Vaginal hysterectomy in nulliparous women without prolapse: a prospective comparative study

Objective To compare vaginal hysterectomy success and complication rates in nulliparous and primiparous or multiparous women.
Design A comparative prospective study.
Setting Department of Gynaecology, La Conception Hospital, Marseille, France.
Population Three hundred and forty-five consecutive patients without genital prolapse requiring hysterectomy for benign conditions and without previous pelvic surgery or caesareans were treated prospectively by vaginal hysterectomy. Fifty-two patients were nulliparous and 293 were primiparous or multiparous.
Methods Data of patients were collected prospectively.
Main outcome measures Operative time, length of hospital stay, oophorectomy, conversion to laparotomy, intra- and post-operative complications.
Results The mean operative time was significantly longer in nulliparous patients [95 (55.2) vs 79.9 (34.9) minutes,   P < 0.01  ]. The overall complication rate was significantly higher [7/52 (13.46%) vs 13/293 (4.44%),   P = 0.02, RR = 3.03 (1.27–7.23)  ] as was the haemorrhage rate in nulliparous compared with the primiparous and multiparous women [4/52 (7.69%) vs 5/293 (1.7%),   P = 0.03, RR = 4.51 (1.25–16.23)  ]. Vaginal hysterectomy was successfully performed in 96.2% (50/52) of the nulliparous and 99.7% (292/293) of the parous patients [   P = 0.06, RR = 1.04 (0.98–1.09)  ].
Conclusion The success rate of vaginal hysterectomy in nulliparous women is high. However, the risk of complications seems higher than in the parous women. Laparoscopy assisted vaginal hysterectomy in nulliparous women needs further investigations.     

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.     

Gasless laparoscopic hysterectomy: a comparative study with total abdominal hysterectomy

AIM: To evaluate the short-term results of gasless laparoscopic hysterectomy (GLH) compared to total abdominal hysterectomy. METHODS: A comparative study of GLH using an abdominal wall-lifting device (n = 31) and total abdominal hysterectomy (TAH) (n = 31) was carried out between July 1999 and July 2001. RESULTS: One patient (3.2%) in the GLH group required conversion to TAH. The operative time was 168 +/- 38 min and 112 +/- 29 min (P < 0.001) for the GLH and TAH groups, respectively. Gasless laparoscopic hysterectomy cases had a shorter hospital stay and convalescent period (2.6 +/- 0.9 days vs 5.0 +/- 1.3 days, P < 0.001 and 8.0 +/- 3.0 days vs 15.8 +/- 2.4 days, P < 0.001, respectively). Postoperative meperidine use and estimated blood loss were lower for GLH (P < 0.001). Complications were comparable in the two groups. Hospital charges were 8.5% higher for GLH (P = 0.02). CONCLUSIONS: Gasless laparoscopic hysterectomy may be an alternative technique for hysterectomy which provides laparoscopic benefit with minimal increase in hospital charges.     

Hypertension is associated with an increased risk for hysterectomy: a Danish cohort study

OBJECTIVE: To assess whether hypertension is a risk factor for hysterectomy, endometrial resection, and myomectomy. STUDY DESIGN: Self-report questionnaires were collected from 81% of 1959 Danish women aged 30 or 40 years selected at random in 1976-1991, in four different cohort studies. Baseline data included standardized information about cardiovascular diseases, hypertension, use of medicine, gynecologic history, social background, and life style factors. Weight, height and blood pressure were measured. The women were followed via central registers to assess the incidence of hysterectomy, endometrial resection, and myomectomy performed for benign diagnoses. Cox regression analyses were used to control for confounding. RESULTS: The average time to follow-up was 15 years, and 135 operations performed for benign diagnoses were identified. Women with a history of hypertension had a double risk of having an operation compared to women without hypertension, independent of confounders. CONCLUSION: Hypertension seems to be a risk factor for hysterectomy performed for benign diagnoses, and thus contributes to women undergoing hysterectomy having an increased risk of cardiovascular diseases. It might be relevant to pay increased attention to the blood pressure in candidates for hysterectomy, as optimal antihypertensive treatment could decrease their otherwise increased risk of cardiovascular disease years after hysterectomy.     

The epidemiology of hysterectomy: findings in a large cohort study.

OBJECTIVE: To examine patterns of hysterectomy in the Oxford-Family Planning Association (Oxford-FPA) study in relation to age, parity, social class and calendar period (-1974, 1975-79. 1980-84, 1985-89). DESIGN: The Oxford-FPA study is a large scale prospective study of 17,032 women recruited from 1968-74 and still under observation. SETTING: Seventeen family planning centres throughout England and Scotland. SUBJECTS: At recruitment the 17,032 women were all white, British, married, aged 25-39 and willing to co-operate. In addition, they were using the pill or an intrauterine device or a diaphragm as their method of contraception. MAIN OUTCOME MEASURE: Hysterectomy rates per 1000 woman-years of observation in various subclasses of the data. RESULTS: Up to the end of 1989, 1885 (11.1%) of the 17,032 women in the study were known to have undergone hysterectomy. Fibroids were the most common cause followed closely by menstrual disturbances in the absence of fibroids (hereafter referred to as 'menstrual disturbances'). Social class had a modest influence on hysterectomy rates. Hysterectomy for fibroids, prolapse, endometriosis and 'other reasons' showed little trend with calendar period while hysterectomy for menstrual disturbances and for cancer showed a sharp increase with calendar time especially at ages 30-39. Hysterectomy generally tended to increase with age and showed a strong relation to parity; in particular, hysterectomy for fibroids fell with parity and hysterectomy for menstrual disturbances rose sharply with parity. Using lifetable methods, it was estimated that almost 20% of the women in the study would have had a hysterectomy by age 55. CONCLUSIONS: The results give insights into factors affecting hysterectomy rates. Of particular interest is the modest influence of social class, the strong influence of parity and the rise in rates with calendar time at ages 30-39 for those undergoing hysterectomy for menstrual disturbances or cancer, but since the cohort is not directly representative of the population, some caution is required in extrapolating these findings. The estimated hysterectomy rate of about 20% by age 55 is in line with other similar estimates for the United Kingdom.     

The association of hysterectomy and menopause: a prospective cohort study

OBJECTIVE: To determine whether or not hysterectomy leads to an earlier onset of the menopause. DESIGN: A prospective cohort study. SETTING: Gynaecology service of large urban hospital. POPULATION: Premenopausal women with and without hysterectomy. METHODS: Multivariate survival analysis techniques were used to adjust for differences in initial follicle stimulating hormone (FSH) levels, body mass index, smoking and unilateral oophorectomy between the groups. MAIN OUTCOME MEASURES: FSH levels were measured for five years following hysterectomy and compared with the comparison group. Menopause was defined as a single FSH measurement of at least 40 IU/L. RESULTS: Two hundred and fifty-seven women undergoing hysterectomy were compared with 259 women who had not undergone a hysterectomy. Fifty-three women (20.6%) in the hysterectomy group and 19 women (7.3%) in the comparison group reached menopause over the five years of the study. Women in the hysterectomy group with a pre-operative FSH <10 IU/L reached menopause 3.7 years (95% CI 1.5-6.0 years) earlier than women in the comparison group independent of BMI, smoking and unilateral oophorectomy. Twenty-eight women in the hysterectomy group had unilateral oophorectomy and 10 (35.7%) of these women reached menopause over the five years of follow up. Women in the hysterectomy group with unilateral oophorectomy reached menopause 4.4 years (95% CI 0.6, 7.9 years) earlier than women with both ovaries in the hysterectomy group independent of baseline FSH, BMI and smoking. CONCLUSIONS: Hysterectomy is associated with an earlier onset of menopause. Hysterectomy with unilateral oophorectomy is associated with an even earlier onset of the menopause in this study.     

Surgical outcomes of laparoscopic hysterectomy with concomitant endometriosis without bowel or bladder dissection: a cohort analysis to define a case-mix variable

Background

Pelvic endometriosis is often mentioned as one of the variables influencing surgical outcomes of laparoscopic hysterectomy (LH). However, its additional surgical risks have not been well established. The aim of this study was to analyze to what extent concomitant endometriosis influences surgical outcomes of LH and to determine if it should be considered as case-mix variable.

Results

A total of 2655 LH’s were analyzed, of which 397 (15.0%) with concomitant endometriosis. For blood loss and operative time, no measurable association was found for stages I (n?=?106) and II (n?=?103) endometriosis compared to LH without endometriosis. LH with stages III (n?=?93) and IV (n?=?95) endometriosis were associated with more intra-operative blood loss (p =?<?.001) and a prolonged operative time (p =?<?.001) compared to LH without endometriosis. No significant association was found between endometriosis (all stages) and complications (p?=?.62).

Conclusions

The findings of our study have provided numeric support for the influence of concomitant endometriosis on surgical outcomes of LH, without bowel or bladder dissection. Only stages III and IV were associated with a longer operative time and more blood loss and should thus be considered as case-mix variables in future quality measurement tools.

     

Laparoscopically assisted vaginal hysterectomy for large uterus: a comparative study

OBJECTIVE: To examine the safety and feasibility of laparoscopically assisted vaginal hysterectomy (LAVH) for uteri weighing 500 g or more as compared to uteri weighing less than 500 g in the management of benign gynecological diseases. METHOD: In this prospective comparative study, 189 women with different benign gynecological diseases were scheduled for laparoscopically assisted vaginal hysterectomy. They were divided into two groups, with uterine weight greater than 500 g and uterine weight less than 500 g. Outcome measures for both the groups were studied comparatively in terms of length of operative time, amount of blood loss, requirement of blood transfusion and length of hospital stay. RESULTS: Length of operation and amount blood loss were significantly greater in the uteri >o r = 500 g group than in the <500 g at 91.1 +/- 28.7 min versus 77.4 +/- 26.6 min (P < 0.01), and 570.5 +/- 503.6 ml versus 262.5 +/- 270.0 ml (P < 0.001), respectively. However, there was no difference in length of hospital stay and overall incidence of operative complications between the two groups. None of the women had any major complications though 17 minor complications were noted. There was no incidence of switching to abdominal laparatomy during the operation except for one patient who required "minilaparotomy" for removal of large surgical specimen (2400 g). Extreme intra-operative hemorrhage of more than 1000 ml occurred in five patients, however, they made full recovery after blood transfusion. Rate of blood transfusion was significantly lower in the uteri <500 g group (4.8% versus 34.9%, (P < 0.001). CONCLUSION: This study demonstrates that despite the increased operating time and blood loss, LAVH can be safely performed for large uterus. However, surgeons need to be aware of the high risk of blood transfusion in these patients.     

Robotic versus open radical hysterectomy: a comparative study at a single institution

ObjectiveTo compare the short-term surgical outcome of patients undergoing robotic radical hysterectomy (RRH) versus open radical hysterectomy (ORH) for the treatment of early stage cervical cancer.MethodsIRB approval was obtained for a retrospective chart review of all radical hysterectomies (RHs) for Stage I and II cervical cancer performed at Brigham and Women's Hospital between August 1, 2004 and August 1, 2007. Prior to August 1, 2006 all procedures were ORHs. After this date, all procedures were RRHs. Demographic data, operative data and short-term outcomes were compared. Statistical analysis using t-tests and Fisher's Exact test were performed with SAS software.ResultsA total of 48 RHs were identified, including 16 RRHs and 32 ORHs. The groups did not differ significantly in age, body mass index, stage, or histology. Mean operative time was significantly longer for RRH than ORH (4:50 vs 3:39 h, p = 0.0002). The mean estimated blood loss was significantly less for RRH than ORH (81.9 vs 665.6 mL, p < 0.0001). The mean number of lymph nodes resected did not differ between RRHs and ORHs (15.6 vs 17.1, p = 0.532). There were no intra-operative complications in the RRH group and one ureteral transection in the ORH group. Three RRH patients (18.8%) suffered post-operative complications which included a vaginal cuff infected hematoma, a transient ureterovaginal fistula, and a pelvic lymphocele, in comparison to seven in the ORH group (21.9%) which included 3 wound infections, two patients with pulmonary emboli, a partial small bowel obstruction with a mesenteric abscess, and a post-operative ileus (p = 0.999). Mean length of stay was significantly shorter for the RRH group (1.7 vs. 4.9 days, p < 0.0001).ConclusionRRH results in lower blood loss and shorter length of stay, compared to ORH. Intra-operative and post-operative complication rates are comparable. RRH is a promising new surgical technique that deserves further study.     

Laparoscopic and abdominal sacral colpopexies: a comparative cohort study

OBJECTIVE: This study was undertaken to compare laparoscopic and open sacral colpopexies for efficacy and safety. STUDY DESIGN: Charts were reviewed for 56 patients who underwent laparoscopic sacral colpopexy and 61 patients who underwent open sacral colpopexy. Demographic and hospital data, complications, and follow-up visits were reviewed. RESULTS: Mean follow-up was 13.5 +/- 12.1 months and 15.7 +/- 18.1 months in the laparoscopic and open groups, respectively. Mean operating time was significantly greater in the laparoscopic versus open cohort, 269 +/- 65 minutes and 218 +/- 60 minutes, respectively (P < .0001). Estimated blood loss (172 +/- 166 mL vs 234 +/- 149 mL; P = .04) and hospital stay (1.8 +/- 1.0 days vs 4.0 +/- 1.8 days; P < .0001) were significantly less in the laparoscopic group than the open group. Complication and reoperation rates were similar. CONCLUSION: Laparoscopic and open sacral colpopexies have comparable clinical outcomes. Although laparoscopic sacral colpopexy requires longer operating time, hospital stay is significantly decreased.     

A comparative study of laparoscopic radical hysterectomy with radical abdominal hysterectomy for early-stage cervical cancer: a long-term follow-up study

Objective

To determine whether laparoscopic radical hysterectomy (LRH) is a feasible alternative to radical abdominal hysterectomy (RAH) for early-stage cervical cancer.

Study design

A retrospective, matched case-control study of 24 consecutive cases with International Federation of Gynecology and Obstetrics stage I-II cervical cancer who underwent LRH by a single surgeon between January 1994 and December 2001. Cases were matched with controls (ratio 1:2) who underwent RAH by surgeon, age, stage and histology. Patient characteristics, clinical course, intra-operative complications and disease-free survival were compared between the two groups. Median counts were analyzed using the Mann-Whitney U-test. Differences between means were compared using Student's t-test. Dichotomous groupings were analyzed using Chi-squared test and Fisher's exact test as appropriate. Survival data were estimated using Kaplan-Meier estimates and compared with the log-rank test.

Results

The mean estimated blood loss in the RAH group was significantly greater than that in the LRH group (836.0 ml and 414.3 ml, respectively; p < 0.001). Five patients (20.8%) from the LRH group and 23 patients (47.9%) from the RAH group received blood transfusion (p < 0.03). The mean length of hospital stay was significantly shorter in the LRH group compared with the RAH group (10.7 days and 18.8 days, respectively; p < 0.01). No statistically significant difference existed between the two groups with respect to operative time, pelvic lymph node count, frequency of lymph node involvement, extent of parametrial or vaginal resection margins, adjuvant treatment and intra-operative complications. Median follow-up was 78 months for the LRH group and 75 months for the RAH group. There was no significant difference in the 5-year disease-free survival rate between the groups (90.5% and 93.3% for LRH and RAH, respectively; p = 0.918).

Conclusions

LRH is a useful alternative to RAH for the management of early-stage cervical cancer. The benefits of LRH include reduced blood loss, fewer transfusions and shorter hospital stay, with comparable oncologic outcome.     

Total laparoscopic hysterectomy in cases of very large uteri: a retrospective comparative study

In this review, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uteri weighting more than 500 grams. We compared surgical outcomes and short term follow-up in 149 patients with the uterus weighing less than 350 g (group A: 40-350 g) and 100 patients with the uterus weighing more than 500 g (group B: 500-1550 g). We discovered no statistical difference between the 2 groups in terms of intraoperative complications (group A: 0%; group B: 2%) and postoperative stay (group A: 3.05 +/- 1.89 days; group B: 3.2 +/- 1.28 days). There were statistically significant differences between the 2 groups in terms of operative time (group A: 101.3 +/- 34.3 min; group B: 149.1 +/- 57.2 min.; p <.0001) and postoperative hospital stay length (group A: 2.8 +/- 0.7 days; group B: 3.5 +/- 1.7 days; p <.0001). No major complications occurred in either group. Postoperative minor complications were more frequent in group B (group A: 8.7%; group B: 18%; p = .03). Median time to well-being was comparable in both groups. In conclusion, TLH is a feasible surgical technique also in cases of very large uteri. An increase in operative time, intraoperative blood loss, hospital stay length, and postoperative minor complications can be expected as the uterine weight increases.     

Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH

STUDY OBJECTIVE: To compare results of a vaginal approach to colpotomy (type IA) and laparoscopic-assisted abdominal colpotomy (type ID) in performing a laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: Prospective, randomized study (Canadian Task Force classification I). SETTING: Tertiary teaching hospital. PATIENTS: Five hundred forty-one women, 274 in group 1 (type 1D) and 267 in group 2 (type 1A). INTERVENTION: LAVH with follow-up for 3 months to 5 years. MEASUREMENTS AND MAIN RESULTS: There were no statistically significant differences in age, preoperative and postoperative hemoglobin values, or postoperative hospital stay between groups. Operating time and estimated blood loss were significantly reduced in group 2 (p <0.001 and <0.001, respectively). Women in group 1 had nine urinary tract injuries (3.28%), including eight cases of intraoperative bladder injury (2.91%) and one vesicovaginal fistula (0.36%), but no ureteral injury.The bladder injury rate in group 2 was 0.37%, which was significantly lower (p = 0.038). There were no significant differences in ureteral or bowel injuries, pelvic hematomas, or pelvic abscesses. CONCLUSION: LAVH type IA achieved better results than type ID in preventing bladder injury.     

Modified radical vaginal hysterectomy with or without laparoscopic nerve-sparing dissection: a comparative study

OBJECTIVE: Nerve-sparing dissection of the lateral portion of the cardinal ligament (paracervical lymphadenectomy) has been recently developed with the goal of reducing the late urinary adverse effects of radical hysterectomy without impairing the outcome. This work has been carried out in order to investigate the influence of additional paracervical lymph node dissection at the time of laparoscopically assisted modified radical hysterectomy on outcome and urinary sequelae. METHODS: A total of 95 patients underwent a modified radical hysterectomy using a combined laparoscopic and vaginal approach since 1991. In 47 of these patients treated since 1996 an additional laparoscopic paracervical lymphadenectomy was performed. The operative, postoperative, and survival outcomes were assessed. In 60 patients, 32 and 28 in the groups of patients with or without paracervical dissection, respectively, a careful interview on urinary symptoms was conducted by an independent investigator. RESULTS: Paracervical dissection involves no operative complication and lenghthens the postoperative urinary retention, but has no adverse influence on long-term urinary discomfort. The yield of paracervical dissection is negligible for small tumors: no positive node was found in 38 patients with tumors less than 2 cm in diameter. The outcome of patients after minimal access surgery for tumors less than 2 cm is excellent whether or not a paracervical dissection has been performed. CONCLUSION: Paracervical dissection does not worsen the late urinary symptoms after vaginal radical hysterectomy. It has a limited value in the surgical management of small-size (less than 2 cm) cervical cancers, although it may prevent long-term lateropelvic recurrences.     

Thirty-day postoperative mortality after hysterectomy in women with liver cirrhosis: a Danish population-based cohort study

BACKGROUND: Women with liver cirrhosis have a higher incidence of hysterectomy than the general population, generally because of abnormal bleeding. They may also have an increased risk of postoperative mortality and morbidity. METHODS: In the nationwide Danish National Patients Register (NPR) we identified all women diagnosed with liver cirrhosis from 1977 to 1993. From this cohort we selected all women undergoing hysterectomy. A random sample of women without liver cirrhosis undergoing hysterectomy was selected as controls. Outcome was defined as mortality within the first 30 days after discharge. Logistic regression analysis was used to estimate the association between liver cirrhosis and 30-day postoperative mortality, adjusted for age, comorbidity, and type of admission. RESULTS: Out of 8539 women with liver cirrhosis 105 underwent hysterectomy. We found a 30-day postoperative mortality of 7.6% (95% confidence interval (CI) 2.5-12.7%) and 0.6% (95% CI 0.5-0.7%) in women with and without liver cirrhosis, respectively. The crude odds ratio was 14 (95% CI 6.5-29) and the adjusted odds ratio was 11 (95% CI 4.8-24) for 30-day postoperative mortality in women with liver cirrhosis compared with non-cirrhotic controls. CONCLUSION: Hysterectomy in women with liver cirrhosis is associated with an 11-fold increased risk of death within the first 30 days after discharge.     

Hysterectomy technique and risk of pelvic organ prolapse repair: a Danish nationwide cohort study

Purpose

The purpose was to investigate, in a large cohort, how hysterectomy technique influences the incidence of subsequent pelvic organ prolapse (POP) repair among women hysterectomized for benign conditions.

Methods

From the Danish National Patient Registry, we collected data on all hysterectomies on benign indications, and all POP operations performed in Denmark from January 1, 1977 to June 10, 2016. We excluded patients with prior POP repair. We analyzed the incidence of POP surgery by cumulative incidence curves and hazard ratio (HR) for women with and without POP diagnoses or concomitant POP repair at hysterectomy.

Results

In all, 178,282 women underwent hysterectomy in the study period and were included in the cohort. When examining the crude HR for the risk of POP repair after hysterectomy, vaginal hysterectomy (VH) had a threefold rise in HR compared to total abdominal hysterectomy (TAH). When restricting the analyses to women without POP at time of hysterectomy, the HR for VH decreased to 1.25. The same tendency was noticed when stratifying by compartment. In the subgroup of women without POP at hysterectomy, we found that supravaginal abdominal hysterectomy had a small increase in risk compared to TAH. Laparoscopic hysterectomy had the same risk of POP as TAH.

Conclusions

Overall, we found only small differences in risk of POP repair between the different hysterectomy techniques after restricting the analyses to women without POP at hysterectomy.