A comparison of abdominal and vaginal hysterectomy for the large uterus.

OBJECTIVE: To compare the perioperative outcomes of women with an enlarged uterus (>or=250 g) who had abdominal and vaginal hysterectomies. METHOD: Retrospective study of the perioperative outcomes of 288 consecutive women with an enlarged uterus, of whom 200 underwent an abdominal hysterectomy and 88 a vaginal hysterectomy, all for benign gynecological conditions. RESULTS: Among the perioperative complications, only the risk of ileus was significantly higher in the group that underwent abdominal hysterectomy. Although the need for blood transfusions was similar between the groups, mean perioperative hemoglobin change was significantly lower for women who had the abdominal approach. Vaginal hysterectomy shortened the length of hospitalization significantly but did not affect the operative time. All of these differences remained significant after adjusting for uterine weight (P<0.05). Baseline characteristics were similar between the groups, except for uterine weight. CONCLUSIONS: For women with a uterus weighing 250 g or more, vaginal hysterectomy shortens the hospital stay without significantly increasing perioperative morbidity when compared with the abdominal route.     

The influence of body mass index on the prevalence of complications after vaginal and abdominal hysterectomy

AIM OF STUDY: To investigate the association between obesity and peri- or postoperative complications after hysterectomy for nonmalignant bleeding disorders. MATERIAL AND METHODS: Data from 444 vaginal hysterectomies and 503 abdominal hysterectomies indicated by benign bleeding disorders were drawn from a regional database. Data on peri- or postoperative complications and postoperative stay were related to preoperative body mass index (BMI). RESULTS: Obesity was related to longer operation time for vaginal as well as abdominal hysterectomy and to large perioperative blood loss for vaginal hysterectomy only. No association was found between BMI and serious complications such as ileus, infection or hematomas except for a higher prevalence of wound hematoma after abdominal hysterectomy in underweight and normal weight patients. Neither was any association found between BMI and use of blood transfusion, reoperation or prolonged postoperative stay. CONCLUSION: Vaginal and abdominal hysterectomy have a significant risk of complications, but obese patients did not experience an increased risk of serious morbidity compared to normal weight women. Obesity per se is not a contraindication of vaginal or abdominal hysterectomy in otherwise healthy women.     

Laparoscopically-assisted vaginal hysterectomy for fibroid uteri weighing at least 500 grammes

We retrospectively reviewed the medical records of 13 women who underwent laparoscopically-assisted vaginal hysterectomy (LAVH) where the uterus weighed 500 g or more. LAVH was successfully performed in 10 of these 13 women for whom the mean uterine weight was 619 g, mean operating time 99 minutes, and mean postoperative hospital stay 3.7 days. One of the 3 women who underwent abdominal hysterectomy required blood transfusion for intraoperative bleeding. There was no febrile or other operative morbidity associated with any patient. As up to 75% of hysterectomies are performed abdominally, LAVH may replace many abdominal hysterectomies for large fibroid uteri when vaginal hysterectomy is not feasible.     

Minilaparotomy hysterectomy: a valid option for the treatment of benign uterine pathologies

OBJECTIVE: To evaluate feasibility and outcome of minilaparotomy hysterectomy in a consecutive series of patients. STUDY DESIGN: Cohort analytic study. From October 1995 to March 2001, 148 out of 228 (65%) consecutive hysterectomies for benign gynecologic disease were performed by an abdominal route. Minilaparotomy hysterectomy (transversal cutaneous incision < 10 cm, within the pubic hair) was attempted in all patients with benign uterine disease and contraindications for vaginal surgery. Surgical parameters were prospectively assessed in terms of length of incision, operative time, estimated blood loss, duration of ileus, perioperative complications and length of postoperative stay. RESULTS: A minilaparotomic approach was performed in 118 patients (80%). Conversion to Pfannenstiel was necessary in three cases. The minilaparotomy incision, 8 cm (range 6-10) of median length, was performed below the pubic hair line. The median operating time was 50 min (range 34-88). No intraoperative complications or perioperative blood transfusions were reported, while minor postoperative complications occurred in 16 patients (14%). The median postoperative stay was three days (range 2-5). CONCLUSIONS: The minilaparotomy hysterectomy is feasible in the majority of women undergoing hysterectomy for benign disease. Because of the excellent outcome achieved, it should be considered a valid alternative to the classic abdominal hysterectomy.     

Vaginal hysterectomy for the enlarged uterus

OBJECTIVE: To evaluate the effect of uterine weight on the perioperative outcomes of vaginal hysterectomy for benign gynecological conditions. MATERIALS AND METHODS: The medical records of 312 consecutive women who underwent vaginal hysterectomies for benign gynecological conditions without major pelvic reconstruction at Temple University Hospital between March 1994 and August 1999 were reviewed. 88 women with uterine weights > or =250 g were compared with 224 women with uterine weights <250 g. The risk of perioperative complications, operative time, perioperative hemoglobin change, length of postoperative hospital stay, and readmission were evaluated between the groups. RESULTS: Groups were similar with respect to age, parity, history of previous pelvic surgery and concurrent adnexal removal. Operative time was significantly increased for women with uteri weighing > or =250 g. Women with uterine weight > or =250 g had a higher risk for postoperative febrile morbidity. The risks of all other major complications, perioperative change in hemoglobin concentration, length of stay, and readmission risk were not statistically different between the groups (p < 0.05). CONCLUSIONS: Despite the increased postoperative febrile morbidity and prolonged operative time, women with uteri weighing > or =250 g who underwent vaginal hysterectomy were discharged from the hospital without any increase in other complications when compared to women with a smaller uterus.     

Persistent high rates of hysterectomy in Western Australia: a population-based study of 83 000 procedures over 23 years

OBJECTIVE: To investigate incidence trends and demographic, social and health factors associated with the rate of hysterectomy and morbidity outcomes in Western Australia and compare these with international studies. DESIGN: Population-based retrospective cohort study. SETTING: All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003. POPULATION: All women aged 20 years or older who underwent a hysterectomy. METHODS: Statistical analysis of record-linked administrative health data. MAIN OUTCOME MEASURES: Rates, rate ratios and odds ratios for incidence measures and length of stay in hospital and odds ratios for morbidity measures. RESULTS: The age-standardised rate of hysterectomy adjusted for the underlying prevalence of hysterectomy decreased 23% from 6.6 per 1000 woman-years (95% CI 6.4-6.9) in 1981 to 4.8 per 1000 woman-years (95% CI 4.6-4.9) in 2003. Lifetime risk of hysterectomy was estimated as 35%. In 2003, 40% of hysterectomies were abdominal. The rate of hysterectomy to treat menstrual disorders fell from 4 per 1000 woman-years in 1981 to 1 per 1000 woman-years in 1993 and has since stabilised. Low socio-economic status, having only public health insurance, nonindigenous status and living in rural or remote areas were associated with increased risk of having a hysterectomy for menstrual disorders. Indigenous women had higher rates of hysterectomy to treat gynaecological cancers compared with nonindigenous women, particularly in rural areas. The odds of a serious complication were 20% lower for vaginal hysterectomies compared with abdominal procedures. CONCLUSION: Western Australia has one of the highest hysterectomy rates in the world, although proportionally, significantly fewer abdominal hysterectomies are performed than in most countries.     

Comparative study of vaginal,laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study

BACKGROUND: The purpose of this study was to compare peri-operative morbidity, preoperative sonographic estimation of uterine weight and postoperative outcomes of women with uterine fibroids larger than 6 cm in diameter or uteri estimated to weigh at least 450 g, undergoing either vaginal, laparoscopically assisted vaginal or abdominal hysterectomies. METHOD: Ninety patients who met the criteria of uterine fibroids larger than 6 cm by ultrasonographic examination were included in our prospective study. Patients were randomized into laparoscopic-assisted vaginal hysterectomy (30 patients), vaginal hysterectomy (30 patients) and abdominal hysterectomy (30 patients) groups. RESULTS: The laparoscopically assisted vaginal hysterectomy group had significantly longer operative times than the abdominal and vaginal hysterectomy groups (109 +/- 22 min, 98 +/- 16 min, and 74 +/- 22 min, respectively, p < 0.001). Blood loss for vaginal hysterectomy was significantly lower than for either abdominal or laparoscopically assisted vaginal hysterectomies (215 +/- 134 ml, 293 +/- 182 ml, and 343 +/- 218 ml, respectively, p = 0.04). Vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy groups had shorter hospital stays, lower postoperative pain scores, more rapid bowel recovery and lower postoperative antibiotic use than the abdominal hysterectomy group. Uterine weight in the abdominal hysterectomy group was significantly heavier than in the vaginal and laparoscopically assisted vaginal hysterectomy groups (1020 +/- 383 g, 835 +/- 330 g, and 748 +/- 255 g, respectively, p = 0.02). We estimated that when a myoma measured between 8 and 10 cm, the uterus weighed approximately 450 g, and the sensitivity of this prediction was 57.5%. For a myoma larger than 13 cm, the estimated uterine weight was more than 900 g and the sensitivity of this prediction was 71%. CONCLUSION: The study shows vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy can be performed in women with uterine weight of at least 450 g. Preoperative ultrasonographic examination can provide the surgeon with valuable information on the size of the fibroid and the estimated weight of the enlarged uterus before implementing a suitable surgical method.     

Impact of Obesity on Outcomes of Hysterectomy

Study ObjectivesTo evaluate the impact of obesity on complications of hysterectomy.Study DesignRetrospective cohort study (Canadian Task Force II-2).SettingThe Department of Obstetrics and Gynecology, Women and Infants Hospital of Rhode Island, Providence, RI.PatientsPatients who had a hysterectomy at WIH between July 2006 and January 2009.InterventionsHysterectomy by any mode.Measurements and Main ResultsWe collected data from medical records of all laparoscopic hysterectomies during the time period and collected data from a random subset of abdominal and vaginal hysterectomies. The independent variable, body mass index, was grouped according to World Health Organization guidelines. A composite of surgical complications was generated. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). We collected data from 907 hysterectomies, and 29.9% (n = 267) of the population was obese. Eighteen percent of patients (n = 154) had at least 1 complication. Compared to non-obese women, obese women were at increased odds of having any complication (OR 1.62, 95% CI 1.12-2-34). Performing subgroup analyses by mode of hysterectomy and controlling for confounding factors, we were unable to detect differences odds of complications between obese and non-obese women who underwent either an abdominal, vaginal, or laparoscopic hysterectomy.ConclusionIn our study, we found that among women who had a hysterectomy, obese women had a higher rate of complications than nonobese women.     

Factors associated with increased charges for hysterectomy

OBJECTIVE: To evaluate factors associated with increased hospital charges for hysterectomy with specific attention to differences based on surgical approach. METHODS: We performed a retrospective cohort study of 686 patients who underwent hysterectomy between January 1997 and September 1997 using medical chart review and hospital financial information. Demographic information, surgical approach (abdominal, vaginal, or laparoscopic), and surgical and postoperative factors were extracted from the medical record. Hospital charges were obtained from the hospital billing database. Relationships between charges and various clinical and demographic variables were examined using chi(2), Fisher exact test, t tests, or analysis of variance, where appropriate. Logistic regression was used to estimate odds ratios while controlling for important confounding variables. RESULTS: In our logistic regression model, blood loss greater than 1,000 mL (odds ratio [OR] 11.8, 95% confidence interval [CI] 4.2-33.2) and operative time 105 minutes or more (OR 14.2, CI 5.8-34.5) were strongly associated with higher charges for hysterectomy. Other factors associated with higher charges included: postoperative fever (OR 2.2, CI 1.1-4.5), increasing length of hospitalization (OR 5.3, CI 3.7-7.7), the use of prophylactic antibiotics (OR 3.0, CI 1.3-6.6), and the laparoscopic surgical approach compared with vaginal hysterectomy (OR 2.7, CI 1.0-7.0). CONCLUSION: Surgical factors such as operative time and blood loss were strongly associated with increased hospital charges for hysterectomy.     

A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice

STUDY OBJECTIVE: To compare gynecologic practice and perioperative outcomes of patients undergoing total laparoscopic hysterectomy and robotic hysterectomy before and after implementation of a robotics program. DESIGN: A retrospective chart review of the last 200 consecutive hysterectomy cases completed before and after implementation of a robotics program (Canadian Task Force classification III). SETTING: Community hospital. PATIENTS: All patients requiring hysterectomy for benign indications between November 2004 and January 2007. INTERVENTIONS: Patients were candidates for total laparoscopic, abdominal, or vaginal hysterectomy before February 2006 and were candidates for total laparoscopic, total abdominal, total vaginal, or robotic-assisted laparoscopic hysterectomy after February 2006. Perioperative characteristics and trends were studied. MEASUREMENTS AND MAIN RESULTS: In all, 100 patients intended to be treated by laparoscopic hysterectomy before the implementation of a robotics program were compared with 100 patients treated by robotic hysterectomy after robot implementation. Overall the robotic cohort experienced longer operative times by an average of 27 minutes. The prerobotic cohort, however, when compared with the last 25 robotic cases had longer operative times (92.4 minutes [29.2], 95% CI 46.0-225.0 vs 78.7 minutes [29.5], 95% CI 66.0-91.2, p = .03). The mean blood loss in the prerobotic cohort was twice that of the robotic cohort (113 mL [85.9], 95% CI 95.9-130.1 vs 61.1 mL [60.9], 95% CI 48.9-73.2, p <.0001) and the mean length of hospital stay was half a day longer in the prerobotic cohort than in the robotic cohort (1.6 days [1.4], 95% CI 1.3-1.9 vs 1.1 days [0.7], 95% CI 1.0-1.3, p <.007). The incidence of adverse events was the same in both groups. The total number of exploratory laparotomies in the prerobotic cohort was significantly greater than in the robotic group (11% vs 0%). The rate of intraoperative conversions to total abdominal hysterectomy from laparoscopy was approximately 2-fold higher in the prerobotic cohort as compared with the robotic cohort (9% vs 4%). CONCLUSION: A higher likelihood of exploratory laparotomy for hysterectomy in the prerobotic cohort versus the robotic cohort and a higher likelihood of intraoperative conversion to laparotomy with the prerobotic cohort than with the robotic cohort existed. Reduced operative time, reduced blood loss, and shortened length of stay may be achieved in patients who are treated robotically versus a nonrobotic approach. Robotics may facilitate the minimally invasive treatment of patients while potentially reducing the rate of abdominal hysterectomies.     

Laparoscopic hysterectomy versus total abdominal hysterectomy: a comparative study

OBJECTIVE: The objective of this study was to compare the intraoperative and short-term postoperative complications of laparoscopic hysterectomy and total abdominal hysterectomy. STUDY DESIGN: Retrospective study of 167 women who had laparoscopic hysterectomy and 119 women who had total abdominal hysterectomy. For assessing the learning curve, the laparoscopic hysterectomies were further subdivided to the first 30 hysterectomies and the later hysterectomies. For data analysis Student's t-test, chi2-test and Fisher's exact test were used. RESULTS: There were no statistically significant differences between the two groups for age, body mass index, previous abdominal surgery, uterine weight, first postoperative day hemoglobin drop, blood transfusion and major or minor complications rate. Operation time was significantly longer for laparoscopic than abdominal hysterectomy (156+/-40 and 91.2+/-33 min, respectively; P<0.001) but the length of hospital stay was significantly shorter (3.9 and 6.55 days, respectively; P<0.001). The conversion rate of laparoscopic hysterectomy was 1.8% (three cases). CONCLUSIONS: Laparoscopic hysterectomy can be safely done even during the learning curve with a low and reasonable complication rate, and a shorter hospital stay but with longer operation time. As experience is gained the operation time, complication rate and hospital stay are decreased.     

Hysterectomy rates in the United States, 2003

OBJECTIVE: To estimate hysterectomy rates by type of hysterectomy and to compare age, length of stay, and regional variation in type of hysterectomy performed for benign indications. METHODS: We conducted a cross-sectional analysis of national discharge data using the 2003 Nationwide Inpatient Sample. These data represent a 20% stratified sample of U.S. hospitals. Women aged 16 years or older who underwent a hysterectomy were identified by International Classification of Diseases, 9th Revision, Clinical Modification procedure codes. We extracted data regarding age, race, diagnoses codes, length of stay, and hospital characteristics. Using 2000 National Census data and weighted data analysis for cluster sampling, we calculated hysterectomy rates. RESULTS: In 2003, 602,457 hysterectomies were performed, for a rate of 5.38 per 1,000 women-years. Of the 538,722 hysterectomies for benign disease (rate 4.81 per 1,000 women-years), the abdominal route was the most common (66.1%), followed by vaginal (21.8%) and laparoscopic (11.8%) routes. Mean ages (+/-standard deviation) differed among hysterectomy types (abdominal 44.5+/-0.1 years, vaginal 48.2+/-0.2 years, and laparoscopic 43.6+/-0.3 years, P<.001). Mean lengths of stay (+/-standard deviation) were also different (3.0+/-0.03 days, 2.0+/-0.03 days, 1.7+/-0.03 days, respectively, P<.001). The hysterectomy rate was highest in the South (5.92 per 1,000 women-years) and lowest in the Northeast (3.33 per 1,000 women-years). CONCLUSION: Despite a shorter length of stay, vaginal and laparoscopic hysterectomies remain far less common than abdominal hysterectomy for benign disease. LEVEL OF EVIDENCE: III.     

Factors affecting prophylactic oophorectomy in postmenopausal women

OBJECTIVE: Prophylactic oophorectomy performed concomitantly with hysterectomy may prevent ovarian cancer. Our goal was to better understand the basis for performing concomitant oophorectomy and to determine whether this procedure is associated with increased morbidity. METHODS: Our cross-sectional study used a hospital discharge database to identify women 50 years and older who, between 1994-1996, had hysterectomies in Maryland for a benign condition. We used multiple logistic regression to examine the independent effect of physician and patient factors on the likelihood of receiving a concomitant oophorectomy. RESULTS: Concomitant oophorectomy was performed in 61% of the 6227 women in our sample. Patients undergoing total abdominal hysterectomy (odds ratio [OR] 11.42; 95% confidence interval [CI] 9.65, 13.51) and laparoscopically assisted vaginal hysterectomy (OR 11.34; 95% CI 8.13, 15.81) were substantially more likely to have an oophorectomy than patients treated with vaginal hysterectomy, after adjusting for diagnosis and other covariates. We also found significant variation in the likelihood of receiving oophorectomy for women undergoing vaginal hysterectomy in different geographic regions. Additionally, physicians who performed many vaginal hysterectomies were significantly more likely to perform a concomitant oophorectomy. After adjusting for type of procedure, diagnosis, comorbidities, and age, oophorectomy was not associated with increased surgical morbidity. CONCLUSION: These results suggest that there are marked variations in physician practice style for concomitant oophorectomy. The variation across geographic regions and with case volume suggests the influence of nonclinical factors on oophorectomy rates.     

Cost analysis of myomectomy,hysterectomy, and uterine artery embolization

OBJECTIVE: The purpose of this study was to compare inpatient hospital costs of different treatments of uterine fibroid tumors, including myomectomy, hysterectomy, and uterine artery embolization in a teaching hospital. STUDY DESIGN: We reviewed the hospital database of 545 women with uterine fibroid tumors who were treated with abdominal myomectomy, total abdominal hysterectomy, vaginal hysterectomy, and uterine artery embolization between April 1997 and October 2001. RESULTS: Women who underwent hysterectomies and uterine artery embolization were significantly older than the women who underwent myomectomy. Uterine artery embolization was associated with the shortest hospital stay, although the hospital stay in the vaginal hysterectomy group was shorter than in the abdominal myomectomy and the total abdominal hysterectomy groups. Compared with other groups, the inpatient cost of nursing in the uterine artery embolization group was the lowest. The total inpatient cost of uterine artery embolization ($1,007.44 +/- $60.65 [Canadian dollars]) was significantly lower than the cost of total abdominal hysterectomy ($1,933.37 +/- $47.68 [Canadian dollars]), abdominal myomectomy ($1,781.73 +/- $47.16 [Canadian dollars]), and vaginal hysterectomy ($1,515.39 +/- $66.72 [Canadian dollars]; P <.001). Sixteen of the 85 patients (18.8%) were hospitalized after uterine artery embolization, mainly for abdominal pain. CONCLUSION: Compared with abdominal myomectomy, abdominal hysterectomy, and vaginal hysterectomy, uterine artery embolization is associated with a lower hospital cost and a shorter hospital stay. Hospitalization after uterine artery embolization is mainly for abdominal pain after the procedure. A better method of pain control to reduce the rate of hospitalization and its cost is needed.     

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.     

Minilaparotomy hysterectomy assisted by self-retaining elastic abdominal retractor

STUDY OBJECTIVE: To verify the efficacy and safety of minilaparotomy hysterectomy using a self-retaining elastic abdominal retractor. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Private hospital, department of obstetrics and gynecology. PATIENTS: One-hundred-fifty women, age 37 to 76 years, with benign uterine pathology or preinvasive neoplasia. INTERVENTION: Minilaparotomy hysterectomy assisted by a self-retaining elastic abdominal retractor. MEASUREMENTS AND MAIN RESULTS: The mean surgical time was 70 +/- 23.5 minutes (95% CI 63.1-70.7). There were no intraoperative complications. There was no need to extend the initial incision. Eight patients developed complications during the immediate postoperative period (fever in 2, hematoma of the surgical wound in 2, sub-aponeurotic seroma in 2, pubic edema in 1, and pulmonary embolism in 1). During the late postoperative period, a vaginal cuff dehiscence was reported. Mean postoperative hospital stay was 2.5 +/- 0.2 days (95% CI 2.4-2.6). CONCLUSION: Minilaparotomy hysterectomy assisted by a self-retaining abdominal elastic retractor is a safe and effective minimally invasive procedure. Also, it appears to be a good alternative to laparoscopic hysterectomy for institutions that do not have the required expensive equipment or for gynecologists who do not have laparoscopic experience.     

The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital

Objective: Our purpose was to evaluate the medical and economic impact of operative laparoscopy on the surgical approach to hysterectomy for benign disease in a large, metropolitan, not-for-profit hospital.Study design: Retrospective analyses were performed on 2563 hysterectomies (without vaginal or bladder repair) for benign disease, performed and stapling devices were not used at any time during the study period. Electrosurgery and sutures were used for hemostasis. Parameters analyzed included surgical approach (total abdominal hysterectomy, vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and failied laparoscopically assisted vaginal hysterectomy), operative time, postoperative diagnosis, operative blood loss, length of stay, complications, uterine weight, and hospital changes. Changes in each of these parameters were analyzed and compared in 6-month increments.Results: During the study period the percent of hysterectomies performed abdominally declined from 65% to 36%. Laparoscopically assisted vaginal hysterectomy increased from 12% to 45%, and vaginal abdominal hysterectomy, 102 minutes (=2.3 minutes) for laparoscopically assisted vaginal hysterectomy, and 63 minutes (±2 minutes) for vaginal hysterectomy. Hospital stay was 68 hours (±1.5 hours) for total abdominal hysterectomy, 44 hours (±1.2 hours) for laparoscopically assited vaginal hysterectomy, and 43 hours (±4.1 hours) for vaginal hysterectomy. The average hospital charge was $6552 (±$108) for total abdominal hysterectomy, $6431 (±$100) for laparoscopically assisted vaginal hysterectomy, and $5869 (±$116) for vaginal hysterectomy.Conclusions: Contrary to previously published studies, our study demonstrates (1) laparoscopically assisted vaginal hysterectomy is a cost-effective procedure when performed with reusable instruments, (2) laparoscopically assisted vaginal hysterectomy is a safe procedure, even when performed by a variety of gynecologists with different skill levels, and (3) the number of hysterectomies performed abdominally was decreased by 29% without incurring more complications or reducing the number of vaginal cases.     

Uterine morcellation during vaginal hysterectomy: apropos of a series of 216 prospective cases

OBJECTIVE: The purpose of this study was to compare the surgical outcomes of women undergoing vaginal hysterectomy with and without morcelation. PATIENTS AND METHOD: Between December 1999 and December 2000, 216 women underwent vaginal hysterectomy without laparoscopic assistance at the Department of Gynecology of H?tel-Dieu hospital in Paris. The patients were divided into two groups: 114 of them underwent vaginal hysterectomies with morcelation whereas 102 underwent vaginal hysterectomies without morcelation. The two groups were compared as to demographic data, total complications, operative time, hospital stay length and peri-operative hemoglobin concentration change. RESULTS: Although women undergoing morcelation were significantly younger (mean 49 versus 52, p = 0.01) and less parous (mean 1.9 versus 2.3, p = 0.03), there were no significant differences in other surgical or anesthetic risks factors, including weight, BMI, nulliparity and preexisting surgical diseases. Mean uterine weight was significantly greater in those undergoing morcelation (331 versus 110 g, p < 0.001); operative time was increased in the group which had undergone morcelation (331 versus 110 g, p < 0.001). There were no significant differences between the two groups with respect to peri-operative hemoglobin concentration change or hospital stay length. Finally, the rate of surgical complication was similar in the two groups (17.5 versus 21.5%). CONCLUSION: Although vaginal hysterectomy requires an increase in operative time, morcelation at the time of vaginal hysterectomy is safe and facilitates the vaginal removal of enlarged uteri without increasing peri-operative morbidity.     

Immediate Foley removal after laparoscopic and vaginal hysterectomy: determinants of postoperative urinary retention

STUDY OBJECTIVE: We sought to evaluate the incidence of postoperative voiding dysfunction in patients undergoing vaginal hysterectomy (VH) or total laparoscopic hysterectomy (TLH) and to identify risk factors for the development of postoperative urinary retention after uncomplicated total hysterectomy. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: Gynecology department of a university hospital. PATIENTS: Two hundred thirty-three consecutive women undergoing TLH or VH for benign gynecologic disease. INTERVENTIONS: A regimen of immediate catheter removal after the operation was instituted. A strict voiding trial protocol was used during the study period. Postoperative voiding dysfunction was defined as failure of first voiding trial after surgery (urinary retention) or postvoid residual volume of greater than 150 mL necessitating recatheterization. MEASUREMENTS AND MAIN RESULTS: A total of 49 women (21%) developed postoperative voiding dysfunction, of which 32 (13.7%) had complete urinary retention and 17 (7.3%) had a postvoid residual volume greater than 150 mL. None of these patients experienced voiding dysfunction beyond 48 hours. There was no statistical correlation between development of postoperative voiding dysfunction and demographic, historic, preoperative, and postoperative variables collected. The only factor with significant impact on postoperative voiding dysfunction was vaginal approach to hysterectomy (OR 2.8; 95% CI 1.5-5.4). Hospital stay was significantly longer for women experiencing voiding difficulties than for those who voided efficiently (2.2 +/- 0.8 [95% CI 1.5-1.9] vs 1.7 +/- 1.2 [95% CI 1.9-2.4] days; p <.0001). Voiding dysfunction was an independent predictor of postoperative urinary tract infection (OR 4.9; 95% CI 1.6-15.4). CONCLUSION: Patients undergoing VH are more likely to develop postoperative voiding dysfunction than those who undergo TLH, when a policy of immediate catheter removal after surgery is used.