Comparison of one- and two-layer vaginal cuff closure and open vaginal cuff during laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To evaluate clinical outcomes of three surgical techniques during laparoscopic-assisted vaginal hysterectomy. DESIGN: Prospective, randomized study (Canadian Task Force classification I). SETTING: Medical school-affiliated hospital. PATIENTS: Four-hundred twenty-seven women. INTERVENTION: By means of a computer-generated randomization code, patients were assigned immediately before operation to one of three groups according to type of surgical procedure: group 1, 147 women having one-layer closure of the vaginal cuff; group 2, 138 having two-layer closure of the vaginal cuff; and group 3, 142 having open vaginal cuff. MEASUREMENTS AND MAIN RESULTS: Patients were observed for morbidity during hospitalization, and 1 and 6 weeks and 6 months postoperatively. No significant differences were found among the groups for length of surgery, operative blood loss, postoperative hematocrit, length of hospital stay, postoperative febrile morbidity, frequency of pelvic and urinary tract infection, dyspareunia, postcoital spotting, vaginal discharge, and morbidity of the cuff (cellulitis, abscess formation, bleeding, hematoma, dehiscence). Operating time was greatest for two-layer closure. The frequency of postoperative granulation of cuff tissue and vaginal discharge was greater for group 1 than for the other two groups. CONCLUSION: Two-layer closure of the vaginal cuff during laparoscopic-assisted vaginal hysterectomy is associated with fewer instances of vaginal vault granulation and vaginal discharge than either one-layer closure or open vaginal cuff.     

Outpatient laparoscopic-assisted vaginal hysterectomy

Study Objective.To compare laparoscopic-assisted hysterectomy (LAVH) with conventional abdominal hysterectomy.Design.First 50 consecutive LAVH procedures.Setting.An outpatient facility at a major medical center (35 procedures) and a nonhospital free-standing surgicenter (15).Patient.Sequential sample of 50 women requiring hysterectomy.Interventions.LAVH in 46 women, converted to open laparotomy in 4.Measurements and Main Results.Outpatient LAVH was performed successfully in the majority of women. Most patients had significant uterine enlargement, pelvic adhesions, or endometriosis. Only six required replacement of autologous blood postoperatively. Other complications were cystotomy and postoperative pelvic hematoma in one patient each.Conclusions.LAVH can be performed safely in free-standing surgicenters. It offers several advantages to patients, and is considered cost effective by third-party payers.     

Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To compare laparoscopic supracervical hysterectomy (LSH) with laparoscopic-assisted vaginal hysterectomy (LAVH) in terms of indications, pathology, length and weight of removed uteri, operative time, intraoperative blood loss, intra and postoperative complications, and later sexual function. DESIGN: Cohort retrospective analysis of consecutive cases (Canadian Task Force classification II-3). SETTINGS: Hutzel Hospital, Detroit Medical Center,Wayne State University, Detroit, Michigan; Vert-Pre Nouvelle Clinique, Geneva, Switzerland; and Benha University Hospitals, Egypt. PATIENTS: Two hundred and fifty-nine women. INTERVENTIONS: LSH and LAVH. MEASUREMENTS AND MAIN RESULTS: Patients in both groups were matched regarding age, indications, and pathology of the removed uteri. Blood loss with the LSH procedure was significantly lower than it was with the LAVH procedure (mean 125 +/- 5 vs 149 +/- 7 mL, p =.001). Patients that underwent LSH had significantly shorter operating times (mean 120 +/- 3 vs 150 +/- 5 minutes, p =.007). The length of the removed uteri was 14.2 +/- 0.5 cm (range 5.2-18) in the LSH group versus 11.8 +/- 0.4 cm (range, 5.6-14) in the LAVH group. Weight of the removed uteri was 280 +/- 6 g (range, 65-750) in the LSH group compared with 235 +/- 8 g (range, 59-560) in the LAVH group. There was no difference between the groups in hospital length of stay. The number of complications was less in the LSH group (3/123, 2.4%) compared with 5/136 (3.7%) in the LAVH group. Sexual function after surgery was better in the LSH group. CONCLUSION: After exclusion of preoperative cervical disease, LSH can be considered as a safer alternative to LAVH in patients that are candidates for laparoscopic hysterectomy.     

Pneumothorax complicating laparoscopic-assisted vaginal hysterectomy

Right pneumothorax occurred 2 days after laparoscopic-assisted vaginal hysterectomy. The mechanism was most likely CO2 diffusion from pneumoperitoneum through a diaphragmatic defect. It is essential to be aware of this rare complication because of its late onset after the surgical procedure.     

The laparoscopic-assisted vaginal approach to early endometrial cancer

Introduction  

For the surgical treatment of endometrial cancer laparotomy still is regarded as the gold standard. Over the past decade, the laparoscopic approach has gained equivalence in FIGO stage I carcinomas.     

Vaginal cuff dehiscence after hysterectomy

Objective

To determine the incidence of vaginal cuff dehiscence (VCD) among women undergoing hysterectomy according to clinico-surgical factors including surgical route, and to describe patient characteristics associated with VCD.

Methods

In a retrospective study, the medical records of all women who underwent hysterectomy between January 2005 and March 2011 at a university teaching hospital in Seoul, Republic of Korea, were reviewed. The incidence of VCD was determined in relation to the following factors: patient age, hysterectomy route, indication for hysterectomy, and extent of resection (either simple or radical hysterectomy).

Results

Among 9973 hysterectomies, 37 (0.37%) cases of VCD were identified. The incidence of VCD was significantly higher after abdominal hysterectomy (0.6%) than after laparoscopic (0.2%) or vaginal (0.4%) hysterectomy (P = 0.016). Compared with laparoscopic approaches, abdominal hysterectomy was associated with a higher risk of VCD (odds ratio, 2.735; 95% confidence interval, 1.380–5.420). However, there was no significant difference in the incidence of VCD according to surgical indication or extent of resection.

Conclusion

Laparoscopic hysterectomy was found to be associated with a lower risk of VCD compared with abdominal hysterectomy. The lower risk is probably related to the different techniques used for colpotomy and cuff closure.     

Laparoscopic-assisted vaginal hysterectomy versus abdominal hysterectomy in endometrial cancer.

OBJECTIVE: To see whether laparoscopy provides exact staging and effective treatment of endometrial cancer patients, compared with total abdominal hysterectomy, with shorter hospital stay, prompter recovery, and better quality of life. METHOD: This retrospective study identified 110 patients scheduled for surgery for early-stage endometrial cancer. Fifty-five (50%) were treated by laparoscopic-assisted vaginal hysterectomy (LAVH) and 55 (50%) by total abdominal hysterectomy (TAH). All patients underwent pelvic lymphadenectomy. The majority of patients (79%) had stage I disease. RESULTS: The mean number of lymph nodes removed was 17 for the LAVH group and 18.5 for the TAH group (p = 0.294). Compared with TAH, LAVH required a significantly longer operating time (220 vs. 175 min; p < 0.01); but shorter hospital stay (4 vs. 8.5 days; p < 0.001) and less estimated blood loss (177 cm3 vs. 285 cm3; p = 0.02). Overall, there were fewer post-operative complications in the LAVH group (6 vs. 11 cases; p < 0.001). Three TAH patients (5.4%) had recurrence of disease. No LAVH patients had recurrences and all are currently disease-free. CONCLUSION: These findings suggest LAVH gives correct staging of endometrial disease, like TAH, but with fewer complications and a slightly longer operating time.     

Predictive factors of recurrence following adjuvant vaginal cuff brachytherapy alone for stage I endometrial cancer

Purpose

The purpose of this study is to identify risk factors for recurrence in a cohort of stage I endometrial cancer patients treated with vaginal cuff brachytherapy at a single academic institution.

Methods and materials

From 1989 to 2011, 424 patients with stage I endometrial cancer underwent total hysterectomy and bilateral salpingo-oophorectomy, with or without lymphadenectomy (LND), followed by high-dose-rate vaginal cuff brachytherapy (VCB) to patients felt to be high or intermediate risk FIGO stage IA and IB disease. Covariates included: 2009 FIGO stage, age, grade, histology, presence of lymphovascular space invasion, LND, and receipt of chemotherapy.

Results

With a median follow-up of 3.7 years, the 5 and 10-year disease free survival were 98.4% and 95.9%, respectively. A total of 30 patients developed recurrence, with the predominant pattern of isolated distant recurrence (57.0%). On multivariate analysis, grade 3 (p = 0.039) and LND (p = 0.048) independently predicted of increased recurrence risk. χ² analysis suggested that higher-risk patients were selected for LND, with significant differences in age, stage, and grade noted between cohorts. Distant metastatic rate was significantly higher for patients who qualified for GOG 0249 at 23.1% (95% CI 10.7–35.5%) compared to those who did not at 6.8% (95% CI 1.8–11.8%, p < 0.001).

Conclusion

Overall disease-free survival for this cohort of patients was > 95% at 10 years. Univariate analysis confirmed previously identified risk factors as predictors for recurrence. Multivariate analysis found that grade 3 and LND correlated with risk for recurrence. Of those that did recur, the initial site of relapse included distant metastasis in most cases.