Peripartum hysterectomy in Taiwan

OBJECTIVE: To investigate the incidence and associated risk factors for peripartum hysterectomy in singleton pregnancies. METHODS: A retrospective cohort study of all women with singleton pregnancies admitted for delivery in 2002 taken from the National Healthcare Insurance database. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for maternal and hospital characteristics using logistic regression. RESULTS: There were 287 peripartum hysterectomies in 214 237 singleton pregnancies (0.13%). Cesarean delivery, vaginal birth after cesarean (VBAC), and repeat cesarean delivery had higher hysterectomy rates than vaginal delivery, with adjusted ORs of 12.13 (95% CI 8.30-17.74), 5.12 (95% CI 1.19-21.92), and 3.84 (95% CI 2.52-5.86), respectively. Pregnancies complicated with placenta previa, gestational diabetes mellitus (GDM), and premature labor were associated with significantly increased risks for peripartum hysterectomy (P<0.05). CONCLUSION: Risk factors for peripartum hysterectomy included cesarean delivery, VBAC, repeat cesarean, placenta previa, GDM, and premature labor. VBAC and repeat cesarean had a similar risk.     

Emergency peripartum hysterectomy in a teaching hospital in Eastern Taiwan.

This study aims to review the incidence, indications, risk factors and complications associated with emergency peripartum hysterectomy in a teaching hospital. We reviewed records of patients undertaking emergency peripartum hysterectomy performed at our institution from 1998 to 2004. Emergency peripartum hysterectomy was defined as one performed for haemorrhage unresponsive to other treatments <24 h after delivery. Eight cases of emergency peripartum hysterectomy were performed. The rate of peripartum hysterectomy was 0.25%. The main indications for hysterectomy were uterine atony and abnormal placentation. No maternal death occurred. Use of peripartum hysterectomy may become necessary in managing obstetrical haemorrhage refractory to other measures.     

Long-term effect of hysterectomy on urinary incontinence in Taiwan

ObjectiveTo investigate the effect of hysterectomy on urinary incontinence (UI) in Taiwanese women aged 60 or older.Materials and MethodsA nationwide epidemiologic study was conducted and a total of 2410 women were selected by a multistage random sampling method. Face-to-face interviews with 1517 women were completed. The prevalence of UI by hysterectomy, route of hysterectomy, medical reasons for hysterectomy, and years after hysterectomy were assessed by frequency and Pearson’s χ² test using a significance level of less than 0.05.ResultsThe prevalence of hysterectomy in Taiwanese women aged 60 or older was 8.83% (134/1,517). Hysterectomy is a risk factor of UI (p = 0.003) with the prevalence of UI estimated to be 42.38% (59/134) and that of nonhysterectomy group to be 27.96% (425/1380). Route of hysterectomy (p = 0.825), reason for hysterectomy (p = 0.060), and how many years after hysterectomy has been performed (p = 0.562) were not associated with deteriorating symptoms of UI.ConclusionThere is a high prevalence of UI among women who have performed hysterectomy, but there is no significant relationship between UI and route of hysterectomy, reason for hysterectomy, including cervical cancer and uterine prolapsed, or year after hysterectomy.     

A prospective study of nerve-sparing radical hysterectomy for uterine cervical carcinoma in Taiwan

ObjectiveSurgical therapy for cervical carcinoma carries a significant risk of functional impairment to the bladder. This study evaluates the feasibility and complications of nerve-sparing radical hysterectomy (NRH) in Taiwan.MethodsBetween March 2010 and March 2011, consecutive patients diagnosed with early stage cervical cancer (FIGO stage Ia2 to Ib1) and tumor size < 3 cm were recruited prospectively to undergo NRH or conventional radical hysterectomy (RH). Patients with histories of urinary stress incontinence or bladder dysfunction disease were excluded. A modified Tokyo nerve-sparing radical hysterectomy was performed.ResultsA total of 30 patients were enrolled. Among these, 18 patients underwent NRH with successful bilaterally nerve-sparing procedures in 15 cases (83%), unilaterally nerve-sparing procedures in 2 cases (11%), and a failure in 1 case (6%). The indwelling catheter was removed on postoperative day 6. The mean ± SD duration from operation to spontaneous voiding was 6.8 ± 1.5 days for women who underwent NRH; the corresponding duration for women who underwent RH or failed NRH was 20.6 ± 3 days. None of the patients who underwent NRH required intermittent catheterization. All 12 patients who underwent RH needed self-catheterization after discharge. There was a significant reduction in the incidence of postoperative self-catheterization (p < 0.01) and bladder dysfunction (p < 0.006). Average satisfaction score analyzed by the Likert-scale questionnaire was 4.5 for the NRH group and 1.9 for RH group (p < 0.0001).ConclusionsWe concluded that the new technique of NRH can reduce postoperative bladder dysfunctions.     

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.     

Appropriateness of antibiotic use in the postpartum period.

OBJECTIVE: To determine the appropriateness of current postpartum antibiotic use in clinical practice. METHODS: Medical records were reviewed for all patients delivering in a 3-month period who received postpartum antibiotics during the delivery hospitalization. Subjects were excluded if they received a single postpartum antibiotic dose as part of a mitral valve prolapse prophylaxis protocol, or if they received no more than one postpartum antibiotic dose for surgical prophylaxis. Characteristics of postpartum antibiotic use were abstracted. RESULTS: Two hundred and eleven of 1537 (14%) delivering patients met the inclusion criteria. Seventy-four (35%) delivered vaginally and 137 (65%) delivered by Cesarean section. Postpartum fevers were found in 40 (54%) of vaginal delivery cases and 80 (58%) of women delivering by Cesarean section who received postpartum antibiotics (p = 0.54). For vaginal deliveries there were no differences in the duration of antibiotic use or number of antibiotic doses based on fever status. For Cesarean deliveries, a fever was associated with more antibiotic doses and a longer duration of antibiotic use. Physician justification for antibiotic use was documented in only 116 cases (55%). CONCLUSIONS: The high proportion of women receiving postpartum antibiotics having no evidence for infection or documented indication for therapy suggests that antibiotics may not be appropriately used in the postpartum period.     

Elective hysterectomy.

Hysterectomy is the most frequently performed major operation. Its frequency is increasing due to greater use of elective indications such as uterine cancer prophylaxis, contraception, and menopausal problems. The effects of elective simple hysterectomy are evaluated in terms of morbidity and mortality rates and costs. Among 35-year-old women operated upon, the average over-all gain in life expectancy is only 0.2 years. This is due to the saving of 1.3 per cent of women who would have died from cancer of the cervix or endometrium; they gained 14.3 years of life. In addition, 3 per cent of women are spared the development of and treatment for these two conditions. All women operated upon would be relieved of some undesirable aspects of the menopausal years such as irregular uterine bleeding. There are also economic gains. However, the operation has adverse health effects which could offset any gains from cancer prevention. In addition, each year of life saved would cost about $12,800 and most of the added years would be lived in old age. Delaying the operation to age 45 and including oophorectomy would result in a lower cost per year of life saved-about $9,800-but the risk of adverse health effects probably would be increased very much. Cancer prophylaxis cannot justify elective hysterectomy; we cannot assess whether quality-of-life considerations do.     

Prevalence of hysterectomy in Ireland.

OBJECTIVES: To assess factors influencing the prevalence of hysterectomy in Ireland. METHODS: Analysis of results of a questionnaire completed by a population-based cohort of 17735 women aged 50-65 years attending for breast screening. RESULTS: Prevalence of hysterectomy was 22.2%, was increased in proportion to parity and was higher in younger women, those who had previously used oral contraception and those who had private health insurance; peak age at operation was 45-49 years. CONCLUSION: The relatively high prevalence parity reflects contraceptive practices and utilization of health service resources.     

单孔腹腔镜与经阴道自然腔道内镜手术子宫切除术比较

单孔腹腔镜子宫切除术与经阴道自然腔道内镜手术（vNOTES）子宫切除术均能最大限度地发挥微创手术的优势。vNOTES是经阴道单孔手术,是行子宫切除术的理想方法,其与腹腔镜下子宫切除术和阴式子宫切除术相比具有一些优点。但是目前关于vNOTES子宫切除术的研究报道很少。文章对单孔腹腔镜下子宫切除术和vNOTES子宫切除术两种手术方法的优点和手术难点进行讨论。     

Laparoscopic supracervical hysterectomy vs. abdominal hysterectomy in a community hospital. A cost comparison.

OBJECTIVE: To evaluate the feasibility for an institution to offer laparoscopic supracervical hysterectomy as a cost-effective alternative to total abdominal hysterectomy (TAH) in a managed care environment. STUDY DESIGN: Retrospective study in which 138 consecutive laparoscopic supracervical hysterectomies performed between December 1992 and May 1996 were reviewed and compared to 354 consecutive TAHs performed during the same period. Operating time, use of operative room supplies, length of stay and actual total, fixed and variable costs of each case were calculated for the entire hospital stay and for each hospital cost center. Differences between costs were analyzed by ANCOVA using age, patient weight, specimen weight and number of operative procedures performed at the time of hysterectomy as covariants. RESULTS: The mean operative room time was significantly greater for laparoscopic supracervical hysterectomy than for TAH (167.4 [SD 51.2] vs. 103 minutes [30.3, P < .001]). In contrast, length of stay was significantly shorter for laparoscopic supracervical hysterectomy than for TAH (0.8 [SD 1.1] vs. 3.4 days [.9, P < .001]). The adjusted mean costs of both operative room time and supplies were significantly higher for laparoscopic supracervical hysterectomy than for TAH (P < .001). In contrast, the mean cost of length of stay for laparoscopic supracervical hysterectomy was significantly lower (P < .001). However, the adjusted mean total costs of the entire hospital stay were not significantly different: $2,716 for laparoscopic supracervical hysterectomy vs. $2,702 for TAH (F = .7, P = .8). The absence of significant differences between procedures resulted from our limited use of disposable supplies (no automated stapling device) and from shorter lengths of stay, which compensated well for the higher operative room costs of time and supplies incurred with laparoscopic supracervical hysterectomy. CONCLUSION: Laparoscopic supracervical hysterectomy is, at least in the short term, a cost-effective alternative to TAH in a managed care environment.     

Emergency peripartum hysterectomy.

A total of 54 166 mothers delivered at the Riyadh Armed Forces Hospital between 1990 and 1997, including 6119 (11.3%) caesarean sections. Emergency peripartum hysterectomy for obstetric haemorrhage was carried out in 16 cases (0.3/1000 deliveries). The operation followed major degrees of placenta praevia in 12 (75%) cases and atonic postpartum haemorrhage in four (25%). All patients required blood transfusion. There was one neonatal death and no maternal deaths. Although the operation was straightforward, bladder injury occurred in five (31%) cases which was repaired with no residual damage. Placenta accreta was confirmed histologically in 12 (75%) patients. In conclusion, all obstetricians should be aware of the strong association between a scarred uterus, placenta praevia and placenta accreta which can be very adherent and difficult to remove causing bleeding and necessitating hysterectomy. The operation should be performed by an experienced obstetrician before the patient's condition is extreme.     

Minilaparotomy-assisted vaginal hysterectomy.

OBJECTIVES: To determine the feasibility and acceptability of minilaparotomy-assisted vaginal hysterectomy. METHODS: A prospective pilot study in a general hospital was conducted. Twenty patients who were on the waiting list for abdominal hysterectomy were included in the study. All these patients had one or more relative contraindications to vaginal hysterectomy. The hysterectomy procedure was started vaginally in all cases. A minilaparotomy incision was performed to complete the procedure if vaginal hysterectomy was not feasible. Results were analyzed on the intention to treat basis. RESULTS: The procedure was successfully completed as intended in 19/20 patients (95%). Six patients had the procedure completed vaginally (30%). Thirteen patients had the procedure completed with minilaparotomy assistance (65%). The mean operative time was 63+/-24.8 min (+/-S.D.). The median estimated blood loss was 155 ml (range: 20-800). One bladder injury occurred. The overall post-operative complication rate was 35% (7/20). This included urinary retention necessitating catheterization for 24 h (n=3), urinary infection (n=2), vaginal infection (n=1) and wound hematoma (n=1). The mean post-operative pain score on a scale from 1 to 10 was 3.1. The overall patient satisfaction based on a scale from 1 to 10 was 9.23 (range: 8-10). CONCLUSIONS: Minilaparotomy-assisted vaginal hysterectomy is a feasible and safe procedure. Our results suggest that this approach is potentially useful in increasing the proportion of hysterectomies performed vaginally.     

Radical hysterectomy in obese women.

OBJECTIVE: To determine whether there is a significant difference in treatment outcome and acute and chronic complications in obese compared with non-obese women having radical hysterectomy for early-stage cervical cancer. METHODS: From 1970-1985, 320 women underwent a class III radical hysterectomy and pelvic lymphadenectomy for stage IB-IIA invasive cervical cancer at Duke University Medical Center. Forty-three of these women weighed at least 80 kg and had a body weight greater than 25% above their ideal predicted weight. These women were compared to 277 patients with normal weight for height. RESULTS: The median age, incidence of diabetes mellitus and hypertension, number of nodes removed at lymphadenectomy, disease-free survival, length of hospital stay, and serious surgical or medical complications were the same in the two groups. However, obese patients had a significantly higher estimated blood loss, greater incidence of transfusion, and longer operative times. CONCLUSIONS: Survival is not compromised and the incidence of serious complications is not increased in obese patients treated with radical hysterectomy, but the operative technique is more difficult, the procedure lasts longer, and the surgery is associated with greater blood loss.     

Appropriateness of hysterectomies performed for multiple preoperative indications.

OBJECTIVE: To correlate the listing of multiple preoperative indications for hysterectomy with the risk of non-confirmation of the preoperative diagnosis. METHODS: Records of 171 women undergoing consecutive hysterectomies for all indications at a large teaching hospital were reviewed for preoperative indication(s), compliance with published preoperative validation criteria for cases in which tissue pathology was not expected, and histologic verification of the preoperative diagnosis for cases in which tissue pathology was expected. Rates of confirmation (histologic verification plus successful compliance with validation criteria) of the preoperative diagnosis were compared between subgroups of cases in which single indications were listed (N = 124) or multiple indications were listed (N = 47) preoperatively. RESULTS: The rate of confirmation of single indications (115 of 124 cases, 93%) was significantly higher than the rate of confirmation of even one indication in cases in which multiple indications were listed (28 of 47 cases, 60%, P < .0001; relative risk for non-confirmation of multiple indications = 1.55). Multiple indications were more likely to be listed when tissue pathology was not expected, representing 49% of validatable indications as compared with only 18% of histologically verifiable indications (P < .0001). Overall, the rate of compliance with validation criteria (70%) was significantly lower than the rate of histologic verification (90%) (P < .01). CONCLUSION: These data suggest that listing of multiple preoperative indications for hysterectomy is associated with both decreased appropriateness, as reflected in decreased compliance with generally accepted preoperative validation criteria, and decreased diagnostic accuracy, as reflected in lower rates of histologic verification.     

Laparoscopic hysterectomy. Initial experience.

Laparoscopic hysterectomy is now being performed in our department in cases where no malignancy is suspected. This study presents the first 10 cases. Indications for hysterectomy were myomas, meno- and metrorrhagia resistant to medical and hysteroscopic treatment, and patients with pain and suspicion of having adenomyosis. No complications have been encountered during the laparoscopic operations, but one patient had a second laparoscopy on the first postoperative day due to postoperative bleeding. Another patient had a postoperative infection leading to a compression of the ureter. This report demonstrates that laparoscopic hysterectomy is a valuable addition to the new procedures in 'minimal invasive surgery', but only after long and appropriate training.     

Laparoscopic versus abdominal hysterectomy.

The perioperative and postoperative courses of hysterectomy with or without bilateral salpingo-oophorectomy were compared for 10 women who underwent total abdominal hysterectomy and 10 who underwent laparoscopically assisted vaginal hysterectomy. Although laparoscopic hysterectomy took longer (160 versus 102 minutes), the women undergoing it had a shorter duration of hospitalization (2.4 versus 4.4 days), more rapid recuperation (3 versus 5 weeks) and fewer complications. These preliminary results suggest that in the hands of experienced operative laparoscopists, laparoscopically assisted vaginal hysterectomy is preferable to abdominal hysterectomy for selected candidates.