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.     

Vaginal hysterectomy: is previous pelvic operation a contraindication?

A retrospective comparison was undertaken between the responses to vaginal hysterectomy of women who had previous pelvic surgery and those who had not. Of 1563 vaginal hysterectomies performed over a 10-year period, 39% had previously undergone pelvic procedures. 6.9% of the patients who had previous pelvic surgery had major complications and 31.2% had minor complications. 6.1% of the 942 patients not previously operated had major complications and 31.8% had minor complications. The range of complications was similar in both groups. The authors conclude that previous pelvic surgery is not a contraindication for vaginal hysterectomy.     

Laparoscopic-assisted radical parametrectomy including pelvic and/or paraaortic lymphadenectomy in women after prior hysterectomy-three cases

BACKGROUND: Radical abdominal surgery in patients who have previously undergone a hysterectomy is a surgical challenge. This type of surgery for invasive cervical cancer after a hysterectomy or vaginal stump metastasis traditionally requires a major laparotomy; however, a minimal-access approach is now being applied to this type of procedure. CASE: A laparoscopic-assisted radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy was performed on two patients presenting invasive cervical cancer diagnosed after a simple hysterectomy and one patient with recurred endometrial cancer in the vaginal stump. All three patients had an excellent clinical outcome and made a rapid recovery with no major complications, even though two cases involved a bladder laceration. CONCLUSION: A laparoscopic radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy is a viable technique for women with invasive cervical cancer or recurrent endometrial vaginal cancer after a prior hysterectomy.     

Vaginal vault suspension for prolapse after hysterectomy using an autologous fascial sling of rectus sheath

Objective To evaluate the results of a modified rectus sheath fascial sling used as a treatment for vaginal.
Design Retrospective analysis of case records.
Setting District General Hospital in South Wales.
Participants Ten women who had had a hysterectomy 2 to 20 years previously (mean 8 years).
Results All the women were cured of symptoms related to vaginal vault prolapse. There were no intra-operative complications. No new urinary symptoms have developed. One woman developed an enterocele which was corrected by the abdominal insertion of a prolene mesh.
Conclusion A modified rectus sheath fascial sling is a safe, simple effective abdominal operation for the surgical correction of vaginal vault prolapse after hysterectomy. vault prolapse after hysterectomy.     

Total laparoscopic hysterectomy versus vaginal hysterectomy: a prospective randomized trial

AIM: The aim of the study was to compare the effects of total laparoscopic hysterectomy with those of vaginal hysterectomy. METHODS: We conducted a prospective randomised trial on 400 patients who agreed to be randomized to either laparoscopic total hysterectomy or vaginal hysterectomy. They were monitored for one year to evaluate the rate of major complications and the results on quality of life. RESULTS: Total laparoscopic hysterectomy was associated with a higher rate of major haemorrhages and ureteric injuries than vaginal hysterectomy (7% vs 2.5% and 2.5% vs 0%; P<0.05) only during the first year of study according to a normal learning-curve. It took longer to perform (85.9 min vs 46.6 min), but was less painful (visual analogue scale 5.3 vs 6.0; P<0.01) and there was a shorter stay in hospital after the operation (2.9 vs 3.3 days). Six weeks after the operation, total laparoscopic hysterectomy was associated with less pain and better quality of life than vaginal hysterectomy (SF-12). CONCLUSION: Total laparoscopic hysterectomy was associated with a significantly higher rate of major haemorrhages and ureteric injuries than vaginal hysterectomy only during the first year of study according to a normal learning-curve. It took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life.     

Risk of urge and stress urinary incontinence at long-term follow-up after vaginal hysterectomy

OBJECTIVE: The purpose of this study was to evaluate the prevalence of urinary symptoms at long-term follow-up after vaginal hysterectomy. STUDY DESIGN: One hundred seventeen patients who had a vaginal hysterectomy for menorrhagia from January 1991 to December 2001 answered a self-report questionnaire about de novo urinary symptoms. The control group was a population of 116 patients who had a conservative treatment for dysfunctional uterine bleeding by endometrial thermocoagulation from January 1994 to December 2001. RESULTS: Patient characteristics (mean age, mean parity, menopausal status, smoking status, drink habits) were similar in the 2 groups. Mean follow-up was 4.6+/-2.2 years (range, 1.5-11 years) after vaginal hysterectomy and 4+/-1.8 years (range, 1.5-7 years) after conservative treatment. The prevalence of urinary symptoms, which included urge and stress incontinence, was statistically similar in the 2 groups. CONCLUSION: This study reveals no risk of urge or stress urinary incontinence at long-term follow-up after vaginal hysterectomy, compared with conservative treatment.     

Is vaginal hysterectomy a risk factor for urinary incontinence at long-term follow-up?

OBJECTIVE: The purpose of this study was to evaluate the prevalence of urinary symptoms at long-term follow-up after vaginal hysterectomy. STUDY DESIGN: One hundred and seventeen patients, who had a vaginal hysterectomy for menorrhagia, from January 1991 to December 2001, answered to a self-report questionnaire about de novo urinary symptoms. The control group was a population of 116 patients who had a conservative treatment for dysfunctional uterine bleeding by endometrial thermocoagulation from January 1994 to December 2001. RESULTS: Patient characteristics (mean age, mean parity, menopausal status, smoking status, drink habits) were similar in the two groups. Mean follow-up was 4.6+/-2.2 years (range 1.5-11) after vaginal hysterectomy and 4+/-1.8 years (range 1.5-7) after conservative treatment. The prevalence of urinary symptoms, included urge and stress incontinence, were statistically similar in the two groups. CONCLUSION: This study reveals no risk of urge or stress urinary incontinence at long-term follow-up after vaginal hysterectomy, compared with conservative treatment.     

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.     

Outcome of uterine embolization and hysterectomy for leiomyomas: results of a multicenter study

OBJECTIVE: The purpose of this study was to estimate the outcomes of uterine embolization and hysterectomy for uterine leiomyomas.Study design This was a multicenter prospective study of patients who were treated with embolization (n=102 patients) and hysterectomy (n=50 patients) for leiomyomas. Changes in symptoms, complications, and quality of life were measured. The data analysis included linear and logistic regression, the Student t and paired t test, Fisher's exact test, and chi-squared test. RESULTS: For patients who underwent embolization, there were marked reductions in blood loss scores (P <.001) and menorrhagia questionnaire scores (P <.001) compared with baseline. At 12 months, a larger proportion of the patients who had undergone hysterectomy experienced improved pelvic pain (P=.021). Both groups had marked improvement in other symptoms and quality of life scores, with no difference between groups. Complications were more frequent in patients who underwent hysterectomy (50% vs 27.5%; P=.01). CONCLUSION: Both procedures substantially improved symptoms for most patients, with an advantage for hysterectomy at 12 months for pelvic pain. Serious complications were infrequent in both groups.     

Hysterectomies in patients with no history of vaginal delivery. A study of 243 cases

OBJECTIVE: The object of this study was to audit the policy of hysterectomy in nulliparous women in a university hospital. PATIENTS AND METHODS: A retrospective medical records analysis of all hysterectomies performed during an 8-year period. Patients with no history of vaginal delivery were stratified into three groups: group 1, patients who underwent abdominal hysterectomies; group 2, patients undergoing vaginal hysterectomy (2a) or laparoscopy-assisted vaginal hysterectomy (2b). The groups were compared as to demographic data, surgical complications and outcomes. RESULTS: During the study period, there were 243 hysterectomies in patients with no history of vaginal delivery. Among these, vaginal hysterectomies (group 2) were undertaken in 75% (182 patients) and successfully performed in all but 13 patients (7.1%). Mean uterine weight was 943 grams in group 1 and 370 grams in group 2. Abdominal route (group 1) was associated with longer operative time (average: 105 min) than vaginal route (group 2a; 81 min) but shorter operative time that laparoscopy-assisted vaginal route (group 2b; 173 min). There was no significant difference in mean estimated blood loss and complications rates between groups 1 and 2. Hospital stay was shorter in group 2. Laparoscopic assistance was not associated with bigger uteri, neither with fewer complications. DISCUSSION AND CONCLUSION: Nulliparity should no longer be considered a contraindication to vaginal hysterectomy. In such patients, many more hysterectomies should be carried out vaginally and laparoscopic assistance does not offer obvious advantages over the standard vaginal approach.     

Risk factors for vaginal prolapse after hysterectomy

Objective

To identify risk factors for pelvic organ prolapse (POP) and their influence on the occurrence of vaginal prolapse after hysterectomy.

Methods

Medical records from 2 groups of women who had undergone hysterectomy were reviewed retrospectively. The study group was 82 women who had undergone surgery for vaginal prolapse after hysterectomy; the control group was 124 women who had undergone hysterectomy with no diagnosis of vaginal prolapse by the time of the study. All hysterectomy procedures had been performed for benign gynecological disease, including POP. Both groups of women completed a self-administered questionnaire to obtain additional information on the occurrence of POP.

Results

The incidence of vaginal prolapse after hysterectomy was significantly higher in women with a higher number of vaginal deliveries, more difficult deliveries, fewer cesareans, complications after hysterectomy, heavy physical work, neurological disease, hysterectomy for pelvic organ prolapse, and/or a family history of pelvic organ prolapse. Premenopausal women had vaginal prolapse corrected an average of 16 years after hysterectomy, and postmenopausal women 7 years post hysterectomy.

Conclusion

Before deciding on hysterectomy as the approach to treat a woman with pelvic floor dysfunction, the surgeon should evaluate these risk factors and discuss them with the patient.     

Transvaginal evisceration after hysterectomy: Is vaginal cuff closure associated with a reduced risk?

OBJECTIVE: To evaluate the overall incidence of transvaginal evisceration following hysterectomy and to assess the risk associated with indication, route of surgery, age and vaginal cuff closure technique. MATERIALS AND METHODS: A database was used to identify all patients undergoing hysterectomy from 1995 to 2001 at our institution and all the patients admitted for vaginal evisceration during the same period. Each vaginal evisceration was analyzed for time of onset, trigger event, presenting symptoms, details of prolapsed organs and type of repair surgery. RESULTS: Of the 3593 patients enrolled in the study, 63.5% underwent abdominal hysterectomy, 33.0% vaginal hysterectomy, and 3.5% laparoscopic hysterectomy. Ten patients (0.28%) presented to the emergency room with vaginal evisceration. No statistical differences in evisceration rates were seen according to the route of surgery. No differences were found between the 1440 patients who had closure of the vaginal cuff and the 2153 who had an unclosed cuff closure technique. CONCLUSIONS: Our data suggest that, in young patients, sexual intercourse is to be considered the main trigger event before the complete healing of the vaginal cuff while, in elderly patients, the evisceration is a spontaneous event. Uterine prolapse was not associated with a higher rate and the route of surgery or vaginal cuff closure technique did not influence the dehiscence rate.     

Laparoscopic assisted vaginal hysterectomy in obese women.

Twenty-two consecutive patients weighing 100 kg or more and requiring hysterectomy were treated by laparoscopic assisted vaginal hysterectomy. The mean patient weight was 105.2 kg. In 21 patients, the indication for hysterectomy was menorrhagia (9 of these had uterine fibroids) and one patient had microinvasive carcinoma of the cervix. Mean operating time was 1 hr. 53 mins; and mean hospital stay was 4.5 days. One patient (4.5%) had intraoperative injury to the interior epigastric vessels. One patient who had anterior colporrhaphy at the same time suffered transient urinary retention which resolved after one week. There were no major or long term complications. Our experience suggests that laparoscopic assisted vaginal hysterectomy is a feasible and safe option in obese patients. The low complication rate may be due, in part, to improved access through the use of this approach.     

The Manchester operation for uterine prolapse.

OBJECTIVE: To evaluate the clinical characteristics, complications, and satisfaction scores of patients who underwent the Manchester operation. METHODS: This retrospective observational study evaluated data from 204 women who underwent the Manchester operation at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey, from January 1985 to April 2004. RESULTS: Mean age was 34.68+/-4.24 years and parity 2.47+/-0.96; 85.8% of the patients were premenopausal; 176 patients (86.28%) had grade 3 and 28 (13.72%) had grade 2 uterine prolapse; 95.1% of the patients had associated cystoceles and 51.3% had associated rectoceles; and 81.4% had urinary incontinence. Regarding early postoperative complications, 27 patients (13.23%) had febrile morbidity; retroperitoneal hematoma occurred in 1 patient (0.49%); urinary retention occurred in 45 patients (22.05%), and cervical stenosis occurred in 23 patients (11.27%). At 1 year, 1 patient had undergone abdominal hysterectomy because of unsuccessful cervical dilatation; and a mean of 3.6 years following the operation, 8 patients (3.9%) had undergone the tension-free vaginal tape procedure plus a vaginal hysterectomy for recurrent stress urinary incontinence and uterine prolapse. The mean satisfaction/acceptance score for the operation was 8.52+/-2.13 (range, 2-10). CONCLUSION: A high degree of acceptance/satisfaction and a low morbidity rate show the Manchester operation to be a good option for the treatment of uterine prolapse in women who wish to keep their uterus.     

Use of MRI for evaluation of retained uterine fundus mimicking a pelvic mass

Increased use of less invasive hysterectomy techniques requires awareness of the unique potential complications they pose in patients with continued symptoms after surgery. Retained uterine fundus is rare after vaginal hysterectomy; only 2 other cases have been reported in the English literature. Magnetic resonance imaging (MRI) was not used preoperatively in either case. However, imaging evaluation, in particular with MRI because of its superior soft tissue resolution, can be helpful in suggesting the diagnosis. Herein is presented the case of a 40-year-old woman who had undergone vaginal hysterectomy several years previously, but was experiencing abdominal pain. MRI was performed, which revealed a supravesical mass. Visualization at MRI of intact round ligaments arising from the mass favored the diagnosis of retained uterine fundus and confirmed after surgical excision.     

Emergency obstetric hysterectomy

BACKGROUND: All cases of obstetric hysterectomies that were performed in our hospital during a seven-year study period were reviewed in order to evaluate the incidence, indications, risk factors, and complications associated with emergency obstetric hysterectomy. METHODS: Medical records of 45 patients who had undergone emergency hysterectomy were scrutinized and evaluated retrospectively. Maternal age, parity, gestational age, indication for hysterectomy, the type of operation performed, estimated blood loss, amount of blood transfused, complications, and hospitalization period were noted and evaluated. The main outcome measures were the factors associated with obstetric hysterectomy as well as the indications for the procedure. RESULTS: During the study period there were 32,338 deliveries and 9,601 of them (29.7%) were by cesarean section. In this period, 45 emergency hysterectomies were performed, with an incidence of 1 in 2,526 vaginal deliveries and 1 in 267 cesarean sections. All of them were due to massive postpartum hemorrhage. The most common underlying pathologies was placenta accreta (51.1%) and placenta previa (26.7%). There was no maternal mortality. CONCLUSIONS: Obstetric hysterectomy is a necessary life-saving procedure. Abnormal placentation is the leading cause of emergency hysterectomy when obstetric practice is characterized by a high cesarean section rate. Therefore, every attempt should be made to reduce the cesarean section rate by performing this procedure only for valid clinical indications.     

Challenging generally accepted contraindications to vaginal hysterectomy

OBJECTIVE: A number of preexisting clinical conditions are generally accepted as contraindications to vaginal hysterectomy. The purpose of this study was to evaluate the validity of this concept. STUDY DESIGN: The study vaginal hysterectomy group consisted of 250 consecutive patients undergoing vaginal hysterectomy. These patients (1) had a large uterus (>180 g), (2) either were nulliparous or had no previous vaginal delivery, or (3) had a previous cesarean delivery or pelvic laparotomy. Three control groups used for comparison underwent (1) laparoscopically assisted vaginal hysterectomy, (2) vaginal hysterectomy, or (3) abdominal hysterectomy. The records for all patients were analyzed for age, weight, parity, primary diagnosis, uterine size, operative time, blood loss, analgesia, hospital stay, resumption of diet, incidence of morcellation, and surgical complications. Sample size calculations were based on previous studies of complications associated with vaginal hysterectomy (alpha =.05; beta =.20). RESULTS: Hysterectomy was successfully completed by the intended vaginal route in all study patients. Major and minor complications (3.2%) were significantly less (P <.001) than in the other groups as follows: vaginal hysterectomy, 10.4%; laparoscopically assisted vaginal hysterectomy, 11.6%; and abdominal hysterectomy, 13.6%. The decrease in hematocrit was 5.7% in the study vaginal hysterectomy group compared with 6.2% for vaginal hysterectomy, 6.5% for abdominal hysterectomy (P =.009), and 6.6% for laparoscopically assisted vaginal hysterectomy (P =.002). Hospital stay was shorter for the study group (2.1 days) than for vaginal hysterectomy (2.3 days; P <.001) and abdominal hysterectomy (2.7 days; P <.001). Operative time was shorter in the study vaginal hysterectomy group (49 minutes) than with laparoscopically assisted vaginal hysterectomy (76 minutes; P <.001) or abdominal hysterectomy (61 minutes; P <.001), although morcellation was carried out more frequently in the study group (34%) than with vaginal hysterectomy (4%) or laparoscopically assisted vaginal hysterectomy (11%). CONCLUSION: Our data indicate that a large uterus, nulliparity, previous cesarean delivery, and pelvic laparotomy rarely constitute contraindications to vaginal hysterectomy.     

Subtotal abdominal hysterectomy: a surgical advance or a backward step?

Objective To review the short and medium term outcomes of subtotal abdominal hysterectomy. We also describe the management of cervical stump complications by vaginal trachelectomy or large loop excision of the transformation zone.
Design Retrospective analysis.
Setting Warwick General Hospital, Warwickshire, UK.
Sample One hundred and fifty women underwent subtotal abdominal hysterectomy between 1993 and 1999. Five women had vaginal trachelectomy and another five had large loop excision of the transformation zone for complications relating to the cervical stump.
Results The prevalence of intra-operative and early post-operative complications was 4% and 7.3%, respectively. Twenty women (13.3%) had late complications, of whom 17 (11%) presented with symptoms directly related to the stump (two had also genuine stress incontinence). Three presented with genuine stress incontinence alone. The commonest problem was regular menstruation, which occurred in 12 women (8%). Ten of these women underwent vaginal trachelectomy or large loop excision of the transformation zone. None had intra-operative or post-operative complications.
Conclusions The high prevalences of cervical stump problems should be taken into account before a change in surgical procedure from total to subtotal hysterectomy is recommended. Further prospective studies with prolonged follow up are needed to evaluate the risks and benefits of retaining the cervix at hysterectomy. Total hysterectomy, preferably by the vaginal route, remains the procedure of choice for most women. Should a problem develop, vaginal trachelectomy or large loop excision of the transformation zone by an experienced surgeon are the best options for these women.     

The Hohl instrument for optimizing total laparoscopic hysterectomy procedures

STUDY OBJECTIVE: To evaluate the feasibility of total laparoscopic hysterectomy (TLH) using the Hohl instrument in an initial cohort of patients. DESIGN: Retrospective cohort analysis (Canadian Task Force classification II-3). SETTING: Department of Obstetrics and Gynecology, Erlangen University Hospital, Erlangen, Germany. PATIENTS: Forty-four women underwent the new TLH procedure using the Hohl instrument from May 2004 through January 2005. The laparoscopic approach was used when the patient had undergone more than one previous pelvic abdominal operation and/or had a reduced vaginal capacity. The indications for hysterectomy were symptomatic leiomyoma in 25 patients and hypermenorrhea in 19 patients. INTERVENTION: Total laparoscopic hysterectomy using the Hohl instrument. MEASUREMENTS AND MAIN RESULTS: No ureteral or bladder injury occurred in any of the patients. The complication rate during surgery and in the postoperative period was zero. The mean loss of hemoglobin was 1.68+/-0.96 g/dL, the mean operating time was 108+/-21 minutes, and the mean uterine weight was 302+/-121 g. CONCLUSION: Total laparoscopic hysterectomy using the Hohl instrument simplifies the surgical procedure. The reported technique is an option comparable with laparoscopic-assisted vaginal hysterectomy and may be effective in preventing minor and major complications during TLH.