics Committee, 18 February 2021 (Ethics ref: 21/WM/0019). REC approval for the protocol version 2.0 dated 2 February 2021 was issued on 18 February 2021.We will present the findings in national and international conferences. We will also aim to publish the findings in high impact peer-reviewed journals. We will disseminate the completed paper to the Department of Health, the Scientific Advisory Committees of the RCOG, the Royal College of Nurses (RCN) and the BSGE.

TRIAL REGISTRATION NUMBER

ISRCTN14566195.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH).

OBJECTIVES

To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

SEARCH METHODS

We searched the following databases (from their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

MAIN RESULTS

We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies.

AUTHORS' CONCLUSIONS

Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.

Learning laparoscopic hysterectomy: analysis of different surgeons' individual learning curves

OBJECTIVE

The aim of this study was to examine the development of surgical skills among surgeons learning total laparoscopic hysterectomy (TLH), using differences in complication rates between surgeons with different levels of experience and analyzing the development of individual operating times.

STUDY DESIGN

This retrospective, single-center cohort study included 576 total laparoscopic hysterectomy procedures conducted between January 2015 and December 2019 at the municipal hospital in Karlsruhe, Germany. All TLHs were performed by eight surgeons, two of whom were experienced and six inexperienced. Complications were graded using the Clavien-Dindo classification.

RESULTS

No differences in complication rates were seen between experienced and inexperienced surgeons. With growing numbers of procedures, most surgeons quickly became faster, leading to reduced operating times. However, experienced surgeons who had performed more than 100 procedures also became faster, not reaching a time plateau after adjustment for weight of the uterus, presurgery score, and adnexal score.

CONCLUSIONS

Learning laparoscopic hysterectomy in routine practice is safe for patients, and surgeons rapidly become faster as growing numbers of procedures are performed. Operating times for experienced surgeons who have carried out more than 100 operations also improve, and a time plateau is not reached.

Urinary tract injury during hysterectomy: Does surgeon specialty and surgical volume matter?

BACKGROUND

Ureteral injury is a known complication of hysterectomies. Recent studies have attempted to correlate surgeon volume and experience with incidence of urinary tract injuries during hysterectomies. Some studies have reported that as surgeon volume increases, urinary tract injury rates decrease. To our knowledge, no studies have assessed the relationship between surgeon subspecialty and the rate of urinary tract injury rates during minimally invasive hysterectomy.

AIM

To determine the incidence of urinary tract injury between urogynecologists, gynecologic oncologists, and general gynecologists.

METHODS

The study took place from January 1, 2016 to December 1, 2021 at a large community hospital in Detroit, Michigan. We conducted a retrospective chart review of adult patients who underwent minimally invasive hysterectomy. After we identified eligible patients, the surgeon subspecialty was identified and the surgeon’s volume per year was calculated. Patient demographics, medical history, physician-dictated operative reports, and all hospital visits postoperatively were reviewed.

RESULTS

Urologic injury occurred in four patients (2%) in the general gynecologist group, in one patient (1%) in the gynecologic oncologist group, and in one patient (1%) in the urogynecologist group. When comparing high and low-volume surgeons, there was no statistically significant difference in urinary tract injury (1% vs 2%) or bowel injury (1% vs 0%). There were more complications in the low-volume group vs the high-volume group excluding urinary tract, bowel, or major vessel injury. High-volume surgeons had four (1%) patients with a complication and low-volume surgeons had 12 (4%) patients with a complication (P = 0.04).

CONCLUSION

Our study demonstrated that there was no difference in the urinary tract injury rate in general gynecologists vs subspecialists, however our study was underpowered.

Risk Factors for Adhesion-Related Readmission and Abdominal Reoperation after Gynecological Surgery: A Nationwide Cohort Study

More than half of women in developed countries undergo surgery during their lifetime, putting them at risk of adhesion-related complications. Adhesion-related complications include small bowel obstruction, chronic (pelvic) pain, subfertility, and complications associated with adhesiolysis during reoperation. The aim of this study is to predict the risk for adhesion-related readmission and reoperation after gynecological surgery. A Scottish nationwide retrospective cohort study was conducted including all women undergoing a gynecological procedure as their initial abdominal or pelvic operation between 1 June 2009 and 30 June 2011, with a five-year follow-up. Prediction models for two- and five-year risk of adhesion-related readmission and reoperation were constructed and visualized using nomograms. To evaluate the reliability of the created prediction model, internal cross-validation was performed using bootstrap methods. During the study period, 18,452 women were operated on, and 2719 (14.7%) of them were readmitted for reasons possibly related to adhesions. A total of 2679 (14.5%) women underwent reoperation. Risk factors for adhesion-related readmission were younger age, malignancy as indication, intra-abdominal infection, previous radiotherapy, application of a mesh, and concomitant inflammatory bowel disease. Transvaginal surgery was associated with a lower risk of adhesion-related complications as compared to laparoscopic or open surgeries. The prediction model for both readmissions and reoperations had moderate predictive reliability (c-statistics 0.711 and 0.651). This study identified risk factors for adhesion-related morbidity. The constructed prediction models can guide the targeted use of adhesion prevention methods and preoperative patient information in decision-making.

Is there a need for a technical certification system for gynecological robotic surgery? Questionnaire survey of members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy

The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) introduced a system for the certification of laparoscopic surgeons in 2002 and a system for the certification of facilities in 2014. We examined the opinions of the members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) regarding the necessity of a certification training system and a technical certification system for robotic surgery skills in Japan. Members of the JSGOE were surveyed with two questionnaires. Overall, 870 and 519 participants responded to the first and second questionnaires, respectively. Half of the respondents indicated that both systems were necessary. The breakdown by age and qualifications showed that this was especially true for the younger generation and respondents with more experience with robotic surgery. Overall, 40% of the respondents judged that a certification system for robotic surgery alone (with or without certification in laparoscopic surgery but with a requirement of experience in laparoscopic surgery) would be necessary. The opinions of the JSGOE members on making a certification system for robotic surgery were split into two clear-cut camps. Thus, we must further seek the extent of public demand for using a public survey so that a final decision can be made on whether to establish this system.

Systematic review of urological injury during caesarean section and hysterectomy

INTRODUCTION AND HYPOTHESIS

We aim to review iatrogenic bladder and ureteric injuries sustained during caesarean section and hysterectomy.

METHODS

A search of Cochrane, Embase, Medline and grey literature was performed using methods pre-published on PROSPERO. Eligible studies described iatrogenic bladder or ureter injury rates during caesarean section or hysterectomy. The 15 largest studies were included for each procedure sub-type and meta-analyses performed. The primary outcome was injury incidence. Secondary outcomes were risk factors and preventative measures.

RESULTS

Ninety-six eligible studies were identified, representing 1,741,894 women. Amongst women undergoing caesarean section, weighted pooled rates of bladder or ureteric injury per 100,000 procedures were 267 or 9 events respectively. Injury rates during hysterectomy varied by approach and pathological condition. Weighted pooled mean rates for bladder injury were 212-997 events per 100,000 procedures for all approaches (open, vaginal, laparoscopic, laparoscopically assisted vaginal and robot assisted) and all pathological conditions (benign, malignant, any), except for open peripartum hysterectomy (6,279 events) and laparoscopic hysterectomy for malignancy (1,553 events). Similarly, weighted pooled mean rates for ureteric injury were 9-577 events per 100,000 procedures for all hysterectomy approaches and pathologies, except for open peripartum hysterectomy (666 events) and laparoscopic hysterectomy for malignancy (814 events). Surgeon inexperience was the prime risk factor for injury, and improved anatomical knowledge the leading preventative strategy.

CONCLUSIONS

Caesarean section and most types of hysterectomy carry low rates of urological injury. Obstetricians and gynaecologists should counsel the patient for her individual risk of injury, prospectively establish risk factors and implement preventative strategies.

Does the experience of the first assistant affect organ injuries in laparoscopic hysterectomy for benign diseases?

PURPOSE

This study sought to explore whether the experience level of the first assistant surgeon influences perioperative organ injuries (ureteral, bladder, and intestinal injuries) in patients undergoing total laparoscopic hysterectomy (TLH) for benign diseases. We defined an experienced surgeon as a surgeon certified by the Skill Qualification Committee of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy or a surgeon with equivalent surgical skills.

METHODS

We reviewed our surgical registry database of TLH for benign indications between 2014 and 2020 and only selected cases performed by an experienced primary surgeon. Patients were divided into two groups based on the experience level of the first assistant. Inverse probability of treatment weighting by propensity score, which was adjusted for patient and procedure characteristics, was used to examine differences in perioperative organ injuries according to the experience level of the first assistant.

RESULTS

Among 1682 patients who underwent TLH, 18 organ injuries were found (0.83%). In the propensity score inverse probability of treatment weighting models, less experience of the first assistant had no significant impact on the occurrence of perioperative organ injuries (p = 0.348).

CONCLUSION

In TLH for benign indications at our hospital, given an experienced primary surgeon, the inclusion of a less experienced first assistant does not negatively affect the occurrence of perioperative organ injuries.

Total laparoskopik histerektomi ile total abdominal histerektomi olgularının karşılaştırılması

Amaç: Amacımız, benign endikasyonlarda yapılan total laparoskopik histerektomi ve total abdominal histerektomi operasyonlarının sonuçlarını literatür eşliğinde retrospektif olarak karşılaştırmaktır. Gereç ve Yöntem: Antalya Serik Devlet Hastanesi Kadın Hastalıkları ve Doğum Kliniğinde Temmuz 2015 ve Ekim 2020 yılları arasında benign endikasyonlarda total histerektomi uygulanan 240 hastanın kayıtları literatür eşliğinde retrospektif olarak incelendi. Yaş aralığı 40-75 idi. Vakaların 120‘si total laparoskopik histerektomi (TLH Grup1) ve 120‘si total abdominal histerektomi (TAH Grup2) olarak sınıflandırıldı. Malignitesi olanlar, sezaryen sonrası histerektomiler, supraservikal histerektomi, laparoskopik asiste vajinal histerektomi, vajinal histerektomi yapılanlar ve kayıtları eksik olanlar çalışma dışı bırakıldı. Hastalardan operasyon öncesi yazılı onam formu alındı. Hastaların ortalama yaşı, parite, vücut kitle indeksi, çıkarılan ortalama uterus ağırlığı, geçirilmiş batın cerrahisi öyküsü, histerektomi endikasyonları, operasyon süresi, komplikasyon oranları, kan kaybı miktarı, post operatif hastanede yatış süresi iki grup arasında karşılaştırıldı. Bulgular: İki grup arasında demografik özellikler açısından, istatiksel olarak anlamlı fark yoktu. İki grupta da en sık saptanan endikasyonlar, fibromiyom ve tedaviye dirençli anormal uterin kanamaydı. grup 1’de ortalama ameliyat süresi grup 2 ye göre daha uzun olup istatiksel açıdan anlamlı bulundu. grup 1’de ortalama hastanede kalma süresi daha kısa saptandı ve istatiksel açıdan anlamlı bulundu. Operasyonla çıkarılan ortalama uterus ağırlığı grup 2 de daha ağır saptandı. Sonuç: Laparoskopik histerektomi, seçilmiş hastalar için operasyon süresinin daha uzun olması ve tecrübe gerektirmesi ile birlikte güvenli ve uygun bir minimal invaziv cerrahi işlemdir. Daha çabuk iyileşme, daha erken taburcu olma, daha az kan kaybı avantajı vardır.

Incidence Rates of Myomectomy-Related Mortality and Venous Thromboembolism in South Korea: A Population-Based Study

Background

Uterine leiomyomas are the most commonly observed pathologies, with an estimated prevalence of 4. 5–68.6%. We aimed to calculate myomectomy-related mortality and venous thromboembolism incidence rates in the Republic of Korea.

Methods

The data of patients who underwent myomectomy (2009–2018) were obtained from the Health Insurance Review and Assessment Service-National Inpatient Sample. The mortality rate after myomectomy was calculated using the leiomyoma diagnostic codes and myomectomy procedure codes. The incidence rates of venous thromboembolism, deep vein thrombosis, and pulmonary embolism were calculated using their diagnostic codes, with concomitant use of an antithrombotic agent during the same period or within 90 days after myomectomy.

Results

The data of 23,549 women aged 15–55 years who underwent myomectomy were extracted. The myomectomy rate was 14.6 ± 0.1 per 10,000 patients. The average age was 39.39 ± 0.04 years. One patient who underwent myomectomy died; this patient did not have concomitant venous thromboembolism. The post-myomectomy mortality rate was 1.3 ± 0.8 per 10,000 patients. The incidence rates of venous thromboembolism, deep vein thrombosis, and pulmonary embolism after myomectomy were 5.7 ± 1.6 per 10,000 patients, 4.4 ± 1.4 per 10,000 patients, and 2.5 ± 1 per 10,000 patients, respectively. The conversion rate to hysterectomy was 2.9 ± 1.1 per 10,000 patients.

Conclusion

The current mortality rate after myomectomy (0.013%) is substantially lower than that described in previous studies at the turn of the 20th century. The incidence of venous thromboembolism is also considerably lower than that in the general population worldwide.

Incidence of bowel injury during gynecologic surgery for benign indications: A nationwide cross-sectional study of cases from 2009 to 2018

OBJECTIVE

To investigate the incidence and risk factors of intestinal injury during gynecologic surgery for benign diseases, based on a national database.

METHOD

The study cohort was generated by extracting patients with operation codes for benign gynecologic diseases from the Health Insurance Review & Assessment Service National Inpatient Sample from 2009 to 2018. After analyzing the incidence of bowel injury during gynecologic surgery, a multivariate analysis was performed to identify the associated risk factors for bowel injury.

RESULTS

Among 81 451 patients who underwent gynecologic surgery for benign diseases, the incidence of bowel injury was 6.14 per 1000 women. The risk of bowel injury decreased with laparoscopy (odds ratio [OR] 0.54; 95% confidence interval [CI] 0.41-0.69; P < 0.001) and increased with subtotal hysterectomy (OR 2.83; 95% CI 1.79-4.46; P < 0.001) and adnexectomy (OR 2.83; 95% CI 1.93-4.16; P < 0.001). Old age, higher Charlson comorbidity index, low socioeconomic status, and a higher clinic grade were associated with a higher risk of bowel injury.

CONCLUSION

This study revealed the incidence of bowel injury during benign gynecologic surgery in a Korean national population-based cohort. The risk of bowel injury increased with open surgery, subtotal hysterectomy, and adnexectomy.

Incidence of and risk factors for vaginal cuff dehiscence following total laparoscopic hysterectomy: a monocentric hospital analysis

PURPOSE

Vaginal cuff dehiscence (VCD) is one of the major surgical complications following hysterectomy with data on incidence rates varying largely and studies assessing risk factors being sparse with contradictive results. The aim of this study was to assess the incidence rate of and risk factors for VCD in a homogenous cohort of women treated for benign uterine pathologies via total laparoscopic hysterectomy (TLH) with standardized follow-up.

METHODS

All patients undergoing TLH at the Department of Gynecology and Obstetrics, Saarland University Hospital between November 2010 and February 2019 were retrospectively identified from a prospectively maintained service database.

RESULTS

VCD occurred in 18 (2.9%) of 617 patients included. In univariate and multivariate analyses, a lower level of surgeon laparoscopic expertise (odds ratio 3.19, 95% confidence interval (CI) 1.0-9.38; p = 0.03) and lower weight of removed uterus (odds ratio 0.99, 95% CI 0.98-0.99; p = 0.02) were associated positively with the risk of VCD.

CONCLUSION

In this homogenous cohort undergoing TLH, laparoscopic expertise and uterine weight influenced the risk of postoperative VCD. These findings might help to further reduce the rate of this complication.

Prevalence of Hysterectomy among Gynecological Surgeries in a Tertiary Care Hospital

INTRODUCTION

Hysterectomy is the most common gynecological procedure. Over the last decade, the minimally invasive approach has been practiced more frequently. Fibroid uterus being the most common indication for hysterectomy justifies this minimal approach, however, whenever feasible, vaginal hysterectomy can be the preferred route. The objective of this study was to find out the prevalence and indication of hysterectomy among major gynecological surgeries in a tertiary care hospital.

METHODS

A descriptive cross-sectional study was done at a tertiary care hospital among 1912 patients who had major gynecological surgeries from January 2017 to December 2019. Ethical clearance was obtained from the institutional review committee (ref. no. ACD 935/076/077). Convenient sampling was used. Statistical analysis was done using Statistical Package for Social Sciences version 21.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

RESULTS

During the study period, there were 1,912 major gynecological surgeries and the prevalence of hysterectomy was 1,131 (59.15%) (56.94-61.35 at 95% Confidence Interval). Fibroid uterus was the most common clinical indication for hysterectomy which was done in 397 (35.10%) patients, followed by uterovaginal prolapse in 254 (22.46) patients, adnexal mass in 210 (18.56%), and abnormal uterine bleeding in 117 (10.34%) patients.

CONCLUSIONS

Hysterectomy, being the most common gynecological surgery, selection of the most appropriate route is of paramount importance. As for any other surgery, it is not without complication and hysterectomy should always be justified. With the advancement in the conservative approaches, these organ-preserving options should be explored rigorously before opting for hysterectomy.

Robotic Vaginal Natural Orifice Transluminal Endoscopic Hysterectomy for Benign Indications

STUDY OBJECTIVE

The Hominis surgical system is a novel robot-assisted system, designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). We presented our experience of the first 30 RvNOTES hysterectomies assessing the feasibility and safety of this technology.

DESIGN

A two-center prospective study.

SETTING

Academic tertiary referral centers. The ethics committees approved the study in both centers.

PATIENTS

Thirty women with benign indication for hysterectomy.

INTERVENTION

RvNOTES hysterectomy performed by the Hominis surgical system.

MEASUREMENTS AND MAIN RESULTS

The primary outcome of the study was the rate of conversion to open or conventional laparoscopic approaches. Secondary outcomes included intra- and postoperative adverse events, operative time, estimated blood loss, length of hospital stay, and 6-week follow-up assessment. A total of 15 women were enrolled at each site. The median age was 59 years (range: 37-79) and the median body mass index was 25.4 kg/m² (range: 17.6-40.0). Twenty-four women (80%) had comorbidities. All the procedures were completed successfully without conversion to open abdominal, traditional vaginal, or conventional laparoscopic surgery. No intraoperative complications were observed. Median blood loss and procedure duration were 50 mL (range: 20-400) and 57 minutes (range: 24-88), respectively. Postoperative pain was minimal, with a median visual analog scale of 3 (range: 1-5) for the first 24 hours following surgery. The median hospital stay was 3 days (range: 2-8). According to the treating physicians' evaluations, the vaginal cuff was fully healed in all patients at the 6-week postoperative follow-up visit.

CONCLUSIONS

This is the first publication of robot-assisted vaginal hysterectomy using the Hominis surgical system. The positive results of this study show this new technology to be a safe and effective tool for vaginal natural orifice transluminal endoscopic surgery, enabling surgeons to operate vaginally with the known advantages of robotic modality.

Re-evaluating "Success" as It Pertains to Surgical Trials

The objective of this article is to review the difficulties with the design and interpretation of surgical clinical trials. Few surgical procedures are evaluated in a randomized fashion. There are a number of factors that make the design of surgical trials diffiuclt, and many surgical questions cannot be answered with a clinical trial. Issues with standardization of the surgical procedure, variability of surgical skills, and changes in surgical expertise over time further complicate the design and implementation of surgical trials. Statistical methods for surgical trials often require a noninferiorty design and are more complicated to interpret than the more common superiority trial. Even when properly conducted, both superiority and noninferiority trials are often misinterpreted. Because of the relatively high success rate in surgery, trials require large numbers of patients and noninferiority trials are often inconclusive with respect to the primary outcome. Surgical trials are often misinterpreted or over interpreted, and there can be confusion in how the findings of these trials should be incorportated into clinical practice. The interpretation of the results of a surgical trial often differ significantly from the primary and secondary outcomes that were specified in the trial design.

Laparoscopic Hysterectomy for Benign Pathology Does Not Yield More Perioperative Complications than Abdominal or Vaginal Hysterectomies: Our Experience in Introducing Laparoscopic Hysterectomy

Objectives

Total laparoscopic hysterectomy (TLH) is increasing as a substitute for total abdominal hysterectomy (TAH) and total vaginal hysterectomy (TVH) with the growing prevalence of laparoscopic surgery. The aim of this study is to assess perioperative complications of the chosen hysterectomy techniques performed for benign indications when started performing TLH. This was retrospective cohort study. This study was conducted at Nagahama City Hospital.

Materials and Methods

There were 176 patients who underwent hysterectomy for benign indications from 2013 to 2016. Perioperative and postoperative outcomes were compared for the three different hysterectomy approaches laparoscopic; abdominal; and vaginal. Data were analyzed using the t-test or Chi-square and Fisher's exact test.

Results

TAH, TLH, and TVH were performed on 118 patients (67.0%), 32 (18.2%), and 26 (14.8%), respectively. Operation time was significantly longer for the TLH group than for the TAH and TVH groups. Blood loss was lower for the TVH and TLH groups than for the TAH group. Three days after surgery, C-reactive protein was lower in the TVH group than in the TAH group. The average uterus size in the TAH group was larger than in the TVH and TLH groups. Patients undergoing TLH experienced fewer perioperative complications than patients in the TAH and TVH groups; however, this difference was not statistically significant.

Conclusion

TLH for benign pathology does not yield more perioperative complications than TAH or TVH. However, vaginal hysterectomy is the least invasive approach. The final choice for the route of hysterectomy depends on many factors, including body mass index, uterus size, and experience of the gynecologist.

Protocol for a modified vaginal pipe for total laparoscopic hysterectomies: Experimental research

Background

The Vagi-Pipe® is a useful device for performing a total laparoscopic hysterectomy. The conventional model of the Vagi-Pipe® is unable to grasp the uterus during colpotomy for recovery of the resected uterus. However, the modified C-Type Vagi-Pipe® model has a shape that allows insertion into the vagina without removing the uterus manipulator. In this study, we will prospectively investigate the safety and efficacy of the C-Type Vagi-Pipe® in total laparoscopic hysterectomies.

Materials and methods

In total, 25 female subjects aged between 20 and 60 years with uterine fibroids or adenomyosis will be included. Patients with complications regarded as unsuitable for this study by the investigators will be excluded. The C-Type Vagi-Pipe® will be used rather than the conventional Vagi-Pipe® when performing a total laparoscopic hysterectomy. The primary endpoint will be safety and the secondary endpoints will be operation time, bleeding volume, and presence of complications.

Ethics and dissemination

The protocol was approved by the institutional review boards. Written informed consent will be obtained from all patients before registration in accordance with the Declaration of Helsinki. Results of the study will be disseminated via publications in peer-reviewed journals.

[Ambulatory minimally invasive hysterectomy: Limiting factors related to health professionals]

OBJECTIVES

The feasibility of minimally invasive hysterectomy for ambulatory benign pathology has been demonstrated in many international studies. France has a considerable delay of multifactorial origin in this field. The objective of this study is to identify the limiting factors related to health professionals to the realization of minimally invasive ambulatory hysterectomy and to determine possible strategies to increase its rate.

METHODS

This is a cross-sectional survey conducted over 2 months using a self-administered questionnaire sent by email to 180 gynecological surgeons in 2 French regions (Grand Est and Bourgogne-Franche Comté).

RESULTS

A total of 22% of health professionals responded to the survey. The vast majority of practitioners (60%) said they did not carry out ambulatory care by habit. The apprehension of the reaction of the patients (47.5%), the fear of delayed diagnosis of complications (12.5%), the management of pain in the postoperative period (42.5%) also participated in brake of the promotion of ambulatory care.

DISCUSSION

Improvement of the organisation of city and hospital management allowing a better continuity of care (70%), the economic valuation (37.5%) and the increase in the hourly amplitude of the ambulatory surgery unit (5%) would improve the rate of ambulatory care of minimally invasive hysterectomies, according to the gynecologist surgeons surveyed. In addition, a prospective study evaluating the quality of life of patients after ambulatory care of minimally invasive hysterectomy would allow better adherence of health professionals and patients to the ambulatory care project in 70% of cases.

CONCLUSION

The change of mentality of health professionals remains a priority for the promotion of ambulatory surgery in gynecology. Information and communication are therefore essential to the expansion of the ambulatory.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center

OBJECTIVES

To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula.

METHODS

We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted.

RESULTS

Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion.

CONCLUSIONS

Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula.

Postoperative infections in women undergoing hysterectomy for benign indications: a cohort study

BACKGROUND

There is limited data on the incidence of postoperative infections following hysterectomy by route of surgery. We hypothesize that vaginal hysterectomy has lower rates of postoperative infection than laparoscopic and abdominal hysterectomies.

METHODS

A retrospective cohort study and independent hand review of charts of participants undergoing hysterectomy at five hospitals from September 2011 through May 2015 was performed. Cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and were reviewed by the investigators. The primary outcome was the development of Clostridium difficile infection, urinary tract infection, surgical site infection, or yeast vaginitis within 60 days following surgery.

RESULTS

In total, 2742 women underwent hysterectomy: abdominal 17.5% (AH), laparoscopic 65.8% (LH), and vaginal 16.7% (VH). The composite postoperative infection rate for the four specified variables was 8.5% (232). In comparing surgical route, AH was most commonly associated with CDI (0.6%, p <0.001), SSI (6.0%, P=0.001), and yeast vaginitis (1.9%, p <0.001), while VH was most commonly associated with UTI (8.1%, P=0.002). After controlling for demographic and operative factors, multivariable analysis showed that hysterectomy route was not associated with infection. Independent predictors for postoperative infection were increasing age, American Society of Anesthesiologists physical status classification, operative time, and hospital type.

CONCLUSIONS

Infectious complications after hysterectomy are uncommon, accounting for 8.5% of cases. Multivariable analysis showed that demographic and operative variables were more likely to serve as independent predictors of development of infection than hysterectomy route.

How to train practising gynaecologists in total laparoscopic hysterectomy: protocol for the stepped-wedge IMAGINE trial

INTRODUCTION

Hysterectomy is the most common major gynaecological procedure in women and minimally invasive approaches should be used wherever possible; total laparoscopic hysterectomy (TLH) is one such surgical approach which allows removal of the uterus entirely laparoscopically. However, lack of surgical training opportunities is impeding its increased adoption. This study will formally test a surgical outreach training model to equip surgeons with the skills to provide TLH as an alternative to total abdominal hysterectomy (TAH).

METHODS AND ANALYSIS

Stepped wedge implementation trial of a surgical training programme for practising obstetrician gynaecologist specialists in four hospitals.

PRIMARY OUTCOMES

Change in the proportion of hysterectomies performed by TAH, measured between preintervention and postintervention; we aim to reduce TAH by at least 30% in 75% of the trainees.

SECONDARY OUTCOMES

(1) Number of hospitals screened, eligible, agree to training and complete the training; (2) number of surgeons screened for eligibility, eligible, agree to training, who complete training and achieve proficiency; (3) proportion of trainees achieving proficiency in correct theatre setup, vascular exposure, mobilisation and surgery closure; change in proportion proficient over time; (4) adverse events (conversion from TLH to TAH, anaesthetic incident, intraoperative visceral injury, red cell transfusions, hospital stay >7 days, incidental finding of malignancy, unplanned readmission, admission to intensive care, return to theatre, postoperative pulmonary embolism or deep vein thrombosis, development of a fistula, vault haematoma, vaginal vault dehiscence or pelvic infection); (5) hospital length-of-stay; (6) cost-effectiveness and (7) trainee surgeon proficiency with TLH.

ETHICS AND DISSEMINATION

The study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee and has received site-specific approval from all participating hospitals. Results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03617354; Pre-results.

Massive prolapsed submucous fibroid treated with laparoscopic surgery: A case report

Prolapsed uterine fibroids are pedunculated submucous fibroids that prolapse through the cervical canal. Herein, we describe the laparoscopic treatment of massive prolapsed submucous fibroids. A 47-year-old woman had experienced frequent urination and abnormal vaginal bleeding for 7 years. She presented with persistent lower abdominal pain. The uterine fundus was palpable at 3 cm above the umbilicus. Vaginal examination revealed a dark purple and easily bleeding mass in her vagina. Pelvic magnetic resonance imaging revealed a large mass prolapsing from the uterine endometrium, which occupied the cervical canal and vagina, without evidence of malignancy. Under a preoperative diagnosis of uterine fibroids with edematous degeneration, we performed laparoscopic uterine artery cutting, transvaginal removal of the fibroid by twisting, and total laparoscopic hysterectomy. Histopathological examination revealed leiomyoma with partial ischemia. Six days postoperatively, the patient was discharged without complications. This approach may be appropriate for the treatment of massive prolapsed submucous fibroids.

A nationwide survey on gynecologic endoscopic surgery in Japan, 2014-2016

AIM

Since 2014, Japan Society of Gynecologic and Obstetric Endoscopy and minimally invasive therapy (JSGOE) conducted a nationwide survey on gynecologic endoscopic surgery. We aimed to evaluate the current status and complications associated with endoscopic surgery by Japan gynecologic and obstetric endoscopy-database registry system (JOE-D).

METHODS

Electrical medical records concerning the endoscopic surgery were generated from the daily use of reporting system. The subjects were all patients who underwent gynecologic endoscopic surgery. In addition to assessment of actual numbers, diagnosis, and operative methods, adverse events were registered.

RESULTS

Total 203 970 patients performed laparoscopic, hysteroscopic and falloposcopic surgery for 3 years, 2014-2016. The numbers of endoscopic surgeries conducted in 2016 were increased more than 67 000, 13 000 or 450 cases, respectively. Incidence rates of complications involving these three types of surgeries in each year were approximately 3.1%. Incidences of intraoperative complications were relatively high in malignant diseases, laparoscopic-assisted vaginal hysterectomy (LAVH) and myomectomy (LAM). In total laparoscopic hysterectomy/laparoscopic hysterectomy (TLH/LH) performed from 2014 to 2016, ureteral injury as intra and postoperative complication occurred in 0.35%. In the past 3 years, the rates of vascular injury, urinary tract, and bowel injury as intraoperative complications caused by laparoscopic surgery were approximately 0.1%. In the hysteroscopic surgery, the rates of total intra- and postoperative complications were 0.78%.

CONCLUSION

We exhibited the current status by the nationwide survey of gynecologic endoscopic surgery all over Japan. Severe intra or postoperative complications were identified over the 3 years at a rate of 0.04%.

Influence of previous abdominal surgery on clinical outcomes of patients undergoing total laparoscopic hysterectomy

Objective

To evaluate the potential effects of previous abdominal surgery on post-operative outcome and incidence of complications after total laparoscopic hysterectomy (TLH).

Methods

Between June 2008 and December 2016, 331 patients who underwent TLH were retrospectively reviewed. Participating patients were divided into 2 groups according to previous abdominal surgery. We compared the 2 groups based on estimated blood loss, operation time, hospital stay, surgery-related complications, and conversion to laparotomy rates.

Results

Group 1 included patients without a history of abdominal surgery (n=186), group 2 included patients with a history of abdominal surgery (n=145). The complication rate was 3.2% in group 1 and 2.8% in group 2. Other post-operative outcome and complications such as estimated blood loss, hospital stay and conversion to laparotomy rates did not differ significantly between groups. Adhesiolysis was significantly more common in group 2 (P<0.001) and operation time was significantly longer in the group 2 (P=0.004). The rate of conversion to laparotomy was higher in group 2, but this difference was not significant (P=0.115). Group 2 patients were divided into subgroups according to the number of surgery. In subgroups analysis of group 2, there were 70 patients who had one previous abdominal surgery and 75 patients who had 2 or more previous surgeries. Moreover, there were significant differences in adhesiolysis (P=0.004) and conversion to laparotomy (P=0.034). There were no significant differences in other complications observed upon subgroup analysis.

Conclusion

TLH can be conducted successfully regardless of previous abdominal surgery. Patients with previous abdominal surgery are suitable and feasible candidates for TLH.

Development of an objective assessment tool for total laparoscopic hysterectomy: A Delphi method among experts and evaluation on a virtual reality simulator

INTRODUCTION

Total Laparoscopic hysterectomy (LH) requires an advanced level of operative skills and training. The aim of this study was to develop an objective scale specific for the assessment of technical skills for LH (H-OSATS) and to demonstrate feasibility of use and validity in a virtual reality setting.

MATERIAL AND METHODS

The scale was developed using a hierarchical task analysis and a panel of international experts. A Delphi method obtained consensus among experts on relevant steps that should be included into the H-OSATS scale for assessment of operative performances. Feasibility of use and validity of the scale were evaluated by reviewing video recordings of LH performed on a virtual reality laparoscopic simulator. Three groups of operators of different levels of experience were assessed in a Marseille teaching hospital (10 novices, 8 intermediates and 8 experienced surgeons). Correlations with scores obtained using a recognised generic global rating tool (OSATS) were calculated.

RESULTS

A total of 76 discrete steps were identified by the hierarchical task analysis. 14 experts completed the two rounds of the Delphi questionnaire. 64 steps reached consensus and were integrated in the scale. During the validation process, median time to rate each video recording was 25 minutes. There was a significant difference between the novice, intermediate and experienced group for total H-OSATS scores (133, 155.9 and 178.25 respectively; p = 0.002). H-OSATS scale demonstrated high inter-rater reliability (intraclass correlation coefficient [ICC] = 0.930; p<0.001) and test retest reliability (ICC = 0.877; p<0.001). High correlations were found between total H-OSATS scores and OSATS scores (rho = 0.928; p<0.001).

CONCLUSION

The H-OSATS scale displayed evidence of validity for assessment of technical performances for LH performed on a virtual reality simulator. The implementation of this scale is expected to facilitate deliberate practice. Next steps should focus on evaluating the validity of the scale in the operating room.

The use of barbed sutures for vaginal cuff closure during laparoscopic hysterectomy

PURPOSE

To compare surgical outcomes and complications of 334 women who underwent total laparoscopic hysterectomy with or without the use of barbed sutures for vaginal cuff closure.

METHODS

A retrospective study was conducted on a cohort of women who underwent total laparoscopic hysterectomy for benign gynecologic diseases at Dae-Jeon St. Mary's Hospital, between May 2009 and May 2016. Surgical outcomes and complications were compared between the two groups.

RESULTS

A total of 334 women were included: 212 cases of vaginal cuff suture performed with traditional suture material and 122 cases of vaginal cuff suture performed with the barbed suture. No difference in major complications including vaginal bleeding and vaginal cuff dehiscence was found between the two groups, with a significant reduction in operative times for the barbed suture group (P = 0.002). Underlying clinical variables including diabetes, pelvic adhesion, and obesity showed no significant differences in complication rate.

CONCLUSION

Vaginal cuff suture performed with barbed suture material is a safe and well-tolerated procedure and reduces operative times. We did not find any meaningful decrease in postoperative vaginal complications including vaginal cuff dehiscence based on the suture material.

Bipolar vessel-sealing devices in laparoscopic hysterectomies: a multicenter randomized controlled clinical trial

OBJECTIVE

To compare operating time and blood loss in patients undergoing total laparoscopic hysterectomies (TLH) for benign conditions with either the Marseal™ IQ 5 mm (MS) or the Ligasure™ 5 mm (LS) vessel-sealing device.

DESIGN AND SETTING

A randomized controlled clinical trial (RCT) in two German gynecology departments.

PATIENTS

74 patients scheduled to undergo TLH for a symptomatic fibroid uterus, adenomyosis or severe meno-metrorrhagia.

INTERVENTIONS

Patients were randomized to receive a TLH with either the MS or the LS device. 27 variables were prospectively collected to address potential confounding issues.

MEASUREMENT AND MAIN RESULTS

Operating time, defined as the time period between the first (round ligament dissection) and the last (uterine vessels sealing) use of the device, estimated and calculated intraoperative blood loss. The mean operating time (95% confidence interval, CI) was 22.7 min (95% CI 17.6-27.7) for LS and 26.4 min (95% CI 20-32.8) for the MS device (p = .89). The estimated intraoperative blood loss was 164 ml (95% CI 110-217) for LS and 160 ml (95% CI 116-203) for the MS device (p = .36). The multivariate analyses accounting for BMI, endometriosis, uterine weight and appearance of fibroids did not reveal any significant effect of the type of device used on operating time and estimated blood loss.

CONCLUSION

In this RCT, both devices provided reliable and effective sealing and dissection. The reusable MS showed non-inferiority against the disposable LS device with regard to operating time and estimated intraoperative blood loss.

Effect of surgeon's experience on complications from laparoscopic hysterectomy

OBJECTIVE

To analyze the effect of learning in two surgeons on complications and conversion to laparotomy during total and subtotal laparoscopic hysterectomy.

MATERIAL AND METHODS

We analyzed retrospectively 236 total and subtotal laparoscopic hysterectomies done by two surgeons from the time they first performed the procedure. The interventions were classified in three groups based on the surgeon's experience: the first 75 hysterectomies ("novice period"), the subsequent 75 hysterectomies ("intermediate"), and the subsequent 86 hysterectomies ("routine period").

RESULTS

Patient's characteristics changed as surgeons gained experience, with more complex operations (greater obesity, previous surgery and malignant disease) becoming more frequent. During the second group of operations when surgeons had an intermediate level of experience, the risk of major complications decreased (adjusted odds ratio: 0.28, 95% confidence interval: 0.10-0.85), as did the risk of type III complications of Clavien-Dindo classification (adjusted odds ratio 0.15, 95% confidence interval: 0.03-0.93). However, the percent rate of conversion to laparotomy remained stable in the second (intermediate experience) group. In the third group, after the surgeons had performed 150 procedures and when the risk of any type of complication was lowest, the risk of conversion to laparotomy decreased compared to the routine group.

CONCLUSIONS

The surgeon's experience in performing laparoscopic hysterectomy plays an essential role in the decrease in the risk of complications, and this finding supports the importance of providing appropriate training for residents and gynecologists to enable them to perform this procedure with an optimal degree of competence and safety.

Anatomical complications of hysterectomy: A review

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.

Comparison of abdominal, vaginal, and laparoscopic hysterectomies in a tertiary care hospital in Turkey

AIM

The aim of this retrospective study was to assess and compare the clinical results of three hysterectomy techniques: abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH).

METHODS

A total of 2163 patients having undergone AH (n = 1226), VH (n = 426), and LH (n = 511) procedures were analyzed. The mean age, body mass index (BMI), parity, uterus weight, operation time, blood loss, duration of hospitalization, analgesic needs, intra- and postoperative complications, and indications for hysterectomy were analyzed and compared.

RESULTS

There were no differences between the groups with respect to the BMI, parity, and intra- or postoperative major and minor complications. The operation time was significantly shorter in the VH group than in the other two groups (p < 0.001), and the blood loss was significantly lower in the LH group than in the others (p < 0.001). The duration of hospitalization and analgesic needs were the shortest in the LH group (p < 0.001), while the uterus weight and previous intra-abdominal surgery rate were the lowest in the VH group (p < 0.001).

CONCLUSION(S)

Despite the fact that the LH exhibited a longer operation time than the VH, the LH was considered to be a safe and effective surgical procedure due to the lesser blood loss, hospital stay, and analgesic needs.

Predictive model of urinary tract infection after surgical treatment for women with endometrial cancer

PURPOSE

The aim of the study was to identify risk factors associated with postoperative urinary tract infections (UTIs) following hysterectomy-based surgical staging in women with endometrial cancer.

METHODS

This is a retrospective study utilizing an institutional database (2008-2016) of stage I-IV endometrial cancer cases that underwent hysterectomy-based surgery. UTIs occurring within a 30-day time period after surgery were examined and correlated to patient clinico-pathological demographics.

RESULTS

UTIs were observed in 44 (6.4%, 95% confidence interval 4.6-8.2) out of 687 cases subsequent to the diagnosis of endometrial cancer. UTI cases were significantly associated with obesity, advanced stage, prolonged operative time, hysterectomy type, pelvic lymphadenectomy, non-β-lactam antibiotics, and intraoperative urinary tract injury (all, p < 0.05). On multivariate analysis, three independent risk factors were identified for UTIs: prolonged operative time [odds ratio (OR) 3.36, 95% CI 1.65-6.87, p = 0.001], modified-radical/radical hysterectomy (OR 5.35, 95% CI 1.56-18.4, p = 0.008), and an absence of perioperative β-lactam antibiotics use (OR 3.50, 95% CI 1.46-8.38, p = 0.005). In a predictive model of UTI, the presence of multiple risk factors was associated with significantly increased risk of UTI: 4.1% for the group with no risk factors, 7.3-12.5% (OR 1.85-3.37) for single risk factor group, and 30.0-30.8% (OR 10.1-10.5) for two risk factor group.

CONCLUSION

Urinary tract infections are common in women following surgical treatment for women with endometrial cancer with risk factors being a prolonged surgical time, radical hysterectomy, and non-guideline perioperative anti-microbial agent use. Consideration of prophylactic anti-microbial agent use in a high-risk group of postoperative urinary tract infection merits further investigation.

Outcomes and Postoperative Complications After Hysterectomies Performed for Benign Compared With Malignant Indications

OBJECTIVE

To compare complications and outcomes after hysterectomy for benign compared with malignant indications in the United States.

METHODS

Women who underwent hysterectomy in the United States for either benign or malignant indications from January 2008 to December 2012 were retrospectively identified using the National Surgical Quality Improvement Program database. Patients were excluded if the procedure was not performed for primary gynecologic indications. Appropriate procedures were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. Univariate and multivariable models for complication risk were estimated using logistic regression.

RESULTS

We identified 59,525 eligible patients, with 49,331 (82.9%) hysterectomies performed for benign and 10,194 (17.1%) for malignant indications. All complications, including wound complications (2.5% benign compared with 5.5% malignant, P<.001), venous thromboembolism (0.33% compared with 1.7%, P<.001), urinary tract infection (2.7% compared with 3.2%, P=.009), sepsis (0.53% compared with 1.9%, P<.001), blood transfusion (2.6% compared with 11.5%, P<.001), death (0.02% compared with 0.10%, P<.001), unplanned readmission (1.8% compared with 4.5%, P<.001), and returns to the operating room (0.91% compared with 1.4%, P<.001), were significantly more common for malignant hysterectomies. The overall rate of complications for benign cases was 7.9% compared with a rate of 19.4% for malignant hysterectomy. The median operating time for laparoscopy in benign cases was significantly longer than for open or vaginal hysterectomy procedures (127 minutes compared with 105 or 94 minutes, respectively; P<.001). The median operating time in malignant cases was significantly longer than for benign cases (P<.001).

CONCLUSION

Hysterectomies performed for gynecologic malignancies are associated with a more than twofold higher complication rate compared with those performed for benign conditions. Minimally invasive surgery is associated with a decreased complication rate compared with open surgery. These data can be used for patient counseling and surgical planning, determining physician and hospital costs of care, and considered when assigning value-based reimbursement.

Are perioperative bundles associated with reduced postoperative morbidity in women undergoing benign hysterectomy? Retrospective cohort analysis of 16,286 cases in Michigan

BACKGROUND

Healthcare teams that frequently follow a bundle of evidence-based processes provide care with lower rates of morbidity. Few process bundles to improve surgical outcomes in hysterectomy have been identified.

OBJECTIVE

The purpose of this study was to investigate whether a bundle of 4 perioperative care processes is associated with fewer postoperative complications and readmissions for hysterectomies in the Michigan Surgical Quality Collaborative.

STUDY DESIGN

A bundle of perioperative care process goals was developed retrospectively with 30-day peri- and postoperative outcome data from the Hysterectomy Initiative in Michigan Surgical Quality Collaborative. All benign hysterectomies that had been performed between January 2013 and January 2015 were included. Based on evidence of lower complication rates after benign hysterectomy, the following processes were considered to be the "bundle": use of guideline-appropriate preoperative antibiotics, a minimally invasive surgical approach, operative duration <120 minutes, and avoidance of intraoperative hemostatic agent use. Each process was considered present or absent, and the number of processes was summed for a bundle score that ranged from 0-4. Cases with a score of zero were excluded. Outcomes measured were rates of complications (any and major) and hospital readmissions, all within 30 days of surgery. Postoperative events that were considered a "major complication" included acute renal failure, cardiac arrest that required cardiopulmonary resuscitation, central line infection, cerebral vascular accident, death, deep vein thrombosis, intestinal obstruction, myocardial infarction, pelvic abscess, pulmonary embolism, rectovaginal fistula, sepsis, surgical site infection (deep and organ-space), unplanned intubation, ureteral obstruction, and ureterovaginal and vesicovaginal fistula. The outcome "any complication" included all those events already described in addition to blood transfusion within 72 hours of surgery, urinary tract infection, and superficial surgical site infection. Outcomes were adjusted for patient demographics, surgical factors, and hospital-level clustering effects.

RESULTS

There were 16,286 benign hysterectomies available for analysis. Among all hysterectomies that were reviewed, 33.6% met criteria for all bundle processes; however, there was wide variation in the rate among the 56 hospitals in the study sample with 9.1% of cases at the lowest quartile and 60.4% at the highest quartile of hospitals that met criteria for all bundle processes. Overall, the rate of any complication was 6.8% and of any major complication was 2.3%. The rate of hospital readmissions was 3.6%. After adjustment for confounders, in cases in which all bundle criterion were met compared with cases in which all bundle criterion were not met, the rate of any complications increased from 4.3-7.8% (P<.001); major complications increased from 1.7-2.6% (P<.001), and readmissions increased from 2.6-4.1% (P<.001). After adjustment for confounders, hospitals with greater rates of meeting all 4 criteria were associated significantly with lower hospital-level rates of postoperative complications (P<.001) and readmissions (P<.001).

CONCLUSIONS

This multiinstitutional evaluation reveals that reduced morbidity and readmission are associated with rates of bundle compliance. The proposed bundle is a surgical goal, which is not possible in every case, and there is significant variation in the proportion of cases meeting all 4 bundle processes in Michigan hospitals. Implementation of evidence-based process bundles at a healthcare system level are worthy of prospective study to determine whether improvements in patient outcomes are possible.