Why vaginal hysterectomy?

The article presents current view on vaginal hysterectomy. Arguments in favour of this miniinvasive, minimal access surgical technique are presented. In conclusion the authors underline that vaginal hysterectomy is a cheap, miniinvasive technique which doesn't require expensive, sophisticated equipment and, what is the most important, which is relatively easy to learn. Due to these advantages, if hysterectomy is necessary, vaginal route should be considered as a technique of choice. While taking a decision which technique to choose, a surgeon should rather look for contraindications for vaginal hysterectomy than indications for this technique.     

Laparoscopically assisted vaginal hysterectomy. A suitable substitute for abdominal hysterectomy?

OBJECTIVE: To compare short-term clinical results in a retrospective case-control review of laparoscopically assisted vaginal hysterectomy (LAVH) versus total abdominal hysterectomy (TAH). STUDY DESIGN: One hundred seventeen women undergoing laparoscopically assisted vaginal hysterectomy were compared to 117 women undergoing total abdominal hysterectomy, with or without bilateral salpingo-oophorectomy. The perioperative and postoperative courses of the matched groups were compared. RESULTS: The time intraoperatively was longer in the LAVH group. The mean blood loss was increased in the LAVH group. The need for blood transfusion was higher in the LAVH group. The number of women with intraoperative complications differed significantly between LAVH and TAH. The number of postoperative complications did not. Postoperative time in the hospital was shorter in the LAVH group. The cost of the average case, including operating room time, instruments and hospital stay, did not differ. CONCLUSION: LAVH offers benefits to patients in the form of less time in the hospital and presumably, therefore, faster recovery, though at the expense of potentially longer intraoperative time, increased risk of blood transfusion and increased risk of intraoperative complications.     

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.     

Vaginal versus transabdominal hysterectomy: is mode of hysterectomy to influence pelvic statics or is pelvic statics to influence mode of hysterectomy?

BACKGROUND: To check the hypothesis that the mobility of the urethrovesical junction in the preoperative phase is different in women that will undergo either vaginal, abdominal, or laparoscopic-assisted vaginal hysterectomy. METHODS: Eighty-seven consecutive hysterectomies, carried out between January 1999 and December 2001 in our Department, were retrospectively considered. The type of surgical procedure as well as the approach was decided by the surgeon, according to personal experience. Each patient underwent a preoperative transperineal ultrasound, measuring urethral mobility. The ultrasounds were repeated 1 month and 1 year after surgery. RESULTS: In 35 out of 36 women (97.2%) that underwent vaginal hysterectomy and in nine out of 12 (75%) that underwent laparoscopic-assisted vaginal hysterectomy, we detected a high level of urethral mobility in the preoperative phase, compared with nine out of 39 (23.1%) women that underwent transabdominal hysterectomy. CONCLUSIONS: The results of our study allow us to confirm our starting hypothesis. Statistical analysis highlights that preoperative data are significantly different for the three types of hysterectomies, both as urethral mobility values (analysis of variance P相似文献   

Does hysterectomy affect genital sensation?

OBJECTIVES: To evaluate vaginal and clitoral sensation before and after hysterectomy and to assess pre- and post-surgery changes in sexual function. STUDY DESIGN: Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina and clitoris 1 day prior to and 3 months following surgery. A survey was performed 18 months following operation to evaluate long-term changes in sexual function. PARTICIPANTS: Twenty-seven women, aged 30-57 years, who were admitted for elective hysterectomy. MAIN OUTCOME MEASURES: Genital sensation and reported sexual function. RESULTS: There was significant deterioration in sensation to cold and warm stimuli at the anterior and posterior vaginal wall after surgery. Vaginal vibratory sensation thresholds tended to increase. Clitoral thermal and vibratory sensation thresholds remained unchanged before and after surgery. Of the 22 patients who participated in the follow-up survey, 17 did not report any decline in sexual function, while 4 patients reported deterioration in genital sensation and in sexual function. CONCLUSION: The results demonstrate quantifiable sensory loss in the vagina after hysterectomy, with preservation of clitoral sensation. Only a minority of patients reported a decline in their sexual function. These findings highlight the relative importance of clitoral as compared to vaginal sensation in sexual function.     

Laparoscopic assisted vaginal hysterectomy (LAVH) — An effective alternative to conventional abdominal hysterectomy

Objectives

To compare LAVH with TAH in terms of indications, operable uterine size, operative time, intraoperative blood loss, complications, postoperative pain and hospital stay, convalescence and average total cost; also to evaluate LAVH for its feasibility in patients with previous abdominal surgery and those requiring other surgical procedures.

Material and Methods

Aretrospective study was conducted on 550 patients (350 patients of LAVH, 200 patients of TAH) who underwent surgery at Fortis Escorts Hospital, Faridabad, between January 2005 and May 2007. Statistical analysis was done using Student-t test and Chisquare test.

Results

On comparing LAVH with TAH, the mean operative time was 63 vs 55 min (p<0.001), blood loss 116 vs 150ml (p<0.001), major complication rate 2% vs 5% hospital stay 2.7 vs 5.7 days (p<0.001). Patients of LAVH had statistically significant lower pain scores, higher activity scores, shorter convalescence and quicker resumption of normal activity. LAVH was marginally costlier than TAH.

Conclusion

LAVH enables the surgeon to convert most of the difficult abdominal hysterectomies into vaginal ones with all the benefits of a vaginal procedure. It is also a feasible and safe procedure in patients with previous abdominal surgery, large uteri and adnexal masses. LAVH enjoys patient’s support with lesser postoperative pain, shorter hospital stay, rapid return to normal activity and better body image.     

Robotic hysterectomy versus conventional laparoscopic hysterectomy: Outcome and cost analyses of a matched case–control study

Objective

Robotic surgery, with its technical advances, promises to open a new window to minimally invasive surgery in gynaecology. Feasibility and safety of this surgical innovation have been demonstrated in several studies, and now a critical analysis of these new developments regarding outcome and costs is in place. So far only a few studies compare robotic with conventional laparoscopic surgery in gynaecology. Our objective was to evaluate our initial experience performing total robot-assisted hysterectomy with the da Vinci^® surgical system and compare peri-operative outcome and costs with total laparoscopic hysterectomy.

Study design

For this prospective matched case–control study at our institution, peri-operative data from our first 40 consecutive total robot-assisted hysterectomies for benign indications were recorded and matched 1:1 with total laparoscopic hysterectomies according to age, BMI and uterus weight. Surgical costs were calculated for both procedures. Surgeons’ subjective impressions of robotics were evaluated with a self-developed questionnaire.

Results

No conversions to laparotomy or severe peri-operative complications occurred. Mean operating time was 109 (113; 50–170) min for the robotic group and 83 (80; 55–165) min for the conventional laparoscopic group. Mean postoperative hospitalisation for robotic surgery was 3.3 (3; 2–6) days versus 3.9 (4; 2–7) days for the conventional laparoscopic group. Average surgical cost of a robot-assisted laparoscopic hysterectomy was €4067 compared to €2151 for the conventional laparoscopic procedure at our institution. For the robotic group wider range of motion of the instruments and better ergonomics were considered to be an advantage, and lack of direct access to the patient was stated as a disadvantage.

Conclusion

Robot-assited hysterectomy is a feasible and interesting new technique with comparable outcome to total laparoscopic hysterectomy. Operating times of total laparoscopic hysterectomy seem to be achieved quickly especially for experienced laparoscopic surgeons. However, costs of robotic surgery are still higher than for conventional laparoscopy. Randomised clinical trials need to be conducted to further evaluate benefits of this new technology for patients and surgeons and analyse its cost-effectiveness in gynaecology.     

Women’s preference for laparoscopic or abdominal hysterectomy

In the present study, women’s preferences on advantages and disadvantages of laparoscopic hysterectomy (LH) and abdominal hysterectomy (AH) have been studied. Patients’ preferences were evaluated in individual, structured interviews in women scheduled for hysterectomy and questionnaires in nurses. Forty-three patients and 39 nurses were included. After general information, 84% of patients and 74% of nurses preferred LH over AH. This preference did not change after supplying more detailed information or after hysterectomy. The avoidance of complications was indicated as the most important factor in the decision. More than half of the women evaluated a difference of 1% as the maximum acceptable risk of major complications. When confronted with scenarios based on current evidence, both patients and nurses prefer LH over AH. This study supports further implementation of LH in clinical practice. The actual major complication rate in hysterectomy, however, is perceived as high. I declare that the experiments comply with the current laws of the Netherlands. No financial support and no conflict of interest to declare. I had full control of all primary data of the study and I would allow the journal to review the data if requested.     

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.