Severe complications of hysterectomy: the VALUE study

The Prevalence, Indications, Outcomes of the Most Common Major Gynecological Surgeries in Kazakhstan and Recommendations for Potential Improvements into Public Health and Clinical Practice: Analysis of the National Electronic Healthcare System (2014-2019)

OBJECTIVES

Major gynecological surgeries are indicated for the treatment of female genital pathologies. It is key to examine trends in gynecologic surgical procedures and updated recommendations by international gynecological societies to find opportunities for improvement of local guidelines. To date, a very limited number of reports have been published on the epidemiology of gynecological surgeries in Kazakhstan. Moreover, some local guidelines for gynecological conditions do not comply with the international recommendations. Thus, this study aims to investigate the prevalence, indications, and outcomes of the most common major gynecological surgeries by analyzing large-scale Kazakhstani healthcare data, and identifying possible opportunities for improvement of the local public health and clinical practice.

METHODS

A descriptive, population-based study among women who underwent a gynecological surgery in healthcare settings across the Republic of Kazakhstan during the period of 2014-2019 was performed. Data were collected from the Unified Nationwide Electronic Health System (UNEHS).

RESULTS

In total, 80,401 surgery cases were identified and analyzed in the UNEHS database for a period of 6 years (2014-2019). The median age of the participants was 40 years old, with 61.1% in reproductive age. The most prevalent intervention was a unilateral salpingectomy-29.4%, with 72.6% patients aged between 18-34 years. The proportion of different types of hysterectomies was 49.4%. In 20% of cases, subtotal abdominal hysterectomy was performed due to uterine leiomyoma. The proportion of laparoscopic procedures in Kazakhstani gynecological practice is as low-11.59%.

CONCLUSIONS

The Kazakhstani public health and gynecological care sector should reinforce implementation of contemporary treatment methods and up-to-date policies and guidelines. The overall trends in surgical procedures performed for gynecological pathologies, including uterine leiomyoma and ectopic pregnancy treatment, should be changed in favor of the minimally invasive methods in order to adopt a fertility-sparing approach.

Comparing Characteristics of and Postoperative Morbidity after Hysterectomy for Endometriosis versus other Benign Indications: A NSQIP Study

STUDY OBJECTIVE

Compare the difference in postoperative morbidity for benign total hysterectomy by indication.

DESIGN

Retrospective cohort.

SETTING

United States hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project database from 2018 to 2019.

PATIENTS

Patients undergoing total hysterectomy for benign indications age 18 to 55 years old.

INTERVENTIONS

Univariate comparisons were made between patients with hysterectomies for endometriosis and other benign indications. Unadjusted and adjusted logistic regression models were used to investigate the association between primary outcomes and hysterectomy indication; covariates in the adjusted model include age, race, ethnicity, and route.

MEASUREMENTS AND MAIN RESULTS

A total of 29 742 women underwent hysterectomies, of which 3596 (12.1%) were performed for endometriosis. Patients undergoing hysterectomy for endometriosis were likely to be younger, were predominately White, and had less comorbidities. They were also more likely to have previous abdominal surgery, have previous pelvic surgery, undergo a laparoscopic approach, and undergo lysis of adhesions (all p <.001). Overall length of stay (≥1 day 73.1% vs 78.6%; p = .983) and operative time (median 118.0 vs 125.0 minutes; p <.001) were similar in both groups. Examining primary outcomes, patients with endometriosis were more likely to experience major morbidity (3.8% vs 3.4%; adjusted odds ratio [OR], 1.25; p = .033), with no difference in minor or overall morbidity (5.8% vs 6.9% [p = .874] and 8.8% vs 9.4% [p = .185], respectively). There were two 30-day mortalities, none in the endometriosis group. Patients with endometriosis were more likely to develop deep surgical site infection (SSI)/organ-space infection (2.3% vs 1.6%; OR, 1.42; p = .024) and less likely to receive blood transfusion (1.8% vs 3.0%; OR, 0.58; p <.001). There was no difference in occurrence of superficial SSI, sepsis, venous thromboembolism, readmission, or reoperation between groups.

CONCLUSION

Patients undergoing hysterectomy for endometriosis were more likely to experience major morbidity and deep SSI, although overall major morbidity is rare.

Did COVID-19 quarantine redirect habitual patient visits in the gynecology emergency room?

Objective

COVID-19 pandemic caused a dramatic decline in the gynecology emergency department (ED) visits. The Israeli government took a determined step of quarantine to suppress and control the spread. This study evaluates the effect of the COVID -19 quarantine on gynecology emergency department (ED) visits compared to the previous year.

Materials and methods

A retrospective case-control study was conducted during the first half-year of the COVID-19 pandemic and focused on the quarantine during April. In order to identify differences in the population's epidemiology and changes in the amount and type of emergency gynecological visits and surgeries, we compared patients during April 2020 (COVID-19 quarantine) to those who visited the gynecology ED during April 2019.

Results

During January–June 2020 period, there was an overall 3707 patient visits in the gynecology ED, which represents a 22.8% decrease in patient visits compared to the previous year (2019, 4803 patients). There was a 36% decrease in the gynecology ED visits during the quarantine period. Patient demographics were similar between groups. Visits of nulliparous women were more common in the study group (p = .0001) and self-referral (p = .017). More post-operative complications and fewer patients with abdominal pain were admitted to the study group (p = .034 and p = .054, respectively). During the study, the hospitalization rate did not change 18.2% vs. 17.5% (p = 0.768). Hospitalization duration was significantly longer in the COVID-19 quarantine (2.8 ± 1.3 vs. 3.1 ± 1.5, p < 0.001). There was no significant difference among surgical procedure incidents.

Conclusion

Visits in the gynecology ED service decreased during the COVID-19 quarantine without compromising the treatment of gynecology emergencies. Many gynecologic complaints can be managed in community care settings without referral to an ED.

Quality of life and sexuality of postmenopausal women with intrauterine pathologies: a recommended three-step multidisciplinary approach focusing on the role of hysteroscopy

Intrauterine pathologies are common in postmenopausal women and clinicians must identify signs and symptoms accurately to provide the adequate diagnosis and treatment. The quality of life (QoL) and sexuality of women are important outcomes to be considered to provide adequate clinical management of the postmenopausal patient with gynecologic pathologies. The aim of this paper is to propose a simple and replicable three-step multidisciplinary approach to evaluate the psychological outcomes of postmenopausal women with intrauterine pathologies, focusing on the role of hysteroscopy. In particular, the article describes three evaluation steps of those psychological outcomes corresponding to three fundamental moments of the patient's diagnostic and therapeutic path: the initial symptoms, diagnosis, and treatment. In our viewpoint, the standard use of such a protocol might considerably improve the QoL of postmenopausal patients undergoing hysteroscopic procedures due to intrauterine pathologies.

Assessment of surgeon and hospital volume for robot-assisted and laparoscopic benign hysterectomy in Sweden

INTRODUCTION

The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume.

MATERIAL AND METHODS

All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses.

RESULTS

TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9).

CONCLUSIONS

RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.

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.

Triptorelin for the treatment of adenomyosis: A multicenter observational study of 465 women in Russia

Objective

To evaluate the effectiveness of triptorelin for the treatment of adenomyosis, the benign invasion of endometrial tissue into the myometrium, as a fertility‐preserving alternative to the gold standard hysterectomy.

Methods

In this multicenter, open‐label, observational study in Russia, performed from November 3, 2011, to August 24, 2015, we assessed the efficacy and safety of triptorelin 3.75 mg administered intramuscularly every 28 days in Russian women who were gonadotropin‐releasing hormone agonist treatment‐naïve, aged 25–40 years, and had a diagnosis of endometriosis or adenomyosis with heavy menstrual bleeding. We performed a medical record review, interviews to assess symptom severity, and pelvic assessments including transvaginal ultrasound. Data were obtained at first injection of triptorelin (visit 1), on the day of last injection (visit 2), 6 months after last injection (visit 3), and 9 months after last injection (visit 4). Significance was assessed by Wilcoxon signed rank test.

Results

A total of 465 women were included. There was a significant improvement from baseline in severity of heavy menstrual bleeding in 390/463 (84.2%) of women 6 months after last injection (P<0.0001). Severity of dysmenorrhea, abnormal uterine bleeding, and pelvic pain was decreased at visit 3 compared with baseline (P<0.0001). Endometriosis symptoms stopped in 253/262 (96.6%) of women at visit 2 and in 243/263 (92.4%) of women at visit 3. Pregnancy was reported in 116/465 (24.9%) women within 9 months following the end of treatment.

Conclusion

Triptorelin has a favorable safety profile, is highly efficacious in treating clinical symptoms of adenomyosis, and improves reproductive function.

ClinicalTrials.gov registration number: A‐38‐52014‐191, registered October 2011.

Tranexamic acid in gynecologic surgery

Objective: To review the mechanism of action, pharmacology, dosing, and complications of tranexamic acid (TXA) and consolidate current evidence for TXA in gynecologic surgery.Methods: A literature search of PubMed, Ovid (MEDLINE), Google Scholar, and Elsevier was performed, in addition to a targeted search of cited references involving TXA and gynecologic surgery. Preference was given to systematic reviews and randomized control trials (RCTs).Results: TXA reversibly binds to plasminogen, preventing clot degradation. RCTs on hysterectomy, myomectomy, cervical conisation, hysteroscopy, and surgery for cervical and ovarian cancer were identified, as were case reports on TXA use for ectopic pregnancy. During hysterectomy, TXA reduces blood loss (two RCTs, n = 432, mean difference -66.0 mL and 180 mL), blood transfusion (1 RCT, n = 100, 12% vs. 42%, p < .00001). For myomectomy, a systematic review and meta-analysis showed a statistically significant decrease in blood loss with TXA (two RCTs, mean difference -213.1 mL, 95% CI: -242.4 mL to -183.7 mL). Following cervical conisation, TXA decreased the risk of delayed hemorrhage (four RCTs, RR 0.23, 95% CI: 0.11-0.50). A single RCT for cervical and ovarian cancer surgery demonstrated a decrease mean blood loss of 120 mL-135 mL and 210 mL, respectively, and fewer blood transfusions for the latter (OR 0.44, upper 95% CI: 0.97, p = .02). Less robust data suggest a possible benefit from TXA during hysteroscopy and surgery for ectopic pregnancies. Most commonly, 1 g of intravenous TXA is given intraoperatively.Conclusion: TXA is a safe adjunct that can be considered in a variety of gynecologic surgeries to decrease blood loss and risk of blood transfusion.

Surgical Outcomes in Patients With Endometriosis: A Systematic Review

OBJECTIVE

Among women treated surgically for endometriosis-associated pain, comprehensive data are lacking on the proportions of patients who experience little or no symptom relief, develop recurrent symptoms, or require further surgical treatment for endometriosis. The aim of this study was to assess the efficacy of surgical procedures used to treat endometriosis-associated pain.

METHODS

Medline and Embase were searched on October 13, 2016. Articles referring to women undergoing surgery for the treatment of endometriosis-associated pain were screened by two independent investigators. For each included treatment arm, data were extracted for the proportion of patients reporting partial or no improvement after surgery for endometriosis-associated pain, pain recurrence, or requirement for further surgery.

RESULTS

A total of 38 studies were included. Most studies did not report relevant outcomes to evaluate pain (71.1%) and recurrent surgery (68.4%). Of the women who underwent lesion excision, 11.8% reported no improvement in pain, and 22.6% underwent further surgery. Postoperative pain, recurrent pain, and adverse events were reported by 34.3%, 28.7%, and 14.8%, respectively, of patients who underwent excision or ablation of endometriosis combined with pelvic denervation and in 25.0%, 15.8%, and 8.1% of women who underwent lesion excision alone. Of the patients who were treated surgically for deep endometriosis affecting the bowel and/or bladder, 7.0% experienced recurrent symptoms, and 4.1% underwent further surgery.

CONCLUSION

This review supports the findings of previous studies and highlights the need for standardized reporting and more detailed follow-up after surgery for endometriosis-associated pain.

A Comparative Study of Non-descent Vaginal Hysterectomy and Laparoscopic Hysterectomy

Objective

To compare intra- and post-op complications between non-descent vaginal hysterectomy and laparoscopic hysterectomy and establish the better method for hysterectomy in non-descent uterus.

Methods

A prospective comparative study of 80 hysterectomies was done over a period of January 2017-Dec 2017, with 40 cases each in one group of non-descent vaginal hysterectomy (NDVH) and other group of total laparoscopic hysterectomy (TLH). Demographic characteristics, co-morbid conditions, indications for surgery, operative time, intra-operative blood loss, post-operative analgesia requirements, post-operative hospital stay and post-operative complications were compared between both groups.

Results

The most common age in both groups was 41-50 years. Fibroid uterus was the most common indication for surgery in both groups. The mean operative time in NDVH group was 40 min while it was 120 min in TLH group, and the mean blood loss in NDVH group was 50 ml, while it was 120 ml in TLH group. P < 0.001 when intraoperative blood loss and operative time were compared between both groups. There were no conversions to laparotomy in NDVH group, while there were three conversions to laparotomy in TLH group. Both groups were similar in post-operative analgesia requirement and post-operative hospital stay. Post-operative complications were similar in both groups.

Conclusions

Non-descent vaginal hysterectomy has advantage over laparoscopic hysterectomy as scarless surgery with fewer complications.

Uterus at a price: Disability insurance and hysterectomy

Taiwanese Labor, Government Employee, and Farmer Insurance programs provide 5 to 6 months of salary to enrollees who undergo hysterectomies or oophorectomies before their 45th birthday. These programs create incentives for more and earlier treatments, referred to as inducement and timing effects. Using National Health Insurance data between 1997 and 2011, we estimate these effects on surgery hazards by difference-in-difference and bunching-smoothing polynomial methods. For Government Employee and Labor Insurance, inducement is 11-12% of all hysterectomies, and timing 20% of inducement. For oophorectomies, both effects are insignificant. Enrollees' behaviors are consistent with rational choices. Each surgery qualifies an enrollee for the same benefit, but oophorectomy has more adverse health consequences than hysterectomy. Induced hysterectomies increase benefit payments and surgical costs, at about the cost of a mammogram and 5 pap smears per enrollee.

Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit

OBJECTIVE

To examine the factors associated with receiving surgery for heavy menstrual bleeding (HMB) in England and Wales.

DESIGN

National cohort study.

SETTING

National Health Service hospitals.

PARTICIPANTS

Women with HMB aged 18-60 who had a new referral to secondary care.

METHODS

Patient-reported data linked to administrative hospital data. Risk ratios (RR) estimated using multivariable Poisson regression.

PRIMARY OUTCOME MEASURE

Surgery within 1 year of first outpatient clinic visit.

RESULTS

14 545 women were included. At their first clinic visit, mean age was 42 years, mean symptom severity score was 62 (scale ranging from 0 (least) to 100 (most severe)), 73.9% of women reported having symptoms for >1 year and 30.4% reported no prior treatment in primary care. One year later, 42.6% had received surgery. Of these, 57.8% had endometrial ablation and 37.2% hysterectomy. Women with more severe symptoms were more likely to have received surgery (most vs least severe quintile, 33.1% vs 56.0%; RR 1.6, 95% CI 1.5 to 1.7). Surgery was more likely among those who reported prior primary care treatment compared with those who did not (48.0% vs 31.1%; RR 1.5, 95% CI 1.4 to 1.6). Surgery was less likely among Asian and more likely among black women, compared with white women. Surgery was not associated with socioeconomic deprivation.

CONCLUSIONS

Receipt of surgery for HMB depends on symptom severity and prior treatment in primary care. Referral pathways should be locally audited to ensure women with HMB receive care that addresses their individual needs and preferences, especially for those who do not receive treatment in primary care.

A Psychiatrist with Postoperative Anxiety After Hysterectomy: How Could This Be Fatal?

Hysterectomy is a common surgery and rarely fatal. Here, we present a case of hysterectomy with postoperative complications, leading to a fatal outcome. The autopsy revealed the cause of death and clinicopathologic correlation suggested multiple lessons for patient safety. Patient safety can be enhanced by appropriate boundaries in the care of physician-patients, proactive monitoring and prompt treatment of postoperative asthma, nasogastric suction for postoperative ileus associated with vomiting, and assessment of the patient situation by a good history and physical examination, going to see the patient in person.

Type of Pelvic Disease as a Risk Factor for Surgical Site Infectionin Women Undergoing Hysterectomy

STUDY OBJECTIVE

To quantify the relationship between type of benign pelvic disease and risk of surgical site infection (SSI) after hysterectomy.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

PATIENTS

Women who underwent hysterectomy from 2006-2015 and recorded in NSQIP database.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

SSI risk was compared for type of benign pelvic disease, patient characteristics (i.e., age, race, and selected comorbidities) and process of care variables (i.e., admission status, type of hysterectomy, and operative time). SSI occurred in 2.48% of the 125,337 women who underwent hysterectomy. SSI was most frequent in patients with endometriosis and least frequent in those with genital prolapse (3.13% vs 1.39%; p <.0001). Following adjustment for potential confounders, the odds of SSI were higher in women undergoing hysterectomy for endometriosis (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.43- 2.25), uterine myomas (aOR, 1.28; 95% CI, 1.05-1.55), menstrual disorders (aOR, 1.46; 95% CI, 1.20-1.78), and pelvic pain (aOR, 1.75; 95% CI, 1.34-2.27) compared with women undergoing hysterectomy for genital prolapse. Other patient factors associated with SSI included age, body mass index, smoking, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and American Society of Anesthesiologists classification. Among process-of-care factors, inpatient status, route of hysterectomy, total vs subtotal hysterectomy, and operative time were also associated with SSI.

CONCLUSION

In addition to various patient and process-of-care factors known to be associated with SSI, type of underlying pelvic disease is an independent risk factor for SSI in women undergoing hysterectomy for benign indications.

Prevalence of surgical complications in gynecological surgery at the Hospital Universitario San José in Popayán, Colombia. 2015

Introduction: Every surgery has risk of complications; prognosis depends on prompt diagnosis and timely management.Objective: To determine the prevalence of surgical complications in gynecological surgery in a tertiary care hospital and to explore associated factors.Materials and methods: Prevalence study with secondary analysis of medical records of patients who underwent scheduled gynecological surgery. The outcome variable was complications reported during a period of less than 30 days. The universe was established, and clinical, biological and sociodemographic variables were collected. To determine prevalence, the total number of complications was taken as the numerator and the total number of records was used as the denominator. To explore associated factors, odds ratio (OR) was used as a measure of association with a 95% CI.Results: 591 records were reviewed, finding a surgical management of ectopic pregnancy prevalence of 3.8% (OR=3.73, CI95%: 2.41-92.52). Obesity (OR 12.47, CI95%: 4.48-33.19) and gynecological surgery for malignancy (OR 3.73, CI95%: 1.14- 10.48) were associated with complications.Conclusion: The prevalence found in our institution was similar to what most studies have reported.

THIRTY DAY RE-ADMISSION RATE AFTER SHORT STAY HYSTERECTOMY

Background: Concept of short stay surgery is getting popular globally to maximize use of available health resources. The objective of the study was to determine thirty day readmission rate due to complications after short stay hysterectomy. Material & Methods: This descriptive cross sectional study was conducted in Department of Obstetrics & Gynae from 1st January 2018 to 31 December 2018. Sample size was 72. Sampling technique was consecutive, non-probability. Patients having obstetrical hysterectomy or co-morbidities needing prolonged hospital stay were excluded. Data collecting tool was specially designed proforma. The observation for readmission was spread over a span of 30 days. Our socio-demographic variables were age in years, parity, residence and education. Age and parity were measured on numerical scale and expressed as mean and SD. Education and residence were categorical variables. Research variables were type of hysterectomy and re-admission due to complications measured on nominal scale. Categorical were analyzed as frequency and percentages using SPSS version 17. Results: Out of 72 hysterectomies, 42(58.33%) were performed abdominally and 30(41.67%) were performed vaginally. In TAH group, 3(7.14%) patients and in VH group, 2(6.66%) patients had complications that required readmission. Pelvic Hematoma was found in 2(4.76%) patients of TAH group and in 1(3.3%) patients of VH group. Pelvic abscess was formed in VH group in 1(3.33%) of patients but not in TAH group. Urinary retention occurred in 1(2.38%) of TAH group but not in VH group. Conclusion: Short stay hysterectomy has lower re-admission rate due to less number of complications, with a view to explore ways to increase bed availability in our setup.

[Vaginal hysterectomy in outpatient procedure: Feasibility and satisfaction study]

OBJECTIVES

To study the feasibility and patient satisfaction for vaginal hysterectomy in a new outpatient procedure.

METHODS

This retrospective study was directed in CHU de Saint-Étienne, Loire, France. All patient who underwent a vaginal hysterectomy in outpatient procedure were included from January 2014 and January 2017. Descriptive data were collected and all patients were called back for satisfaction study.

RESULTS

Sixty-five patients were included. Vaginal hysterectomy was performed for 52.3% for pre-menopause bleeding, 24.6% for prolapse, 15.4% for uterine fibroids and 7.6% diverse. Outpatient procedure was performed in 96.9%. Peroperative outcome from Oslo classification were 1.5% for grade 1 and 1.5% for grade 2. Postoperative complications from Clavien-Dindo classification were: 16.9% grade 1 and 6.2% grade 2. Mean postoperative pain scale was 1.02 between H1 and H3 post-operative and 0.84 between H3-H6. Among the patients, 89.2% were very satisfied, 91.9% recommend the same outpatient procedure and 43.2% assumed their daily life since first day postoperative.

CONCLUSION

Vaginal hysterectomy in outpatient procedure is today's reality. It is a simple, economic, with few postoperative complications and very high satisfaction scores procedure. Standardized procedure, good patient selection and information are necessary to minimize complications.

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.

Surgical technique of concomitant laparoscopically assisted vaginal hysterectomy and laparoscopic cholecystectomy

Background

Laparoscopically assisted vaginal hysterectomy is one of the most frequently performed gynecologic operations, and numerous authors have demonstrated its safety and feasibility.

Case presentation

We practiced in some selected cases simultaneous laparoscopically assisted vaginal total hysterectomy with bilateral adnexectomy and laparoscopic cholecystectomy using 5 trocars without uterine manipulator. Previous examinations included abdominal ultrasound, cervix biopsy and CT of abdomen and pelvis.

Our aim was to evaluate the surgical technique of our initial experiences for combined laparoscopically assisted vaginal hysterectomy and laparoscopic colecystectomy.

Conclusions

Laparoscopic hysterectomy had a number of advantages over the conventional technique given the underlying associated diseases, postoperative pain, rapid recovery and aesthetic benefits.

Vaginal vault drainage after complicated single-port access laparoscopic-assisted vaginal hysterectomy

Study objective:

To evaluate the feasibility and safety of vaginal vault drainage after complicated singleport access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH).

Design:

Retrospective cohort study.

Setting:

Ulsan University Hospital (tertiary teaching hospital), South Korea.

Patients:

A total of 359 women underwent SPA-LAVH for the following conditions: benign uterine tumor, preinvasive uterine lesion, and microinvasive cervical cancer.

Interventions:

The participants included 124 women with vault drains and 235 women without drains.

Measurements:

Surgical outcomes, perioperative complications and morbidity, postoperative febrile morbidity.

Results:

There were no differences in background features between drain and no-drain groups. In surgical outcomes, mean uterine weight (364.2 ± 184.9 g vs. 263.7 ± 138.6 g; p < 0.001), operation time (87.4 ± 21.5 min vs. 73.0 ± 17.6 min; p < 0.001), blood loss (225.3 ± 122.2 mL vs. 150.4 ± 95.2 mL; p < 0.001), and hemoglobin decline (1.97 ± 0.96 g/dL vs. 1.42 ± 0.89 g/dL; p < 0.001) were significantly larger for the drain group compared with the no-drain group. However, with regard to postoperative morbidity and complications, there were no group differences in the transfusion rates (6.5% vs. 3.8%; p = 0.300), intraoperative complications (2.4% vs. 1.3%; p = 0.420), perioperative complications (2.4% vs. 0.9%; p = 0.345), and febrile morbidity ≥ 37.5°C (8.9% vs. 11.5%; p = 0.477), although the drain group was more prone to the development of pelvic fluid collection and febrile morbidity than the no-drain group.

Conclusion:

Vaginal vault drainage could be a safe alternative that allows for the management of postoperative morbidity and retains the advantages of minimally invasive surgery after complicated SPA-LAVH.

Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroids: an updated decision analysis following the 2014 Food and Drug Administration safety communications

Previous decision analyses demonstrate the safety of minimally invasive hysterectomy for presumed benign fibroids, accounting for the risk of occult leiomyosarcoma and the differential mortality risk associated with laparotomy. Studies published since the 2014 Food and Drug Administration safety communications offer updated leiomyosarcoma incidence estimates. Incorporating these studies suggests that mortality rates are low following hysterectomy for presumed benign fibroids overall, and a minimally invasive approach remains a safe option. Risk associated with morcellation, however, increases in women age >50 years due to increased leiomyosarcoma rates, an important finding for patient-centered discussions of treatment options for fibroids.

Uterine Cancer After Risk-Reducing Salpingo-oophorectomy Without Hysterectomy in Women With BRCA Mutations

IMPORTANCE

The link between BRCA mutations and uterine cancer is unclear. Therefore, although risk-reducing salpingo-oophorectomy (RRSO) is standard treatment among women with BRCA mutations (BRCA+ women), the role of concomitant hysterectomy is controversial.

OBJECTIVE

To determine the risk for uterine cancer and distribution of specific histologic subtypes in BRCA+ women after RRSO without hysterectomy.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective cohort study included 1083 women with a deleterious BRCA1 or BRCA2 mutation identified from January 1, 1995, to December 31, 2011, at 9 academic medical centers in the United States and the United Kingdom who underwent RRSO without a prior or concomitant hysterectomy. Of these, 627 participants were BRCA1+; 453, BRCA2+; and 3, both. Participants were prospectively followed up for a median 5.1 (interquartile range [IQR], 3.0-8.4) years after ascertainment, BRCA testing, or RRSO (whichever occurred last). Follow up data available through October 14, 2014, were included in the analyses. Censoring occurred at uterine cancer diagnosis, hysterectomy, last follow-up, or death. New cancers were categorized by histologic subtype, and available tumors were analyzed for loss of the wild-type BRCA gene and/or protein expression.

MAIN OUTCOMES AND MEASURES

Incidence of uterine corpus cancer in BRCA+ women who underwent RRSO without hysterectomy compared with rates expected from the Surveillance, Epidemiology, and End Results database.

RESULTS

Among the 1083 women women who underwent RRSO without hysterectomy at a median age 45.6 (IQR: 40.9 - 52.5), 8 incident uterine cancers were observed (4.3 expected; observed to expected [O:E] ratio, 1.9; 95% CI, 0.8-3.7; P = .09). No increased risk for endometrioid endometrial carcinoma or sarcoma was found after stratifying by subtype. Five serous and/or serous-like (serous/serous-like) endometrial carcinomas were observed (4 BRCA1+ and 1 BRCA2+) 7.2 to 12.9 years after RRSO (BRCA1: 0.18 expected [O:E ratio, 22.2; 95% CI, 6.1-56.9; P < .001]; BRCA2: 0.16 expected [O:E ratio, 6.4; 95% CI, 0.2-35.5; P = .15]). Tumor analyses confirmed loss of the wild-type BRCA1 gene and/or protein expression in all 3 available serous/serous-like BRCA1+ tumors.

CONCLUSIONS AND RELEVANCE

Although the overall risk for uterine cancer after RRSO was not increased, the risk for serous/serous-like endometrial carcinoma was increased in BRCA1+ women. This risk should be considered when discussing the advantages and risks of hysterectomy at the time of RRSO in BRCA1+ women.

The impact of surgeon volume on perioperative outcomes in hysterectomy

Background and Objectives:

To estimate the effect of surgeon volume on key perioperative outcomes after all modes of hysterectomy.

Methods:

We performed a review of 1914 hysterectomies performed at a large, academic tertiary-care hospital. Women who underwent abdominal, laparoscopic, vaginal, or robotic hysterectomy for benign non-obstetric indications in 2006, 2009, and 2010 were included.

Results:

Gynecologic surgeons were categorized according their average annual hysterectomy case volume: low volume (<11 cases per year), intermediate volume (11–50 cases per year), and high-volume (>51 cases per year). Taking all modes of hysterectomy together, surgeries performed by high-volume surgeons required a shorter operative time (155.11 minutes vs 199.19–203.35 minutes, P < .001) and resulted in less estimated blood loss compared with low- and intermediate-volume surgeons (161.09 mL vs 205.58–237.96 mL, P < .001). The 3 surgical volume groups did not differ from each other significantly in the conversion to laparotomy, readmission rate, or incidence of intraoperative or postoperative complications. These findings were maintained when subgroup analyses were performed by type of hysterectomy, with few exceptions. In the subgroup of vaginal hysterectomies by intermediate-volume surgeons, there were slightly more postoperative complications. There were fewer intraoperative complications in laparoscopic/robotic hysterectomies performed by high-volume surgeons, though not statistically significant.

Conclusions:

Hysterectomies performed by high-volume surgeons at our institution during the 3-year study period were associated with shorter operative times and less estimated blood loss.

Using international data to set benchmarks for morbidity outcomes after hysterectomy

OBJECTIVE

To set an international benchmark for monitoring morbidity after hysterectomy.

METHODS

In a retrospective, observational study, data were assessed from women who underwent abdominal, vaginal, or laparoscopic hysterectomy in three countries (Australia, England, and the USA) between 2008 and 2012. The main outcome measures were length of stay (LOS), readmission, hemorrhage, and intraoperative conversion.

RESULTS

Overall, 32 181 procedures were included. The intraoperative conversion rate from vaginal and laparoscopic to abdominal hysterectomy was 1.5%. The LOS was significantly higher after abdominal surgery (3 days) than after vaginal (2 days; P<0.001) or laparoscopic (1 day; P<0.001) surgery. LOS was also higher after conversion (3 days) than after vaginal and laparoscopic hysterectomy (P<0.001 for both). Conversion cases had the highest rate of hemorrhage (7.5% vs 2.4% for abdominal, 1.8% vaginal, and 1.2% laparoscopic) and readmission (5.0% vs 4.2% for abdominal, 3.1% vaginal, and 2.8% laparoscopic). The odds of readmission were higher after abdominal than after laparoscopic hysterectomy (odds ratio 1.41, 95% confidence interval 1.19-1.67; P<0.001).

CONCLUSION

The morbidity associated with different surgical approaches to hysterectomy, including after intraoperative conversion, should be used as a benchmark. There is a need to measure and publish morbidity data after hysterectomy.

Cost-Effectiveness of Laparoscopic Hysterectomy With Morcellation Compared With Abdominal Hysterectomy for Presumed Myomas

STUDY OBJECTIVE

Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH.

DESIGN

Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III).

SETTING

U.S. hospitals.

PATIENTS

Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata.

INTERVENTIONS

We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature.

MEASUREMENTS AND MAIN RESULTS

Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of $2193 ($24 181 vs $26 374). Over 5 years, women in the LH group experienced 4.99 QALY versus women in the AH group with 4.91 QALY (incremental gain of .085 QALYs). LH dominated AH in base-case estimates: LH was both less expensive and yielded greater QALY gains. The ICER was sensitive to operative costs for LH and AH. Varying operative costs of AH yielded an ICER of $87 651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time; 17.4% of simulations fell above the willingness-to-pay threshold of $50 000/QALY gained.

CONCLUSION

When considering total direct hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. Driven by the rarity of occult LMS and the reduced incidence of intra- and postoperative complications, LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata.

Laparoscopic hysterectomy in large uteri: Experience from a tertiary care hospital in Bangladesh

INTRODUCTION

The purpose of this study was to examine the safety and feasibility of laparoscopically assisted vaginal hysterectomy for uteri weighing more than 500 g as compared to uteri weighing less than 500 g in benign gynecological diseases.

METHODS

This was a retrospective study. Patients were admitted through the outpatient department. They were divided into two groups: uterine weight ≥500 g (group 1) and uterine weight >500 g (group 2). There were no exclusion criteria based on the size, number, or location of leiomyomas. The patient characteristics for the two groups were compared in terms of demographic and socioeconomic details, operating time, amount of blood loss, requirement of blood transfusion, need for analgesia, and length of hospital stay.

RESULTS

The characteristics age and BMI were well balanced between the two groups. Uterine weight was 267.2 ± 97.6 g in group 1 and 740.0 ± 371.4 g in group 2 (P < 0.001). Length of operation and amount of blood loss were greater in group 2 than in group 1 (operation: 89.1 ± 26.7 vs 73.3 ± 24.6 min, P < 0.01; blood loss: 570.5 ± 503.6 vs 262.5 ± 270.0 mL, P < 0.001). However, there was no significant difference in hospital stay or incidence of operative complications between the two groups. No patients were switched from laparoscopy to laparotomy during operation. The rate of blood transfusion was lower in group1 than in group 2 (4.9% vs 32.6%; P < 0.001).

CONCLUSION

This study demonstrated that despite the increased operating time and blood loss, laparoscopy should be considered instead of laparotomy in cases of large uteri. Laparoscopically assisted vaginal hysterectomy can be performed safely for a large uterus.

Tactile Electrosurgical Ablation: A Technique for the Treatment of Intractable Heavy and Prolonged Menstrual Bleeding

Objective. To study the efficacy and safety of tactile electrosurgical ablation (TEA) in stopping a persistent attack of abnormal uterine bleeding not responding to medical and hormonal therapy. Methods. This is a case series of 19 cases with intractable abnormal uterine bleeding, who underwent TEA at the Women's Health Center of Assiut University. The outcomes measured were; patient's acceptability, operative time, complications, menstrual outcomes, and reintervention. Results. None of the 19 counseled cases refused the TEA procedure which took 6-10 minutes without intraoperative complications. The procedure was successful in the immediate cessation of bleeding in 18 out of 19 cases. During the 24-month follow-up period, 9 cases developed amenorrhea, 5 had scanty menstrual bleeding, 3 were regularly menstruating, 1 case underwent repeat TEA ablation, and one underwent a hysterectomy. Conclusions. TEA represents a safe, inexpensive, and successful method for management of uterine bleeding emergencies with additional long-term beneficial effects. However, more studies with more cases and longer follow-up periods are warranted.

Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroid tumors in premenopausal women: a decision analysis

OBJECTIVE

The purpose of this study was to model outcomes in laparoscopic hysterectomy with morcellation compared with abdominal hysterectomy for the presumed fibroid uterus and to examine short- and long-term complications and death.

STUDY DESIGN

A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women who underwent hysterectomy for presumed fibroid tumors over a 5-year time horizon. Parameter and quality-of-life utility estimates were determined from published literature for postoperative complications, leiomyosarcoma incidence, death related to leiomyosarcoma, and procedure-related death.

RESULTS

The decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy compared with abdominal hysterectomy (98 vs 103 per 100,000). Although there were more deaths from leiomyosarcoma after laparoscopic hysterectomy (86 vs 71 per 100,000), there were more hysterectomy-related deaths with abdominal hysterectomy (32 vs 12 per 100,000). The laparoscopic group had lower rates of transfusion (2400 vs 4700 per 100,000), wound infection (1500 vs 6300 per 100,000), venous thromboembolism (690 vs 840 per 100,000) and incisional hernia (710 vs 8800 per 100,000), but a higher rate of vaginal cuff dehiscence (640 vs 290 per 100,000). Laparoscopic hysterectomy resulted in more quality-adjusted life years (499,171 vs 490,711 over 5 years).

CONCLUSION

The risk of leiomyosarcoma morcellation is balanced by procedure-related complications that are associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit on which patient-centered decisions can be made.

Abdominal, multi-port and single-port total laparoscopic hysterectomy: eleven-year trends comparison of surgical outcomes complications of 936 cases

PURPOSE

To compare surgical outcomes and complications of 284 patients who had total abdominal hysterectomy (TAH), 366 patients who had multi-port access total laparoscopic hysterectomy (MPA-TLH), and 286 patients who had single-port access total laparoscopic hysterectomy (SPA-TLH) using a transumbilical single-port system.

METHODS

A retrospective study was conducted on a cohort of women who underwent TAH, MPA-TLH, or SPA-TLH for benign gynecologic diseases at DaeJeon St. Mary's Hospital, between January 2003 and December 2013. Surgical outcomes and complications were compared between the three groups.

RESULTS

The total operative time (min) was longest in the SPA-TLH group (188.3 ± 51.3), followed by the TAH (176.4 ± 47.9) and MPA-TLH (149.3 ± 59.5) groups (p < 0.05). The estimated blood loss (mL) did not differ between MPA-TLH and SPA-TLH (163.8 ± 168.9 vs. 176.9 ± 197.8 mL), but it was the greatest in TAH (427.1 ± 250.6, p < 0.05). The weight of the uterus (gm) was highest in TAH (375.8 ± 380.1, p < 0.05) and similar in MPA-TLH and SPA-TLH (10.1 ± 2.6 vs. 9.7 ± 2.6 cm). The hospital stay (days) was longest in the TAH (7.0 ± 2.1) and SPA-TLH (6.3 ± 2.0) groups, followed by the MPA-TLH (5.5 ± 2.0) group (p < 0.05). The major complication rate was 2.5 % (7 cases) in the TAH group, 5.5 % (20 cases) in the MPA-TLH group, and 0.7 % (2 cases) in the SPA-TLH group. In the MPA-TLH group, the complication rate of the first half of the cases was significantly higher than in the latter half of cases, especially with regards to vaginal cuff dehiscence (p < 0.05). In the SPA-TLH group, no statistically significant difference was found between the two sub-groups.

CONCLUSIONS

Our study showed that MPA-TLH and SPA-TLH were feasible and safe when compared to TAH. Furthermore, after acquiring technical skills in laparoscopic surgery, conversion from MPA-TLH to SPA-TLH might be easier than the initial conversion from laparotomy to laparoscopy. The advantage of SPA-TLH over MPA-TLH is questionable, considering the longer learning curve; however SPA-TLH is an effective alternative for both the patient and surgeon.

Abnormal uterine bleeding in reproductive-aged women

Abnormal uterine bleeding is a common medical condition with several causes. The International Federation of Gynecology and Obstetrics published guidelines in 2011 to develop universally accepted nomenclature and a classification system. In addition, the American College of Obstetrics and Gynecology recently updated recommendations on evaluation of abnormal uterine bleeding and indications for endometrial biopsies. This article reviews both medical and surgical treatments, including meta-analysis reviews of the most effective treatment options.

Mortality risk associated with surgical treatment of female genital fistula

OBJECTIVE

To describe the mortality risk associated with surgical treatment of female genital fistula and the contributory and contextual factors.

METHODS

In a descriptive study, confidential inquiries and clinical audits were conducted at 14 fistula repair sites in seven resource-poor countries between January 2005 and March 2013. Data collection included interviews with key personnel involved in the clinical management of the deceased, and a review of hospital records and patient files following an audit protocol.

RESULTS

Overall, 26060 fistula repairs were performed at 44 sites located in 13 countries; 30 deaths were reported in this period. Twenty-one deaths were attributable to surgery, yielding a case fatality of 0.08 per 100 procedures. The cause of death in nearly half of the cases was various manifestations of sepsis and inflammation.

CONCLUSION

The case fatality rate for fistula repair surgery in resource-poor countries was in the same range as that for comparable gynecologic operations in high-resource settings. Clinical and systemic issues to be addressed to reduce the case fatality rate include improvement of perioperative care and follow-up, assuring prudent referral or deferral of difficult cases, and maintaining better records.

The dangers of the day of birth

OBJECTIVE

To compare the risk of fetal death on the day of childbirth, with the risk of death at other ages, and with the risks of some hazardous activities, on a common scale of risk per day.

DESIGN

Review of publicly available data.

SETTING UK SAMPLE

Data extracted from the Office of National Statistics and other sources.

METHODS

Data from the Office of National Statistics and other sources were used to calculate death rates at different ages expressed as rates per day of life. Death rates for different activities were also calculated as risks per day, or risks per activity, as appropriate. All risks were expressed in micromorts, the number of one in a million chances of dying. Figures on life expectancy (LE) were used to compare potential life years lost.

MAIN OUTCOME MEASURES

Daily, or unit of activity, risk of dying for different activities compared with the risk of dying on the day of childbirth.

RESULTS

The risk of dying on the day of birth (0.43 per 1000, or 430 micromorts) exceeds that of any other average day of life until the 92nd year. It is comparable with other apparently more dangerous activities, such as undergoing major surgery. For comparison, the average risk of non-natural death per day and the increased risk from smoking one cigarette or travelling 200 miles by car are all about 1 micromort.

CONCLUSIONS

The lifetime risk of death in childbirth is low, but is concentrated in a short period, making being born a high-risk activity. Parents considering interventions to reduce these risks should be made aware of this.

Trends in the surgical options for the treatment of menorrhagia in Scotland: examination of health episode statistics, 2000-2008

Menorrhagia is a common and important problem that has a significant impact on women's health. Menorrhagia is treated by surgical methods if primary medical methods fail. Surgical methods have changed over time and the traditional method of hysterectomy has been replaced by minimally invasive techniques. An examination of practice in Scotland suggests that minimally invasive techniques are now the most common surgical method of treating menorrhagia. Abdominal hysterectomies are still performed commonly, but the trend is towards a reduction in procedures performed annually. The changing technique of managing menorrhagia has an impact on the training of future gynaecologists.

An audit of indications and complications associated with elective hysterectomy at a public service hospital in South Africa

OBJECTIVE

To assess relationships between clinical indication for hysterectomy and postoperative histologic findings, and to audit complications of hysterectomy at the gynecologic surgical unit of a public-service hospital in South Africa.

METHODS

Surgical indications and details, histologic findings, and postoperative course were reviewed and analyzed for 335 patients who underwent hysterectomy at Groote Schuur Hospital, Cape Town, South Africa, in 2007.

RESULTS

Hysterectomy was performed abdominally in 265 patients (79.1%) and vaginally in 70 (20.9%) patients (5 of these procedures were laparoscopically assisted). The most common indication was fibroid-related menorrhagia (23%), followed by abnormal uterine bleeding (14.9%). The incidence of intraoperative complications was 6-fold greater among patients with malignant disease than among those with a benign condition (P=0.001). The incidence of postoperative complications was greater following abdominal rather than vaginal surgery, whether traditional or laparoscopic (P=0.02).

CONCLUSION

Most hysterectomies were carried out abdominally rather than vaginally, in part because many patients presented with advanced cancer or other condition that warranted this approach. Because of resource constraints, patients with benign conditions were more likely to be offered surgery if they had a clearly defined condition.