Hysterectomy Rates Research Articles

Severe maternal morbidity trends over 20 years in a tertiary referral stand-alone maternity unit

ObjectiveSevere maternal morbidity (SMM) is a better indicator of quality of care than maternal mortality, which is a rare event. Risk factors such as advanced maternal age, caesarean section (CS) and obesity are increasing. The aim of this study was to examine the rate and trends in SMM at our hospital over a 20-year period. Study designRetrospective review was performed of cases of SMM from January 1st 2000 to December 31st 2019. Yearly rates for SMM and Major Obstetric Haemorrhage (MOH) were calculated (per 1000 maternities) and linear regression analysis was used to model the trends over time. Average SMM and MOH rates were also calculated for the periods 2000–2009 and 2010–2019 and compared using a chi-square test. The patient demographics of the SMM group were compared to the background population delivered at our hospital using a chi-square test. Results702 women with SMM were identified out of 162,462 maternities over the study period yielding an incidence of 4.3 per 1000 maternities. When the two time periods (2000–2009 and 2010–2019) are compared, the rate of SMM increased 2.4 vs 6.2 (p < 0.001), largely due to an increase in MOH 1.72 vs 3.86 (p < 0.001) and pulmonary embolus (PE) also increased 0.2 vs 0.5 (p = 0.012). Intensive-care unit (ICU) transfer rates more than doubled 0.19 vs 0.44 (p = 0.006). Eclampsia rates decreased 0.3 vs 0.1 (p = 0.047) but the rate of peripartum hysterectomy 0.39 vs 0.38 (p = 0.495), uterine rupture 0.16 vs 0.14 (p = 0.867), cardiac arrest (0.04 vs 0.04) and cerebrovascular accidents (CVA) (0.04 vs 0.04) remained unchanged. Maternal age > 40 years 9.7% vs 5% (p = 0.005), previous CS 25.7% vs 14.4%; p < 0.001 and multiple pregnancy 8 vs 3.6% (p = 0.002) were more prevalent in the SMM cohort compared to the hospital population. ConclusionsOverall, rates of SMM have increased threefold and transfer for ICU care has doubled over 20 years in our unit. The main driver is MOH. The rate of eclampsia has decreased and peripartum hysterectomy, uterine rupture, CVA and cardiac arrest remain unchanged. Advanced maternal age, previous caesarean delivery and multiple pregnancy were more prevalent in the SMM cohort compared to the background population.

Who Places High Value on the Uterus? A Cross-sectional Survey Study Evaluating Predictors for Uterine Preservation

ABSTRACT The prevalence of inpatient hysterectomy, a common surgical procedure in the United States, decreased by 36.4% between 2002 and 2010 in women with benign gynecologic conditions. One major factor contributing to the decline in inpatient hysterectomies was the growing number of uterine-preserving treatment options. Alternatives to hysterectomy include hormonal management, endometrial ablation, myomectomy, or uterine artery embolization. Additional reasons for desiring uterine preservation among women who do not desire future fertility may include the belief that the uterus provides improved sense of self, relationship, and femininity. There are ethnic and racial disparities in the number and route of hysterectomies performed. Rates are higher among Black women than among White women. Variations in hysterectomy rates are likely exacerbated in marginalized racial groups who have less access to uterine-sparing treatments or delayed care at earlier disease states. Although patient preferences may influence the choice of hysterectomy or uterine-preserving therapy, the contribution of race and socioeconomic status to one's preference for uterine preservation is unknown. The aim of this cross-sectional survey was to determine predictors for uterine preservation among patients who no longer desire fertility. A secondary aim was to identify reasons for placing high value on the uterus. The study was conducted at 3 hospital-based clinics in a large health care system in the United States. Participants were new patients 45 years or older seeking care for benign gynecologic conditions (including abnormal uterine bleeding, uterine fibroids, pelvic organ prolapse, endometriosis, or pelvic pain). The primary study outcome was the summative score of the VALUS ( Value of Uterus) instrument in predicting that a woman will undergo uterine preservation. The VALUS, a validated and reliable instrument, measures patient preferences and value placed on uterine preservation. Respondents placed either “low value” versus “high value” for the uterus in ovarian preservation. Secondary outcomes included individual questions within the VALUS instrument to determine drivers of uterine preservation. There were no prior data. Of the 230 surveys distributed, 206 (89.6%) were returned for analysis, and 163 of these (79.2%) met the criteria for completion. Using the VALUS cutoff, 64 patients (45.7%) were considered to have low value for their uterus (VALUS score &lt;14), whereas 76 patients (54.3%) were considered to have high value for their uterus (VALUS score ≥14). Among women who wanted to be sexually active in the future, the likelihood of a high value for the uterus was substantially higher compared with those who did not; the adjusted odds ratio was 5.06, with a 95% confidence interval (CI) of 1.55 to 16.52, P = 0.01. Sexually active patients were substantially more likely to place a higher value on the uterus compared with those not sexually active or those who did not wish to be (adjusted odds ratio, 3.94; 95% CI, 1.36–11.43; P = 0.01). Non-White race, religion, and personal history of cancer were not statistically significant. These findings show that sexually active women and those who desire future sexual activity have 5- and 4-times higher odds of placing high value on the uterus compared with patients who are not sexually active. Patients who highly value the uterus believe that it is important for sexual function, sexual pleasure, sense of self, and staying complete as a woman. Future large-scale studies are needed to determine whether patient preferences contribute to the racial disparities in hysterectomy rates.

Perioperative complication rates of colpocleisis performed with or without concomitant hysterectomy: a large population-based study.

We aimed to compare perioperative complications for women who underwent colpocleisis with and without concomitant hysterectomy, and report the rate of concomitant hysterectomy. We conducted a retrospective study using the Healthcare Cost and Utilization Project (HCUP) - Nationwide Inpatient Sample 2004 to 2014. We used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify women with pelvic organ prolapse (POP) who underwent colpocleisis with or without concomitant hysterectomy. Trend over time of each procedure type was created. We calculated odds ratios (ORs) to determine the risk of perioperative complications with or without concomitant hysterectomy. ORs were adjusted for age, race, income, insurance plan, and hypertension. Of 253,100 adult women who underwent POP repair, 7,431 had colpocleisis. Colpocleisis with concomitant hysterectomy was performed in 1,656 (22.2%) and 5,775 (77.7%) underwent colpocleisis alone (2,469 [33.2%] had a previous hysterectomy). Hysterectomy rates among women with POP undergoing colpocleisis remained relatively steady, whereas those undergoing colpocleisis without hysterectomy declined over time. Prevalence of any complications was higher among those with concomitant hysterectomy (11.4% vs 9.5%, p=0.023). Adjusted OR showed that concomitant hysterectomy increased the risk of complications (OR 1.93, 95% CI 1.45-2.57, p<0.001). Our large administrative data analysis suggests an increased risk of complications when performing a hysterectomy at the time of colpocleisis. A concomitant hysterectomy was performed in 22% of cases. Whether or not to include hysterectomy at the time of colpocleisis is based on shared decision making, influenced by individual patients' values, comorbidities, and risk of complications.

The anesthetic approach to a patient with placenta accreta spectrum.

Placenta accreta poses significant risk of morbidity and mortality to a laboring patient. Here we review available treatment options, highlight trends in bleeding prevention and diagnosis that have been shown to improve patient outcome, and provide best practice suggestions. We also discuss the decision-making process for choice of anesthesia, as it is not based on a gold-standard paradigm. The use of resuscitative endovascular balloon occlusion of the aorta has been gaining popularity around the world. It has been shown to cause an equivocal reduction in perioperative bleeding in placenta accreta spectrum (PAS), reduce the rate of hysterectomies, and is a safe and relatively easy technique. There are other invasive radiology techniques that have also proven to be beneficial in bleeding prevention: balloon occlusion of hypogastric arteries intraoperatively, internal iliac artery embolization, and intraoperative ligation of the hypogastric or uterine arteries. Optimal management of PAS begins with early and definitive diagnosis. A multidisciplinary approach along with preparation of special equipment and the use of a check-list maximize the chance for success. Anesthesia could be done with all types of regional or under general, considering case-by-case factors but most importantly choosing according to the institution's best facility and skill.

Trends in Hysterectomy Rates Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic.

To compare nationwide trends in the rate of inpatient and outpatient hysterectomy between 2019 and 2020 during the coronavirus disease 2019 (COVID-19) pandemic. Using weighted data from the National Inpatient Sample and the National Ambulatory Surgery Sample, we examined the number of hysterectomies performed by month from 2019 through 2020. Monthly trends were compared between years overall, stratified by the route of surgery (abdominal, laparoscopic, and vaginal) and by indication for surgery (benign, preinvasive, cancer). Trends analyses were conducted using Joinpoint regression and reported as average monthly percentage change (AMPC). Differences in demographic characteristics between the years were compared using χ 2 tests. From January 2019 through December 2020, after weighting, 1,029,792 hysterectomies were performed, including 548,802 (53.2%) in 2019 and 480,990 (46.7%) in 2020. Starting in January 2020, monthly cases declined significantly, from 40,240 to a nadir of 10,566 hysterectomies in April 2020 (AMPC -29.2%, 95% CI -39.8% to -16.8%) ( P <.001). The subsequent months saw a significant increase in cases, from the nadir in April 2020 to 40,023 cases in July 2020 (AMPC 39.4%, 95% CI 18.6-63.9%) ( P =.001), which then stabilized to the end of the year (AMPC -1.3%, 95% CI -4.8% to 2.4%) ( P =.46). In March 2020 there was a 24.0% decrease, in April 2020 a 74.2% decrease, and in May 2020 a 35.1% decrease compared with the respective months in 2019. The rates of vaginal hysterectomy declined more than the rates of other routes of surgery, and procedures performed for benign and preinvasive disease decreased more than those for cancer. The rate of hysterectomy in the United States decreased in 2020 compared with 2019, with the greatest decrease from March to May of 2020, corresponding with the initial wave of COVID-19.

A 10-Year Analysis of Complete Uterine Rupture in Pregnant Women with an Intact Uterus: A Multi-Center Cross-Sectional Study in Sichuan, China

Background: Complete uterine rupture can lead to serious adverse maternal and child outcomes. Uterine rupture is rare, and it can occur in an intact uterus. Methods: We identified patients with intact uterus who encountered uterine rupture between 2010 and 2020 from the medical records of 10 hospitals in Sichuan Province. Results: In total, 37 cases of uterine rupture in intact uteri were identified. Eight ruptures (8/37, 21.6%) occurred before spontaneous labor, 11 ruptures (11/37, 29.7%) occurred during spontaneous labor, and 18 ruptures (18/37, 48.6%) occurred during induced labor. The clinical manifestations of the patients were abdominal pain in 20 cases (20/37, 54.1%), vaginal bleeding in three cases (3/37, 8.1%), and abdominal pain and vaginal bleeding in eight cases (8/37, 21.6%). The rate of hysterectomy/death was significantly higher in patients with more than three previous vaginal deliveries (p = 0.005). In addition, the rate of hysterectomy/death in the spontaneous labor group was significantly higher than that in the induced labor group (p = 0.011). The fetal survival rate in patients with uterine rupture at the uterine horn was significantly higher than that in patients with uterine rupture at the lower uterine segment (p = 0.007). Conclusions: Uterine rupture in an intact uterus was associated with a high hysterectomy rate and high fetal/neonatal mortality rate. For pregnant women with sudden abdominal pain and abnormal fetal heart rate, we should be alert to the possibility of uterine rupture. Induction and augmentation of labor need to be performed with caution to avoid this potential obstetric emergency.

Vaginal Natural Orifice Transluminal Endoscopic Surgery Revolution: The Next Frontier in Gynecologic Minimally Invasive Surgery.

Despite guidelines that assert that the vaginal route for benign hysterectomy is preferred as the most minimally invasive approach, rates of vaginal hysterectomy remain very low in the United States. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) might reverse the trend. Potential advantages of vNOTES compared to traditional laparoscopic and robotic approaches include the potential for less pain, decreased operative time, improved cosmesis, and decreased risks. Importantly, vNOTES might allow for the conversion of laparoscopic and robotic routes back to vaginal due to surgeon factors.

Incidence and determinants of hysterectomy among North Indian women: An 8-year follow-up study.

Despite indications of a rapid increase in the number of hysterectomies performed in India, very few studies have methodically investigated the rate and determinants of the incidence of hysterectomy. The present study aims to estimate the rate of incidence of hysterectomy and identify predictors/determinants of incident hysterectomy in a cohort of North Indian women. In the present study, a cohort of 1,009 ever-married North Indian women (aged 30-75 years) was followed up after a median of 8.11 years. Those hysterectomized at the baseline (63) were excluded; and of the rest 946 participants, 702 (74.2%) could be successfully followed-up. During the baseline assessment, data about sociodemographic variables, reproductive history, menopausal status, physiological health, and selected blood biochemicals were collected. During the end-line assessment, data about sociodemographic variables, current menopausal status, and incident hysterectomy were recorded. The overall rate of incidence of hysterectomy was found to be 11.59 per 1,000 women-years, in the study population. Interestingly, the incidence rates were found to be similar among pre- and post-menopausal women. Further, while late age at menarche was found to be negatively associated with incident hysterectomy, folate repletion and high triglyceride (TG) at the baseline were found to be positively associated. High rate of incident hysterectomy in the studied population points toward the huge burden of gynecological morbidity and the unavailability of non-invasive protocols. Such a situation warrants immediate policy intervention. Further, maintaining TG and folate within normal physiological ranges may be beneficial in gynecological ailments necessitating hysterectomy.

Analysis of the Risk Factors for Massive Hemorrhage in Pernicious Placenta Previa and Evaluation of the Efficacy of Internal Iliac Artery Balloon Occlusion.

To investigate the risk factors of intraoperative massive hemorrhage in patients with pernicious placenta previa (PPP) and analyze the value of bilateral internal iliac artery balloon occlusion in Cesarean section for these patients. The clinical data of 134 patients with PPP admitted to the Second Hospital of Shanxi Medical University from January 2012 to January 2019 were analyzed. A logistic regression analysis was used to analyze the risk factors for intraoperative massive hemorrhage in PPP. The study subjects were divided into the intervention group (38 cases) and the routine group (96 cases) according to whether bilateral internal iliac artery balloon occlusion was conducted during the operation. The differences in some clinical indicators were compared between the two groups. The risk factors for intraoperative massive hemorrhage in PPP were age ≥35 years, gestational age ≥34 weeks, complete placenta previa, and the presence of placenta accreta. The differences in the operation time, postoperative transfer to the intensive care unit, postoperative length of the hospital stay, and neonatal weight and score were not statistically significant between the intervention group and the routine group (P > 0.05 for all). While the intraoperative blood loss and the transfusion volume in the intervention group were lower than in the routine group, the hospitalization cost was higher in the former than in the latter, and the differences were statistically significant (P < 0.05 for all). Moreover, there was no case of hysterectomy in the intervention group, while there were two cases of hysterectomies in the routine group. The risk factors for intraoperative massive hemorrhage in PPP were age ≥35 years, gestational age ≥34 weeks, complete placenta previa, and the presence of placenta accreta. Internal iliac artery balloon occlusion during PPP could reduce intraoperative blood loss and the hysterectomy rate.

Short interdelivery interval in modern obstetrics: Maternal and neonatal outcomes.

To investigate the maternal, neonatal outcomes of the patients with short interdelivery interval (IDI) considering initial pregnancy outcomes. Women with two consecutive deliveries between 2016 and 2020 were included in the study. The maternal and neonatal outcomes of both pregnancies were reviewed. The time interval between consecutive deliveries was calculated. The patients were divided into two groups in terms of IDI either less or more than 24 months. The number of patients with short IDI (≤24 months), and normal IDI was 1.915 and 1.370, respectively. About 15% of the women in both groups had at least one obstetric morbidity. The rates of uterine rupture, placenta previa, and peripartum hysterectomy were higher in women with short IDI. The number of patients with low birth weight, very low birth weight, and stillbirth was higher in the short IDI group. Patients with short interpregnancy intervals should be considered high-risk pregnancy. Adequate contraceptive methods should be used to prevent unintended pregnancies.

Postpartum Hemorrhage Trends and Outcomes in the United States, 2000-2019.

To analyze temporal trends in and risk factors for postpartum hemorrhage and to analyze the association of risk factors with postpartum hemorrhage-related interventions such as blood transfusion and peripartum hysterectomy. This repeated cross-sectional study analyzed delivery hospitalizations from 2000 to 2019 in the National (Nationwide) Inpatient Sample. Trends analyses were conducted using joinpoint regression to estimate the average annual percent change (AAPC) with 95% CIs. Unadjusted and adjusted survey-weighted logistic regression models were performed to evaluate the relationship between postpartum hemorrhage risk factors and likelihood of 1) postpartum hemorrhage, 2) postpartum hemorrhage that requires blood transfusion, and 3) peripartum hysterectomy in the setting of postpartum hemorrhage, with unadjusted odds ratios and adjusted odds ratios with 95% CIs as measures of association. Of an estimated 76.7 million delivery hospitalizations, 2.3 million (3.0%) were complicated by postpartum hemorrhage. From 2000 to 2019, the rate of postpartum hemorrhage increased from 2.7% to 4.3% (AAPC 2.6%, 94% CI 1.7-3.5%). Over the study period, the proportion of deliveries to individuals with at least one postpartum hemorrhage risk factor increased from 18.6% to 26.9% (AAPC 1.9%, 95% CI 1.7-2.0%). Among deliveries complicated by postpartum hemorrhage, blood transfusions increased from 5.4% to 16.7% from 2000 to 2011 and then decreased from 16.7% to 12.6% from 2011 to 2019. Peripartum hysterectomy among hospitalized individuals with postpartum hemorrhage increased from 1.4% to 2.4% from 2000 to 2009, did not change significantly from 2009 to 2016, and then decreased significantly from 2.1% to 0.9% from 2016 to 2019 (AAPC -27.0%, 95% CI -35.2% to -17.6%). Risk factors associated with postpartum hemorrhage and transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with previa or placenta accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption. Postpartum hemorrhage and related risk factors increased over a 20-year period. Despite the increased postpartum hemorrhage rates, blood transfusions, and hysterectomy rates decreased in recent years.

Association of obstetrical Hysterectomy with rising rates of cesarean section among women with Placenta Previa.

To analyze the impact of previous cesarean section on rates of obstetrical hysterectomy among women with placenta previa. A retrospective cohort study done at the Department of Obstetrics & Gynecology, Nishtar University Hospital, Multan from January 2017 to December 2021. A total of 374 women aged between 20 to 50 years with diagnosis of placenta previa who underwent cesarean delivery were included. Age, BMI, area of residence, gestational age, gravidity status and past history of cesarean section were noted from medical records of all women. Relationship of previous number of cesarean sections and with obstetrical hysterectomy was noted among women with placenta previa. In a total of 374 women, mean age was 33.45±7.3 years. Mean gestational age was 37.4±3 weeks. Obstetrical hysterectomy was done in 110 (29.4%) women. Significant association of gravidity status was noted with hysterectomy as 95 (86.4%) women with hysterectomy had gravidity status ≥3 in comparison to 197 (74.6%) with no hysterectomy (p=0.030). Number of cesarean section was found to have significant association with obstetrical hysterectomy as 55 (50.0%) women with obstetrical hysterectomy reported ≥3 previous cesarean section versus 29 (11.0%) with no obstetrical hysterectomy (p<0.001). Strong association of previous number of cesarean section and obstetrical hysterectomy was found with placenta previa. There should be protocols for early identification and prediction of adverse outcomes among women with placenta previa with past history of cesarean section.

Comparison between placenta accreta scoring system, ultrasound staging, and clinical classification.

Placenta accreta spectrum (PAS) is a series of disorders, which means that the placental trophoblast invades into the myometrium of the uterine wall. It is a serious obstetric complication which could be detected by ultrasound prenatally. In order to compare our placenta accreta scoring system with prenatal ultrasound staging system and International Federation of Gynecology and Obstetrics (FIGO) clinical classification, we did a retrospective study including 105 patients diagnosed with PAS disorders by operation or pathology at Peking University First Hospital, Beijing, China, between January, 2019 and December, 2020. Placenta accreta scoring system, prenatal ultrasound staging system and FIGO clinical classification were used on each patient. Basic information and clinical outcomes including gestational weeks, intraoperative hemorrhage, hysterectomy rate and blood transfusion were also counted. Both of placenta accreta scoring system, prenatal ultrasound staging system can give a rather clear prediction of placenta percreta, with their area under curve were 0.872 (95% confidential interval [CI]: 0.793-0.951) and 0.864 (95%CI: 0.779-0.949), P value were .000 compared with clinical classification. Beside for ultrasound staging system was designed for placenta previa patients, all those 3 criteria showed their relationships with preterm birth, hysterectomy rate and intraoperative bleeding. PAS scoring system also had the ability to predict a gestational week of delivery ≤34 weeks, intraoperative massive bleeding ≥2000 mL and hysterectomy at over 12 points. Our placenta accreta scoring system had good accordance with pre-operational ultrasound staging and FIGO clinical classification, with higher universality for patients without placenta previa.

Characteristics of Submucous Myomas and the Risk of Anemia.

Background and Objectives: Uterine fibroids still represent the most common indication for hysterectomy for benign pathologies. In the United States, more than 479,000 hysterectomies are performed annually, 46.6% for myomas and 47.7% in women aged from 18 to 44 years. By applying appropriateness criteria to this procedure, it has been estimated that overuse ranges from 16 to 70%. One of the main reasons that induce patients and gynecologists to consider hysterectomy is represented by severe anemia. Materials and Methods: This is a retrospective cohort study of 202 patients with uterine fibroids diagnosed by transvaginal ultrasound who underwent a hysteroscopic procedure. Myoma grade, size, location, and number were assessed by transvaginal scan and office hysteroscopy and correlated to the pre-treatment hemoglobin level. Results: Univariate analysis showed that anemia does not have a statistically significant association with myoma number and with age considered as a numerical predictor. In the patients with myoma type 0, there is a possibility of 81% having anemia regardless of menorrhagia. On the contrary, in patients with myoma type 1 or type 2, the possibility of having anemia varies according to the presence or absence of menorrhagia. If there is menorrhagia, the risk of moderate anemia is only present for myomas &gt;60 mm. Conclusions: The results of this study may contribute to defining objective criteria for the management of submucous myomas and anemia. Our data suggest that submucosal myomas type 0 &gt;10 mm should always be treated, putting patients at risk for anemia. Myomas type 2 and 3 should be treated for the risk of anemia in the presence of menorrhagia episodes or if &gt; of 60 mm. Adequate management of anemia and myomas could reduce the rate of unnecessary hysterectomies.

7754 The Impact of Physician Remuneration Incentive on Laparoscopic Hysterectomy Practice in Canada: An Interrupted Time Series Analysis

<h3>Study Objective</h3> To determine whether the introduction of a physician remuneration incentive within certain Canadian provinces resulted in increased practice of laparoscopic hysterectomy over time. <h3>Design</h3> Retrospective population-based study with interrupted time series analysis of federal health administrative data from the Canadian Institute for Health Information <h3>Setting</h3> Hospitals in all the provinces of Canada, excluding territories <h3>Patients or Participants</h3> 81,507 patients aged ≥18 years undergoing hysterectomy for benign gynecologic indication in Canada from 2006/07 to 2016/17 <h3>Interventions</h3> Hysterectomy <h3>Measurements and Main Results</h3> Reviewof physician remuneration fee schedules for each province in Canada identified three provinces where a physician incentive (additional 25-50% remuneration) was introduced: British Columbia (BC) (2013), Saskatchewan (SK) (2012), and Prince Edward Island (PEI) (2011). During the 10-year period, the rates of laparoscopic hysterectomy increased rapidly in BC (6.0%-54.7%), SK (13.5%-66.7%), and PEI (<1.0%-36.9%) (<i>p</i><0.05 for all trends). In SK (n=7,857 hysterectomies), there was a significant additional increase in the rate of laparoscopic hysterectomy from 40.6% to 49.4% in the quarter following the incentive (<i>p</i><0.0001). In BC (n=16,332), there was no significant additional increase in the rate of laparoscopic surgeries after the introduction of a financial incentive. Though PEI appeared to demonstrate an increase in the rate of laparoscopic hysterectomy following the incentive, ITS analyses were not performed due to the small sample size (n=2,583). <h3>Conclusion</h3> The introduction of physician remuneration incentive appears to be associated with an increase in practice of laparoscopic hysterectomy in some provinces but not others. While physician incentive may help encourage minimally invasive surgical practice, the effects are likely modified by other important factors, such as operating room resources and training opportunities.

7709 Tips and Tricks for Vaginal Hysterectomy

<h3>Study Objective</h3> The objective of this video is to review surgical techniques and tips for vaginal hysterectomy to improve provider confidence and serve as an educational tool. <h3>Design</h3> Audio narration, still images, and surgical footage will be used to review difficult scenarios and present an evidence-based approach to troubleshoot common issues. <h3>Setting</h3> Video footage was filmed with patients in dorsal lithotomy positioning in the operating room. <h3>Patients or Participants</h3> Patients with varying degrees of pelvic organ prolapse, ranging from stage 0-IV on POP-Q (Pelvic Organ Prolapse Quantification), were filmed during vaginal hysterectomy for heavy menstrual bleeding or prolapse repair. <h3>Interventions</h3> This video will review four common difficulties faced during vaginal hysterectomy: patient selection, the colpotomy, vaginal salpingectomy, and laparoscopically assisted vaginal hysterectomy. <h3>Measurements and Main Results</h3> This video discusses how to select candidates for vaginal hysterectomy including commonly misquoted contraindications. An approach, using the physical exam as guidance, is given for the anterior and posterior colpotomy and video footage is used to review how to troubleshoot the anterior entry. Steps to improve visualization for vaginal salpingectomy are discussed. Finally, laparoscopically assisted vaginal hysterectomy and how to divide the case between laparoscopic and vaginal approaches is reviewed to optimize success in the operating room. <h3>Conclusion</h3> This video reviews important steps of vaginal hysterectomy and provides tips to improve surgeon confidence. It can serve as an educational resource for trainees and early-career surgeons to improve their knowledge and confidence in performing vaginal hysterectomy. These types of resources are important to counter declining rates of vaginal hysterectomy and decreasing provider comfort in performing this operation.

8341 Implementation of Robotic Surgery in a Rural Setting: Impact on Need for Assistant Surgeon and Route of Hysterectomy

<h3>Study Objective</h3> Robot-assisted hysterectomy allows the surgeon improved visualization, range of motion, and ergonomics which in some cases may obviate the need for an assistant surgeon. In rural hospitals where physician shortages remain a major barrier to care, reducing the number of surgeons necessary to perform hysterectomy would be of significant consequence. We sought to evaluate the impact of robotic surgery on the need for an assistant surgeon at time of hysterectomy at a rural community hospital. <h3>Design</h3> We performed a retrospective chart review of hysterectomies performed at a rural community hospital by general gynecologists, focusing on the 12-month period prior to, and the 12-month period 2 years following, implementation of a robotic surgical program. We chose 2 years to allow for gradual surgeon adoption of robotic technology. Our primary outcome was need for an assistant surgeon at time of hysterectomy. Our secondary outcome was route of hysterectomy. Billing records were cross-referenced against the medical record, and statistical analyses performed. <h3>Setting</h3> A rural community hospital in northcentral Pennsylvania. <h3>Patients or Participants</h3> Patients undergoing hysterectomy by general obstetrician-gynecologists. <h3>Interventions</h3> All modes of hysterectomy (abdominal, laparoscopic, robotic, and vaginal). <h3>Measurements and Main Results</h3> Following implementation of a robotic surgical program we observed a statistically significant decrease in the presence of an assistant surgeon at the time of hysterectomy from 86.7% to 29.7% (p<0.05). The percentage of hysterectomies performed by minimally-invasive technique (laparoscopic, robotic, and vaginal) versus open technique (total abdominal) increased from 67.0% to 87.4% following implementation of a robotic surgical program (p<0.05). <h3>Conclusion</h3> Access to robotic surgical technology reduced the need for an assistant surgeon at time of hysterectomy and increased the rate of minimally-invasive hysterectomy performed. These findings are of particular relevance to rural hospitals facing physician shortages.

Moving the Needle on Vaginal Hysterectomy: Implementing vNOTES at a Large Academic Medical Center

<h3>Study Objective</h3> To evaluate the adoption of vNOTES at a large resident driven county hospital and determine if this approach could significantly increase rates of vaginal hysterectomy. <h3>Design</h3> All hysterectomies done on the benign gynecology resident service of the presenter were included. A period of 24 months preceding the introduction of vNOTES (VANH: vaginal assisted vNOTES hysterectomy) was compared to a period of 24 months following the introduction of VANH. <h3>Setting</h3> Large County hospital resident gynecology service. <h3>Patients or Participants</h3> All patients presenting for hysterectomy for a 4-year period. <h3>Interventions</h3> The residents on each service block were introduced to vNOTES (VANH) as a route of hysterectomy. Residents suggest the desired route of surgery for each case, with faculty guidance as to relative and absolute contraindications for the planned route. In the early cohort, routes of hysterectomy were TVH, TLH, RA-TLH, and TAH. In the post intervention cohort, the routes of hysterectomy were TVH, VANH, TLH, RA-TLH, and TAH. <h3>Measurements and Main Results</h3> The main metric was the percentage of cases completed by each route, especially the percentage of cases completed vaginally, comparing TVH to TVH+VANH. An expansion in access to the daVinci Xi system resulted in an increase in the percentage of RA-TLH, so for the purposes of this analysis, these routes were considered together. Secondary considerations were conversion from planned route or complications. There were no conversions in the TVH or VANH category. Complications were correlated more with uterine size than planned route. <h3>Conclusion</h3> The addition of VANH to gynecological education can improve the access of residents to vaginal hysterectomies. By reducing perceived barriers to vaginal hysterectomy, it increases the number of patients considered candidates for vaginal surgery without increasing complications rates.

Venous Thromboembolism after Abdominal and Minimally Invasive Large Specimen Hysterectomy

<h3>Study Objective</h3> To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population. <h3>Design</h3> Cohort study of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States. <h3>Setting</h3> National Surgical Quality Improvement Program Database. <h3>Patients or Participants</h3> Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into four groups according to uterine weight: <100g, 100-249g, 250g-499g, and specimens >500g. <h3>Interventions</h3> Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index (BMI), smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists (ASA) classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight. <h3>Measurements and Main Results</h3> A total of 122,408 patients were included in the study, of which 28,397 (23%) underwent abdominal, 75,490 (62%) laparoscopic, and 18,521 (15%) vaginal hysterectomy. The VTE rate for large specimen hysterectomy (>500g) was 0.64%. After adjusting for confounders, patients who underwent minimally invasive hysterectomy had a lower rate of VTE for the laparoscopic (aOR 0.62; CI:0.47-0.81) and vaginal (aOR 0.46; CI:0.31-0.68) routes when compared to open surgery. Total operative time was independently associated with postoperative VTE (>120min, aOR 1.85; CI:1.5-2.27). Uterine weight even for specimens >500g was not significantly associated with the rate of VTE. Interestingly, only 30% of the surgeries with uterine weight above 500g were done with a minimally invasive route. <h3>Conclusion</h3> The occurrence of VTE after benign large specimen hysterectomy is rare. The rate of VTE is higher with longer operative times and is lower with minimally invasive approaches even for markedly enlarged uteri.

Developing a new preoperative iron-deficiency anaemia service for major gynaecological surgery – improving multiple patient outcomes

Background: Preoperative anaemia is an independent predictor of poorer outcomes after surgery. Alongside this, allogeneic blood transfusion is also associated with increased complications and length of stay. Iron deficiency anaemia (IDA) is frequently found in patients undergoing major gynaecological surgery. Together with surgical blood loss, blood transfusions are therefore common. The national transfusion rate for hysterectomy is 9%.1 We recognised the need for a dedicated service for the management of preoperative IDA, developing it over several quality improvement (QIP) cycles.