Transfusion rate associated with hysterectomy for benign disease

Outcomes of vaginal hysterectomy combined with anterior and posterior colporrhaphy for pelvic organ prolapse: a single center retrospective study

Objective

To evaluate the efficacy of vaginal hysterectomy combined with anterior and posterior colporrhaphy (VH APR) for the management of pelvic organ prolapse (POP).

Methods

A total of 610 patients with POP who underwent VH APR from January 2010 to June 2019 at Asan Medical Center were included in this study. We analyzed the patient characteristics and surgical outcomes. In addition, we compared the POP quantification system (POP-Q) pre- and postoperatively at 2 weeks, 3 months, and 1 year, and analyzed the risk factors for recurrence.

Results

The mean age of the patients was 65.5±7.6 years. The most common preoperative POP-Q stage was stage 2 (60.8%), followed by stage 3 (35.9%). Complications were identified during surgery in 1.6% of the patients. The most common postoperative complication (6.4%) was voiding difficulty. All POP-Q scores significantly decreased at 1 year after surgery (P<0.0001). The recurrence rate was 9.6%, and most recurrences (77.5%) occurred in the anterior compartment. An advanced stage of preoperative POP was a risk factor for recurrence (stage 3 or 4 vs. stage 1 or 2; odds ratio [OR], 5.337, 95% confidence interval [CI], 2.58–11.036, P<0.0001). Only two patients underwent surgical correction for POP recurrence, and most of the remaining patients did not undergo further treatment for prolapse.

Conclusion

VH APR is a safe and effective surgical procedure for POP, with a low recurrence rate. In addition, advanced preoperative stage was the only risk factor for recurrent POP.

Perioperative outcomes for benign hysterectomy among women with thrombocytopenia

OBJECTIVE

To determine whether mild or moderate thrombocytopenia is associated with postoperative complications after benign hysterectomy.

METHODS

A retrospective study of data from women who underwent benign hysterectomy included in the American College of Surgeons National Surgical Quality Improvement Project Database. The data were stratified by normal platelet count, mild thrombocytopenia (100-149 × 10³ platelets/µl), and moderate thrombocytopenia (50-99 × 10³ platelets/µl). Multivariable logistic regression was used to determine the relationship between mild or moderate thrombocytopenia and the main outcome measures.

RESULTS

Moderate thrombocytopenia was associated with an increased risk of perioperative transfusion (adjusted odds ratio [aOR], 2.87; 95% confidence interval [CI], 1.96-4.21) and reoperation (aOR, 4.03; 95% CI, 1.94-17.33), but mild thrombocytopenia was not. There was an increased risk of infection among women with both mild (aOR, 1.38; 95% CI, 1.12-1.69) and moderate (aOR, 2.00; 95% CI,1.23-3.22) thrombocytopenia. There was no association between either mild or moderate thrombocytopenia and readmission, prolonged hospital stay, or longer surgical time.

CONCLUSION

Thrombocytopenia was found to be associated with increased infectious morbidity after hysterectomy, and moderate thrombocytopenia was associated with an increased risk of perioperative transfusion and reoperation.

Estimated Blood Loss During Vaginal Hysterectomy and Adnexal Surgery Described With an Intraoperative Pictographic Tool

OBJECTIVE

We describe a novel way to calculate estimated blood loss (EBL) using an intraoperative pictographic tool in gynecologic surgery.

METHODS

A pictographic tool to estimate sponge saturation was developed to calculate EBL during surgery. A prospective cohort of women 18 years or older undergoing benign vaginal hysterectomy with planned adnexal surgery at Mayo Clinic were consented for use of the pictographic tool. Demographic, preoperative, intraoperative, and postoperative data were abstracted. Estimated blood loss was compared among surgeons, anesthesia providers, and the pictographic tool and then correlated with change in hemoglobin.

RESULTS

Eighty-one patients met inclusion with mean age of 45.3 ± 8.7 years. Successful vaginal hysterectomy was achieved in all patients with successful completion of planned adnexectomy in 69 (85.2%). Mean EBL among surgeons, anesthesia providers, and pictographic estimates, respectively, was as follows: 199.4 ± 81.9 mL, 195.5 ± 152.2 mL, and 288.5 ± 186.6 mL, with concordance correlation coefficients for surgeons and anesthesia providers versus pictographic tool of 0.40 (95% confidence interval, 0.29-0.51) and 0.68 (95% confidence interval, 0.57-0.79), respectively. The mean postoperative change in hemoglobin was -1.8 g/dL; there were no postoperative transfusions. Change in hemoglobin was more correlated with blood loss estimates from surgeons (r = -0.31, P = 0.008) and anesthesia providers (r = -0.37, P = 0.003) than the pictographic tool (r = -0.19, P = 0.11).

CONCLUSIONS

Use of a pictographic tool to objectively estimate blood loss demonstrated significant overestimations compared with both anesthesia providers' and surgeons' estimates because the pictographic tool was less correlated with postoperative change in hemoglobin than anesthesia provider and surgeon estimates.

Cost effectiveness of preoperative screening for healthy patients undergoing robotic hysterectomy

The objective of this study was to determine whether routine preoperative type and screen blood testing is cost effective and medically warranted for benign diagnosis in healthy patients undergoing robotic hysterectomy. The study was designed as a cross sectional retrospective descriptive study. Four hundred and twenty two medical records of American Society of Anesthesiologists (ASA) Classifications I and II patients undergoing robotically-assisted laparoscopic hysterectomy between 1 June 2011 and 31 May 2014 at a 211 bed regional medical center were analysed. The results from this study paralleled the findings of other published research. Preoperative type and screen testing was performed on 249 (59%) of the patients in the study. Ten patients (2.4% of the group) converted to open laparotomy. Mean estimated blood loss was 59.59ml. No perioperative transfusions were required. The results indicate that preoperative type and screen testing is not warranted for patients meeting the inclusion criteria.

A model to predict risk of blood transfusion after gynecologic surgery

BACKGROUND

A model that predicts a patient's risk of receiving a blood transfusion may facilitate selective preoperative testing and more efficient perioperative blood management utilization.

OBJECTIVE

We sought to construct and validate a model that predicts a patient's risk of receiving a blood transfusion after gynecologic surgery.

STUDY DESIGN

In all, 18,319 women who underwent gynecologic surgery at 10 institutions in a single health system by 116 surgeons from January 2010 through June 2014 were analyzed. The data set was split into a model training cohort of 12,219 surgeries performed from January 2010 through December 2012 and a separate validation cohort of 6100 surgeries performed from January 2013 through June 2014. In all, 47 candidate risk factors for transfusion were collected. Multiple logistic models were fit onto the training cohort to predict transfusion within 30 days of surgery. Variables were removed using stepwise backward reduction to find the best parsimonious model. Model discrimination was measured using the concordance index. The model was internally validated using 1000 bootstrapped samples and temporally validated by testing the model's performance in the validation cohort. Calibration and decision curves were plotted to inform clinicians about the accuracy of predicted probabilities and whether the model adds clinical benefit when making decisions.

RESULTS

The transfusion rate in the training cohort was 2% (95% confidence interval, 1.72-2.22). The model had excellent discrimination and calibration during internal validation (bias-corrected concordance index, 0.906; 95% confidence interval, 0.890-0.928) and maintained accuracy during temporal validation using the separate validation cohort (concordance index, 0.915; 95% confidence interval, 0.872-0.954). Calibration curves demonstrated the model was accurate up to 40% then it began to overpredict risk. The model provides superior net benefit when clinical decision thresholds are between 0-50% predicted risk.

CONCLUSION

This model accurately predicts a patient's risk of transfusion after gynecologic surgery facilitating selective preoperative testing and more efficient perioperative blood management utilization.

Morbidity associated with vaginal hysterectomies in Queensland public teaching hospitals

Hysterectomies performed vaginally are associated with less perioperative risk than those performed abdominally but the risk is not negligible. There are little sizable and/or contemporary Australian data of adverse outcomes associated with vaginal hysterectomy available. A retrospective analysis was undertaken in each of five Queensland public teaching hospitals of the last 200 women in each centre who underwent a vaginal hysterectomy for benign reasons. Serious morbidity complicated 14.0% of vaginal hysterectomies, minor morbidity was associated with 24.0% of hysterectomies and, overall, 29.9% suffered any (ie serious or minor) morbidity. Following multivariate analysis there remained an association between serious perioperative morbidity and ASA > or = 2 (relative risk (RR) 1.89 (1.37-2.61)) and omission of prophylactic antibiotics (RR 2.0 (1.45-2.78)). There also remained an association between any morbidity and use of antidepressants (RR 1.35 (1.07-1.72)), epilepsy (RR 2.00 (136-2.95)), preoperative hypoalbuminaemia (albumin < or = 35 g/L RR 2.08 (1.33-3.24)) as well as ASA > or = 2 (RR 1.24 (1.00-1.54)) and omission of prophylactic antibiotics (RR 1.45 (1.18-1.79)).