Hysterectomy Rates Research Articles

Beliefs, Credence Goods and Information Campaigns

We study the role of beliefs about experts' honesty in a market for credence goods with second opinions and overtreatment. Experts are honest or dishonest. The population shares a common belief about the share of honest experts, which may be incorrect. We characterize the belief that maximizes consumer's expected utility and show that it is generically different from the true share of honest experts and larger than the one that maximizes the equilibrium level of honesty. We then analyze the decision of an authority that has learned the actual share of honest experts whether to publicly reveal it through a costless information campaign, thus correcting people's beliefs, and show that it does not depend on how wrong beliefs are. We further show how increasing market transparency (making experts more aware of the number of opinions collected) affects the optimal belief and may have a positive as well as a negative effect on overtreament. Finally, we briefly see how a successful campaign run in Switzerland in the mid '80s to reduce excessive hysterectomy rates can be read through the lenses of our model and how accounting for beliefs about honesty might allow theoretical predictions to better fit experimental evidence.

The Dying Art of Vaginal Hysterectomy: A Novel Simulation.

The rate of vaginal hysterectomy has decreased despite the procedure being the preferred hysterectomy method according to the American College of Obstetricians and Gynecologists (ACOG). Physicians have reported that some of the main barriers to performing minimally invasive hysterectomy are the size and shape of the uterus, difficulty of accessibility to the uterus, and surgeons' lack of training and experience. A simulation model for vaginal uterine morcellation was created in an effort to increase surgeons' confidence and to encourage them to select vaginal hysterectomy for their patients.The Conner model, where polyvinyl chloride (PVC) piping is used to simulate the pelvis and vaginal canal, was used as the basis for the pelvis. A medium-density fiberboard (MDF) was used as a base, while a PVC piping structure was used to stimulate the pelvis. The uterus was created from a peanut (car-wash) sponge that was carved into a triangle shape. The reusable MDF/PVC model was built in approximately one hour and cost under USD 30. The sponge uterus was built in approximately 10 minutes and cost under USD 2.Senior residents and faculty who have previously performed uterine morcellation participated in our simulation. Resident physicians reported that they felt more confident in their skills after the simulation. Both resident and staff physicians reported that the model had created a realistic experience.We created a novel model for vaginal uterine morcellation that was reported to be realistic in the initial investigation and increased confidence in the procedure for physicians. The model is easy to create, affordable, and partially reusable.

Effect of laparoscopic versus abdominal radical hysterectomy on major surgical complications in women with stage IA-IIB cervical cancer in China, 2004–2015

ObjectivesTo report the trends in surgical approaches and compare the major surgical complication rates of laparoscopic and abdominal radical hysterectomy for cervical cancer. MethodsFrom the major surgical complications of cervical cancer in China (MSCCCC) database, we obtained the demographic, clinical, treatment hospital and complication data of patients with cervical cancer who underwent radical hysterectomy from 2004 to 2015 at 37 hospitals. The patients were assigned to the laparoscopic and abdominal surgery groups. The differences in the complication rates were analyzed using univariate and multivariable logistic regression models. ResultsWe identified a total of 18447 patients; 5491 (29.8%) underwent laparoscopic surgery and 12956 (70.2%) underwent abdominal surgery. The proportion of laparoscopic surgery rose from 0.35% in 2004 to 49.31% in 2015. In the multivariate analysis, the laparoscopic group had increased odds of intraoperative and postoperative complications (OR = 3.88, 95% CI = 2.47–6.11; OR = 1.42, 95% CI = 1.11–1.82). A more detailed analysis showed that laparoscopic surgery was associated with increased rates of intraoperative ureteral injury (OR = 3.83, 95% CI = 2.11–6.95), bowel injury (OR = 14.83, 95% CI = 1.32–167.25), vascular injury (OR = 3.37, 95% CI = 1.18–9.62), postoperative vesicovaginal fistula (OR = 4.16, 95% CI = 2.08–8.32), ureterovaginal fistula (OR = 4.16, 95% CI = 2.08–8.32), rectovaginal fistula (OR = 8.04, 95% CI = 1.63–39.53), and chylous leakage (OR = 10.65, 95% CI = 1.18–95.97), while abdominal surgery was more likely to cause bowel obstruction (OR = 0.55, 95% CI = 0.35–0.87). The two groups had similar rates of bladder injury, obturator nerve injury, pelvic hematoma, rectovaginal fistula and venous thromboembolism (P > 0.05). ConclusionLaparoscopic surgery was associated with more major surgical complications, especially intraoperative ureteral injury and postoperative fistula, than abdominal surgery among women with cervical cancer.

Increasing the Rate of Laparoscopic Hysterectomy Safely for Benign Gynecologic Disease

Objective: Complication rates during laparoscopic hysterectomy performed at high-volume surgical centers have not been reviewed recently; rather, reliance is placed on older data when counseling pa...

Trends in Use and Effect on Survival of Simple Hysterectomy for Early-Stage Cervical Cancer.

To identify use and outcomes of simple hysterectomy compared with radical hysterectomy for women with early-stage cervical cancer. The National Cancer Database was used to review the cases of women with stage IA2 and IB1 (2 cm or less) cervical cancer from 2004 to 2015. Patients were classified based on whether they underwent simple or radical hysterectomy. Survival was examined after propensity score weighting. Simple hysterectomy was performed in 44.6% of women with stage IA2 (n=1,530) and 35.3% of those with stage IB1 (n=3,931) tumors. Rates of simple hysterectomy increased from 37.8% to 52.7% from 2004 to 2014 for stage IA2 cancers and from 29.7% to 43.8% between 2004 and 2013 for stage IB1 cancers. For stage IA2 cancers, younger women and those treated at an academic medical center were less likely to undergo simple hysterectomy. For stage IB1 cancers, black women were more likely to undergo simple hysterectomy, and those treated at an academic medical center were less likely to undergo simple hysterectomy. After propensity score weighting, there was no association between route of hysterectomy and survival for stage IA2 cancers (hazard ratio [HR] 0.70, 95% CI 0.41-1.20, 5-year survival 95.1% for radical hysterectomy vs 97.6% for simple hysterectomy). For stage IB1 cancers, patients who underwent simple hysterectomy were at 55% increased risk of death (HR 1.55, 95% CI 1.18-2.03, and 5-year survival was 95.3% for radical hysterectomy vs 92.4% for simple hysterectomy). Although there was no association between surgical radicality and survival for women with stage IA2 tumors, there was a 55% increase in mortality for women with stage IB1 neoplasms who underwent simple compared with radical hysterectomy. Radical hysterectomy is the treatment of choice for women with stage IB1 cervical cancer.

Prophylactic intraoperative uterine or internal iliac artery embolization in planned cesarean for pernicious placenta previa in the third trimester of pregnancy: An observational Study (STROBE compliant).

The aim of this study was to evaluate the efficacy and safety of prophylactic intraoperative bilateral uterine or internal iliac artery embolization in planned cesarean for pernicious placenta previa in the third trimester of pregnancy.The patients with pernicious placenta previa were retrospectively included from January 2011 to May 2018, being divided into embolization group and control group. Intraoperative uterine artery embolization (UAE) or internal iliac artery embolization (IIAE) was undertaken to stop intrapartum and postpartum hemorrhage in embolization group.There were no significant differences on age, pregnancy times, gestational age, neonatal weight, neonatal asphyxia, prenatal bleeding, placental implantation, and mortality between embolization group and control group (P > .05). The amount of intraoperative and postoperative bleeding in embolization group was significantly greater than that in control group (P < .05). However, the hysterectomy rate in the embolization group was significantly lower than that in the control group (P < .05). Two (6.25%, 2/32) cases had undergone the second time embolotherapy after 8 hours of cesarean surgery because of severe vaginal bleeding. One case (3.13%, 1/32) died of diffuse intravascular coagulation because of hemorrhagic shock in embolization group. Transient and self-remitted lumbosacral pain was present in 28 (95%, 28/32) patients and no other severe interventional complications were reported in embolization group. All babies in 2 groups were healthy at half to 5 years’ follow-up.The prophylactic intraoperative embolization of bilateral UAE or IIAE may be an effective strategy to treat intractable peripartum hemorrhage and preserve the fertility in patients with pernicious placenta previa.

Outcomes of the first 50 patients with abnormally invasive placenta managed using the "Triple P Procedure" conservative surgical approach.

To determine maternal outcomes for women with abnormally invasive placenta (AIP) managed using the Triple P Procedure and establish its safety as a conservative surgical management option. A retrospective study of the outcomes of the first 50 patients who underwent the Triple P Procedure for AIP from September 2010 to May 2017 at St George's Maternity Unit. Maternity case notes and the database were reviewed to determine the volume of bleeding, procedure-related complications, hysterectomy rate, and postoperative hospitalization. Mean operative blood loss was 2318mL (range, 400-7300mL and the incidence of bladder and ureteric injuries was 2% (n=1) and 0%, respectively. Median length of hospital stay was 4days (range, 2-8days). Three women (6.0%) developed arterial thrombosis without any long-term complications and none of the patients required peripartum hysterectomy. The Triple P Procedure should be considered as a conservative, less risky alternative to a peripartum hysterectomy during counselling prior to surgery for women with AIP.

1322 Comparison of Two Endometrial Ablation Techniques

Study Objective To compare the effectiveness of two methods (Novasure and Minerva) of endometrial ablation in a single community private practice. Design Retrospective chart review of all practice patients undergoing Novasure or Minerva endometrial ablation between 2015 and 2018. Minimum follow-up after the procedure was six months. Setting Procedures were all performed at Saddleback Center for Surgery (ambulatory surgery center) under general anesthesia by the physicians of Orange Coast Women's Medical Group. Patients or Participants All ablations performed between 2015 and 2018 were reviewed. 208 total ablations were performed. There were 127 in the Minerva cohort and 81 in the Novasure cohort. Interventions Not Applicable Measurements and Main Results Charts were reviewed for patient age, amenorrhea rates, rate of subsequent hysterectomy, improvement in bleeding, number of procedures performed by each provider, and days of follow up. Key results revealed no significant difference in the rate of amenorrhea in patients undergoing ablation with Minerva 32.3% (41/127) and Novasure 40.7% (33/81), (p=0.21). There was no significant difference in the rate of subsequent hysterectomy, 5.5% in the Minerva group and 9.9% in the Novasure group (p=0.24). There was no significant difference in patients showing improvement in bleeding without amenorrhea, 48.8% in the Minerva group and 44.4% in the Novasure group (p=0.72). There was no significant difference in the total combined amenorrhea and bleeding improvement; 81.1% in the Minerva group and 85.1% in the Novasure group (p= 0.45). Conclusion In our series, there was no significant difference in the Minerva or Novasure endometrial ablation systems in the rate of amenorrhea, subsequent hysterectomy, and overall decrease in bleeding.

2921 Trends in Endometrial Hyperplasia Over the Past Decade – Is It on the Increase?

Study Objective Atypical Hyperplasia carries a 30% risk of developing endometrial cancer over 20 years. Endometrial cancer has increased by 54% since the 1998. Overall hysterectomy rates are falling, and obesity increases. We reviewed 3 snapshot years over 10 years, in terms of hyperplasia numbers, management and surveillance. Design Retrospective case note audit with histological diagnosis of endometrial hyperplasia with or without atypia for 2008, 2013 and 2018. Setting Northern Health and Social Care Trust, Northern Ireland Patients or Participants 74 patients with a histological diagnosis of endometrial hyperplasia with or without atypia were identified. Interventions Medical treatment or hysterectomy. Measurements and Main Results • Endometrial Hyperplasia incidence 2008 - 19 cases (23% atypical / 77% without atypia); 2013 - 24 cases (42% atypical /58% without atypia) and 2018 - 31 cases (29% atypical /71% without atypia). • Mean BMI was 35, 39 and 36 in 2008, 2013 and 2018 respectively. • Age range 33 – 80 years. Mean age 2008 - 59; 2013 - 56; 2018 - 53. • 74% (n=17) with atypical hyperplasia underwent hysterectomy. 26% (n=6) had medical treatment with levonorgestrel IUS or oral progestogens, and surveillance due to surgical unsuitability or patient choice. • Hyperplasia without atypia was managed conservatively with progestogens and surveillance in 71% (n= 36) whilst 29% (n= 15) underwent hysterectomy; persistent bleeding in the absence of progressive histology being the main indication. • 84% (n= 26) of 2018 cohort were followed up according to 2016 Royal College of Obstetricians and Gynaecologists guidance. Conclusion Overall hyperplasia incidence is increasing. While BMI is elevated, there was no upward trend observed. Does the insidious decline in age demographic suggest that hyperplasia is occurring in younger women? Our review did not demonstrate a continuous increase in atypia, however there was a higher incidence in the 2013 group, who were also the most obese. Adherence to best practice surveillance in our hospitals was falling short.

2526 Utilizing Quality and Value Metrics to Improve Patient Outcomes Through the Kaiser Permanente Minimally Invasive Hysterectomy Initiative

Study Objective We present a case study in improving quality metrics with the Kaiser Permanente Minimally Invasive Hysterectomy Initiative to address the high rates of abdominal hysterectomies. Design Quality Improvement Project. Setting Route of hysterectomy (abdominal, laparoscopic, vaginal, robotic). Patients or Participants 31,385 patients who underwent surgical hysterectomy at Kaiser Permanente Northern California between 2008-2015. Interventions We initiated a four-pronged quality improvement program to increase the rate of minimally invasive hysterectomies, including: 1) Leadership engagement to set goals and achievable targets; 2) Surgeon education and training; 3) Utilization of targeted medical data to track outcomes and drive performance; and 4) Delineation of Obstetrics and Gynecology surgical teams and establishment of criterion-based credentialing. Measurements and Main Results Total abdominal hysterectomy percentages decreased from 50.5% to 6.9%, and total laparoscopic hysterectomy percentages increased from 21.9% to 61.9%. Robotic hysterectomy percentages only increased from 0.1% to 7.8%, and total vaginal hysterectomy percentages were maintained. Conclusion Our experience indicates that a quality improvement program to reduce abdominal hysterectomies while improving patient care can be successfully instituted on a large scale with limited reliance on less cost-effective robotic technology. The core aspects of the strategy should be highly incentivized under programs like Medicare Access and CHIP Reauthorization Act (MACRA). Moreover, this model can be used to address other quality issues in gynecologic surgery. It is our hope that the future of gynecologic surgery moves towards such a model that prioritizes optimal patient care. Please note that this abstract includes information that was presented in the paper, “Measuring Quality in Minimally Invasive Gynecologic Surgery: What, How, and Why?” by Abel et. al. in JMIG February 2019.

Mortality Rates in Laparoscopic and Robotic Benign Gynecologic Surgery- A Systemic Review and Meta-Analysis

Study Objective review mortality rates in benign gynecologic laparoscopic and robotic surgery (MIS), and to evaluate the mortality rates associated with commonly performed MIS procedures. Design Meta-analysis. Setting NA Patients or Participants An electronic-based search was performed on Pubmed, Embase, Scopus, Web of Science, and Cochrane Database. All MIS studies in benign gynecology reporting operative mortality (within 30 days) were reviewed. Meta-analysis was applied to calculate pooled mortality rates using the inverse-variance method. The relative risks (RRs) and their corresponding 95% confidence intervals (95% CIs) were calculated using the Mantel-Haenszel method. Interventions Meta-analysis. Measurements and Main Results 21 articles (12,5738 patients) were included. Operative mortality from any benign MIS (laparoscopy and robotics) procedure was 1:4243 (95% CI 1:1573- 1:11450). Studies were then grouped based on surgical procedure. Mortality rate for hysterectomy (43,112 patients) was 1:4920 (95% CI 1:2233, 1:10845); for sacrocolpopexy was 1:1246 (95% CI 1:36, 1:44700); and for adnexal surgery and diagnostic laparoscopy was 1:2245 (95% CI 1:45, 1:113372). Seventeen studies reported operative mortality for laparoscopic surgery, and 4 for robotic surgery. Conclusion Operative mortality in benign minimally invasive gynecologic surgery is low. There is no major difference for laparoscopic and robotic approaches.

Trends of Hysterectomies Performed by Graduating Residents Using American College of Graduate Medical Education Case Log

Study Objective We sought to evaluate the overall trend in hysterectomies for obstetrics and gynecology (OBGYN) resident surgeons from 2002 through 2017 using the data from the Accreditation Counsel for Graduate Medical Education (ACGME). The data stratifies hysterectomy type by abdominal (TAH), vaginal (TVH), and laparoscopic (TLH). We hypothesize that the rates of TVH and TAH will decrease during this time period with a concurrent increase in TLH. Design The publicly available data from the ACGME website from 2002 through 2017 was reviewed and abstracted into an excel document to graph trends. Data was further analyzed with SPSS where linear regression was performed using the mean hysterectomy numbers for each route and mean total hysterectomy. Setting N/A Patients or Participants Participants include OBGYN resident surgeons from 2002 through 2017 who logged hysterectomy data in the ACGME case log system as the primary surgeon. Interventions NA Measurements and Main Results A linear regression was performed to test if the year predicted the mean hysterectomy rates reported by OBGYN resident surgeons for total, as well as different routes of hysterectomy. The results of the regression indicate that the year of reporting is statistically significantly associated with route of hysterectomy mean totals. For every subsequent year, the mean TAH decreases by 3.5 (p Conclusion While the trend appears to decrease for total hysterectomy numbers, this decrease is not statistically significant. The route of hysterectomy, though, is statistically significantly different with a fluctuation towards more TLH, with the largest decrease in TAH. It appears TLH is replacing TAH with a transition towards more minimally invasive routes of hysterectomy.

Effect of gestational thrombocytopenia on negative fetal and maternal outcomes in low-risk pregnancies

Objective: Thrombocytopenia, expressed as platelet counts lower than 150 × 10 9 /L, is a common hematological anomaly seen in 6.6% of the pregnancies. Incidental thrombocytopenia of the pregnancy, commonly referred to as gestational thrombocytopenia, accounts for 70%–80% of cases. This study aimed to elucidate the effect of gestational thrombocytopenia on negative fetal and maternal results in low-risk pregnancies. Method: The patients were divided into two groups. The control group ( n = 240) consisted of healthy pregnant women with normal platelet count, and the study group ( n = 80) consisted of pregnant women with gestational thrombocytopenia. Results: Maternal age, pre-pregnancy body mass indexes, parity, and previous cesarean history rates were similar in both groups. Gestational age during delivery, fetal weight, delivery induction, amniotic fluid stained with meconium, hyperbilirubinemia, admission to neonatal intensive care unit, transient tachypnea of the newborn , respiratory distress syndrome, hypoxic–ischemic encephalopathy, necrotizing enterocolitis, intraventricular hemorrhage, and 5-min Apgar scores of <7 were not different between the groups ( P = 0.056, P = 0.233, P = 0.582, P = 0.798, P = 0.711, P = 0.859, P = 0.634, P = 1, P = 1, P = 1, P = 1,and P = 1, respectively). Spontaneous vaginal delivery, necessity for emergency cesarean delivery, postpartum hemorrhage , abnormal hemorrhage during cesarean , necessity for blood transfusion, and postpartum hysterectomy rates did not differ between the groups ( P = 0.530, P = 0.752, P <0.001, P <0.001, P = 0.758, P = 1, P = 1,and P = 1, respectively) . Despite being within normal limits, discharge time after C/S and spontaneous vaginal delivery was longer in the gestational thrombocytopenia group than in the control group. Conclusions: The results of the study showed that gestational thrombocytopenia did not pose a risk for both the mother and the fetus in low-risk pregnancies.

Women undergoing peripartum hysterectomy due to obstetric hemorrhage: A prospective population-based study.

Peripartum hysterectomy is usually undertaken in cases of life-threatening obstetric hemorrhage to prevent the death of the mother. Near-miss events are still under-researched and inappropriate care continues to be a critical issue, even in countries with advanced obstetric surveillance systems. The aim of the present study was to estimate the prevalence, associated factors, management and intraoperative and postoperative complications of peripartum hysterectomy due to obstetric hemorrhage. A prospective population-based study has been conducted in six Italian regions covering 49% of births in Italy. The study population comprised all women aged 11-59years undergoing peripartum hysterectomy, from September 2014 to August 2016, due to obstetric hemorrhage within 7days of delivery. In each maternity unit a trained reference person reported incident cases using electronic data collection forms. The background population comprised all women who delivered in the participating regions during the study period. The overall peripartum hysterectomy prevalence was 1.09 per 1000 maternities, with a large variability among regions, ranging from 0.52 to 1.60. Previous cesarean section (relative risk [RR] 4.97, 95% CI 4.13-5.96), assisted reproductive technology (RR 5.99, 95% CI 4.42-8.11) multiple pregnancy (RR 5.03, 95% CI 3.57-7.09) and maternal age ≥35years (RR 2.69, 95% CI 2.25-3.21) were the main associated factors for hysterectomy. The most common causes of peripartum hysterectomy were uterine atony (45.1%) and abnormally invasive placentation (40.2%). Intensive care unit admission was reported in 49.9% of cases, 16.8% of women suffered severe morbidity and 5 women died. The rate of peripartum hysterectomy in Italy was three times higher compared with the UK, the Netherlands and the Nordic countries. The wide difference may be associated with women's characteristics, such as age at delivery and previous cesarean section, and with different management options leading to peripartum hysterectomy.

Prophylactic abdominal aortic balloon occlusion in patients with pernicious placenta previa during cesarean section: a systematic review and meta-analysis from randomized controlled trials.

Pernicious placenta previa induces severe hemorrhage during cesarean section. Abdominal aorta balloon occlusion (AABO) is considered as an effective operation for patients with pernicious placenta previa. The aim of this study was to investigate the clinical application of abdominal aortic balloon occlusion in the placenta previa and cesarean section by systematic review and meta-analysis. MEDLINE, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WAN-FANG DATA and CQVIP were searched from inception to Jan. 15th, 2019. Operative time, intraoperative blood loss volume, postoperative hospitalization duration, intraoperative blood transfusion volume, hysterectomy rate, lower extremity thrombosis rate, ICU admission rate, adverse reaction rate, neonatal birth weight, Apgar 1-min and 5-min scores were regarded as the endpoints. Randomized controlled trials (RCT) were used for meta-analysis. Fourteen articles were retrieved from total 650 articles, and the results of meta-analysis showed that application of intraoperative AABO had the ability to reduce the operative time (WMD = - 16.581, 95% CI - 26.690 to - 6.472; P = 0.001), the intraoperative blood loss volume (WMD = - 1202.69, 95% CI - 1732.25 to - 673.12; P < 0.001), the intraoperative blood transfusion volume (WMD = - 1202.69, 95% CI - 1732.25 to - 673.12; P < 0.001). The hysterectomy rate (RR = 0.279, 95% CI 0.164-0.474; P < 0.001), postoperative hospitalization duration (WMD = - 1.423, 95% CI - 2.070 to - 0.776; P < 0.001) and the balloon preset time (WMD = - 13.793, 95% CI - 15.341 to - 12.244; P < 0.001; I2 = 0.0%) were also reduced in AABO group. Application of AABO in patients with pernicious placenta previa is safe and effective, which is worthy of clinical promotion.

Differential effect of GLUT1 overexpression on survival and tumor immune microenvironment of human papilloma virus type 16-positive and -negative cervical cancer

Glucose transporter-1 (GLUT1) has been proposed as a prognosticator in various cancers associated with therapeutic resistance and immune evasion; however little data is available on the role of GLUT1 in cervical cancer. Most cervical cancers are caused by human papilloma virus (HPV), but studies on the treatment response and prognosis depending on the HPV subtype, are conflicting. This hypothesis-generating study aims to investigate the prognostic impact of GLUT1 in cervical cancer, in conjunction with HPV subtype. Clinicopathologic factors, along with mRNA expression data were obtained using The Cancer Genome Atlas database. Tumor HPV status and immune cell scores were extracted from previous publications. In total, 298 patients were analyzed. High GLUT1 expression was associated with old age, squamous cell carcinoma, high tumor stage, pelvic lymph node metastases, and low hysterectomy rate. Multivariate survival analysis revealed that high GLUT1 expression (Hazard ratio (HR) 2.57, p = 0.002) and HPV16 subtype (HR 0.56, p = 0.033) were independent prognostic factors for overall survival. In the subgroup analysis, poor prognostic impact of high GLUT1 expression was maintained in HPV16-positive group (p < 0.001), but not in HPV16-negative group (p = 0.495). Decreased immune cell scores of CD8+ T cells, B cells, and Th1 cells by high GLUT1 expression were observed only in HPV16-positive group. In conclusion, these results suggested that GLUT1 expression and HPV16 subtype might have an independent prognostic value in cervical cancer. GLUT1-mediated immunomodulation might be an important cause of treatment failure, especially in HPV16-positive group.

Racial/Ethnic Disparities/Differences in Hysterectomy Route in Women Likely Eligible for Minimally Invasive Surgery

Evaluate racial/ethnic variation in hysterectomy surgical route in women likely eligible for minimally invasive hysterectomy. Cross-sectional study. Multistate including Colorado, Florida, Maryland, New Jersey, and New York. Women aged ≥18 years without diagnoses of leiomyomas, obesity, or previous abdominopelvic surgery who underwent hysterectomy for benign conditions from the State Inpatient and Ambulatory Surgery Databases, 2010-2014. None. Primary exposure is race/ethnicity. Racial/ethnic variation in annual hysterectomy rates and surgical route. To calculate hysterectomy rates per 100000 women/year, denominators were adjusted for the proportion of women with previous hysterectomy. A marginal structural log binomial regression model was used to estimate adjusted standardized prevalence ratios (aPRs) for vaginal or laparoscopic vs abdominal hysterectomy, controlling for clustering within hospitals. In addition, hospitals were stratified into quintiles to examine surgical route in hospitals that serve a higher vs lower proportion of African American patients. A total of 133082 adult women underwent hysterectomy for benign conditions from 2010 to 2014. Annual laparoscopic rates increased more slowly for African Americans (1.6-fold) than for whites (1.8-fold) and Hispanics (1.9-fold). African American and Hispanic women were less likely to undergo vaginal (aPR = 0.93; 95% confidence interval [CI], 0.90-0.96 and aPR = 0.95; 95% CI 0.93-0.97, respectively) and laparoscopic hysterectomy (aPR = 0.90; 95% CI, 0.87-0.94 and aPR = 0.95; 95% CI, 0.92-0.98, respectively) than white women; Asian/Pacific Islander women were less likely to undergo vaginal hysterectomy (aPR = 0.88; 95% CI, 0.81-0.96). Hospitals serving a higher proportion of African American persons performed more abdominal and fewer vaginal procedures across all groups, and more racial/ethnic minority women sought care at those hospitals than white women. African American, Hispanic, and Asian/Pacific Islander women eligible for minimally invasive hysterectomy were more likely than white women to receive abdominal hysterectomy. The proportion of all women undergoing abdominal hysterectomy was highest at hospitals serving higher proportions of African American persons. This difference in treatment type can lead to disparities in outcomes, in part owing to their association with complications.

Retrospective analysis of 586 cases of placenta previa and accreta

In this study, we conducted a retrospective investigation of all cases of placenta previa and accreta that were treated at a tertiary-level hospital to assess the effectiveness of balloon catheterisation at different levels. We evaluated the surgical and neonatal outcomes of 586 cases of placenta previa and accreta that were treated at our facility. This is the largest study of its kind. Depending on the severity and position of accreta, patients underwent balloon catheter placement in the aorta (n = 252) or common iliac artery (n = 38) before delivery by caesarean section. Data were collected regarding the duration of the surgery, number of cases (percentage) of balloon occlusion, and annual rate of hysterectomy. The blood loss (2207.89 ± 2044.95 ml) and transfusion volume (7.42 ± 7.872 U) in the common iliac occlusion group was greater than those in the aortic occlusion group (1967.66 ± 1466.64 ml and 6.54 ± 5.67 U, respectively); however, this difference did not reach statistical significance (p > .05). With the increase in the number of procedures performed over the years of study, the surgeons’ skills improved significantly. The choice of balloon catheterisation must be made with careful consideration. Our results highlight the significance of suture skill and the experience level of surgeons.IMPACT STATEMENTWhat is already known on this subject: The optimal method for the management of placenta accreta remains debateable. Prophylactic balloon catheters placed within arteries to control intraoperative bleeding play an important role in the management of patients with placenta accreta.What the results of this study add: The common iliac artery occlusion group tended to have a greater amount of blood loss and a higher requirement of transfusion than the aortic occlusion group; however, this difference was not statistically significant. We also analysed the difference in the complications across different periods of the study period and observed a clear improvement in the operative procedures over time.What the implications are of these findings for clinical practice and/or further research: Our study revealed that the surgeons’ proficiency increases over time, leading to improved results and a lower rate of hysterectomy over the course of several years. We recommend that the choice for balloon catheter occlusion be made with caution and after careful consideration.

Differential Effect of GLUT1 Overexpression on Survival and Tumor Immune Microenvironment of Human Papilloma Virus Type 16-Positive and -Negative Cervical Cancer

Glucose transporter-1 (GLUT1) has been reported as a poor prognosticator associated with radioresistance and immune evasion through metabolic communication in various cancers, but little data is available on cervical cancer. Meanwhile, most cervical cancer is known to be caused by human papilloma virus (HPV), but treatment response and prognosis according to the HPV subtype are also unknown. This hypothesis-generating study was conducted to investigate the prognostic impact of GLUT1 in cervical cancer, in conjunction with HPV subtype. Clinicopathologic factors along with mRNA expression data were obtained using The Cancer Genome Atlas database. Tumor HPV status and immune cell abundance scores were extracted from previous publications. Total 298 patients with appropriate information were analyzed. High GLUT1 expression was associated with old age, squamous cell carcinoma, high tumor stage, pelvic lymph node metastases, and low hysterectomy rate. HPV16 positivity itself was not associated with other factors, except low tumor grade. Multivariate survival analysis revealed that high GLUT1 expression (HR 2.57, p = 0.002) and HPV16 subtype (HR 0.56, p = 0.033) were independent prognostic factors for OS. In the subgroup analysis, poor prognostic impact of high GLUT1 expression was maintained in the HPV16-positive group (p < 0.001), but not in the HPV16-negative group (p = 0.495). Decreased immune cell abundance scores of B cells, CD8 T cells, and Th1 cells by high GLUT1 expression were observed only in the HPV16-positive group. Despite of heterogenous treatments, our results suggested that GLUT1 expression and HPV16 subtype may have an independent prognostic value in cervical cancer. Especially in the HPV16-positive group, GLUT1-mediated immunomodulation might be an important cause of treatment failure. Further proof-of-concept study is warranted to identify novel immunometabolic targets to overcome radioresistance.

PREVALENCE, INDICATION, TYPE AND COMPLICATION OF ELECTIVE HYSTERECTOMY IN A TERTIARY HOSPITAL IN ETHIOPIA

ABSTRACTBACKGROUND: Hysterectomy is a surgical removal of the uterus. It is one of the commonly performedsurgical procedures worldwide. In obstetric and gynecologic context, it is the second to cesarean section. Theaim of this study was to analyze the rate, indications, complications, and type of elective hysterectomy in Aydercomprehensive specialized hospital.METHODOLOGY: Retrospective study of all women for whom elective hysterectomy was done from January 2009-December 2016 in Ayder Comprehensive Specialized Hospital. RESULTS: A total of 385 elective hysterectomies were done out of 1058 major gynecologic surgeries duringthe study period. This makes a rate of hysterectomy of 36.4%. Majority of the cases were in the age group of 41-50years (31.6%) with the mean age of 47.5 years. The leading indication for elective hysterectomy was uterovaginalprolapse184 (57.3%), followed by leiomyoma 48 (15%) and ovarian tumor 47(14.6%). Vaginal hysterectomy was thecommonest route of surgery 159(49.5%) followed by total abdominal hysterectomy (TAH) 75(23.4%). Half of thepatients who had elective hysterectomy had pain during their hospital stay and 36.4 % of them were anemic afterthe operation. CONCLUSION: The rate of elective hysterectomy was 36.4% of all major gynecologic surgeries during thestudy period and more than half the indication was done for uterovaginal prolapse. Post-operative surgical site painwas the most common complication identified in about half of the cases during the study period.KEY WORDS: Total abdominal hysterectomy, vaginal hysterectomy, Uterovaginal Prolapse, Leiomyoma,Ovarian tumor