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International Urogynecology Journal Feb 2022Chronic non-puerperal complete uterine inversion is a relatively rare condition. Abdominal Haultain's operation is the usual management. We present such a case with...
INTRODUCTION AND HYPOTHESIS
Chronic non-puerperal complete uterine inversion is a relatively rare condition. Abdominal Haultain's operation is the usual management. We present such a case with fundal fibroids managed by modified vaginal hysterectomy.
METHODS
Preoperative computerized tomography enhanced intravenous urogram depicted normal ureters and bladder. Diluted vasopressin (10 U in 100 ml normal saline) was infiltrated at the base of the myoma and a myomectomy was performed. The fundal raw area was pierced to reach the formed space between the anterior and posterior uterine serosa. The bilateral round ligaments were clamped, cut, and ligated. Diluted vasopressin was injected into the fundal anterior uterine wall and about 1 cm was excised. Then, the bilateral utero-ovarian ligaments were clamped, cut, and ligated. In the same way another 1 cm of anterior uterine wall was excised and the bilateral uterine vessels were clamped, cut, and ligated. The rest of the uterine wall area was infiltrated with diluted vasopressin circumferentially. An incision at the vesico-cervical junction was made and the bladder pushed up. The posterior fornix area was incised and the Pouch of Douglas (POD) opened. Vesico-uterine pouch opened under finger guidance placed through POD. The rest of the anterior uterine wall was excised. Exposed bilateral cardinal-uterosacral ligament complexes (CULCs) were clamped, cut, and ligated. The remaining vaginal attachments ligated hemostatically and the vault was closed. For vault prolapse prevention, vault closure suture ends were tied with ipsilateral CULC suture end, brought outside the vagina at vault angle.
RESULTS
A follow-up visit up to 1 year found no complications.
CONCLUSION
This novel reverse vaginal hysterectomy combining the principles of both abdominal and vaginal hysterectomy can successfully manage chronic non-puerperal complete uterine inversion.
Topics: Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Ligaments; Uterine Inversion; Uterine Prolapse; Uterus
PubMed: 34236467
DOI: 10.1007/s00192-021-04903-x -
Cureus Oct 2022Middle-aged women with ureterovaginal fistula (UVF) after hysterectomy represent a painful condition for the patients in the community. Accurate diagnosis and proper...
Middle-aged women with ureterovaginal fistula (UVF) after hysterectomy represent a painful condition for the patients in the community. Accurate diagnosis and proper planning before surgery are essential for effective outcomes. CT urography is the modality of choice in diagnosing ureterovaginal fistula. CT urography helps in evaluating the fistula as well the associated renal complications following the condition. Here we present a case of ureterovaginal fistula reported with a history of vaginal hysterectomy for subserosal fibroid in December 2021.
PubMed: 36439605
DOI: 10.7759/cureus.30694 -
Journal of Obstetrics and Gynaecology... Oct 2023To study the epidemiology and various methods of repair of vaginal vault prolapse in selected group of patients and the benefits of various modes of treatment in the...
PURPOSE OF STUDY
To study the epidemiology and various methods of repair of vaginal vault prolapse in selected group of patients and the benefits of various modes of treatment in the management of vault prolapse.
METHODS
Thirty-seven patients with grade lll or lV vault prolapse were enrolled in our study. Sacrospinous fixation was performed in 37 patients. High risk factors for prolapse, surgical results and complications were evaluated.
RESULTS
In the current study, maximum cases of vault prolapse, 67.6%, were in the age group of 51-60 years. Out of 37 patients, 18.9% had a history of chronic cough secondary to bronchial asthma or past history of tuberculosis And 13.5% had a bowel dysfunction (chronic constipation). Vaginal vault prolapse most commonly was seen following vaginal hysterectomy (43.3%) as compared to total abdominal hysterectomy (29.7%). Most common surgery was performed for post-hysterectomy vault prolapse being sacrospinous fixation in the current study. In total, 29.7% of the patients had early post-operative complications like urinary tract infection (16.2%), urinary retention (5.4%) and buttock pain (5.4%), and 2.7% had vaginal cuff cellulitis. Dyspareunia is a common complication post-operatively following sacrospinous fixation, due to shortening of vaginal length post-procedure.
CONCLUSION
Only 29.7% patients had complications, among which most common complication was urinary tract infection, which was treated with injectable antibiotics, urinary retention and buttock pain being the less common complication. Dyspareunia was present only in 18.9% cases post-operatively due to vaginal shortening associated with the procedure. Sacrospinous fixation is a safe and effective procedure.
SUPPLEMENTARY INFORMATION
The online version contains supplementary material available at 10.1007/s13224-023-01757-9.
PubMed: 37916016
DOI: 10.1007/s13224-023-01757-9 -
Obstetrics and Gynecology Apr 2022To assess 30-day outcomes for hysterectomy by body mass index (BMI) classification and estimate trends in 30-day outcomes by BMI over time.
OBJECTIVE
To assess 30-day outcomes for hysterectomy by body mass index (BMI) classification and estimate trends in 30-day outcomes by BMI over time.
METHODS
This is a retrospective cohort study of patients older than age 18 years undergoing hysterectomy with data in the National Surgical Quality Improvement Program database from 2005 to 2018. Exclusions were made for ambiguous indication or route of surgery and missing values in covariates or outcomes of interest. Patient characteristics and outcomes were compared across BMI classifications. Outcomes included operative time, length of stay, and major and minor complications. Multivariable linear regression models were used for continuous outcomes, and modified Poisson regression models were used for binary outcomes. Patients with benign and malignant indications for hysterectomy were analyzed separately. Models were adjusted for age, race, hysterectomy route, hypertension, diabetes, smoking, selected preoperative laboratory values, and cancer type, if applicable.
RESULTS
Obesity rate increased from 41.2% in 2005-2007 to 51.8% in 2018. Among 319,462 patients, minimally invasive surgery was the most common approach (58.8% vs 24.5% laparotomy vs 16.7% vaginal). Higher BMI classifications were associated with longer operative times (benign indication: average 25.0 minutes longer, 95% CI 22.1-27.9; malignant indication: average 25.1 minutes longer, 95% CI 20.8-29.4) and higher risk of complications compared with normal-weight BMIs, though operative time declined over time for patients with malignant surgical indications. Relative to normal-weight patients, rates of major complications did not increase until a BMI of 40 for hysterectomy for benign indications and 50 for hysterectomy for malignant indications.
CONCLUSION
Operative times and complications both increase with obesity when performing hysterectomy. Knowledge of evolving risk level at various weight subclassifications can improve shared decision making preoperatively.
Topics: Adolescent; Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Laparoscopy; Morbidity; Obesity; Operative Time; Postoperative Complications; Retrospective Studies
PubMed: 35271543
DOI: 10.1097/AOG.0000000000004699 -
Gynecologic Oncology Jul 2022Radical hysterectomy and pelvic lymphadenectomy are considered the standard treatment for early-stage cervical cancer (ECC). Minimal Invasive approach to this surgery... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Radical hysterectomy and pelvic lymphadenectomy are considered the standard treatment for early-stage cervical cancer (ECC). Minimal Invasive approach to this surgery has been debated after the publication of a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC trial). It demonstrated poorer oncological outcomes for Minimal Invasive Surgery in ECC. However, the reasons are still an open debate. Laparo-Assisted Vaginal Hysterectomy (LAVRH) seems to be a logical option to Abdominal Radical Hysterectomy (ARH). This meta-analysis has the aim to prove it.
METHODS
Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, the Pubmed database and Scopus database were systematically searched in January 2022 since early first publications. No limitation of the country was made. Only English article were considered. The studies containing data about Disease-free Survival (DFS) and/or Overall Survival (OS) and/or Recurrence Rate (RcR) were included.
RESULTS
19 studies fulfilled inclusion criteria. 9 comparative studies were enrolled in meta-analysis. Patients were analyzed concerning surgical approach (Laparo-Assisted Vaginal Radical Hysterectomy) and compared with ARH Oncological outcomes such as DFS and OS were considered. 3196 patiets were included for the review. Meta-analysis of 1988 0f them highlighted a non-statistic significant difference between LARVH and ARH (RR 0.8 [95% CI 0.55-1.16] p = 0.24; I = 0%; p = 0.98). OS was feasible only for 4 studies (RR 0.84 [95% CI 0.23-3.02] p = 0.79; I = 0 p = 0.44). Sub-analysis for tumor with a maximum diameter greater than 2 cm was performed. Data about the type of recurrences (loco-regional vs distant) were collected.
CONCLUSION
LARVH does not appear to affect DFS and OS in ECC patients. The proposed results seem to be comparable with the open approach group of the LACC trial, which today represents the reference standard for the treatment of this pathology. More studies will be needed to test the safety and efficacy of LARVH in the ECC.
Topics: Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Laparoscopy; Neoplasm Staging; Retrospective Studies; Uterine Cervical Neoplasms
PubMed: 35513934
DOI: 10.1016/j.ygyno.2022.04.010 -
International Journal of Gynaecology... Jan 2024Despite the rising rates of opportunistic salpingectomy at the time of surgery for non-malignant conditions, salpingectomy is not widely adopted during vaginal... (Review)
Review
BACKGROUND
Despite the rising rates of opportunistic salpingectomy at the time of surgery for non-malignant conditions, salpingectomy is not widely adopted during vaginal hysterectomy (VH) and has not been extensively investigated.
OBJECTIVES
The aim of the primary study was to determine the feasibility of bilateral opportunistic salpingectomy at the time of VH. Secondary aims included surgical outcomes, factors associated with patient selection, and the prevalence of incidental tubal malignancies.
SEARCH STRATEGY
In this systematic review and meta-analysis we searched Pubmed, Embase and ClinicalTrials.gov databases from inception to September 1, 2023, using relevant keywords.
SELECTION CRITERIA
Original articles with no language restriction reporting outcomes of women undergoing planned VH with opportunistic salpingectomy, were considered eligible. Studies including patients undergoing VH with and without opportunistic salpingectomy were also included.
DATA COLLECTION AND ANALYSIS
The Newcastle-Ottawa scale was used to assess quality of observational studies. DerSimonian-Laird random effects meta-analysis was performed and pooled effect estimates and proportions with corresponding 95% confidence intervals were computed. Heterogeneity was assessed using the I statistic.
RESULTS
Seven observational cohort studies including 4808 women undergoing opportunistic salpingectomy at the time of VH and 10 295 patients undergoing VH alone were selected. The pooled proportion of success was 81.83 per 100 observations (95% CI: 75.35-87.54). Opportunistic salpingectomy at the time of VH, when feasible, was associated with a significant reduction in intraoperative complications (OR 0.06, 95% CI: 0.01, -0.37, P = 0.03) and total operative time (95% CI: -17.80, -1.07, P = 0.03) compared to those where it failed. Successful salpingectomy was significantly hindered by nulliparity (OR 0.12, 95% CI: -17.69, -1.21, P < 0.001) and favored by pelvic organ prolapse (OR 3.20, 95% CI: 1.35, 7.55, P = 0.008). Immunohistochemical tubal abnormalities were found in 13/579 (2.1%) patients. The overall quality of the evidence, according to the GRADE assessment, was low.
CONCLUSION
Opportunistic salpingectomy is safe, effective, and feasible at the time of VH. Nulliparity and pelvic organ prolapse are factors potentially influencing surgical outcomes.
PubMed: 38247214
DOI: 10.1002/ijgo.15386 -
Obstetrics and Gynecology Sep 2021To compare prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension to recurrence after supracervical hysterectomy with mesh...
OBJECTIVE
To compare prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension to recurrence after supracervical hysterectomy with mesh sacrocervicopexy for the primary management of uterovaginal prolapse.
METHODS
We conducted a retrospective cohort study of women undergoing uterovaginal prolapse repair at an academic center from 2009 to 2019. Women who underwent vaginal hysterectomy with uterosacral ligament suspension or laparoscopic supracervical hysterectomy with mesh sacrocervicopexy were included. The primary outcome was composite prolapse recurrence (prolapse beyond the hymen or retreatment with pessary or surgery). Secondary outcomes included mesh complications, time to recurrence, and overall reoperation for either prolapse recurrence or mesh complication. We used propensity scoring with a 2:1 ratio of sacrocervicopexy to uterosacral suspension.
RESULTS
The cohort consisted of 654 patients, of whom 228 (34.9%) underwent uterosacral suspension and 426 (65.1%) underwent sacrocervicopexy. The median follow-up was longer for the sacrocervicopexy group (230 vs 126 days, P<.001) and less than 1 year for both groups. The uterosacral group had a greater proportion of composite prolapse recurrence (14.9% [34/228] vs 8.7% [37/426], P=.02) and retreatment for recurrent prolapse (7.5% [17/228] vs 2.8% [12/426], P=.02). The uterosacral group demonstrated a shorter time to prolapse recurrence on multivariable Cox regression (hazard ratio 3.14, 95% CI 1.90-5.16). There were 14 (3.3%) mesh complications in the sacrocervicopexy group. Overall reoperation was similar between groups (4.8% [11/228] vs 3.8% [16/426], P=.51).
CONCLUSION
Total vaginal hysterectomy with uterosacral ligament suspension was associated with higher rate of, and shorter time-to-prolapse recurrence compared with supracervical hysterectomy with mesh sacrocervicopexy.
Topics: Cohort Studies; Disease-Free Survival; Female; Humans; Hysterectomy; Hysterectomy, Vaginal; Ligaments; Middle Aged; Reoperation; Retrospective Studies; Surgical Mesh; Treatment Outcome; Uterine Prolapse
PubMed: 34352830
DOI: 10.1097/AOG.0000000000004484 -
Obstetrics and Gynecology Feb 2020To characterize trends in self-reported numbers and routes of hysterectomy for obstetrics and gynecology residents using the Accreditation Council for Graduate Medical...
OBJECTIVE
To characterize trends in self-reported numbers and routes of hysterectomy for obstetrics and gynecology residents using the Accreditation Council for Graduate Medical Education (ACGME) case log database.
METHODS
Hysterectomy case log data for obstetrics and gynecology residents completing training between 2002-2003 and 2017-2018 were abstracted from the ACGME database. Total numbers of hysterectomies and modes of approach (abdominal, laparoscopic, and vaginal) were compared using bivariate statistics, and trends over time were analyzed using simple linear regression.
RESULTS
Hysterectomy data were collected from 18,982 obstetrics and gynecology residents in a median of 243 (interquartile range 241-246) ACGME-accredited programs. The number of graduating residents increased significantly over time (12.1/year, P<.001), whereas the number of residency programs decreased significantly (0.52 fewer programs per year, P<.001) over the 16-year period. For cases logged as "surgeon," the median number of abdominal hysterectomies decreased by 56.5% from 85 (interquartile range 69-102) to 37 (interquartile range 34-43) (P<.001). The median number of vaginal hysterectomies decreased by 35.5% from 31 (interquartile range 24-39) to 20 (interquartile range 17-25) (P=.002). The median total number of hysterectomies per resident decreased by 6.3% from 112 (interquartile range 97-132) to 105 (interquartile range 92-121) (P=.036). In contrast, the median number of laparoscopic hysterectomies increased by 115% from 20 (interquartile range 13-28) in 2008-2009 to 43 (interquartile range 32-56) in 2017-2018, despite the decrease in overall number of hysterectomies (P<.001). These trends were statistically significant.
CONCLUSIONS
The total number of hysterectomies performed by obstetrics and gynecology residents in the United States is decreasing, and the routes are changing with decreases in abdominal and vaginal approaches, and an increase in use of laparoscopic hysterectomy.
Topics: Accreditation; Clinical Competence; Education, Medical, Graduate; Female; Gynecology; Humans; Hysterectomy, Vaginal; Internship and Residency; Laparoscopy; Obstetrics; Pregnancy; Retrospective Studies; United States
PubMed: 31923067
DOI: 10.1097/AOG.0000000000003637 -
Female Pelvic Medicine & Reconstructive... Jun 2021Although guidelines recommend hysterectomy be performed vaginally whenever possible, recent trainees have decreased exposure to vaginal hysterectomy given the...
OBJECTIVE
Although guidelines recommend hysterectomy be performed vaginally whenever possible, recent trainees have decreased exposure to vaginal hysterectomy given the availability of laparoscopic hysterectomy, nonsurgical management, and falling volume nationwide. We sought to estimate hysterectomy volume in the 5 years after residency. Our secondary objective was to compare vaginal hysterectomy utilization between recent graduates and senior surgeons.
METHODS
Retrospective, statewide data from 2005 to 2014 was obtained from the Massachusetts Center for Health Information Analysis. All hysterectomies performed in Massachusetts, regardless of payer type, were included. Surgeon identifiers were cross-referenced to another data set with provider demographics. Hysterectomies performed in the first 5 years after graduation were compared with a group 21 to 25 years after residency.
RESULTS
Data from inpatient and outpatient databases revealed 87,846 hysterectomies performed by 1967 physicians, including 3146 simple hysterectomies by 192 recent graduates. Recent graduates chose abdominal hysterectomy (44.2%) most commonly, followed by laparoscopic (29.4%), vaginal (16.1%), and laparoscopically assisted vaginal (10.4%). Recent graduates performed a median of 3 to 4 hysterectomies in each of the first 5 years with no increase over time (P = 1). The median number of vaginal or laparoscopic hysterectomies was 0 in these 5 years (interquartile ranges, 0-1 and 0-2, respectively). Members of the senior cohort performed a median of 8 to 9 hysterectomies annually, completing them vaginally more often (24.7% vs 16.1%, P < 0.01). When controlling for patient age and hysterectomy indication, this effect dissipated.
CONCLUSIONS
Recent graduates perform 3 to 4 (interquartile range, 1-7) hysterectomies annually, predominantly by laparotomy. Although senior surgeons perform vaginal hysterectomy more often, this is explained by patient characteristics.
Topics: Adult; Cohort Studies; Female; Gynecology; Humans; Hysterectomy; Internship and Residency; Middle Aged; Obstetrics; Procedures and Techniques Utilization; Retrospective Studies
PubMed: 32371719
DOI: 10.1097/SPV.0000000000000879 -
JSLS : Journal of the Society of... 2023Despite guidelines that assert that the vaginal route for benign hysterectomy is preferred as the most minimally invasive approach, rates of vaginal hysterectomy remain... (Review)
Review
Despite guidelines that assert that the vaginal route for benign hysterectomy is preferred as the most minimally invasive approach, rates of vaginal hysterectomy remain very low in the United States. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) might reverse the trend. Potential advantages of vNOTES compared to traditional laparoscopic and robotic approaches include the potential for less pain, decreased operative time, improved cosmesis, and decreased risks. Importantly, vNOTES might allow for the conversion of laparoscopic and robotic routes back to vaginal due to surgeon factors.
Topics: Female; Humans; Vagina; Hysterectomy, Vaginal; Hysterectomy; Natural Orifice Endoscopic Surgery; Minimally Invasive Surgical Procedures; Laparoscopy
PubMed: 36818766
DOI: 10.4293/JSLS.2022.00082