A randomized control trial comparing vaginal and laparoscopically-assisted vaginal hysterectomy in the absence of uterine prolapse in a South African tertiary institution

OBJECTIVES

The primary objectives of this study were to estimate blood loss, operation time and cost differences in patients undergoing vaginal hysterectomy (VH) versus laparoscopically-assisted vaginal hysterectomy (LAVH). The secondary objectives were to determine differences in hospital stay, need for postoperative analgesia, intra- and immediate post-operative complications, and the rate of conversion to laparotomy. VH was hypothesized to be the preferred route for hysterectomy for benign uterine conditions.

STUDY DESIGN

A randomized control study was undertaken at the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital and included the women admitted between January 2017 and December 2019 for hysterectomy due to benign conditions, meeting the inclusion criteria (vaginally accessible uterus, estimated uterine size ≤ 12 weeks of gestation or ≤ 280 g on ultrasound examination and pathology confined to the uterus). Surgical procedures were performed by the residents in training under the supervision of specialists with large experience. The patient demographic characteristics, uterine weight, operative time, estimated blood loss(expressed as the difference between preoperative and postoperative day one serum haemoglobin),direct surgery-associated costs, intra- and immediate post-operative complications and the length of hospital stay were recorded and comparatively analysed among patients randomly placed in VH and LAVH group.

RESULTS

A total of 227 women were included (151 patients underwent VH and 76 LAVH, upon 2:1 randomization, performed on this way to reflect the previous pattern of operating of the unit). The patients were matched with respect to age, parity and body mass index. No significant differences between two groups were found in mean uterine weight and also in mean serum haemoglobin shift, intra- and immediate post-operative complications, and convalescence period duration. There were statistically significant differences in operating time and in cost between the two procedures. On average, LAVH took longer than VH to be performed (62.8 ± 9.3 vs 29.9 ± 6.6 min, p < 0.0001) and it was more costly, mainly due to the longer operating time and required disposables. An amount of 15698.20 South African Rand (ZAR) or 1145.85 United States Dollar (USD) more were needed to perform LAVH in comparison to VH. All VHs and LAVHs were successfully accomplished without major complications or conversation to laparotomy.

CONCLUSION

Our data indicate that VH is a feasible and safe alternative for a large group of women with benign pathology and non-prolapsed uteri, being a faster and less costly procedure than LAVH.

Cervical cancer in women under 30 years of age in Norway: a population-based cohort study

BACKGROUND

We compared women with incident cervical cancer under the age of 30 with older women with regard to stage, morphology, screening history and cervical cancer mortality in a population-based cohort study.

METHODS

We included data from the Cancer Registry of Norway. Incidence rates (per 100,000 women-years) were calculated and joinpoint regression was used to analyse trends. The Nelson-Aalen cumulative hazard function for risk of cervical cancer death during a 15-year follow-up was displayed. The hazard ratios (HRs) of cervical cancer mortality with 95% confidence intervals (CIs) were derived from Cox regression models.

RESULTS

The incidence of cervical cancer in women under the age of 30 has almost tripled since the 1950s, with the steepest increase during 1955-80 (with an annual percentage change (APC) of 7.1% (95%CI 4.4-9.8)) and also an increase after 2004 (3.8% (95%CI -1.3-9.2)). Out of 21,160 women with cervical cancer (1953-2013), 5.3% were younger than 30 years. A lower proportion of younger women were diagnosed at more advanced stages and a slightly higher proportion were diagnosed with adenocarcinoma and adenosquamous carcinoma comparing women above 30 years. The cumulative risk of cervical cancer death was lower for patients under the age of 30. However, the difference between the age groups decreased over time. The overall adjusted HR of cervical cancer mortality was 0.69 (95% CI 0.58-0.82) in women diagnosed under the age of 30 compared to older women.

CONCLUSION

There has been an increase in cervical cancer incidence in women under the age of 30. Cervical cancer in younger women was not more advanced at diagnosis compared to older women, and the cervical cancer mortality was lower.

Formal institutional guidelines promotes the vaginal approach to hysterectomy in patients with benign disease and non-prolapsed uterus

OBJECTIVES

This study was undertaken at the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital to determine if the use of formal guidelines and a standardised surgical technique would increase the rate of vaginal hysterectomy (VH) and result in an overall decline in open abdominal hysterectomy (AH).

STUDY DESIGN

All women admitted between July 2001 and December 2014 for hysterectomy due to benign conditions, meeting the guidelines criteria (vaginally accessible uterus, uterus ≤ 12 weeks size or ≤ 280 g on ultrasound examination and pathology confined to the uterus) were included. The surgical route was determined using the Unit surgical decision tree algorithm. In cases where the pathology was not confined to the uterus or success in VH was uncertain, laparoscopic assisted vaginal hysterectomy (LAVH) was performed. The VH procedures were performed by the residents in training, under the supervision of specialists with large experience in vaginal surgery. In addition to the patient characteristics and surgical approach to hysterectomy, length of hospital stay, intra-operative and immediate post-operative complications were also recorded and analysed.

RESULTS

A year before the initiation of the study, the percentage of all VHs undertaken in the Department was 9.8 % (mainly performed for utero-vaginal prolapse). During the study period, 1143 vaginal procedures (1017 VHs and 126 LAVHs) were performed. The most common indications were cervical dysplasia, uterine fibroids, dysmenorrhoea or abnormal uterine bleeding, adenomyosis, endometrial hyperplasia and chronic pelvic pain. Introducing a formal clinical decision tree algorithm and a standardised surgical technique resulted in an increase in the rate of VH to 48.4 % and overall decline in open AH from 91.2%-51.6%. Thus, the VH/AH ratio increased from 1/9 at the beginning of the study (July 2001) to 1/1 by its end (December 2014). In all cases, VH was performed without the need to convert the vaginal to the abdominal route.

CONCLUSION

The use of institutional guidelines for determining the hysterectomy route and a standardised VH technique resulted in an increased number of performed VHs. This provided an essential opportunity for residents to acquire, improve and maintain the skills required to safely perform VH.

The Oak-wood Extract Robuvit® Improves Recovery and Oxidative Stress after Hysterectomy: A Randomized, Double-blind, Placebo-controlled Pilot Study

Hysterectomy has a variety of medical indications and improves pre-operative symptoms but might compromise the quality of life during recovery due to symptoms such as fatigue, headache, nausea, depression, or pain. The aim of the present study was to determine the effect of a standardized extract from French oak wood (Quercus robur) containing at least 40% polyphenols of the ellagitannins class, Robuvit^®, on convalescence and oxidative stress of women after hysterectomy. Recovery status was monitored with the SF-36 questionnaire. The supplementation with Robuvit^® (300 mg/day) during 4 weeks significantly improved general and mental health, while under placebo some items significantly deteriorated. Oxidative stress and enhancement of MMP–9 activity was significantly reduced by Robuvit^® versus placebo. After 8 weeks of intervention, the patients’ condition improved independently of the intervention. Our results suggest that the use of Robuvit^® as a natural supplement relieves post-operative symptoms of patients after hysterectomy and reduces oxidative stress. The study was registered with ID ISRCTN 11457040 (13/09/2019).

Atypical glandular lesions of the cervix and risk of cervical cancer

INTRODUCTION

Cytology screening has been effective in reducing risks for cervical squamous cell carcinoma but less so for adenocarcinoma. We explored the association of atypical glandular cells or absence of glandular cells in cytology, and subsequent histological diagnoses and cancer risk.

MATERIAL AND METHODS

All women in Norway with atypical glandular cells of undetermined significance (AGUS), adenocarcinoma in situ (ACIS) and normal/benign cells, but absence of endocervical or metaplastic cells (NC-NEC) in their first cytology during 1992-2014 (NC-NEC; 2005-2014), recorded in the Cancer Registry of Norway, were included (n = 142 445). Histology diagnoses (stratified by age) within 1 and 3 years after cytology were examined. The Nelson-Aalen cumulative hazard function for gynecological cancer risk was displayed.

RESULTS

The majority of AGUS and particularly ACIS were followed with histology within 1 and 3 years. Cervical intraepithelial neoplasia (CIN) lesions were more common in women <35 than in women ≥35 years. Cervical adenocarcinoma followed 13% of ACIS after 1 and 3 years. After ACIS and AGUS, cervical adenocarcinoma was the most frequent cancer subtype. Cumulative risks of cervical adenocarcinoma following ACIS, AGUS and NC-NEC were 3.5%, 0.9% and 0.05%, respectively, after 22, 22 and 9 years of follow-up.

CONCLUSIONS

There was a high-risk of glandular malignancies after AGUS and ACIS in cytology. If effective treatment of pre-cancer and early cancer is available, cytology screening provides some level of prevention of adenocarcinoma. Lack of glandular cells did not entail a higher cancer risk.

Changing trends in the preference of health care facility and reasons for hysterectomy in India

Many community-based studies from India have pointed out a sudden increase in the number of hysterectomy performed in the past few years. Using the data from the fourth round of National Family Health Survey (NFHS-4), we have attempted to examine the changing trends in the preference of health care facilities and reasons for hysterectomy in India. After analyzing the data, we have found that over the years, women are moving toward private health care providers for hysterectomy, and excessive menstrual bleeding is one of the most common reasons among them. A substantially higher proportion of hysterectomy in private health care facilities over the public raises the question of its necessity.

Multidetector CT of expected findings and complications after hysterectomy

Abstract

Indicated to manage a variety of disorders affecting the female genital tract, hysterectomy represents the second most common gynaecological operation after caesarean section. Performed via an open, laparoscopic or vaginal approach, hysterectomy is associated with non-negligible morbidity and occasional mortality. Iatrogenic complications represent a growing concern for gynaecologists and may result in prolonged hospitalisation, need for interventional procedures or repeated surgery, renal impairment and malpractice claims. As a result, radiologists are increasingly requested to investigate patients with suspected complications after hysterectomy. In the vast majority of early postoperative situations, multidetector CT represents the ideal modality to comprehensively visualise the surgically altered pelvic anatomy and to consistently triage the varied spectrum of possible injuries. This pictorial review provides an overview of current indications and surgical techniques, illustrates the expected CT appearances after recent hysterectomy, the clinical and imaging features of specific complications such as lymphoceles, surgical site infections, haemorrhages, urinary tract lesions and fistulas, bowel injury and obstruction. Our aim is to increase radiologists’ familiarity with normal post-hysterectomy findings and with post-surgical complications, which is crucial for an appropriate choice between conservative, interventional and surgical management.

Teaching points

• Hysterectomy via open, laparoscopic or vaginal route is associated with non-negligible morbidity.

• Multiplanar CT imaging optimally visualises the surgically altered pelvic anatomy.

• Familiarity with early post-hysterectomy CT and expected findings is warranted.

• Complications encompass surgical site infections, haemorrhages, bowel injury and obstruction.

• Urological complications include ureteral leakage, bladder injury, urinomas and urinary fistulas.

The influence of total hysterectomy in a cervical cancer screening population: a register-based cross-sectional study

BACKGROUND

High coverage of a screening program is essential to program success. Many European screening programs cover only 10-80% of their target population. A possible explanation for the low coverage may be that some women in the screening population have had a total hysterectomy, thus they are not at risk of cervical cancer. The aim of this study was to identify the prevalence of hysterectomy in the target population of the Danish National Cervical Cancer Screening Program (NCCSP) and to recalculate coverage after excluding women with total hysterectomy. Furthermore, to analyze the association between hysterectomy and sociodemographic factors within the screening population.

METHODS

A population-based cross-sectional study using register data on all women in the target population of the NCCSP on January 12, 2012 (women born January 12, 1947, to January 12, 1986). The total coverage included women with hysterectomy in the target population whereas the recalculated coverage was calculated excluding women with total hysterectomy. To test the differences between the total coverage and the recalculated coverage, a two-sample z-test between the proportion of covered hysterectomized women and the proportion of covered non-hysterectomised women were used. A logistic regression model adjusted for age and sociodemographic characteristics was used to analyze the association between sociodemographic factors and total hysterectomy.

RESULTS

The coverage among women aged 26-49 years and 55-64 years were 77.4% and 72.7%, respectively. The recalculated coverage was 78.2% (26-49 years) and 79.4% (55-64 years). Recalculating the coverage did not result in coverage higher than 82.7% at any age. The effect of excluding women with total hysterectomy increased with age, reaching its maximum of 8 % points for the oldest women. Women with higher socioeconomic status (higher education and higher disposable income) had lower odds of being hysterectomized compared to other women. Also, immigrants and descendants had lower odds of being hysterectomized compared to ethnic Danes.

CONCLUSIONS

Excluding women with total hysterectomy only partly explained the low coverage of the NCCSP. Thus, initiatives must be made to improve acceptability of and accessibility to the NCCSP, especially in the youngest and the oldest women.

The laparoscopic approach is more preferred among nurses for benign gynecologic conditions than among nonmedical working women: A nationwide study in Taiwan

OBJECTIVE

To compare the use of laparoscopy and laparotomy for hysterectomy in treating benign gynecological conditions in nurses and nonmedical working women.

MATERIALS AND METHODS

A nationwide population-based study was conducted using data from inpatient expenditures of Taiwan's National Health Insurance Research Datasets between 2008 and 2011. All women undergoing total hysterectomies via laparoscopy and laparotomy between the ages of 20 years and 65 years were identified. A generalized equation estimation model was used to compare the differences in laparoscopic hysterectomy (LH) and total abdominal hysterectomy (TAH) between the two groups.

RESULTS

There were 1226 nurses, and 36,624 nonmedical working women, serving as controls, in the present study. The LH rate, as compared to the TAH rate, was significantly higher among nurses than among controls (56% vs. 52%, p = 0.006). A multivariate analysis indicated that nurses were significantly more likely to undergo LH (odds ratio, 1.12; 95% confidence interval, 1.01-1.26) than TAH. Nurses were more often treated at medical centers or high-volume hospitals, and were more often treated by high-volume gynecologists.

CONCLUSION

Compared to nonmedical working women, nurses are more likely to undergo LH rather than TAH. These differences may suggest the influence of medical knowledge and physician-patient interaction on the decision to undergo laparoscopy, in addition to patients' medical conditions.

Recent estimates of the incidence of hysterectomy in New South Wales and trends over the past 30 years

BACKGROUND

Hysterectomy remains one of the frequently used surgical operations on women in Australia despite new therapeutic approaches for most of the common conditions for which hysterectomy is indicated.

AIMS

To determine whether the surgical approach to hysterectomy has changed in New South Wales (NSW) over the period 1981 to 2010-2012.

DATA AND METHODS

De-identified individual records for hysterectomy patients during the three-year period (January 2010 to December 2012) provided by the NSW Ministry of Health were used. Robotic assistance with surgery was not recorded in the hysterectomy data. Analysis largely involved the method of indirect standardisation.

RESULTS

The average annual hysterectomy rate during 2010-2012 was 3.07 per 1000 females per annum; the majority of patients stayed an average of four days in hospital. Total abdominal and vaginal hysterectomies were the two most frequently used procedures. One-in-four procedures involved the use of laparoscopes. Principal diagnoses (in descending order) were disorders of menstruation and other abnormal bleeding, genital prolapse, leiomyoma of uterus, malignant neoplasm of genital organs and endometriosis. While declining trends in hysterectomy rates were noted since 1981, an increasing trend in the use of laparoscopy was evident.

CONCLUSIONS

The 45% decrease in hysterectomy rates was indeed the most striking finding of our analysis. This is probably due to the development of alternative nonsurgical procedures such as oral hormone suppression of menstruation and the levonorgestrel-releasing intrauterine system.

Gynecologists' characteristics associated with the likelihood of performing laparoscopic-assisted hysterectomy: a nationwide population-based study

OBJECTIVE

With continuing development of minimally invasive techniques in gynecology, hysterectomy with laparoscopic assistance is increasingly performed. This study aimed to examine the relationship between the characteristics of gynecologists and the likelihood of performing laparoscopic-assisted hysterectomy (LH) under the case payment system of Taiwan's National Health Insurance.

STUDY DESIGN

A retrospective population-based study was conducted based on the data from Taiwan's National Health Insurance Research Database. A total of 56,532 female residents aged 20 years and older who underwent total hysterectomy with or without laparoscopic assistance between 2004 and 2006 were included in the study. The gender, age and practice volume of their gynecologists were noted. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by univariate and multivariate logistic regression analyses.

RESULTS

Of the women selected, 30,478 underwent traditional total hysterectomy (TH) and 26,054 underwent LH. After controlling for clinical and nonclinical factors, male gynecologists (OR 1.65, 95% CI 1.55-1.76) were more likely to perform LH than their female colleagues. Gynecologists aged 60 years and older (OR 0.31, 95% CI 0.29-0.39) had the lowest likelihood of performing LH compared with their counterparts. In addition, surgeons with low-volume practice (OR 0.31, 95% CI 0.29-0.33) also had a significantly lower probability of performing LH compared with other surgeons.

CONCLUSION

A higher likelihood of performing LH was observed among male and younger gynecologists with high-volume practice in Taiwan. This finding suggests that differences in practice patterns and surgical treatment decision may explain the variation in the approaches to laparoscopy-assisted hysterectomies.

CONDENSATION

Differences in practice patterns and surgical treatment decisions may explain the variation in the approaches to laparoscopic-assisted hysterectomies.