Hysterectomy For Benign Gynecologic Conditions Research Articles

Hysterectomy for Benign Gynaecological Conditions

Hysterectomy for Benign Gynaecological Conditions

Robotic-assisted Versus Conventional Laparoscopic Hysterectomy for Benign Gynecological Conditions: A Systematic Review and Meta-analysis.

Minimally invasive gynecologic surgery is safe and feasible procedure for benign gynaecological conditions with less morbidity. To determine the best approach in benign gynecology and establish superiority of robotic over conventional laparoscopic hysterectomy in terms of safety and effectiveness. Search strategy: Electronic databases: MEDLINE, Embase, CENTRAL (the Registry of Controlled Clinical Studies of the Cochrane Collaboration), Google scholar, Pubmed and Scopus were searched from 2010-2022. Selection criteria: All randomized controlled trials and quasi-randomised trials which compared robotic versus conventional laparoscopic hysterectomy were included to conduct this systematic review and meta-analysis to investigate compared to traditional approaches. Only five RCTs (326 patients in total) comparing robotic and conventional laparoscopic hysterectomy were included after a comprehensive literature search. Results of our analysis showed no clear benefit in any of the two techniques in operating time, estimated blood loss, length of hospital stay and overall complications. This systematic review suggests no statistical difference in surgical and patient outcomes between robotic and conventional laparoscopic hysterectomy relating to OT, EBL, LOHS, overall complications, and survival.

Utility of laparoscopic hysterectomy compared to vaginal and abdominal hysterectomy for benign gynecological conditions

In spite of availability of procedures which are less invasive for hysterectomy, some prefer abdominal approach for the hysterectomy (TAH). Laparoscopic hysterectomy (TLH) is useful for the patients, as they recover fast and the convalescence period is reduced.To compare and evaluate three different methods of hysterectomy for benign gynecological disorders with regard to time for recovery, outcome after surgery, cost-effectiveness and complications due to surgery.Prospective study conducted on 90 patients who underwent hysterectomy for benign gynecological conditions. Patients were assigned to either TAH (n=30), TLH (n=30) or Vaginal hysterectomy (VH) (n=30), with or without salpingo-oophorectomy. All patients presenting in the gynecology OPD with indications for hysterectomy with or without salpingo-oophorectomy were included. Pre-operative parameters like age, basal metabolic index, intra-operative and post-operative parameters like reduction in hemoglobin etc. were compared in three groups.The mean blood loss, Time from surgery to tolerance of normal diet (days), Time from surgery to unassisted ambulation (days), post-operative pain score on day 3, mean reduction in hemoglobin and duration of hospital stay (days) were significantly (p<0.05) higher in patients who underwent total abdominal hysterectomy compared to total laparoscopic or vaginal hysterectomy. In terms of intra-operative and post-operative complications, operative time, hospital bill and satisfaction score the differences were not significant statistically (p>0.05). Total laparoscopic hysterectomy and vaginal hysterectomy are safe and less invasive alternative, compared to abdominal hysterectomy, and show significantly better post-operative reconstitution

Predictive risk factors of vaginal cuff infection and vaginal cuff dehiscence in Egyptian female patients undergoing total laparoscopic hysterectomy for benign gynecological conditions

Predictive risk factors of vaginal cuff infection and vaginal cuff dehiscence in Egyptian female patients undergoing total laparoscopic hysterectomy for benign gynecological conditions

Immunometabolic profiling of cervicovaginal lavages identifies key signatures associated with adenomyosis.

Adenomyosis is a burdensome gynecologic condition that is associated with pelvic pain, dysmenorrhea, and abnormal uterine bleeding, leading to a negative impact on quality of life; and yet is often left undiagnosed. We recruited 108 women undergoing hysterectomy for benign gynecologic conditions and collected non-invasive cervicovaginal lavage samples for immunometabolic profiling. Patients were grouped according to adenomyosis status. We investigated the levels of 72 soluble immune proteins and >900 metabolites using multiplex immunoassays and an untargeted global metabolomics platform. There were statistically significant alterations in the levels of several immune proteins and a large quantity of metabolites, particularly cytokines related to type II immunity and amino acids, respectively. Enrichment analysis revealed that pyrimidine metabolism, carnitine synthesis, and histidine/histamine metabolism were significantly upregulated pathways in adenomyosis. This study demonstrates utility of non-invasive sampling combined with immunometabolic profiling for adenomyosis detection and a greater pathophysiological understanding of this enigmatic condition.

EE58 Budget Impact Analysis of Minimally Invasive Techniques Against Abdominal Hysterectomy for Benign Gynaecological Conditions: A Spanish Hospital Perspective

A hysterectomy is the surgical removal of the uterus, and most likely, the cervix, with four possible surgical approaches for benign disease: abdominal (AH), laparoscopic (LH), vaginal (VH), and robotic-assisted hysterectomy (not assessed). This analysis aims to estimate the budget impact of increasing minimally invasive surgical approaches to hysterectomy for women with benign gynaecological conditions [LH and VH with/without bipolar vessel sealing (BVS) as a haemostatic control method] against AH from a Spanish, tertiary hospital perspective.

Incidence of self-reported pelvic pain and risk factors for pain 1 year after benign hysterectomy: A register study from the Swedish National Quality Registry for Gynecological Surgery.

The primary aim of this study was to determine the incidence of patient-reported pain 1 year after hysterectomy for benign gynecological conditions in relation to occurrence of preoperative pain. The secondary aim was to analyze clinical risk factors for pain 1 year after the hysterectomy in women with and without preoperatively reported pelvic/lower abdominal pain. This was a historical cohort study using data from the Swedish National Quality Registry for Gynecological Surgery on 16 694 benign hysterectomies. Data were analyzed using multivariable logistic regression models. One year after surgery, 22.4% of women with preoperative pain reported pelvic pain and 7.8% reported de novo pelvic pain. For those with preoperative pain younger age (adjusted odds ratio [aOR] 1.75, 95% confidence interval [CI] 1.38-2.23 and aOR 1.21, 95% CI 1.10-1.34 for women aged <35 and 35-44 years, respectively), not being gainfully employed (aOR 1.43, 95% CI 1.26-1.63), pelvic pain as the main symptom leading to hysterectomy (aOR 1.51, 95% CI 1.19-1.90), endometriosis (aOR 1.18, 95% CI 1.06-1.31), and laparoscopic hysterectomy (aOR 1.30, 95% CI 1.07-1.58), were clinically relevant independent risk factors for pelvic/lower abdominal pain 1 year after surgery, as were postoperative complications within 8 weeks after discharge. Meanwhile, clinically relevant independent risk factors for reporting de novo pain 1 year after surgery were younger age (aOR 2.05, 95% CI 1.08-3.86 and aOR 1.29, 95% CI 1.04-1.60 for women aged <35 and 35-44 years, respectively), and postoperative complications within 8 weeks after discharge. The incidence of pelvic pain and de novo pain 1 year after hysterectomy was relatively high. Women with and without reported preoperative pelvic/lower abdominal pain represented clinically different populations. The risk factors for pelvic pain seemed to differ in these two populations. The differences in risk factors couldbe taken into consideration in the preoperative counseling and in the decision-making concerning method of hysterectomy, provided that large well-designed studies confirm these risk factors.

Transdermal Buprenorphine-A Novel Medication for Postoperative Pain Management Following Abdominal Hysterectomy for Benign Gynecological Conditions

Background: Buprenorphine is a semisynthetic derivative of thebaine, which is 75-100 times more potent than morphine and causes less respiratory depression. Efficacy and safety of transdermal buprenorphine have been well established in chronic pain, but data regarding acute postoperative pain relief are still limited. Aim: In this study, we compared the efficacy of transdermal buprenorphine patch with injectable tramadol for the relief of postoperative pain (POP) following abdominal hysterectomy for benign gynecological conditions. Settings and Design: Three-year prospective observational study. Methods and Material: One hundred patients undergoing abdominal hysterectomy were allocated to one of two groups. Buprenorphine group: we applied 10 mcg/hr transdermal buprenorphine patch on the lateral upper arm after surgery. The onset of relief from a patch is 8 to 16 hours. So, all patients were given diclofenac suppository 100mg before induction of anesthesia as a preemptive analgesic to reduce postoperative pain. Injectable Tramadol Group: Received intramuscular tramadol injections 50mg every 8 hours in the postoperative period. Patients were followed for two days to observe postoperative pain relief and adverse effects. If patients showed a Visual Analog pain (VAS) score &gt;3, intravenous paracetamol was administered as a rescue analgesic. Results: POP was assessed at different time frames: 12, 24, 36 and 48 hours after hysterectomy. Mean pain score at rest in the buprenorphine group was significantly lower than that of the tramadol group. Patients experienced less pain on mobility in the buprenorphine group compared with the tramadol group, which was statistically significant. Conclusion: Transdermal buprenorphine is an effective and safe alternative to injectable tramadol for providing postoperative analgesia. It provides a higher degree of pain relief, faster postoperative mobilization, lower incidence of postoperative nausea and vomiting and higher satisfaction scores starting 12 hours after surgery. However, for the first 12 post-operative hours, there is a need for additional analgesia.

Outcome of Non Descent Vaginal Hysterectomy in Benign Gynecological Condition

Background: The most common gynaecological surgery is hysterectomy which is indicated mostly in DUB, fibroids, adenomyosis to malignancies. The various procedures range from laparoscopic to vaginal hysterectomies in non- descent cases. Vaginal Hysterectomy appears to be, relatively advantageous or superior procedure in terms of patient safety, cost-effectiveness, faster recovery (short hospital stay), and dreaded complications. It is the only surgery which has a very good cosmetic benefit that is without any visible scar.Aim: To study the outcomes of Non-descent vaginal hysterectomy in benign gynaecological conditions.Objectives: 1. To assess the outcome of Non- descent vaginal hysterectomy for benign Gynaecological conditions in terms of intra operative characteristics.2. To assess the postoperative outcome in Non-descent vaginal Hysterectomy. Materials: This prospective observational study was conducted between November 2018 to October 2020. The study was done among 100 women who fulfilled the inclusion criteria. Details regarding indication, size of the uterus, operation time, mean blood loss ,hospital stay and intraop and post op complications were noted.Results: The mean age was 46.05±5.413. The mean operating time was 58.46±17.75 minutes, the mean blood loss was 91.79±27.18 ml and the mean hospital stay was 4.24 ± 0.63 days. Majority (57) of the patients indication of surgery was DUB. 47% of the patients had normal uterine size, 23% and 27% had less than 8 weeks and between 8-12 weeks uterine size respectively. Only 3% subjects had uterus size between 12-36 weeks.Majority subjects had no postoperative complications, whereas other complications like fever , UTI , vaginal bleeding and need for blood transfusion were foundin 06,04,03 ,04 subjects respectively, and none of them had any intra op injury

Abstract C052: Premenopausal oophorectomy and survival among women with breast cancer: Evidence of effect measure modification by family history status

Abstract In the US, bilateral oophorectomies are frequently performed before menopause for one of two reasons: 1) in concert with hysterectomy for benign gynecologic conditions or 2) prevention of breast or ovarian cancer risk and mortality. Prior literature has consistently shown a reduction in breast cancer-specific mortality among women who had premenopausal hysterectomy with bilateral oophorectomy (H +BO) prior to their breast cancer diagnosis. The present study sought to assess whether the relationship between prediagnosis premenopausal H + BO and breast cancer-specific mortality differed by family history status in women with breast cancer. It is hypothesized that women who may have prognostically different breast cancer due to having family history disproportionately benefit from premenopausal H+ BO compared to more average-risk women with no family history. This study analyzed data from Phases 1 and 2 of the Carolina Breast Cancer Study (CBCS), a population-based study of Black and White women prospectively identified in central and eastern North Carolina with newly diagnosed breast cancer between 1993 and 2001. Women with invasive breast cancer with known gynecologic surgical status were included (n=1,723). Gynecologic surgery was defined as: no surgery; hysterectomy with bilateral oophorectomy (H+BO); hysterectomy with conservation of ≥1 ovary (H + OC). Cause-specific mortality was ascertained using the National Death Index, last updated in 2016. Hazard ratios (HR) and 95% confidence intervals (CI) for breast cancer-specific mortality were estimated with Cox proportional hazard models. Models were then stratified by family history status, the self-reporting of one or more first-degree relatives with a family history of breast cancer. Models were adjusted for race, age at diagnosis, smoking, alcohol use, menopausal hormone therapy use and reproductive history factors. All participants still living at the end of follow-up were right censored. Among 1,723 women in the sample, 44% (n=759) were Black and 56% (n=964) were White. There were 836 deaths, of which 447 were from breast cancer. In this population, 74.1% (n=1,276) of women reported having no previous premenopausal gynecologic surgery, 8.8% (n=152) reported having H + BO and 17.1% (n=295) reported H + OC. Compared to women who had not had premenopausal gynecologic surgery, the overall adjusted HR for breast cancer-specific mortality associated with H+BO was 0.68 (95% CI: 0.49,0.96) and 0.90 (95% CI: 0.72,1.12) for women with H+OC. In models stratified on family history, the HR for women with H+BO was 0.11 (95% CI: 0.03,0.42) for those with family history and 0.90 (95% CI: 0.63, 1.29) for those without. The HR for women with family history who had H+ OC was 0.77 (95% CI: 0.45, 1.29) and 0.90 (95% CI: 0.63,1.29) for women without. This study suggests that the overall protective relationship observed between premenopausal hysterectomy with bilateral oophorectomy and breast-cancer specific mortality may be driven by a small subset of especially high-risk women. Citation Format: Mya L. Roberson, Whitney R. Robinson, Hazel B. Nichols, Andrew F. Olshan, Melissa A. Troester. Premenopausal oophorectomy and survival among women with breast cancer: Evidence of effect measure modification by family history status [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C052.

Is Vaginal Hysterectomy Safe for an Enlarged Uterus?

ObjectiveThe purpose of this study was to compare the surgical outcomes between two sets of women undergoing vaginal hysterectomy (VH) for benign gynecological conditions: those with moderately enlarged ( ≥12 weeks') uteruses and those with normal-sized uteruses.Materials and MethodsThe medical records of 84 women who underwent vaginal hysterectomies for benign gynecological conditions at Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey between 2013 and 2015 were reviewed. Age, uterine sizes, indications, duration of hospitalization, operation time, hematocrit (HCT) levels, and complications were analyzed.ResultsThe most common indications for VH were uterine descensus. However, most women had presented with more than one indication. The mean age of the patients who underwent VH was 56.12. The maximum volume of the uterus was found to be 1244.74 ml, and the smallest volume was found to be 18.83 ml. The mean volume of the uterus was found as 122.6629 ml. The mean duration of operation was 159.70 minutes, whereas the mean duration of hospital stay was 3.79 days. The mean preoperative HCT and hemoglobin (Hgb) values were 37.098 (±3.64) gr/dl and 12.365 (±1.35) gr/dl respectively. Postoperative HCT and Hgb values were 31.363 (±3.94) gr/dl and 10.52 (±1.38) respectively.ConclusionVH is usually a simple procedure with low morbidity. It is important to choose the appropriate patient when deciding on the operation. In addition, having experienced surgeons in the field of VH increases the success of surgery.

Urinary Tract Infection After Hysterectomy for Benign Gynecologic Conditions or Pelvic Reconstructive Surgery

(Abstracted from Obstet Gynecol 2018;132:1347–1357) About half of all women will experience at least 1 urinary tract infection (UTI) in their lifetimes, and the infection will recur in more than 10% of postmenopausal women. Pelvic surgery increases risk of UTI.

Urinary Tract Infection After Hysterectomy for Benign Gynecologic Conditions or Pelvic Reconstructive Surgery.

To report rates and identify risk factors for urinary tract infection (UTI) after hysterectomy for benign conditions or combined with pelvic reconstructive surgery. This is a cohort study that included women who underwent hysterectomy either for benign gynecologic conditions or hysterectomy combined with pelvic reconstructive surgery from January 1, 2012, through June 30, 2014, at a single institution. The primary outcome was UTI within 8 weeks of surgery. Logistic regression modeling was used to develop a model for predicting UTI after surgery. Of 1,156 women included in the study, 136 (11.8%, 95% CI 10.0-13.8) developed UTI within 8 weeks. Women who underwent hysterectomy for a benign gynecologic condition that was not combined with pelvic reconstructive surgery had an overall UTI rate of 7.3% (95% CI 5.6-9.3) vs 21.7% (95% CI 17.6-26.4) after hysterectomy combined with pelvic reconstructive surgery. After adjusting for hormone therapy use, the following were independent variables associated with postoperative UTI: premenopausal status with an adjusted odds ratio (OR) of 1.80 (95% CI 1.11-2.99), anterior vaginal wall prolapse with an adjusted OR of 4.39 (95% CI 2.77-6.97), and postvoid residual greater than 150 mL with an adjusted OR of 2.38 (95% CI 1.12-4.36). Using this model, postoperative UTI rates ranged from 4.3% to 59.4% with high postvoid residual and presence of anterior prolapse having the strongest association. There are wide variations in the rate of UTI after hysterectomy for begin disease including pelvic reconstructive surgery. These variations can be explained with a model based on available preoperative data.

Alternative Treatment Utilization Before Hysterectomy for Benign Gynecologic Conditions at a Large Integrated Health System

To investigate rates of utilization of alternative treatments before hysterectomy for benign gynecologic indications within a large integrated health care system. Retrospective cohort study of patients who underwent hysterectomies for benign gynecologic conditions between 2012 and 2014 (Canadian Task Force classification II-2). Kaiser Permanente Northern California, a community-based integrated health system. Women who underwent hysterectomy for a benign gynecologic condition between 2012 and 2014. From an eligible cohort of 6892 patients who underwent hysterectomy, a stratified random sample of 1050 patients were selected for chart review. Stratification was based on the proportion of indications for hysterectomy. The primary outcome was the use of alternative treatments before hysterectomy. Alternative treatments included oral hormone treatment, leuprolide, medroxyprogesterone intramuscular injections, a levonorgestrel intrauterine device, hormonal subdermal implants, endometrial ablation, uterine artery embolization, hysteroscopy, and myomectomy. Of the 1050 charts reviewed, 979 (93.2%) met the criteria for inclusion in this study. The predominant indication for hysterectomy was symptomatic myomas (54.4%), followed by abnormal uterine bleeding (29.0%), endometriosis (5.8%), pelvic pain (3.1%), dysmenorrhea (3.4%), and other (4.3%). The major routes of hysterectomy were laparoscopy (68.7%) and vaginal hysterectomy (13.4%). Before hysterectomy, 81.2% of patients tried at least 1 type of alternative treatment (33.8% with 1 treatment and 47.4% with at least 2 treatments), and 99.3% of patients were counseled regarding alternative treatments. Compared with younger women age <40 years, women age 45 to 49 years were less likely to use alternative treatments before hysterectomy (adjusted odds ratio, 0.41; 95% confidence interval, 0.21-0.76). There were no variations in treatment rates by socioeconomic status or between major racial and ethnic groups. The final pathological analysis identified myomas as the most common pathology (n = 637; 65.1%); 96 patients (9.8%) had normal uterine pathology. More than 80% of patients received alternative treatments before undergoing hysterectomy for a benign gynecologic condition. Additional investigation is warranted to assess alternative treatment use as it relates to preventing unnecessary hysterectomies.

Characteristics associated with prolonged length of stay after hysterectomy for benign gynecologic conditions

Length of stay after surgery has become an important quality measure for many common surgical procedures and is now also tied to reimbursement. Currently, little is known about the perioperative factors that contribute to prolonged hospital length of stay in women who undergo hysterectomy for benign conditions. We performed a population-based analysis to investigate the association between perioperative factors and prolonged length of stay in women who undergo minimally invasive, abdominal, and vaginal hysterectomy. We used the National Surgical Quality Improvement Program database to identify women from 2006-2015 who underwent benign hysterectomy. The primary outcome was length of stay >75th percentile. Demographic, preoperative, intraoperative, and postoperative factors were analyzed to determine individual predictorsof prolonged length of stay. Model fit statistics were used to assess the importance of each group of perioperative factors on prolonged length of stay. We identified a total of 157,589 women, including 83,172 (52.8%) of whom underwent minimally invasive hysterectomy, 45,149 (28.6%) of whom underwent abdominal hysterectomy, and 29,268 (18.6%) of whom underwent vaginal hysterectomy. The 75th percentile for length of stay was 1 day for minimally invasive, 3 days for abdominal, and 2 days for vaginal hysterectomy. The measured factors accounted for 11.0% of the ability to predict a prolonged length of stay for minimally invasive, 20.3% for abdominal, and 16.2% for vaginal hysterectomy. Intraoperative factors were the most important contributors to length of stay for minimally invasive and abdominal hysterectomy; demographic factors dominated for vaginal hysterectomy. The most important perioperative factors that contributed to prolonged length of stay for hysterectomy were, in large part, not modifiable and suggest that targeted interventions to reduce length of stay will be challenging.

Opportunistic salpingectomy in women undergoing hysterectomy: Results from the HYSTUB randomised controlled trial

ObjectiveTo evaluate whether opportunistic salpingectomy in premenopausal women undergoing hysterectomy for benign indications is both hormonally and surgically safe, compared with hysterectomy without salpingectomy. Study designIn this multicentre randomised controlled trial, women were randomised to undergo either hysterectomy with opportunistic bilateral salpingectomy (intervention group) or standard hysterectomy with preservation of the Fallopian tubes (control group). Main outcome measuresThe primary outcome was the difference in serum anti-Müllerian hormone concentration (ΔAMH), measured pre-surgery and 6 months post-surgery. Secondary outcomes were surgical outcomes and duration of hospital stay. The sample size was powered at 50 participants per group (n=100) to compare ΔAMH after hysterectomy with salpingectomy to ΔAMH after standard hysterectomy. ResultsBetween March 2013 and December 2016, 104 women, aged 30–55 years, were randomly allocated to hysterectomy with opportunistic bilateral salpingectomy (n=52) or standard hysterectomy (n=52). The baseline characteristics did not differ between the two groups. The median ΔAMH was −0.14pmol/L (IQR −1.47–0.95) in the intervention group and 0.00pmol/L (IQR −1.05–0.80) in the control group (p=0.49). The addition of salpingectomy did not impair surgical results and it did not affect duration of hospital stay. ConclusionAddition of opportunistic bilateral salpingectomy during hysterectomy did not result in a larger effect on ovarian reserve when compared with hysterectomy alone, neither did it affect surgical outcomes. Therefore, opportunistic salpingectomy seems to be a safe procedure in premenopausal women undergoing hysterectomy for benign gynaecological conditions.

Loss of luteotropic prostaglandin E plays an important role in the regulation of luteolysis in women.

Do intraluteal prostaglandins (PG) contribute to luteal regulation in women? Prostaglandin E (PGE), which is produced in human granulosa-lutein cells stimulated with luteotropic hCG, exerts similar luteotropic effects to hCG, and the expression of PG synthetic and metabolic enzymes in the human CL is driven toward less PGE but more prostaglandin F (PGF) during luteolysis. Uterine PGF is a major luteolysin in many non-primate species but not in women. Increases in the PGF synthase, aldo-ketoreductase family one member C3 (AKR1C3), have been observed in the CL of marmoset monkeys during luteolysis. PGE prevents spontaneous or induced luteolysis in domestic animals. Human CL tissues staged as the early-luteal (n = 6), mid-luteal (n = 6), late-luteal (n = 5) and menstrual (n = 3) phases were obtained at the time of hysterectomy for benign gynecological conditions. Luteinized granulosa cells (LGCs) were purified from follicular fluids obtained from patients undergoing assisted conception. Upon collection, one half of the CL was snap-frozen and the other was fixed with formalin and processed for immunohistochemical analysis of a PGE synthase (PTGES). Quantitative RT-PCR was employed to examine changes in the mRNA abundance of PG synthetic and metabolic enzymes, steroidogenic enzymes, and luteolytic molecules in the staged human CL and in human LGCs in vitro treated with hCG, PGE and PGF. A PGE withdrawal experiment was also conducted in order to reveal the effects of the loss of PGE in LGCs. Progesterone concentrations in the culture medium were measured. The key enzyme for PGE synthesis, PTGES mRNA was abundant in the functional CL during the mid-luteal phase (P < 0.01), while mRNA abundance for genes involved in PGF synthesis (AKR1B1 and AKR1C1-3) increased in the CL during the late-luteal phase and menstruation (P < 0.05-0.001). PTGES mRNA expression positively correlated with that of 3β-hydroxysteroid dehydrogenase (HSD3B1; r = 0.7836, P < 0.001), while AKR1C3 expression inversely correlated with that of HSD3B1 (r = -0.7514, P = 0.0012) and PTGES (r = -0.6923, P = 0.0042). PGE exerted similar effects to hCG-promoting genes, such as steroidogenic acute regulatory protein (STAR) and HSD3B1, to produce progesterone and luteotropic PGE, suppress PGF synthetic enzymes and down-regulate luteolytic molecules such as βA- and βB-inhibin subunits (INHBA and INHBB) and bone morphogenetic proteins (BMP2, BMP4 and BMP6). PGE withdrawal resulted in reductions in the enzymes that produce progesterone (STAR; P < 0.001) and PGE (PTGES; P < 0.001), and the capacity to produce PGE decreased, while the capacity to produce PGF increased during the culture. The addition of PGF did not recapitulate the luteolytic effects of PGE withdrawal. None. Changes in mRNA expression of PG synthetic and metabolic enzymes may not represent actual increases in PGF during luteolysis in the CL. The effects of PGF on luteal cells currently remain unclear and the mechanisms responsible for decreases in the synthesis of PGE in vitro and at luteolysis have not been elucidated in detail. The results obtained strongly support a luteotropic function of PGE in regulation of the human CL. They suggest that the main PG produced in human luteal tissue changes from PGE to PGF during the maturation and regression of the CL, and the loss of PGE is more important than the effects of PGF during luteolysis in women. This may be accompanied by reduced effects of LH/hCG in luteal cells, particularly decreased activation of cAMP/protein kinase A; however, the underlying mechanisms remain unknown. This study was supported by the Cunningham Trust to WCD, a Postdoctoral Fellowship for Research Abroad from the Japan Society for the Promotion of Science and the Suntory Foundation for Life Sciences to J.N.-K.; W.C.D. is supported by an MRC Centre Grant G1002033 and a Scottish Senior Clinical Fellowship. The authors have nothing to disclose.

Hysterectomy by Vaginal Route: Not a Pressure

ABSTRACT Introduction Vaginal route of hysterectomy is a safe procedure with less morbidity and hospital stay. So, there is a need to expand the indication for vaginal hysterectomy beyond uterovaginal prolapse. Aims To determine the feasibility and outcome of nondescent vaginal hysterectomy (NDVH) and to assess the pre- and postoperative complications, duration of surgery, and hospital stay. Materials and methods A prospective observational study was conducted between 2012 and 2014 at a tertiary care center. A total of 256 patients satisfying the selection criteria of hysterectomy for benign gynecological conditions, uterus size &lt;16 weeks, and excluding stage IV endometriosis, genital tract malignancy, and uterine prolapse were included. The NDVH was performed by the standard technique, and the following parameters of age, parity, indication for surgery, duration of surgery, intraoperative and postoperative complications, and hospital stay were recorded. The data were analyzed using Statistical Package for the Social Sciences version 16.0 by frequency and percentage analysis and Chi-square test. Results All 256 patients were analyzed. The mean age was 44.4 ± 6.1 years; fibroid uterus was the commonest indication. About 89.4% had a uterine size ≤12 weeks and 59% had uterine volume &lt;200 cm3. The mean duration of surgery was 83.5 ± 11.0 minutes; salpingo-oophorectomy was performed in 25.8% of the patients. Intraoperatively, 1.2% had bladder injury and 0.4% required conversion to laparotomy for pelvic hematoma. The mean duration of hospital stay was 4.9 ± 2.2 days, and the mean pain score in numerical rating scale pain scale was 3.0 ± 0.3. Intraoperative blood transfusion was required in 1.9% of the patients only. Conclusion The NDVH is a safe and feasible procedure for benign gynecological disorders. Clinical significance The NDVH is a boon in this techno-savvy era by reducing the morbidity and promising early return to work. How to cite this article Vembu R, Dharmalingam S. Hysterectomy by Vaginal Route: Not a Pressure. J South Asian Feder Menopause Soc 2017;5(1):8-10.

Spinal Anaesthesia for Quicker Recovery in Fast-Track Abdominal Hysterectomy

Introduction: Fast-track approach during hysterectomy has revolutionized the postoperative recovery. In this study we tried to analyse the effect of one more component (spinal anaesthesia versus general anaesthesia) during hysterectomy for benign gynaecological conditions to further hasten the postoperative recovery and thus evolve the concept. Aim: To compare recovery among those who receive spinal anaesthesia versus those who receive general anaesthesia during fast tract abdominal hysterectomy. Materials and Methods: A total of 97 women were recruited who were planned for hysterectomy for benign conditions and agreed to follow the fast-track protocol. Forty six consented for spinal anaesthesia (three cases were excluded later) and 51 for general anaesthesia. Fast-track protocol was followed that included preoperative counselling, and no preoperative sedation. Postoperatively all patients were monitored for pain, vomiting, drowsiness and fatigue. Early oral intake and ambulation was encouraged. Postoperative events and complications as well as duration of hospital stay were compared among the two groups. Differences in continuous variables were analysed with student’s t-test for normally distributed data and the Mann-Whitney U Test for skewed data. Pain score was analysed by repeated measures of ANOVA. Results: Mean operating time in spinal anaesthesia group, was much less (92.72+23.61 minutes) than in general anaesthesia group (124.20+33.61 minutes), the difference being statistically significant (p<0.001). Mean blood loss was also less in spinal anaesthesia group (298.14+61.34 ml versus 404.90+110.57 ml; p<0.001). Women in this group could be started on oral fluids earlier, had less vomiting and fatigue postoperatively, and passed motion earlier. Duration of hospital stay was not found to be much different between the groups. However, patients who were in the spinal anaesthesia resumed their routine activities earlier (15.47+2.77 versus 18.55+4.25 days; p<0.001). We also noted an interesting finding yet undiscussed in the literature that general anaesthesia group had more than 2.5 times higher incidence of postoperative cough which has the potential to influence postoperative recovery following any abdominal surgery. Conclusion: Spinal anaesthesia should be considered in cases that are planned for hysterectomy under fast-track setting to optimise the results.

A Favorability Score for Vaginal Hysterectomy in a Statewide Collaborative

Study ObjectiveBecause it is associated with fewer complications and more rapid recovery, the vaginal approach is preferred for benign hysterectomy. Patient characteristics that traditionally favor a vaginal approach include adequate vaginal access, small uterine size, and low suspicion for extrauterine disease. However, the low proportion of hysterectomies performed vaginally in the United States suggests that these data are not routinely applied in clinical practice. We sought to analyze the association of parity, prior pelvic surgery, and uterine weight with the use of the vaginal, laparoscopic, robotic, and abdominal approaches to hysterectomy. DesignA retrospective cohort study (Canadian Task Force classification II-2). SettingThe Michigan Surgical Quality Collaborative is a statewide organization of 52 academic and community hospitals in Michigan funded by Blue Cross and Blue Shield of Michigan/Blue Care Network, including patients from all insurance payers. PatientsFive thousand six hundred eight women undergoing hysterectomy for benign gynecologic conditions from January 1, 2013, through December 8, 2013, and included in the Michigan Surgical Quality Collaborative. InterventionsTo assess potential for vaginal hysterectomy, a favorability score of 0, 1, 2, or 3 was calculated by summing 1 point each for parity ≥1, no prior pelvic surgery, and uterine weight <250 g. Frequencies of surgical approaches to hysterectomy were compared using chi-square tests across favorability scores. Measurements and Main ResultsThe use of robotic hysterectomy was most frequent (41.9%, n = 2349/5608) followed by abdominal (19.7%, n = 1103/5608), laparoscopic (14.4%, n = 809/5608), vaginal (13.5%, n = 758/5608), and laparoscopic-assisted vaginal (10.5%, n = 589/5608) hysterectomy. With favorability scores of 0, 1, 2, and 3, vaginal hysterectomy was performed in 0.6% (n = 1/167), 5% (n = 66/1324), 13.7% (n = 415/3036), and 25.5% (n = 276/1081) of cases and abdominal hysterectomy in 41.9% (n = 70/167), 30.8% (n = 408/1324), 17.5% (n = 531/3036), and 8.7% (n = 94/1081), respectively. There was little variation in the rates of laparoscopic hysterectomy (13.3%–16.8%, p = .429) and robotic hysterectomy (39.5%–42.4%, p = .518) across favorability scores. ConclusionIn a population of women undergoing hysterectomy in the state of Michigan, the use of vaginal and abdominal hysterectomy varied with respect to parity, prior pelvic surgery, and uterine weight, but there was little variation in the use of laparoscopic and robotic approaches. The favorability score could potentially be used as a quality improvement tool to evaluate practice patterns with respect to the use of various surgical approaches to hysterectomy.