Surgical Approach For Hysterectomy Research Articles

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis

There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization. This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy. We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated. There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001). This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

Comparison of different surgical approaches for hysterectomy using the modified Clavien Dindo classification

Comparison of different surgical approaches for hysterectomy using the modified Clavien Dindo classification

Accuracy of Preoperative Pelvic Ultrasound in Predicting Uterine Weight Across Varying Pathologies

Objectives: The purpose of this study is to evaluate the accuracy of preoperative pelvic sonography in predicting the weight of a non-gravid uterus at the time of hysterectomy. Additionally, the study seeks to examine the effect of varying uterine pathologies on the accuracy of these predictions. Methods: This was a retrospective comparative study in a tertiary care hospital with a total of 318 patients who underwent pelvic ultrasound, with reported uterine volumes, prior to undergoing hysterectomy in 2018. Estimated uterine weights from preoperative pelvic ultrasounds were compared to actual uterine weights from post-hysterectomy pathology reports. A Bland-Altman plot was constructed to determine intermethod agreement with 95% limits of agreement. Simple linear regression analysis was used to correlate estimated and actual uterine weights. Multivariable linear regression was performed, allowing for subgrouping by uterine pathology. Results: While a strong positive correlation was identified between the two measurements (r = .93, p &lt;.01), the Bland-Altman analysis showed that actual uterine weight ranged from 0.51 to 1.99 times the magnitude predicted by preoperative ultrasound. These wide deviations in intermethod agreement were similar amongst the various uterine pathologies. Multivariable linear regression analysis demonstrated the difference in estimated and actual uterine weight was 2 to 3.5 times larger for patients with endometrial pathology, adenomyosis, and leiomyomata as compared to normal uteri (p &lt; .03). Conclusion: This study shows that in 95% of cases, actual uterine weight ranged from half to twice as large as estimated by preoperative pelvic ultrasound. Uterine pathology had a significant impact on the reliability of ultrasound for estimation of uterine weight. In gynecologic practices where preoperative estimations of uterine weight are instrumental in choosing a surgical approach for hysterectomy, reliance on pelvic ultrasound as a means of predicting uterine weight should be carefully considered.

The shift from inpatient to outpatient hysterectomy for endometrial cancer in the United States: trends, enabling factors, cost, and safety

ObjectiveTo evaluate trends in outpatient versus inpatient hysterectomy for endometrial cancer and assess enabling factors, cost and safety.MethodsIn this retrospective cohort study, patients aged 18 years or older who underwent...

Laparoscopic Hysterectomy with Cervicovaginal Agenesis

Video Objective We present a laparoscopic surgical approach for hysterectomy in Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome with cervicovaginal agenesis. Laparoscopic approaches for removal of uterine remnants have been published with only reports of laparotomy described for hysterectomy with cervicovaginal agenesis. Setting We discuss the diagnosis, management considerations and preoperative planning for definitive surgical treatment of a patient with MRKH with cervicovaginal agenesis presenting with hematometra and pain. Patient initially presenting with primary amenorrhea and pain, with previous medical treatment to achieve amenorrhea. Interventions Laparoscopic hysterectomy with bilateral ureterolysis and uterine artery ligation in a patient with cervicovaginal agenesis. Conclusion We show that laparoscopic hysterectomy is a viable and safe option in patients with cervicovaginal agenesis. The importance of preoperative imaging to rule out associated anomalies and assist in surgical planning is stressed. We highlight necessary alterations in surgical technique to overcome the lack of traction, identify potential anomalous vasculature and ultimately maintain hemostasis, clear delineation of surgical anatomy, and avoid injury. Tissue extraction through laparoscopic in bag morcellation is performed thus avoiding mini laparotomy altogether.

Comparison of Different Surgical Approaches for Hysterectomy: A Single-Institution Experience

Objective: We aimed to compare surgical outcomes and postoperative complications among different hysterectomy approaches such as total abdominal hysterectomy, vaginal hysterectomy, multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy.Study Design: This retrospective, single institution, case control study was carried out at the Obstetrics and Gynecology Department of Baskent University in Ankara, Turkey. We evaluated 86 consecutive patients who underwent hysterectomy for benign gynecological conditions.Results: A total of 86 women underwent hysterectomy: 20 (23.3%) total abdominal hysterectomy, 20 (23.3%) vaginal hysterectomy, 27 (31.3%) multiport access laparoscopic hysterectomy, and 19 (22.1%) single-port access laparoscopic hysterectomy using a transumbilical single-port system. There was no significant difference in uterine size between groups (Z=5.705; p=0.127). A statistically significant (p&lt;0.001) difference in operation time (duration of surgery) was observed among the following groups. The duration of surgery for the multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy groups was similar, with these two laparoscopic procedures requiring significantly more time than total abdominal hysterectomy and vaginal hysterectomy procedures. There was no statistically significant difference in between hemoglobin levels before and after operation between groups. There was no statistically significant difference between groups in intraoperative and postoperative complications. Six patients experienced complications, one intraoperative and five postoperative. Intraoperative complication was ureter injury in single-port access laparoscopic hysterectomy group. The postoperative complication rate was 5.8% (5 cases) in 86 patients. Perirectal abscess in one patient and wound infection in two patients occurred in total abdominal hysterectomy group (15%). Urinary tract infection in one patient and vaginal cuff cellulitis in one patient occurred in vaginal hysterectomy group (4%). No complications were reported in multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy groups. Post-surgery, all patients who underwent single-port access laparoscopic hysterectomy reported that they were satisfied with their incision and cosmetic results.Conclusions: When technically feasible, multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy may be performed instead f total abdominal hysterectomy because of rapid recovery and shorter hospitalization however there are longer operating time.

Hysterectomy Practice Patterns in the Postmorcellation Era.

To characterize long-term national trends in surgical approach for hysterectomy after the U.S. Food and Drug Administration (FDA) warning against power morcellation for laparoscopic specimen removal. This was a descriptive study using data from the American College of Surgeons National Surgical Quality Improvement Program from 2012 to 2016. We identified hysterectomies using Current Procedural Terminology codes. We used an interrupted time-series analysis to evaluate abdominal and supracervical hysterectomy trends surrounding The Wall Street Journal article first reporting morcellation safety concerns and the FDA safety communication. We compared categorical and continuous variables using χ, t, and Wilcoxon rank sum tests. We identified 179,950 hysterectomies; laparoscopy was the most common mode of hysterectomy in every quarter. Before The Wall Street Journal article, there was no significant change in proportion of abdominal hysterectomies (0.3% decrease/quarter, P=.14). After The Wall Street Journal article, use of abdominal hysterectomy increased 1.1% per quarter for two quarters through the FDA warning (P<.001), plateaued for three quarters until March 2015 (P=.65), then decreased by 0.8% per quarter through 2016 (P<.001). Supracervical hysterectomy volume continuously decreased after the FDA warning (1.0% decrease per quarter, P<.001) and after three quarters (0.7% decrease per quarter, P=.01), then plateaued from April 2015 through 2016 (0.05% decrease per quarter, P=.40). Mode of supracervical hysterectomy was unchanged from 2012 to 2013 (P=.43), followed by two quarters of significant increase in proportion of supracervical abdominal hysterectomies (11.7%/quarter, P<.001). This change in mode of supracervical hysterectomy then plateaued through 2016 (P=.06). Despite early studies suggesting that minimally invasive hysterectomy decreased in response to safety concerns regarding power morcellation, we found that this effect reversed 1 year after the FDA safety communication. However, there was a sustained decline in supracervical hysterectomy, and the remaining supracervical hysterectomies were more likely to be performed using laparotomy.

Trends in Route of Hysterectomy after the Implementation of a Comprehensive Robotic Training Program.

Objective To evaluate trends in surgical approach for hysterectomy following the introduction and implementation of a comprehensive robotic surgery program. Methods A retrospective review of all hysterectomies done at two institutions, a community hospital and a suburban, tertiary-care teaching hospital, in the same health system over a five-year period, January 2010 through December 2014. A robotic surgery training program was implemented during the first year of the study and trends in route of hysterectomy were evaluated in the subsequent years. Results A total of 5175 patients undergoing hysterectomy, for both benign and malignant indications, were included in the study. There was a significant decrease in the percent of cases performed through an abdominal approach at both the community and teaching hospitals (19.3% decline at each institution). There was an inversely related significant increase in the percent of robotic procedures at both the community and teaching hospitals (44.5% and 17%, respectively). A decrease in number of cases performed vaginally over this period was only noted in the community hospital site (25.2% decrease), and there was a slightly higher rate of vaginal hysterectomies at the teaching hospital over this study period (21.9% in 2010, 24.1% in 2014). Conclusion The decrease in number of abdominal and laparoscopic hysterectomies and increase in number of robotic hysterectomies that was seen are consistent with national trends. The initiation of a robotic training program did not prevent the proliferation of use of the robot but did aim to ensure proficiency on the robot prior to gaining privileges for patient use. This type of comprehensive training and monitoring program could be applied to future technologic advances to ensure a standard level of surgical proficiency. Trends in route of hysterectomy are clearly multifactorial and involve patient, provider, and location-specific factors that are likely to continue to change.

Patients' Knowledge and Perceptions of Morcellation.

Background and Objectives:Morcellation has received increased media and professional attention, but it remains unclear how much the average patient knows about this topic. We sought to evaluate patients' knowledge of morcellation, assess their perceptions of the risks and benefits, and determine how these perceptions affect their decision regarding the route of surgery.Methods:Anonymous paper surveys were administered to 500 patients attending gynecologic appointments at the University of Michigan. Survey questions gathered demographic information and assessed knowledge of various surgical approaches for hysterectomy and myomectomy. Questions regarding patients' knowledge of morcellation explored various types of morcellation and the risks and benefits of this procedure.Results:Of the 500 surveys administered, 396 patients answered at least 1 survey question resulting in a response rate of 79.2%. The mean ± SD age of respondents was 47.0 ± 14.1 years, 80.8% were white, and 83.1% had completed some college. Only 8.3% of patients reported that they had ever heard of morcellation. Even among women who were actively considering a hysterectomy or myomectomy (n = 33) or those who had undergone a hysterectomy or myomectomy (n = 98), only 12.1 and 7.1%, respectively, had heard of morcellation. Of those who had heard of morcellation (n = 32), only 9.4% correctly identified the definition in a multiple-choice question. Only 4.0% of women would choose an abdominal approach to avoid morcellation.Conclusions:Patients have very little knowledge about morcellation and most patients have never heard of the procedure. Very few patients would refuse morcellation and opt for an abdominal surgery instead.

Trends and Complications in Bilateral Salpingectomy and Hysterectomy for Benign Disease in the United States [7G

INTRODUCTION: Recent literature has shown that bilateral salpingectomy (BS) may reduce the risk of ovarian cancer. However, little evidence exists in the United States on the rates and risks of complications associated with this procedure. We sought to examine current rates and common medical and surgical complications associated with BS with hysterectomy for benign indications in the United States. METHODS: We conducted a retrospective cohort study from the National Inpatient Sample (NIS) database. Patients undergoing hysterectomy for benign gynecological disease during 1998–2012 were identified. First, rates of BS were tested for trends over time. Second, risks of complications with BS were identified. Finally, surgical approaches for hysterectomy with BS were compared based on complications. RESULTS: During the study period 7,009,330 hysterectomies were performed for benign indications. Of these 103,966 had BS with an increase in rate from 1.0% to 5.1% between 1998 and 2012. BS procedures were associated with a significant increased risk of complications (aOR 1.063, P=.01). An abdominal approach had the greatest risk of complications (aOR 1.585, P<.001). There was no difference in risk of complications between a laparoscopic or vaginal approach (aOR 1.093, P=.244). CONCLUSION: Opportunistic BS completed with hysterectomies for benign indications are increasing; yet overall rates are still very low. There is a small statistically significant increase in risk of complications with BS as opposed to hysterectomy alone in benign cases. There is not a significantly increased risk of complications between the vaginal and laparoscopic approach.

Comment on "Minilaparotomy Hysterectomy as a Suitable Choice of Hysterectomy for Large Myoma Uteri: Literature Review".

We read with interest the article by Sato and Fukushima titled “Minilaparotomy Hysterectomy as a Suitable Choice of Hysterectomy for Large Myoma Uteri: Literature Review” [1]. Although this article does an excellent job in discussing benefit of the minilaparotomy approach to perform hysterectomy when laparoscopic or vaginal approach is hampered by the weight of the uterus, the study demonstrates that minilaparotomy should be considered as part of the minimally invasive armamentarium of surgical approaches for hysterectomy offered to patients with myomas.

Comparison of surgical indications for hysterectomy by age and approach in 4653 Chinese women

Approximately one million hysterectomies are performed each year in China. However, national data regarding the indications and the surgical approaches for hysterectomy are lacking. The aim of this study was to examine the surgical indications for hysterectomy in different age groups and the relative merits of different surgical approaches for hysterectomy in Chinese women. Clinical data from 4653 cases of hysterectomy performed in Tongji Hospital from 2004 to 2009 were analysed. Hysterectomy was most commonly performed among women aged 40-49 years (2299; 49.4%). Overall, colporrhagia and abdominal pain were the two most common indications for hysterectomy. The most common indications by age groups were as follows: malignant ovarian tumour, < 20 years; malignant uterine tumour, 20-29 and 30-39 years; uterine myoma, 40-49 and 50-59 years; and uterine prolapse, 60-69 and > 70 years. The proportion of malignant aetiology also varied by age, being the highest in women aged < 20 years (75.0%) and the lowest in those aged 40-49 years (19.9%). Approximately 35% women who had hysterectomies also had concomitant bilateral oophorectomy. The lowest rate of oophorectomy occurred in women aged 30-39 years (15.8%), whereas the highest rate was in those aged 50-59 years (75.9%). The abdominal surgical approach was used in 84% of all hysterectomies. Surgeries using the vaginal approach required a significantly shorter operating time (118 min average) than all other approaches (P < 0.05). Both the amount of bleeding and the blood transfusion volume required were smaller in vaginal approaches, with no significant differences between the others. The surgical approaches used were also related to the scope of surgery. Both the surgical indications and the rates of bilateral oophorectomy varied by age. In terms of both operating time and the amount of bleeding and blood transfusion volume required, the vaginal approach was superior to all other surgical approaches.

Optimal Surgical Approaches for Hysterectomy in Patients with Large Uterine Myoma

Optimal Surgical Approaches for Hysterectomy in Patients with Large Uterine Myoma