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Obstetrics and Gynecology Jun 2024To compare inpatient hospital costs and complication rates within the 90-day global billing period among routes of hysterectomy.
OBJECTIVE
To compare inpatient hospital costs and complication rates within the 90-day global billing period among routes of hysterectomy.
METHODS
The Premier Healthcare Database was used to identify patients who underwent hysterectomy between 2000 and 2020. Current Procedural Terminology codes were used to group patients based on route of hysterectomy. Comorbidities and complications were identified using International Classification of Diseases codes. Fixed, variable, and total costs for inpatient care were compared. Fixed costs consist of costs that are set for the case, such as operating room time or surgeon costs. Variable costs include disposable and reusable items that are billed additionally. Total costs equal fixed and variable costs combined. Data were analyzed using analysis of variance, t test, and χ2 test, as appropriate. Factors independently associated with increased total costs were assessed using linear mixed effects models. Multivariate logistic regression was performed to evaluate associations between the route of surgery and complication rates.
RESULTS
A cohort of 400,977 patients were identified and grouped by route of hysterectomy. Vaginal hysterectomy demonstrated the lowest inpatient total cost ($6,524.00 [interquartile range $4,831.60, $8,785.70]), and robotic-assisted laparoscopic hysterectomy had the highest total cost ($9,386.80 [interquartile range $6,912.40, $12,506.90]). These differences persisted with fixed and variable costs. High-volume laparoscopic and robotic surgeons (more than 50 cases per year) had a decrease in the cost difference when compared with costs of vaginal hysterectomy. Abdominal hysterectomy had a higher rate of complications relative to vaginal hysterectomy (adjusted odds ratio [aOR] 1.52, 95% CI, 1.39-1.67), whereas laparoscopic (aOR 0.85, 95% CI, 0.80-0.89) and robotic-assisted (aOR 0.92, 95% CI, 0.84-1.00) hysterectomy had lower rates of complications compared with vaginal hysterectomy.
CONCLUSION
Robotic-assisted hysterectomy is associated with higher surgical costs compared with other approaches, even when accounting for surgeon volume. Complication rates are low for minimally invasive surgery, and it is unlikely that the robotic-assisted approach provides an appreciable improvement in perioperative outcomes.
PubMed: 38870524
DOI: 10.1097/AOG.0000000000005643 -
Alternative Therapies in Health and... Jun 2024Vaginal Intraepithelial Neoplasia (VaIN) is a prevalent condition that can progress to invasive carcinoma if left untreated. Despite its significance, effective...
BACKGROUND
Vaginal Intraepithelial Neoplasia (VaIN) is a prevalent condition that can progress to invasive carcinoma if left untreated. Despite its significance, effective treatments for VaIN remain limited.
OBJECTIVE
This study aimed to analyze the efficacy of Paiteling in treating VaIN among patients who have undergone total hysterectomy due to high cervical lesions or invasive cervical cancer.
DESIGN
This study employed a retrospective design.
SETTINGS
The study was conducted at Ningxia General Hospital of Medical University from January 2019 to January 2023.
PARTICIPANTS
A total of 67 cases diagnosed with VaIN were included in the study. Inclusion criteria comprised patients who had undergone total hysterectomy for high cervical lesions or invasive cervical cancer and had confirmed VaIN diagnosis through abnormal ThinPrep Cytology Test (TCT) and/or High-risk Human Papillomavirus (HR-HPV) results with colposcopy biopsy.
INTERVENTION
Patients were treated with Chinese patent medicines Paiteling and patulin according to their specific VaIN classification: VaIN1, VaIN2, and VaIN3.
PRIMARY OUTCOME MEASURES
The primary outcome measures included complete negative conversion rates for VaIN1, VaIN2, and VaIN3, as well as overall effective rate and complete negative rate across all VaIN cases. Statistical analysis was performed using IBM SPSS 24.0, with significance set at P < .05.
RESULTS
Patients with VaIN1, VaIN2, and VaIN3 were treated with Chinese patent medicines Paiteling, and patulin, respectively. Complete negative conversion rates were 100% for VaIN1, 72.73% for VaIN2, and 75.67% for VaIN3, resulting in an overall effective rate of 88.89% and a complete negative rate of 72.22% across all VaIN cases.
CONCLUSION
This study underscores the efficacy of Chinese patent medicine Paiteling in managing post-total hysterectomy VaIN. It presents a conservative treatment option for vaginal stump diseases, addressing a crucial gap in therapeutic strategies. The findings advocate for further exploration of Paiteling's potential in VaIN management.
PubMed: 38870504
DOI: No ID Found -
Experimental and Therapeutic Medicine Jul 2024The present study reports a rare case of an exaggerated placental site (EPS) in a caesarean scar that was misdiagnosed as gestational trophoblastic neoplasia (GTN) by...
The present study reports a rare case of an exaggerated placental site (EPS) in a caesarean scar that was misdiagnosed as gestational trophoblastic neoplasia (GTN) by imaging, resulting in unnecessary surgical treatment. A 38-year-old woman underwent hysteroscopic resection of a cesarean scar pregnancy (CSP). The patient's serum β-human chorionic gonadotropin (β-hCG) level was elevated (76,196 mIU/ml) at the 24-day postoperative follow-up visit. On postoperative day 51, the patient experienced vaginal bleeding for three days and β-hCG levels were 2,799 mIU/ml. Ultrasonography and MRI revealed a heterogeneous mass and hypervascularity. The patient was diagnosed with a GTN in a cesarean scar and treated with methotrexate (MTX). β-hCG levels decreased after 3 MTX doses, but the mass did not change in size and was still hypervascular on imaging. Total hysterectomy was performed due to the serious side effects of chemotherapy and the lack of desire to preserve fertility. The histological findings supported the diagnosis of an EPS reaction. The present case is unique because of the rare intrauterine mass and possibility of retained trophoblastic changes causing EPS. EPS differs from GTN both clinically and pathologically and should be considered a possible diagnosis in any woman who has irregular bleeding following CSP resection.
PubMed: 38868614
DOI: 10.3892/etm.2024.12587 -
European Journal of Obstetrics,... Jun 2024Vaginal hysterectomy (VH) is usually performed under general (GA) or regional anaesthesia. In recent years, the possibility of performing vaginal hysterectomy under...
INTRODUCTION
Vaginal hysterectomy (VH) is usually performed under general (GA) or regional anaesthesia. In recent years, the possibility of performing vaginal hysterectomy under local anaesthesia (LA) has also been explored. Our aim was to compare intraoperative and early postoperative outcomes in women who underwent VH under LA with intravenous sedation or GA.
METHODS
In this retrospective study, we collected data of patients who underwent VH at our department from June 2021 to December 2022. For every patient, the following data was obtained: hospitalisation duration, type of anaesthesia (LA or GA), accompanying procedures, the dosage of used local anaesthetic in the LA group, maximal pain score for each day of hospitalisation after the procedure, procedure duration, intraoperative blood loss, and postoperative complication rate. Data was analysed using the SPSS Statistics programme. Statistical significance was set at p < 0.05.
RESULTS
Seventy patients were included in the study. The mean age was significantly higher in the LA group compared to GA group (73.8 ± 8.0 years vs. 67.1 ± 9.3 respectively, p-value = 0.003). LA was associated with statistically lower pain scores in the first two days after the procedure (p = 0.003), and shorter procedure duration (p-value <0.001) as well as hospitalisation duration (p < 0.001). Furthermore, the cumulative dosage of different analgesics used during hospitalisation was higher in the GA group.
CONCLUSIONS
Our results show that LA is a feasible option for patients undergoing VH. Vaginal surgical procedures under LA could be especially beneficial for older patients with medical comorbidities in whom GA would be particularly hazardous.
PubMed: 38865739
DOI: 10.1016/j.ejogrb.2024.06.010 -
Journal of Family & Reproductive Health Mar 2024Aggressive Angiomyxoma (AA) of the vulva is a slow-growing mesenchymal tumour with a tendency to local invasion and recurrence.
OBJECTIVE
Aggressive Angiomyxoma (AA) of the vulva is a slow-growing mesenchymal tumour with a tendency to local invasion and recurrence.
CASE REPORT
We report two cases of vulvoperineal masses that were diagnosed to be Aggressive Angiomyxomas after surgical excision. Both patients presented to the Gynaecology OPD of All India Institute of Medical Sciences, Bathinda, Punjab, India, in 2020 and 2022 with complaints of a mass coming out of introitus of three years duration and 14 years duration, respectively. The first patient was managed by surgical excision of the mass via abdominoperineal approach, while the second patient underwent vaginal hysterectomy along with the removal of the mass. Both patients were given GnRH analogues after the surgery to avoid any further recurrences and have been in remission on follow-ups so far.
CONCLUSION
Due to its rare occurrence, clinicians should consider the possibility of AA while encountering patients with vulvovaginal masses to avoid misdiagnosis and delayed management.
PubMed: 38863840
DOI: 10.18502/jfrh.v18i1.15442 -
American Journal of Obstetrics and... Jun 2024Studies that have compared induction of labor in individuals with one prior cesarean delivery to expectant management have shown conflicting results.
BACKGROUND
Studies that have compared induction of labor in individuals with one prior cesarean delivery to expectant management have shown conflicting results.
OBJECTIVE
To determine the association between clinical outcomes and induction of labor at 39 weeks in a national sample of low-risk patients with one prior cesarean delivery.
STUDY DESIGN
This cross-sectional study analyzed 2016 to 2021 US Vital Statistics birth certificate data. Individuals with vertex, singleton pregnancies and one prior cesarean delivery were included. Patients with prior vaginal deliveries, delivery at 42 weeks and 6 days of gestation, and medical comorbidities were excluded. The primary exposure of interest was induction of labor at 39 weeks 0 days to 39 weeks 6 days compared to expectant management with delivery from 40 weeks 0 days to 42 weeks 6 days. The primary outcome was vaginal delivery. The main secondary outcomes were separate maternal and neonatal morbidity composites. The maternal morbidity composite included uterine rupture, operative vaginal delivery, peripartum hysterectomy, intensive care unit admission, and transfusion. The neonatal morbidity composite included neonatal intensive care unit admission, Apgar score less than 5 at 5 minutes, immediate ventilation, prolonged ventilation, and seizure or serious neurological dysfunction. Unadjusted and adjusted log binomial regression models accounting for demographic variables and the exposure of interest (induction versus expectant management) were performed. Results are presented as unadjusted (RR) and adjusted risk ratios (aRR) with 95% confidence intervals (CI).
RESULTS
From 2016 to 2021, a total of 198,797 individuals with vertex, singleton pregnancies and one prior cesarean were included in the primary analysis. Of these individuals, 25,915 (13.0%) underwent induction of labor from 39 weeks 0 days to 39 weeks 6 days and 172,882 (87.0%) were expectantly managed with deliveries between 40 weeks 0 days and 42 weeks 6 days. In adjusted analyses, patients induced at 39 weeks were more likely to have a vaginal delivery when compared to those expectantly managed (38.0% vs. 31.8%; aRR 1.32, 95% CI 1.28 to 1.36). Among those who had vaginal deliveries, induction of labor was associated with increased likelihood of operative vaginal delivery (11.1% vs. 10.0; aRR 1.15, 95% CI 1.07, 1.24). The maternal morbidity composite occurred in 0.9% of individuals in both the induction and expectant management groups (aRR 0.92, 95% CI 0.79, 1.06). The rates of uterine rupture (0.3%), peripartum hysterectomy (0.04% vs. 0.05%), and intensive care unit admission (0.1% vs. 0.2%) were all relatively low and did not differ significantly between groups. There was also no significant difference in the neonatal morbidity composite between the induction and expectant management groups (7.3% vs. 6.7%; aRR 1.04, 95% CI 0.98, 1.09).
CONCLUSIONS
When compared to expectant management, elective induction of labor at 39 weeks in low-risk patients with one prior cesarean delivery was associated with a significantly higher likelihood of vaginal delivery with no difference in composite maternal and neonatal morbidity outcomes. Prospective studies are needed to better elucidate the risks and benefits of induction of labor in this patient population.
PubMed: 38852849
DOI: 10.1016/j.ajog.2024.06.001 -
American Journal of Obstetrics &... Jun 2024Early identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and...
BACKGROUND
Early identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models.
OBJECTIVE
To develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower-risk laboring obstetric population.
STUDY DESIGN
This retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks' gestation) at 19 US hospitals (2016-2021) using data from 44,509 births at 11 hospitals to train a generalized additive model (GAM) and 21,183 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen.
RESULTS
The GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64-0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50-0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01, 41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40, 22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2-1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI; 1.4-1.6).
CONCLUSION
Our model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.
PubMed: 38851393
DOI: 10.1016/j.ajogmf.2024.101391 -
Asian Journal of Endoscopic Surgery Jul 2024The study aimed to compare the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS)... (Comparative Study)
Comparative Study
Comparison of transvaginal natural orifice transluminal endoscopic surgery versus conventional surgery for uterosacral ligament suspension in patients who had concomitant vaginal hysterectomy for subtotal uterine prolapse.
INTRODUCTION
The study aimed to compare the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS) versus nonendoscopic USLS in patients with subtotal uterine prolapse who had a concomitant vaginal hysterectomy.
METHODS
There were 51 patients who underwent vNOTES USLS, whereas the nonendoscopic conventional USLS group had 49 patients. The information about patient demographics, and perioperative data including the operative duration, blood loss, intraoperative and postoperative complications, and length of postoperative hospital stay were determined from the patients' files. Postoperative follow-up visits were scheduled at the first week and 1 month after surgery.
RESULTS
The demographic variables including age, body mass index, menopausal status, and parity were comparable, and no significant differences were found. A total of 90.2% of the patients in the vNOTES group and 69.4% of the patients in the shull group were at menopause (p = .09). Operation time was significantly shorter in the shull group (p < .001), and the hospitalization period (p = .029) was significantly shorter in the vNOTES group. Ba, Bp, and D points and total vaginal length (TVL) were significantly behind the hymenal ring in patients who had vNOTES USLS procedure (p < .001). None of the patients who had intraoperative significant blood loss required transfusion. One patient in the vNOTES and two patients in the shull group had a postoperative cuff hematoma.
CONCLUSION
vNOTES USLS has a good safety profile, higher percentage of adnexal surgeries with better improvement on POP-Q points Ba, Bp, D, and TVL compared with classic USLS in patients with subtotal uterine prolapse. Studies evaluating short- and long-term results of vNOTES versus conventional USLS are needed.
Topics: Humans; Female; Hysterectomy, Vaginal; Middle Aged; Natural Orifice Endoscopic Surgery; Uterine Prolapse; Ligaments; Aged; Treatment Outcome; Vagina; Operative Time; Retrospective Studies; Adult; Length of Stay; Postoperative Complications
PubMed: 38839273
DOI: 10.1111/ases.13333 -
Gynecologic Oncology Reports Aug 2024Patients with advanced stage ovarian cancers commonly undergo hyperthermic intraperitoneal chemotherapy (HIPEC) following interval debulking via exploratory laparotomy....
Patients with advanced stage ovarian cancers commonly undergo hyperthermic intraperitoneal chemotherapy (HIPEC) following interval debulking via exploratory laparotomy. This video demonstrates the feasibility of HIPEC delivery via a minimally invasive approach with the use of a vaginal GelPoint® port. This video demonstrates a 56-year-old patient with Stage 3 bilateral fallopian tube cancer who underwent 3 cycles of neoadjuvant chemotherapy with cisplatin and paclitaxel. Prior to administration of HIPEC the patient underwent an uncomplicated robotic assisted radical hysterectomy, bilateral salpingo-oopherectomy and infracolic omentectomy. Additionally, the falciform ligament was transected. The vaginal cuff was then used for placement of the GelPoint® port. The inflow and outflow cannulas were placed at the level of the liver and pelvis robotically. To minimize risk of inadvertent spillage, robotic obturators were replaced. Prior to administration of HIPEC, 4 L of warm saline was administered. An additional safety check was performed with no areas of leak. Cisplatin was administered for 90 min followed by sodium thiosulfate and 3 L of normal saline. Confirmation of no residual fluid was noted laparoscopically. The patient was discharged 2 days postoperatively without postoperative complications. In this video we demonstrated the innovative technique of performing HIPEC via a minimally invasive approach, that typically requires an open procedure. With the use of a vaginal Gelpoint® we were able to safely administer intraperitoneal chemotherapy without risk to our patient. We were also able to minimize their length of hospital stay and expedite postoperative recovery. Further implementation of this technique may improve hospital resource allocation.
PubMed: 38831999
DOI: 10.1016/j.gore.2024.101400 -
Clinical Case Reports Jun 2024Vaginal cuff dehiscence post-hysterectomy is rare yet significant. Early recognition and prompt surgical intervention are crucial to prevent complications like bowel...
KEY CLINICAL MESSAGE
Vaginal cuff dehiscence post-hysterectomy is rare yet significant. Early recognition and prompt surgical intervention are crucial to prevent complications like bowel infarction. Consider second-look laparotomy in cases of uncertain bowel viability.
ABSTRACT
Vaginal cuff dehiscence (VCD) is a rare but potentially life-threatening complication following a hysterectomy characterized by the separation of the vaginal vault. This condition, which may result in vaginal evisceration (VE), presents a significant risk of pelvic contents, particularly the small bowel, protruding into the vagina. Early diagnosis and prompt surgical intervention are paramount to prevent severe complications, including bowel infarction, obstruction, and peritonitis. Although VCD and VE are rare, they require urgent surgical management to avoid adverse outcomes. We reported a case of small bowel evisceration in a woman with a history of total abdominal hysterectomy 6 months ago. VCD and VE are very rare but life-threatening complications of hysterectomy. Discussing the symptoms with patients who have multiple risk factors is crucial to avoid severe sequels following hysterectomy. Based on our experience, performing a second-look laparotomy is a reliable approach to ensure the viability of the intestinal loop. However, it will likely increase the risk of infection.
PubMed: 38827941
DOI: 10.1002/ccr3.8910