Surgical Trends and Time Frame Comparison of Surgical Types of Hysterectomy: A Nationwide,Population-based 15-year Study

Study ObjectiveTo investigate the surgical trends among different types of hysterectomy (abdominal, vaginal, laparoscopic, and subtotal) over a 15-year period in Taiwan.DesignA retrospective cohort study.SettingA population-based National Health Insurance Research Database.PatientsWomen undergoing various types of hysterectomy for noncancerous lesions.InterventionsData for this study were extracted from the inpatient expenditures by admissions files of Taiwan's National Health Insurance Research Database from 1998 through 2012 and divided into three 5-year time frames: first (1998–2002), second (2003–2007), and third (2008–2012). The variables included types of hysterectomy, patient age, gynecologist age and sex, hospital accreditation level, and surgical volume. Chi-square and trend tests were used to examine the association between the variables.Measurements and Main ResultsA total of 329 438 patients who underwent various types of hysterectomy were identified; 306 257 were included in the study. During the 15-year period, 45% underwent total abdominal hysterectomy, 41% underwent laparoscopic hysterectomy (LH), 9.8% underwent vaginal hysterectomy, and 4.2% underwent subtotal abdominal hysterectomy. The frequency of LHs increased from 35.9% in the first period to 43.9% in the second period and remained at 44.2% in the third period. During the same time period, there was a decrease in the frequency of total abdominal hysterectomies. Typically, younger patients underwent LHs by gynecologists with large volume surgical practices and medical centers.ConclusionThis 15-year study describes an increase of LHs and subtotal abdominal hysterectomies over time and provides evidence of surgical trends and a paradigm shift of hysterectomies. Surgical skills and performance extended from high- to low-surgical volume gynecologists and from medical centers to regional and local hospitals. This shift may have a great influence on patient and health care provider choice of treatment.     

Trends in Various Types of Surgery for Hysterectomy and Distribution by Patient Age,Surgeon Age,and Hospital Accreditation: 10-Year Population-Based Study in Taiwan

Study ObjectiveTo estimate the trends in various types of hysterectomy (abdominal, vaginal, laparoscopic, and subtotal) and their distribution according to patient age, surgeon age, and hospital accreditation in Taiwan.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingPopulation-based National Health Insurance (NHI) database.PatientsWomen with NHI in Taiwan undergoing various types of hysterectomy to treat noncancerous lesions.InterventionsData for this study were obtained from the Inpatient Expenditures by Admissions files of the NHI research database, released by the NHI program in Taiwan for 1996–2005.Measurements and Main ResultsA total of 234 939 women who underwent various types of hysterectomy were identified for analysis. The number of hysterectomies performed annually remained stationary during the 10-year study. Total abdominal hysterectomies decreased significantly (77.33% in 1996 vs 45.68% in 2005), laparoscopic hysterectomies increased significantly (5.20% vs 40.40%), vaginal hysterectomies decreased (14.70% vs 8.86%), and subtotal abdominal hysterectomies increased (2.76% vs 5.06%). Laparoscopic hysterectomy was more commonly performed in middle-aged women; vaginal hysterectomy was more common in older women; and subtotal abdominal hysterectomy was more common in younger women. Laparoscopic hysterectomy was performed more commonly in regional hospitals (33.11%), followed by medical centers (30.17%) and local hospitals (17.78%). Laparoscopic hysterectomy was performed more commonly in not-for-profit hospitals (30.25%), followed by private hospitals (29.32%) and government-owned hospitals (25.91%).ConclusionThere has been considerable change in the types of surgery used for hysterectomy in Taiwan over the past 10 years. As a minimally invasive approach, laparoscopic hysterectomy represents a profound change for both patients and surgeons.     

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at the Time of Uterosacral Ligament Suspension

Study ObjectiveThe objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension.DesignRetrospective propensity-score matched cohort study.SettingAmerican College of Surgeons National Surgical Quality Improvement Program database.PatientsWe included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy.InterventionsWe compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort.Measurements and Main ResultsThe study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3–2.8; p <.01) and a higher serious complication rate (5.6% vs 3.1%, OR 1.8, 1.1–3.1; p = .02), which excluded urinary tract infection and superficial surgical site infection. The propensity score analysis was performed, and patients were matched in a 1:1 ratio between the TVH-USLS group and the TLH-USLS group. In the matched cohort, patients who underwent TVH-USLS had a higher composite complication rate than those who underwent TLH-USLS (10.3% vs 6.4%, OR 1.7, 95% confidence interval [CI], 1.1–2.7; p = .04), whereas the rate of serious complications did not differ between the groups (4.3% vs 3.1%, OR 1.4, 95% CI, 0.7–2.8; p = .4). On multivariate logistic regression, TVH-USLS remained an independent predictor of composite complications (adjusted OR 1.6, 95% CI, 1.0–2.6; p = .04) but not serious complications (adjusted OR 1.4, 95% CI, 0.7–2.8; p = .3).ConclusionIn this large national cohort, TVH-USLS was associated with a higher composite complication rate than TLH-USLS, largely secondary to an increased rate of urinary tract infection. After matching, the groups had similar rates of serious complications. These data suggest that TLH-USLS should be viewed as a safe alternative to TVH-USLS.     

Mortality Rates in Benign Laparoscopic and Robotic Gynecologic Surgery: A Systematic Review and Meta-analysis

ObjectiveTo review mortality rates in benign gynecologic minimally invasive laparoscopic and robotic surgery (MIS) and the rates associated with commonly performed MIS procedures.Data SourcesAn electronic-based search was performed on PubMed, Embase, Scopus, Web of Science, and Cochrane Database for articles published in the last 10 years in English, French, German, Spanish, and Italian.Methods of Study SelectionAll MIS articles in benign gynecology reporting operative mortality (within 30 days) were reviewed.Tabulation, Integration, and ResultsThe articles identified through the aforementioned search criteria were independently evaluated by the first 2 authors. The Newcastle-Ottawa scale for observational studies and Cochrane risk-of-bias assessment tool for randomized controlled trials were used to assess the risk of bias. Meta-analysis was applied to calculate pooled mortality rates using the inverse-variance method. Twenty-one articles (124 216 patients) were included. Operative mortality from any benign MIS (laparoscopy and robotics) procedure was 1:6456 (95% confidence interval [CI]: 1:3946–1:10 562). Studies were then grouped based on the surgical procedure. The mortality rate for hysterectomy (119 721 patients), sacrocolpopexy, and adnexal surgery and diagnostic laparoscopy was 1:6814 (95% CI: 1:4119–1:11 275), 1:1246 (95% CI: 1:36–1:44 700), and 1:2245 (95% CI: 1:45–1:113 372), respectively. Eighteen articles reported operative mortality for laparoscopic surgery and 4 for robotic surgery.ConclusionOperative mortality in benign minimally invasive gynecologic surgery is low, and mortality for laparoscopic and robotic approaches appears to be similar.     

Total or subtotal hysterectomy?

We compared the risk and benefits subtotal (supracervical) hysterectomy and total hysterectomy in women with nonmalignant conditions (perioperative mortality, intra- and postoperative complications, quality of life, long-term effects on other diseases). The main disadvantage of subtotal hysterectomy over total one is the fact, that in 1 per 1000 women develops carcinoma in cervical stump. CONCLUSION: Total hysterectomy is recommended in benign conditions of the uterine corpus.     

Assessing the Impact of Vaginal Hysterectomy with Vaginal Mesh Attachment on Outcomes and Complications during Minimally Invasive Sacrocolpopexy

Study ObjectiveTo compare mesh complications and failure rates after 1 year in laparoscopic minimally invasive sacrocolpopexy (MISC) with ultralightweight mesh attached vaginally during total vaginal hysterectomy (TVH), laparoscopically if posthysterectomy (PH), or laparoscopically during supracervical hysterectomy.DesignSingle-center retrospective cohort study.SettingTertiary referral center.PatientsWomen with symptomatic pelvic organ prolapse who elected for MISC.InterventionsLaparoscopic MISC with ultralightweight mesh attached vaginally during TVH, laparoscopically if PH, or laparoscopically during supracervical hysterectomy. Composite failure was defined as recurrent prolapse symptoms, prolapse past the hymen, or retreatment for prolapse.Measurements and Main ResultsBetween 2010 and 2017, 650 patients met the inclusion criteria with 278 PH, 82 supracervical hysterectomy, and 290 vaginal hysterectomy patients. Median follow-up was similar for all groups (382 days vs 379 vs 345; p = .31). The majority in all groups were white (66.6%), nonsmokers (74.8%), postmenopausal (82.5%), and did not use estrogen (70.3%). Mesh complications did not differ among groups (1.6% PH, 2.5% supracervical hysterectomy, 2.2% vaginal hysterectomy; p >.99). There was no difference in anatomic failure (5% PH, 1.2% supracervical hysterectomy, 2.1% vaginal hysterectomy; p = .07), reoperation for prolapse (1.4% vs 1.2% vs 0.7%; p = .57), or composite failure (9.0% vs 3.7% vs 4.8%; p = .07).ConclusionsTVH with vaginal mesh attachment of ultralightweight mesh had similar adverse events, mesh exposure rates, and failure rates to those of laparoscopic PH sacrocolpopexy or supracervical hysterectomy with laparoscopic mesh attachment.     

Does mode of hysterectomy influence micturition and defecation?

OBJECTIVE: Hysterectomy may affect bladder and bowel function. A retrospective study was performed to compare the prevalence of micturition and defecation symptoms between different modes of hysterectomy. METHODS: All pre-operatively asymptomatic patients, with uteral size < or =10 cm, who underwent hysterectomy between 1988 and 1997 were interviewed about the prevalence of micturition and defecation symptoms and the experienced physical and emotional limitations of these symptoms. Using logistic regression analysis, odds ratios (OR) were calculated for all symptoms of which the prevalence between modes of hysterectomy differed more than 10%. These odds ratios were adjusted for differences in other prognostic factors. RESULTS: Vaginal hysterectomy was performed on 68 patients, total abdominal hysterectomy on 109 patients and subtotal abdominal hysterectomy on 50 patients. An increased prevalence of urge incontinence (adjusted OR 1.5 (95% CI 0.8-3.1)) and feeling of incomplete evacuation (adjusted OR 1.9 (95% CI 1.0-4.0)) was observed among patients who had undergone vaginal hysterectomy as compared to patients who had undergone total abdominal hysterectomy. The prevalence of urge incontinence (adjusted OR 1.8 (95% CI 0.8-4.2)) and difficulty emptying the rectum (adjusted OR 1.8 (95% CI 0.7-4.4)) was higher among patients who had undergone vaginal hysterectomy than among patients who had undergone subtotal abdominal hysterectomy. Statistically significant odds ratios were not observed. Relevant differences in physical and emotional limitations related to micturition and defecation symptoms were not observed between groups. CONCLUSION: Our results suggest that technique of hysterectomy may influence the prevalence of micturition and defecation symptoms following hysterectomy.     

Vesicoureteral Injury during Benign Hysterectomy: Minimally Invasive Laparoscopic Surgery versus Laparotomy

Study ObjectiveThe findings of previous studies have been inconsistent as to whether benign hysterectomy via minimally invasive laparoscopic surgery increases the risk of vesicoureteral injury when compared with laparotomy. The objectives of our study were to (1) examine the rate of vesicoureteral injury on benign hysterectomy by the surgical approach and (2) compare the risk of vesicoureteral injury specifically between minimally invasive laparoscopic and abdominal hysterectomy on a populational level.DesignRetrospective population-based observational study.SettingThe National Inpatient Sample.PatientsA total of 501 110 women who had undergone hysterectomy for benign gynecologic disease between January 2012 and September 2015 were included as follows: total abdominal hysterectomy (TAH, n = 284 365 [56.7%]), total laparoscopic hysterectomy (TLH, n = 60 410 [12.1%]), abdominal supracervical hysterectomy (Abd-SCH, n = 55 655 [11.1%]), laparoscopic-assisted vaginal hysterectomy (LAVH, n = 45 620 [9.1%]), total vaginal hysterectomy (TVH, n = 34 865 [7.0%]), and laparoscopic supracervical hysterectomy (LSC-SCH, n = 20 195 [4.0%]).InterventionsA comprehensive risk assessment for vesicoureteral injury by hysterectomy mode was performed, adjusting for patient demographics and gynecologic disease types. Propensity score inverse probability of treatment weighing was used to compare (1) TLH versus TAH and (2) LSC-SCH versus Abd-SCH with generalized estimating equations. In a sensitivity analysis, gynecologic disease−specific injury risk and vaginal route−specific injury risk (LAVH vs TVH) were assessed.Measurements and Main ResultsVesicoureteral injury was reported in 1045 (0.21%) women overall. LAVH (0.28%) had the highest bladder injury rate, whereas LSC-SCH had the lowest (0.10%) (p <.001). TLH (0.13%) had the highest ureteral injury rate, whereas TAH had the lowest (0.04%) (p <.001). In propensity score inverse probability of treatment weighing models, compared with TAH, TLH was associated with an increased risk of ureteral injury (odds ratio [OR] 3.95, 95% confidence interval [CI] 2.03−7.67, p <.001) but not bladder injury (OR 1.04, 95% CI 0.57−1.90, p = .897). Risk of ureteral injury was particularly high when TLH was performed for endometriosis (OR 6.15, 95% CI 1.18−31.9, p = .031) or for uterine myoma (OR 4.15, 95% CI 2.13−8.11, p <.001). In contrast, for supracervical or vaginal hysterectomy, minimally invasive laparoscopic approaches were not associated with an increased risk of vesicoureteral injury (LSC-SCH vs Abd-SCH: OR 0.62, 95% CI 0.19−1.98, p = .419; LAVH vs TVH: OR 1.21, 95% CI 0.63−2.33, p = .564).ConclusionThe risk of vesicoureteral injury on benign hysterectomy is low overall regardless of hysterotomy modalities but varies widely with the surgical approach. Compared with TAH, TLH may be associated with an increased risk of ureteral injury.     

Feasibility of Oophorectomy at the Time of Vaginal Hysterectomy in Patients with Pelvic Organ Prolapse

Study ObjectiveTo determine the feasibility of oophorectomy at the time of vaginal hysterectomy in patients with pelvic organ prolapse and to define prognostic factors and perioperative morbidity associated with the procedure.DesignA retrospective cohort study (Canadian Task Force classification II-2).SettingAn academic medical center.PatientsAll women who underwent total vaginal hysterectomy for the treatment of pelvic organ prolapse over 5 years were considered for inclusion in the study.InterventionsTotal vaginal hysterectomy and concomitant pelvic organ prolapse repair with or without oophorectomy.Measurements and Main ResultsA total of 289 women underwent total vaginal hysterectomy with pelvic organ prolapse repair. Vaginal oophorectomy was attempted in 179 patients (61.9%). The procedure was successful in 150 patients (83.8%; 95% confidence interval [CI], 77.6%–88.9%). High ovarian location was the most commonly cited reason for the inability to perform a planned unilateral/bilateral oophorectomy (n = 24, 82.7%). Attempting oophorectomy vaginally was associated with an increased duration of surgery by 7.3 minutes (p = .03), an increased change in hemoglobin by 0.2 g/dL (p = .02), and a higher rate of readmission (7.3% vs 1.8%, p = .04). Multiple logistic regression showed that increasing age (odds ratio = 1.12; 95% CI, 1.05–1.20; p <.001) and body mass index (odds ratio = 1.17; 95% CI, 1.07–1.27; p<.001) were associated with an increased risk of vaginal oophorectomy failure. On univariate analysis, race (p = .64), parity (p = .39), uterine weight (p = .91), need for uterine morcellation (p=.21), presence of endometriosis (p=.66), prior cesarean section (p=.63), prior laparoscopy (p=.37), and prior open abdominal/pelvic surgery (p = .28) did not impact the likelihood of successfully performing oophorectomy.ConclusionIn patients with pelvic organ prolapse, a planned oophorectomy at the time of vaginal hysterectomy can be successfully performed in the majority of cases. Greater age and body mass index are associated with an increased likelihood of failure.     

Intrafascial abdominal hysterectomy: outcomes and complications of 867 operations.

OBJECTIVE: To prospectively evaluate the results and complications of the surgical technique of intrafascial abdominal hysterectomy. METHODS: From March 1993 to February 1998, 867 women at four institutions from the Department of Valle del Cauca, Colombia, underwent intrafascial abdominal hysterectomy. Information on sociodemographic and clinical characteristics before hysterectomy, indications for hysterectomy, surgical outcomes and intra- and post-operative complications were collected. Patients were evaluated at 1, 3, and 12 months post-operatively and annually thereafter. RESULTS: The follow-up period ranged from 6 to 63 months (median=45 months). The mean blood loss was 286+/-112 ml. Operative time averaged 71+/-11 min. The overall operative site infection rate was 4%. Intra- and post-operative hemorrhage occurred in 0.2 and 1.0% of patients, respectively. The transfusion rate was 0.7%. The incidences of ureteral, bladder, and bowel injury were 0.1, 0.4 and 0.0%, respectively. To date, none of the patients followed up between 1 and 5 years have had evidence of vaginal vault prolapse. CONCLUSIONS: Intrafascial abdominal hysterectomy is a safe technique with a low rate of complications.     

Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database

Study ObjectiveThe objective of this study was to describe perioperative outcomes of minimally invasive sacrocolpopexy (MISCP) based on 4 different routes of concurrent hysterectomy: vaginal (VH), laparoscopic-assisted (LAVH), laparoscopic supracervical (LSCH), and total laparoscopic (TLH).DesignThis was a retrospective cohort study. A secondary analysis of the 2006–2015 National Surgical Quality Improvement Program (NSQIP) database was performed analyzing women who underwent concurrent hysterectomy with MISCP based on Current Procedural Terminology (CPT) codes. We excluded open abdominal hysterectomies. We compared outcomes between VH, LAVH, LSCH, and TLH including operative time, length of hospital stay, a composite outcome of 30-day postoperative adverse events, readmission, or reoperation. A logistic regression model was used to correct for pre-identified potential confounding variables. A minimum detectable effect analysis was planned.SettingHospitals participating in the NSQIP program.PatientsWomen who underwent hysterectomy with MISCP.InterventionsNot applicable.Measurement and Main ResultsA total of 524 women underwent hysterectomy with MISCP including VH in 31 (5.9%), LAVH in 40 (7.6%), LSCH in 322 (61.5%), and TLH in 131 (25%). The VH group had a higher incidence of ≥4 concurrent CPT codes (71% vs 27% in other groups, p = .03). Operative times differed significantly between groups (p < .01): TLH had the shortest operating time (171.43 ± 83.77 minutes). There were no significant differences in length of hospital stay, rate of reoperation, 30-day readmission, or the composite outcome (p = .8). Route of hysterectomy was not associated with increased composite outcome on adjustment for confounders (adjusted odds ratio [OR] 1.1, 95% CI 0.3–3.99, p = .88). A minimum detectable effect analysis indicated that this study population had 80% power to detect an OR of 5.07 or greater between the different routes of hysterectomy during concomitant MISCP for the composite 30-day outcome.ConclusionRegardless of route of concurrent hysterectomy, MISCP is associated with low rates of 30-day complications, reoperation, and readmission.     

Changing Practice From Laparoscopic Supracervical Hysterectomy to Total Hysterectomy

ObjectiveTo compare morbidity and mortality related to laparoscopic supracervical hysterectomy (LASH) and laparoscopic total hysterectomy (LTH).MethodsWe reviewed the medical records of 227 patients who underwent laparoscopic hysterectomy for benign gynaecological diseases between January 2004 and March 2008. Before January 2006, we performed mainly LASH (n: 122), and from January 2006 we performed LTH (n: 105). We reviewed and compared operating times, requirement for narcotics, duration of hospital stay, and complications of the two procedures.ResultsThe mean age of the patients in the LASH group was 45.7 ± 0.6 years, and in the LTH group was 45.9 ± 0.7 years. Patients in each group were comparable in mean body mass index and preoperative hemoglobin concentration. There were no differences in the duration of hospital stay or mean postoperative hemoglobin concentration. Patients in the LASH group had a shorter mean operating time than the LTH group (111.0 ± 2.9 vs. 136 ± 3.6 minutes; 95% CI 16–33, P < 0.001), but the patients in the LASH group required a greater mean dose of narcotic than those in the LTH group (28.0 ± 2.9 mg of morphine or morphine equivalent vs. 37.5 ± 3.4 mg; 95% CI 1.5–10.5, P = 0.02). There was no difference between the two groups in the incidence of major and minor complications. However, five patients in the LASH group required a repeat operation, but none of the LTH group did.ConclusionLaparoscopic total hysterectomy is associated with a longer operating time than laparoscopic supracervical hysterectomy, but with less need for postoperative narcotics.     

Laparoendoscopic single-site (LESS) surgery in gynecology: Current status and future directions

BackgroundThe shift from open surgery to operative laparoscopy brought on one of the greatest transformations in the history of surgery. Advancements in surgical instruments, optics, and ports have allowed the development of single port laparoscopy, or laparoendoscopic single-site surgery (LESS).ResultsLESS can be used for salpingostomy or salpingectomy to treat tubal ectopic pregnancy. ESS could be used to treat benign and malignant adnexal disease, and for hysterectomy. For adnexal disease, LESS can be used to remove ovarian cysts, salpingo-oophorectomy, to remove endometriosis, and remove malignant masses. Single-port access subtotal hysterectomy is more commonly used now, with various advancements in place to overcome the limited free movement and technical difficulty. Robotic LESS has been used in gynecology for bilateral salpingo-oophorectomy and total hysterectomy.ConclusionsThe use of LESS in gynecologic surgery is expanding. It has the advantages of reduced postoperative pain, earlier return to daily activities, reduced incidence of port-site hernias and hemorrhage, and improved cosmesis and patient satisfaction.     

Learning curve and surgical outcome for robotic-assisted hysterectomy with lymphadenectomy: case-matched controlled comparison with laparoscopy and laparotomy for treatment of endometrial cancer

Study ObjectiveTo determine the learning curve for robotic-assisted hysterectomy with lymphadenectomy for surgical treatment of endometrial cancer.DesignAn analysis of robotic-assisted hysterectomy with lymphadenectomy vs total laparoscopic hysterectomy with lymphadenectomy and laparotomy with total abdominal hysterectomy with lymphadenectomy (Canadian Task Force classification II-1).SettingSolo, experienced, minimally invasive gynecologic oncology practice in a tertiary hospital.PatientsOne hundred forty-eight patients including 56 patients who underwent robotic-assisted hysterectomy with bilateral pelvic and paraaortic lymph node dissection, 56 patients who underwent total laparoscopic hysterectomy with bilateral pelvic and paraaortic lymph node dissection, and 36 patients who underwent traditional total abdominal hysterectomy with bilateral pelvic and paraaortic lymph node dissection performed by the same surgeon for treatment of endometrial cancer.InterventionsRobotic-assisted hysterectomy with bilateral lymphadenectomy, total laparoscopic hysterectomy with bilateral lymphadenectomy, and traditional total abdominal hysterectomy with bilateral lymphadenectomy were performed. Data were categorized by chronologic order of cases into groups of 20 patients each. The learning curve of the surgical procedure was estimated by measuring operative time with respect to chronologic order of each patient who had undergone the respective procedure.Measurements and Main ResultsFor the 3 surgical procedures, data analyzed included mean age, body mass index, operative time, blood loss, lymph node retrieval, and complications. Mean (SD); 95% confidence interval [CI]) operative time for the 3 procedures was statistically significant: 162.5 (53) minutes (95% CI, 148.6–176.4]), 192.3 (55.5) minutes (95% CI, 177.6–207.0), and 136.9 (32.3) minutes (95% CI, 126.3–147.5), respectively. Analysis of operative time for robotic-assisted hysterectomy with bilateral lymph node dissection with respect to chronologic order of each group of 20 cases demonstrated a decrease in operative time: 183.2 (69) minutes (95% CI; 153.0–213.4) for cases 1 to 20, 152.7 (39.8) minutes (95% CI, 135.3–170.1) for cases 21 to 40, and 148.8 (36.7) minutes (95% CI, 130.8–166.8) for cases 41 to 56. For the groups with laparoscopic hysterectomy with lymphadenectomy and traditional total abdominal hysterectomy with lymphadenectomy, there was no difference in operative time with respect to chronologic group order of cases. There was a difference between the number of lymph nodes retrieved between robotic-assisted hysterectomy with bilateral lymphadenectomy (26.7 [12.8]; 95% CI, 23.3–30.1) compared with laparoscopic hysterectomy with bilateral lymphadenectomy (45.1 [20.9]; 95% CI, 39.6–50.6) and traditional total abdominal hysterectomy with lymphadenectomy (55.8 [23.4]; 95% CI, 48.2–63.4). The rate of intraoperative complications for laparoscopic hysterectomy with bilateral lymphadenectomy was 12.5% (7 of 56) compared with 0 % for robotic-assisted hysterectomy with bilateral lymphadenectomy. The rate of postoperative complications was 14.3% (8 of 56), 21.4% (12 of 56), and 19.4% (7 of 36), respectively, for the 3 groups. There was less blood loss with robotic-assisted hysterectomy with bilateral lymphadenectomy (89.3 [45.4]; 95% CI, 77.4–101.2) compared with laparoscopic hysterectomy with bilateral lymphadenectomy (209.1 [91.8]; 95% CI, 185.1–233.1) and traditional total abdominal hysterectomy with lymphadenectomy (266.0 [145.1]; 95% CI, 218.6–313.4). Duration of hospitalization was shorter in the group with robotic-assisted hysterectomy with bilateral lymphadenectomy (1.6 [0.7]; 95% CI, 1.4–1.8) compared with the groups who underwent laparoscopic hysterectomy with bilateral lymphadenectomy (2.6 [0.9]; 95% CI, 2.4–2.8) or traditional total abdominal hysterectomy with lymphadenectomy (4.9 [1.9]; 95% CI, (4.3–5.5).ConclusionThe learning curve for robotic-assisted hysterectomy with lymph node dissection seems to be easier compared with that for laparoscopic hysterectomy with lymph node dissection for surgical management of endometrial cancer.     

妇科良性疾病全子宫切除术副损伤的临床分析

目的 探讨因妇科良性疾病行全子宫切除术中副损伤发生的原因及处理。方法 回顾性分析1981年1月1日～2000年12月31日期间我院妇科3557例全子宫切除术中11例副损伤的发生及治疗情况。结果 子宫全切术副损伤的发生率经腹为0.28％(9/3268),经阴道为0.7％(2/289)。包括膀胱损伤7例,直肠损伤2例,输尿管损伤2例。发生副损伤的病例多见于子宫前壁峡部大肌瘤、剖宫产手术史、重度子宫内膜异位症和经阴道子宫全切的手术中。8例于术中发现同时行修补术;痊愈时间平均16.5 d;3例术后发现经再次手术,痊愈时间分别为45 d、50 d和10个月。结论副损伤是子宫全切术的并发症,与手术难度有关,及时发现和修补损伤极为重要。     

A Comparison of Quality Outcome Measures in Patients Having a Hysterectomy for Benign Disease: Robotic vs. Non-robotic Approaches

Study ObjectiveTo measure procedure-related hospital readmissions within 30 days after discharge for patients who have a hysterectomy for benign disease. Secondary outcome quality measures evaluated were cost, estimated blood loss, length of stay and sum of costs associated with readmissions.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingAcademic community hospital.PatientsPatients who underwent hysterectomy to treat benign disease from January 2008 to December 2012.InterventionsPatients were grouped according to route of hysterectomy: robotic-assisted laparoscopic hysterectomy (robotic), laparoscopic hysterectomy (laparoscopic), abdominal hysterectomy (open via laparotomy), and vaginal hysterectomy (vaginal).Measurements and Main ResultsInclusion criteria were met by 2554 patients: 601 in the robotic group, 427 in the laparoscopic group, 1194 in the abdominal group, and 332 in the vaginal group. Readmission rates in the robotic cohort were significantly less (p<.05) than in non-robotic cohorts: Robotic (1%), laparoscopic (2.5%), open (3.5%), vaginal (2.4%). Estimated blood loss, length of stay, and sum of readmission costs were also significantly less in the robotic cohort (p<.05) compared with the other 3 cohorts.ConclusionPatients who undergo robotic-assisted laparoscopic hysterectomy have a significantly lower chance of readmission <30 days after surgery compared with those who undergo laparoscopic, abdominal (open) hysterectomy, and vaginal approaches. Patients in the robotics cohort also experienced a shorter length of stay, less estimated blood loss, and a cost savings associated with readmissions when compared to non-robotic approaches. Prospective registries describing quality outcomes, total sum of costs including 30 days follow-up, as well as patient-related quality of life benefits are recommended to confirm these findings and determine which surgical route offers the highest patient and societal value.     

Occult Uterine Malignancy at the Time of Sacrocolpopexy in the Context of the Safety Communication on Power Morcellation by the FDA

Study ObjectiveThe objective of this study was to determine the incidence of occult uterine malignancy at the time of sacrocolpopexy with concurrent hysterectomy, in the context of practice pattern changes as a result of the 2014 Food and Drug Administration (FDA) power morcellation safety communication.DesignRetrospective chart review.SettingTertiary care referral center in the United States.PatientsA total of 839 patients who underwent sacrocolpopexy from January 2004 to December 2018.InterventionsAll patients received a concurrent hysterectomy without a diagnosis of suspected or confirmed gynecologic malignancy before surgery. Trends of surgeries were compared before and after the 2014 FDA power morcellation safety communication.Measurements and Main ResultsDemographic and perioperative data were collected from the system-wide electronic medical record. Operative and pathology reports were reviewed to determine the method of specimen retrieval and specimen pathology results. A total of 238 patients (28.4%) had a hysterectomy at the time of sacrocolpopexy. There were no cases of occult uterine malignancy (0%, 95% CI 0%–1.6%). There was 1 case of borderline tumor of the ovary. The most common mode of hysterectomy over the 15-year period was laparoscopic hysterectomy (n = 84, 35.3%), followed by vaginal hysterectomy (n = 63, 26.5%). After the FDA communication, the most common form of hysterectomy changed significantly to vaginal hysterectomy (n = 35, 55.6%; p <.001). When comparing the first 2 years after the announcement (2014–2016) to the subsequent 2 years (2017–2018), there was again a significant increase in the use of laparoscopic hysterectomy in the latter time period (7.3% vs 40.9%; p <.001).ConclusionIn this cohort of patients undergoing sacrocolpopexy with concurrent hysterectomy, the incidence of occult uterine malignancy was low. After the FDA safety communication, practice patterns with regard to the mode of hysterectomy changed, but the magnitude of these changes were transient.     

Peripartum hysterectomy in a teaching hospital in the eastern region of Turkey

OBJECTIVES: The aim of this study was to find the incidence and clinical implications of peripartum hysterectomy in our hospital at the Eastern region of Anatolia. STUDY DESIGN: We analyzed retrospectively all cases of peripartum hysterectomy performed at YYU Medical Faculty Hospital between January 1995 and April 2003. Emergency peripartum hysterectomy was performed for hemorrhage which cannot be controlled with other conventional treatments within 24h of a delivery. There were 24 cases of emergency peripartum hysterectomy performed. RESULTS: The incidence of emergency peripartum hysterectomy was 5.09 per 1000 deliveries. Half of the hysterectomies followed cesarean section. Eleven patients were referred to our clinics from other hospitals. Uterine atony (45.8%) was the most common indication and placenta accreta (25.0%) was the second most common. Eighteen patients (75%) had subtotal hysterectomy. Bladder injury was seen in three cases. Re-exploration was performed in three cases (12.5%). Seventeen patients stayed in hospital over 7 days. There were four (16.7%) maternal deaths all of whom were referred from other hospitals. CONCLUSION: The mortality and morbidity of performing a peripartum hysterectomy is elevated, especially if performed in critical patients referred from other hospitals.