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European Journal of Obstetrics,... Aug 2023This prospective randomised control trial aimed to compare outcome measures of vaginal hysterectomy (VH) and laparoscopically-assisted vaginal hysterectomy (LAVH) in... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
This prospective randomised control trial aimed to compare outcome measures of vaginal hysterectomy (VH) and laparoscopically-assisted vaginal hysterectomy (LAVH) in obese vs. non-obese women undergoing hysterectomy for benign uterine conditions with a non-prolapsed uterus. The primary objective of the study was to estimate operation time, uterine weight and blood loss amongst obese and non-obese patients undergoing VH and LAVH. The secondary objective was to determine any difference in hospital stay, the need for post-operative analgesia, intra- and immediate post-operative complications, and the rate of conversion to laparotomy for obese vs. non-obese patients undergoing VH and LAVH.
STUDY DESIGN
A prospective randomised control study was undertaken in the Department of Obstetrics and Gynaecology of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Women admitted between January 2017 and December 2019 for hysterectomy due to benign conditions, meeting the inclusion criteria set by the unit (vaginally accessible uterus, uterine size ≤ 12 weeks of gestation or ≤ 280gr on ultrasound examination, pathology confined to the uterus) were included in the study. The VH procedures were performed by the residents in training, under the supervision of specialists with large experience in vaginal surgery. All the LAVHs were performed by one surgeon (AC). In addition to the patient characteristics and surgical approach to hysterectomy, operative time, estimated blood loss, uterine weight, length of hospital stay, intra-operative and immediate post-operative complications were also recorded in obese and non-obese patient groups and comparatively analysed.
RESULTS
A total of 227 women were included in the study. 151 patients underwent VH and 76 LAVH, upon randomisation on a 2:1 basis, reflecting the habitual proportion of hysterectomy cases in the Urogynaecology and Endoscopy Unit at CMJAH. No significant differences were found in mean shift of pre-operative to post-operative serum haemoglobin, uterine weight, intra- and immediate post-operative complications, and convalescence period when comparing obese and non-obese patients in both the VH and LAVH groups. There was a statistically significant difference in operating time between the two procedures. The LAVHs took longer compared to the VHs to be performed (62.8 ± 9.3 vs. 29.9 ± 6.6 min in non-obese patients, and 62.7 ± 9.8 vs 30.0 ± 6,9 min for obese patients). All VHs and LAVHs were successfully accomplished without major complications.
CONCLUSION
VH and LAVH for the non-prolapsed uterus is a feasible and safe alternative for obese patients demonstrating similar perioperative outcome measures as non-obese women undergoing VH and LAVH. Where possible, VH should be preferred to LAVH as it is a safe route of hysterectomy, with operation time being significantly shorter.
Topics: Female; Humans; Hysterectomy, Vaginal; Prospective Studies; Laparoscopy; South Africa; Hysterectomy; Postoperative Complications; Treatment Outcome
PubMed: 37390756
DOI: 10.1016/j.ejogrb.2023.06.001 -
Female Pelvic Medicine & Reconstructive... Mar 2022Compared with surgery under general anesthesia (GA), surgery under neuraxial regional anesthesia (RA) has been associated with economic and clinical benefits in certain...
Vaginal Hysterectomy Performed Under General Versus Neuraxial Regional Anesthesia: Comparison of Patient Characteristics and 30-Day Outcomes Using Propensity Score-Matched Cohorts.
OBJECTIVES
Compared with surgery under general anesthesia (GA), surgery under neuraxial regional anesthesia (RA) has been associated with economic and clinical benefits in certain populations. Our aim was to compare preoperative and postoperative characteristics and 30-day outcomes, including intraoperative complications, for patients undergoing benign vaginal hysterectomy under GA versus RA.
METHODS
This is a retrospective cohort study of patients who underwent vaginal hysterectomy for benign indications between 2015 and 2019 using the American College of Surgeons National Surgical Quality Improvement Program database. Patients were identified using Current Procedural Terminology codes and stratified into GA and RA groups. Propensity score matching was performed to account for selection bias between anesthesia groups.
RESULTS
Of 18,030 vaginal hysterectomies performed during this study period, 17,472 (96.9%) were performed under GA and 558 (3.1%) under RA. The RA group was older, more likely to be White, and more likely to have a history of chronic obstructive pulmonary disease and chronic steroid use (P < 0.01 for all); they were less likely to be discharged the same day (8.6% vs 12.2%, P = 0.01). In the matched cohort, there were similar proportions of major, minor, and composite complications between RA and GA groups (major: odds ratio [OR], 0.95; 95% confidence interval [CI], 0.51-1.78; minor: OR, 1.18; 95% CI, 0.74-1.88; composite: OR, 1.10; 95% CI, 0.75-1.64). Similar proportions of same-day discharge were observed (OR, 0.72; 95% CI, 0.47-1.10).
CONCLUSIONS
Although RA comprises only 3% of the anesthetic modalities used for benign vaginal hysterectomies, it is associated with a similar incidence of postoperative complications compared with general anesthesia.
Topics: Anesthesia, Conduction; Anesthesia, General; Female; Humans; Hysterectomy, Vaginal; Propensity Score; Retrospective Studies
PubMed: 35272341
DOI: 10.1097/SPV.0000000000001163 -
Obstetrics and Gynecology Nov 2023To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications.
OBJECTIVE
To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications.
DATA SOURCES
PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022.
METHODS OF STUDY SELECTION
The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies.
TABULATION, INTEGRATION, AND RESULTS
Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy.
CONCLUSION
Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42021234511.
Topics: Aged; Female; Humans; United States; Healthcare Disparities; Medicare; Hysterectomy; Ethnicity; Hysterectomy, Vaginal; Retrospective Studies
PubMed: 37826848
DOI: 10.1097/AOG.0000000000005389 -
Journal of Minimally Invasive Gynecology Mar 2022To evaluate the 30-day complication rate among different hysterectomy routes and operative times.
STUDY OBJECTIVE
To evaluate the 30-day complication rate among different hysterectomy routes and operative times.
DESIGN
A retrospective cohort study.
SETTING
American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2019.
PATIENTS
A total of 216 621 total cases including total abdominal hysterectomies (TAHs), total vaginal hysterectomies, total laparoscopic-assisted vaginal hysterectomies, and total laparoscopic hysterectomies.
INTERVENTIONS
Eligible cases included benign hysterectomies with operative times between 20 minutes and 500 minutes. We excluded cases involving disseminated cancer, emergency surgery, supracervical approaches, or concomitant procedures.
MEASUREMENTS AND MAIN RESULTS
Multivariable logistic regression was used to evaluate the relationship between postoperative complications and operative time for each operative route. Multivariable logistic regression with a linear spline term was used to analyze differences in the association between postoperative complications and operative time below and above threshold operative times. Multivariable logistic regression demonstrated a significant association between operative time and overall complication rates for all hysterectomy routes. Spline logistic regression demonstrated a significant increase in adjusted odds of a complication occurring at or above the thresholds of 100 minutes for TAH.
CONCLUSION
Patients undergoing a TAH for benign indications had a significantly increased odds of developing a complication within 30 days when operative time exceeded 100 minutes. Operative time may play a larger role in preoperative, intraoperative, and postoperative management than previously recognized for TAH in contrast to other hysterectomy routes.
Topics: Cohort Studies; Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Laparoscopy; Operative Time; Postoperative Complications; Retrospective Studies
PubMed: 34808382
DOI: 10.1016/j.jmig.2021.11.005 -
International Urogynecology Journal Jun 2021To evaluate vaginal hysterectomy (VH) associated with vaginal native tissue repair (VNTR) using Campbell uterosacral ligament suspension (C-USLS) for the treatment of...
INTRODUCTION AND HYPOTHESIS
To evaluate vaginal hysterectomy (VH) associated with vaginal native tissue repair (VNTR) using Campbell uterosacral ligament suspension (C-USLS) for the treatment of predominant uterine prolapse associated with cystocele.
METHODS
We conducted a retrospective monocentric study including patients who underwent VH and C-USLS, without concomitant mesh, for primary urogenital prolapse between January 2011 and June 2018. We evaluated the anterior and apical prolapse recurrence rate, using a composite criterion (symptomatic, asymptomatic recurrence, POP-Q stage ≥ 2). We analyzed 2-year recurrence-free survival using the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify variables associated with recurrence. Secondary outcomes included postoperative complications, lower urinary tract symptoms (LUTS) and sexual satisfaction.
RESULTS
Ninety-four patients were included. Eighty-three (88.3%) and 65 (69.1%) patients had stage ≥ 3 uterine prolapse and cystocele, respectively. Mean follow-up was 36 months. Prolapse recurrence rate was 21.3% including 3.2% of cystocele. Two-year recurrence-free survival was 80%. Age, body mass index, POP-Q stage and associated surgical procedure were not significantly associated with recurrence. Early complications were reported for 20 patients (21.2%), mostly grade ≤ 2 (95%). De novo LUTS were reported in 11 cases (11.7%). Preoperative stress urinary incontinence and urgency were cured for 12 (80%) and 29 (80.6%) patients, respectively. Sexual satisfaction rate for patients with preoperative sexual activity was 95.8%.
CONCLUSION
C-USLS following VH as primary treatment for predominant uterine prolapse with associated cystocele is a safe procedure with satisfying mid-term functional results. This VNTR could be an alternative in light of the worldwide market withdrawal of actual vaginal mesh.
Topics: Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Ligaments; Pelvic Organ Prolapse; Retrospective Studies; Treatment Outcome
PubMed: 33620535
DOI: 10.1007/s00192-021-04674-5 -
BJOG : An International Journal of... Feb 2024To identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery.
OBJECTIVE
To identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery.
DESIGN
Secondary analysis of magnetic resonance images (MRI) of the Defining Mechanisms of Anterior Vaginal Wall Descent cross-sectional study.
SETTING
Eight clinical sites in the US Pelvic Floor Disorders Network.
POPULATION OR SAMPLE
Women who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for uterovaginal prolapse between April 2013 and February 2015.
METHODS
The MRI (rest, strain) obtained 30-42 months after surgery, or earlier for participants with recurrence who desired reoperation before 30 months, were analysed. MRI-based prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create three-dimensional models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position.
MAIN OUTCOME MEASURES
Vaginal angulation (upper, lower and upper-lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume) and position (apex, mid-vagina) at rest.
RESULTS
Of the 82 women analysed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, women with recurrence had a more laterally deviated upper vagina (p = 0.02) at rest than women with successful surgery. After hysterectomy, women with recurrence had a more inferiorly (lower) positioned vaginal apex (p = 0.01) and mid-vagina (p = 0.01) at rest than women with successful surgery.
CONCLUSIONS
Vaginal angulation and position were associated with prolapse recurrence and suggestive of vaginal support mechanisms related to surgical technique and potential unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors.
Topics: Female; Humans; Prospective Studies; Cross-Sectional Studies; Treatment Outcome; Gynecologic Surgical Procedures; Vagina; Hysterectomy, Vaginal; Uterine Prolapse; Pelvic Organ Prolapse
PubMed: 37522240
DOI: 10.1111/1471-0528.17620 -
Ceska Gynekologie 2022Peripartum hysterectomy is a life-saving procedure performed during and after vaginal delivery or cesarean section. The incidence of placental invasion anomaly is...
OBJECTIVE
Peripartum hysterectomy is a life-saving procedure performed during and after vaginal delivery or cesarean section. The incidence of placental invasion anomaly is increasing in parallel with the increase in the number of births by cesarean section. It was aimed to evaluate the frequency, risk factors and outcomes of peripartum hysterectomy performed in a tertiary hospital.
MATERIALS AND METHODS
Research data were obtained by a retrospective review of patient files. Patients who underwent peripartum hysterectomy because of postpartum hemorrhage in the Gynecology and Obstetrics Clinic of Trabzon Kanuni Training and Research Hospital, University of Health Sciences, Turkey, were included in the present study. The patients were divided into two groups as those who underwent emergency peripartum hysterectomy (EPH) and those who did not. Demographic variables, fetal and maternal mortality, EPH indications, additional surgeries performed during EPH, and intra- or postoperative complications were collected. Pearson chi-square test was used for statistical analysis.
RESULTS
There were 22,464 deliveries, of which 13,514 were delivered vaginally and 8,950 by cesarean section. Peripartum hysterectomy was performed on 42 patients (vaginal 16, cesarean section 26). The most common EPH indications in both groups were placenta accreta spectrum (42.9/ 3.2%), followed by uterine atony (38.1/ 2.5%). The most common risk factor for EPH was found to be a history of previous cesarean sections.
CONCLUSION
Placental invasion anomalies that cause severe postpartum hemorrhage are due to increased cesarean rates. Currently, the most common indication of EPH is placental invasion anomalies.
Topics: Cesarean Section; Female; Humans; Hysterectomy; Incidence; Peripartum Period; Placenta; Placenta Diseases; Postpartum Hemorrhage; Pregnancy; Retrospective Studies; Risk Factors
PubMed: 35896395
DOI: 10.48095/cccg2022179 -
Surgical techniques for the removal of Essure microinserts: a literature review on current practice.The European Journal of Contraception &... Oct 2021To evaluate the different techniques for Essure microinserts removal and to assess the risk of fracture of the device and the intra- and post-operative complications in... (Review)
Review
PURPOSE
To evaluate the different techniques for Essure microinserts removal and to assess the risk of fracture of the device and the intra- and post-operative complications in relation to surgical technique variants.
METHODS
Electronic search in Medline, Scopus and Embase databases using the following keywords: Essure; Essure removal; Essure surgical technique.
RESULTS
Out of 95 articles in the initial database, 17 studies were eligible for inclusion in our literature review. Several surgical techniques have been described in which the most frequent were laparoscopic salpingectomy (LS), laparoscopic cornuectomy (LC), laparoscopic or vaginal hysterectomy (LH, VH) with en-bloc salpingectomy. There were more fractures of the device with the LS procedure (6.25%) followed by the LC technique (2.77%), while there was no fracture with hysterectomy. However, peri-and post-operative complications were more severe and frequent with hysterectomy in comparison with the LC and LS procedures (respectively 8.1% Clavien Dindo grade 3 for the hysterectomy group, 1.11% for the LC procedure and 0.69% for the LS technique).
CONCLUSION
Due to the lack of standardised surgical treatment guidelines, a system of care networks for symptomatic patients with adverse effects related to Essure headed by specialised centres may offer a suitable and high-quality management with the appropriate removal techniques within two objectives: limiting the risk of fracture (with an en-bloc removal of the Essure microinserts) and avoiding intra- and post-operative complications.
Topics: Device Removal; Female; Humans; Hysterectomy; Intrauterine Devices; Laparoscopy; Postoperative Complications; Salpingectomy; Sterilization, Tubal; Surveys and Questionnaires; Treatment Outcome
PubMed: 34096440
DOI: 10.1080/13625187.2021.1925883 -
Journal of Minimally Invasive Gynecology Apr 2022To describe trends in minimally invasive hysterectomy (MIH) and assess patient, surgical, and provider characteristics associated with differences in vaginal versus...
STUDY OBJECTIVE
To describe trends in minimally invasive hysterectomy (MIH) and assess patient, surgical, and provider characteristics associated with differences in vaginal versus laparoscopic rates within an integrated healthcare system.
DESIGN
A retrospective cohort study.
SETTING
Kaiser Permanente Northern California from 2008 to 2018.
PATIENTS
Patients who underwent MIH for benign conditions excluding uterine prolapse and incontinence surgeries.
INTERVENTIONS
Hysterectomies.
MEASUREMENTS AND MAIN RESULTS
A total of 27518 hysterectomies were performed for benign indications. Of these, the proportion of MIH increased from 29.1% (2008) to 96.7% (2018) (p <.001). The proportion of vaginal hysterectomies (VHs) of all hysterectomies did not change significantly over the study period (p = .07); however, the proportion of VH among MIH cases decreased from a high of 50.6% in 2008 to 13.2% in 2018 (p <.001). VH rates were lower in obese and morbidly obese patients (p <.001 and p = .02, respectively) and in women with uterine weights >250 g (p <.001). The differences persisted after controlling for patient demographic, clinical, and surgery characteristics. Low surgical volume was inversely associated with VH (adjusted relative risk, 7.19; 95% confidence interval, 6.62-7.81; p <.001). VH rates ranged from 11.5% to 27.8% across service areas (hospitals). Service area remained a significant predictor of VH after controlling for patient (including body mass index and uterine weight) and surgery-related characteristics. Postoperative hospital stay decreased from 33.8 ± 16.4 hours (2008) to 6.1 ± 12.2 (2018) for VH. Operative time was shorter for VH than laparoscopic hysterectomies (LHs) (1.7 vs 2.5 hours; p <.001). Overall operative/perioperative complications were low and not significantly different (VH vs LH).
CONCLUSION
As the proportion of MIH increased, LH became the preferred route despite similar rates of postoperative stay and intraoperative complications and shorter operative time for VH compared with LH. Service area and provider volume were independent predictors of MIH route, suggesting that training and evidence-based guidelines for route selection may help preserve VH rates.
Topics: Delivery of Health Care, Integrated; Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Laparoscopy; Obesity, Morbid; Postoperative Complications; Retrospective Studies
PubMed: 34808378
DOI: 10.1016/j.jmig.2021.11.007 -
Annals of Surgical Oncology Aug 2023The radical vaginal hysterectomy popularized by Schauta has been virtually abandoned due to painful perineal incision, high rate of urinary dysfunction, and inability to...
The radical vaginal hysterectomy popularized by Schauta has been virtually abandoned due to painful perineal incision, high rate of urinary dysfunction, and inability to perform lymph node assessment. However, this approach is still used and taught in a few centers outside its Austrian birthplace. In addition, a combined vaginal and laparoscopic approach, overcoming the flaws of the pure vaginal technique, was developed in the 1990s by French and German surgeons. After the publication of the Laparoscopic Approach to Cervical Cancer trial, the radical vaginal approach has found a very timely application with the closure of the vaginal cuff, aiming at avoiding cancer cell spillage. In addition, it is the basis to perform radical vaginal trachelectomy, or Dargent's operation, the best documented approach for the fertility-sparing management of stage IB1 cervical cancers. Today, the main obstacle to the rebirth of radical vaginal surgical surgery is the lack of teaching centers and the need of a specific learning curve that requires performing 20-50 surgeries. This educational video demonstrates that training is possible using a fresh cadaver model. A type B approach according to the Querleu-Morrow classification of radical vaginal hysterectomy, adapted according to surgeon's choice to stage IB1 or IB2 cervical cancer, is shown. Key specific steps such as the creation of a vaginal cuff and the identification of the ureter within the bladder pillar are highlighted. Fresh cadaver model is a method that spares the patients the risks of early learning curve while allowing the surgeon to acquire skills and keep offering the patient the benefit of the most specifically gynecological approach in cervical cancer surgery.
Topics: Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Laparoscopy; Lymph Node Excision; Neoplasm Staging; Trachelectomy; Uterine Cervical Neoplasms
PubMed: 37074519
DOI: 10.1245/s10434-023-13419-1