Total Hysterectomy For Benign Indications Research Articles

Initial experience with vNOTES hysterectomy for benign conditions in a French university hospital.

Natural orifice transluminal endoscopic surgery by the vaginal route (vNOTES) is a new approach to performing hysterectomy. Clinical outcomes must be evaluated in centres that have started performing this technique. To compare operative outcomes between vNOTES hysterectomy and laparoscopic hysterectomy during the introduction of the vNOTES approach in a teaching hospital. A retrospective study was conducted from November 2019 to May 2021 at a French academic hospital in Marseille. The included patients underwent total hysterectomy for benign indications by vNOTES or conventional laparoscopy. Operative time, uterus weight, intraoperative complications, and postoperative complications according to the Clavien-Dindo classification. Eighty-six patients underwent hysterectomy according to the selected criteria: 36 procedures were performed by vNOTES and 50 by laparoscopy. The mean operative time was shorter in the vNOTES group than in the laparoscopy group [116 min versus 149 min; p=0.003]. The mean uterus weight was not different between the vNOTES group and the laparoscopy group (238g versus 281g; p=0.572). Laparo-conversion occurred in one case in the vNOTES group (2.7%) and three cases in the laparoscopy group (3.4%). One Grade III postoperative complication occurred in the laparoscopy group, and no severe complication occurred in the vNOTES group. Operative outcomes of the vNOTES hysterectomy were favourable and support good feasibility without additional morbidity compared to laparoscopy. During the introduction period of the vNOTES hysterectomy technique in a teaching hospital, reassuring operative outcomes and a low rate of complications were observed.

Vaginal Cuff Dehiscence Among Gender Diverse Persons

<h3>Study Objective</h3> To compare the risk of vaginal cuff dehiscence (VCD) following total hysterectomy among gender diverse (GD) persons and cisgender women (CW) and to identify factors associated with VCD. <h3>Design</h3> This is a retrospective cohort study among adults who underwent total hysterectomy for benign indications between 2014 and 2018 with at least 6-months of postoperative follow-up. <h3>Setting</h3> All surgeries were performed within an integrated closed healthcare delivery system. <h3>Patients or Participants</h3> Adult subjects who underwent non-emergent total hysterectomy for benign indications were included. Subjects who underwent subtotal hysterectomy, concomitant vaginectomy, and hysterectomy for obstetric or oncologic indications were excluded. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> The 18,151 cohort was comprised of 282 (1.6%) GD and 17,869 (98.4%) CW. Compared to the CW group, the GD group was significantly younger (30.8 vs 48.2 years, <i>P</i><0.01) and healthier (Charlson Comorbidity Index≥1 was 5.3% vs 10.4%, <i>P</i><0.01). Hysterectomies among GD had lower blood loss (61.4 vs 128.8 mL, <i>P</i><0.01) and lower rates of perioperative wound infection (0.4% vs 0.7%, <i>P</i><0.01). The overall rate of VCD was 3.9% in the GD group and 2.5% in the CW group (<i>P</i>=0.13). In bivariate analysis, identifying as GD was not a significant risk factor for VCD (OR 1.60, 95%CI 0.87-2.95), whereas hypertension (OR 1.43, 95%CI 1.17-1.74) and laparotomy relative to laparoscopy (OR 1.78, 95%CI 1.22-2.58) were significantly associated with VCD. <h3>Conclusion</h3> VCD is a rare postsurgical complication, and a 1.6-fold increased, non-significant risk among a younger, healthier group with less intraoperative blood loss and fewer post-surgical infections suggests that our findings may represent a clinically significant difference. Hypertension and route of hysterectomy were found to be associated with VCD. We plan to analyze the data using multivariable analyses to control for confounders. We also plan to examine relationship between VCD and gender-affirming use of systemic testosterone by GD persons as a potential explanation for this clinical discrepancy in VCD.

Assessment of surgeon and hospital volume for robot-assisted and laparoscopic benign hysterectomy in Sweden.

The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume. All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n=12386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses. TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500mL aOR 3.5, 95% CI 2.7-4.7; >500mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2h aOR 16.7 95% CI 10.2-27.5; >2h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9). RATLH led to better perioperative outcome and higher patient satisfaction 1year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.

Assessing Physician Adherence to Guidelines for Cervical Cancer Screening and Management of Abnormal Screening Results.

The aim of the study was to survey obstetrician-gynecologists' cervical cancer screening practices and management of cervical abnormalities to ascertain adherence to guidelines. From January to July 2019, obstetrician-gynecologists at 5 St. Louis area hospitals were surveyed online about cervical cancer screening and management practices through 13 clinical vignettes. Survey scores and the American Society of Colposcopy and Cervical Pathology (ASCCP) app use were compared using Mann-Whitney tests. When screening 30- to 65-year-old participants, 114 (98%) of the 116 total participants used co-testing, but only 71 (61%) screened at 5-year intervals. None used primary human papillomavirus (HPV) testing. For 21- to 29-year-old participants, 17 (15%) screened with annual cytology, whereas 14 (12%) used annual or every 3-year co-testing. Forty eight (41%) screened younger than 21 years, regardless of risk factors or only if immunocompromised. Eleven (9%) continued screening after total hysterectomy for benign indications. Only 2 (2%) responded to all clinical vignettes in adherence to guidelines. More than 30% of participants would pursue unnecessary HPV testing and/or loop electrosurgical excision procedure for persistent low-grade cytology. Fifty eight (48%) incorrectly reported hysterectomy as management for adenocarcinoma in situ on biopsy. Participants would undertreat young women with high-grade abnormalities including high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 3 (48, 41%) and high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia 1 (65, 56%). Forty one (35%) reported exiting women from screening prematurely. The median score for participants using the ASCCP app was significantly greater than those who did not (79% vs 71%, p = .002). Midwestern obstetrician-gynecologists' adherence to the guidelines for cervical cancer screening and management of abnormal results is suboptimal. Although co-testing for women aged 30-65 years has been broadly adopted, primary HPV testing has not. Physicians overscreen, overtreat low-grade lesions, and undertreat high-grade lesions in young women.

Effects of Obesity on Peri- and Postoperative Outcomes in Patients Undergoing Robotic versus Conventional Hysterectomy

To assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the outcomes. Cohort study. Prospectively collected data from 3 Swedish population-based registers. Women undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity. Intraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH). Out of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio [aOR]) 1.4; 95% confidence interval [CI], 1.1-1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2-2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2-15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4-124.7 and VH: 17.1; 95% CI, 3.5-83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4-40.5; aOR 8.5; 95% CI, 2.5-29.5; and aOR 5.8; 95% CI, 1.5-22.8, respectively) in women with obesity. The use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.

Can Pap smear and colposcopy predict cervical pathology prior to hysterectomy?

Aim: To evaluate the accuracy of Pap smear and colposcopy as predictors of cervical histopathology in patients undergoing total hysterectomy for benign indications, and to determine the incidence of unexpected cervical pathology in these patients. Study Design: Prospective observational study Patients and Methods: One hundred women scheduled for total hysterectomy for benign indications were subjected to preoperative Pap smear and colposcopy, at Kasr Al-Ainy Hospital, Cairo University, Egypt, during the period from September 2017 to March 2018. Findings were compared with the histopathological results of the cervices of the hysterectomy specimens. Results: Out of 100 patients included in our study, 13 had an abnormal Pap smear and 44 had abnormal findings on colposcopy. Abnormal cervical pathology was found in 30 hysterectomy specimens. Pap smear had a sensitivity and specificity of 33.3% and 95.7%, respectively, while colposcopy had a sensitivity and specificity of 96.7% and 78.6%, respectively. The incidence of unexpected cervical pathology was 66.7% depending on the Pap alone, and 3.3% when depending on colposcopy.Conclusion: Pap smear has a good specificity, but a low sensitivity in predicting cervical histopathology. Meanwhile, colposcopy has a high sensitivity and a reasonable specificity in predicting the histopathology. Colposcopy has a higher sensitivity and specificity as a pathology predictor, when compared to Pap smear.

1235 Myometrial Cells in Pelvic Washings at time of Benign Hysterectomy

Study Objective To evaluate if smooth muscle cells can be detected in pelvic washings at time of intact hysterectomy. Design A multi-centered pilot cohort study. Setting Two academically affiliated tertiary referral centers. Patients or Participants Patients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. Interventions Pelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, slides were stained using hematoxylin and eosin (HE three subjects were excluded due to unplanned morcellation. Smooth muscle uterine cells were detected in 1 pre-wash specimen and 2 post-wash cases. The group with positive washings was noted to have longer procedure time (136 minutes versus 114 minutes), lower blood loss (25 mL versus 86 mL) and higher uterine weight compared to negative washings group (242 grams versus 234 grams). Conclusion Tissue dissemination of uterine cells may be possible at time of hysterectomy. Larger prospective studies are needed in order to better describe the incidence of and risk factors for tissue dissemination.

Smooth Muscle Cells in Pelvic Washings at Time of Benign Hysterectomy

Study ObjectiveTo evaluate if smooth muscle cells can be detected in pelvic washings at the time of intact hysterectomy. DesignA multicentered pilot cohort study (Canadian Task Force classification II-2). SettingTwo academically affiliated tertiary referral centers. PatientsPatients undergoing total hysterectomy for benign indications without morcellation by minimally invasive gynecologic surgeons were enrolled from January 2018 to July 2018. InterventionsPelvic washings were collected at 2 times during surgery: after abdominal entry and after vaginal cuff closure. Cell blocks were generated, and slides were stained using hematoxylin and eosin, smooth muscle actin, and desmin and interpreted by 1 expert pathologist at each institution. Measurements and Main ResultsThirty-eight subjects were recruited; 3 subjects were excluded because of unplanned morcellation. Smooth muscle uterine cells were detected in 1 prewash specimen and 2 postwash specimens. The group with positive washings was noted to have longer procedure times (136 vs 114 minutes), lower blood loss (25 vs 86 mL), and higher uterine weight (242 vs 234 g) compared with negative washings group. ConclusionTissue dissemination of uterine cells may be possible at the time of hysterectomy. Larger prospective studies are needed to better describe the incidence of and risk factors for tissue dissemination.

178 - The American Society of Anesthesiologists Physical Status Score and Decision for Route of Total Hysterectomy for Benign Indications

178 - The American Society of Anesthesiologists Physical Status Score and Decision for Route of Total Hysterectomy for Benign Indications

Wound Infiltration With Extended-Release Versus Short-Acting Bupivacaine Before Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study ObjectiveTo evaluate if preincision infiltration with extended-release liposomal bupivacaine provides improved overall pain relief compared with 0.25% bupivacaine after laparoscopic or robotic-assisted hysterectomy. DesignA single-center double-masked randomized controlled trial (Canadian Task Force Classification I). SettingA tertiary-care community hospital. PatientsPatients recruited from July 2015 through January 2016. Sixty-four patients were randomized, and 59 were analyzed for the primary outcome. InterventionsWomen scheduled to undergo multiport laparoscopic or robotic-assisted total hysterectomy for benign indications were randomized to receive preincision infiltration with undiluted liposomal bupivacaine or 0.25% bupivacaine. Measurements and Main ResultsThe primary outcome was overall average pain intensity by numeric rating scale (0–10) using the Brief Pain Inventory (BPI) via telephone survey on postoperative day (POD) 3. A sample size of 28 per group (N = 56) was planned to detect a 30% change in pain scores. Secondary outcomes were overall average and worst numeric pain scores on PODs 1, 2, and 14; pain scores in hospital; BPI pain interference scores; and total opioid use. There were no demographic differences between the 2 groups. For the primary outcome, we found a decrease in the average (p = .02) pain scores on POD 3 in the liposomal bupivacaine group. We also found a decrease in worst pain scores on POD 2 (p = .03) and POD 3 (p = .01). There were no differences in pain scores while in the hospital or on POD 1 or POD 14. There were no differences in BPI pain interference scores, opioid use, or reported adverse effects. ConclusionFor laparoscopic and robotic-assisted multiport hysterectomies, there is evidence of decreased average postoperative pain with liposomal bupivacaine compared with 0.25% bupivacaine for port-site analgesia on POD 3, but no difference in opioid use or measures of functioning.

Perioperative Outcomes of Robotically Assisted Hysterectomy for Benign Cases With Complex Pathology

To report on the perioperative outcomes after robotically assisted total hysterectomy for benign indications in a large patient population with predominantly complex pathology. One hundred fifty-two patients underwent robotic hysterectomy for noncancer indications from May 2005 to May 2008. A systematic chart review of consecutive robotic cases was conducted based on preoperative and perioperative characteristics of each patient. Each case was evaluated for its complexity based on preoperative diagnosis, prior pelvic or abdominal surgery, patient's body mass index, and uterine weight. The overall operative time was 122.9 minutes, estimated blood loss was 79.0 mL, and there were three (2.1%) intraoperative complications, with no perioperative blood transfusions or conversions. There were five (3.5%) patients with postoperative complications, and length of hospital stay was 1.0 days on average. Of the characteristics indicating complexity, only uterine weight greater than 250 g resulted in significantly increased operative times, attributable to increased morcellation time. Robotically assisted total hysterectomy for benign indications in patients with complex pathology is feasible, with low morbidity and a short hospital stay. This study suggests that robotic assistance facilitates the use of a minimally invasive approach in high-risk patient populations. III.

The influence of preoperative vaginal cleansing on postoperative infectious morbidity in abdominal total hysterectomy for benign indications

To evaluate whether vaginal cleansing reduces the risk of postoperative infection after abdominal total hysterectomy on benign indications and to analyze risk factors. Retrospective cohort study. All clinics including patients in the Swedish National Register for Gynecological Surgery. All 7,193 women who underwent abdominal total hysterectomy for benign indications from 2000 to 2007. Information on clinic routines for preoperative vaginal cleansing was obtained retrospectively in a postal survey. Associations between routines for vaginal cleansing and structured data from the Register were analyzed by means of multivariate logistic regression models. The main effect variable was postoperative infections defined as infections treated with antibiotics within six to eight weeks postoperatively, reported by the patient or the physician. Prevalence and risk factors for postoperative infections. Prevalence of postoperative infections was 14.4%. The prevalence did not differ between those having had vaginal cleansing using chlorhexidine and those without vaginal cleansing, whereas using saline solution was encumbered with a significantly increased risk. Risk factors for postoperative infections were age >60, obesity, smoking, weight of the uterus, duration of hospital stay, blood transfusion, and peroperative injury of the urinary bladder or ureter. Vaginal cleansing using chlorhexidine solution did not reduce the risk of postoperative infections, whereas vaginal cleansing using saline solution seemed to increase the risk. Some risk factors for postoperative infectious morbidity seem to be preventable.

The Influence of Preoperative Vaginal Cleansing on Postoperative Infectious Morbidity in Abdominal Total Hysterectomy for Benign Indications: A Study From the Swedish National Register for Gynecological Surgery

A significant complication of hysterectomy is postoperative infections. It is believed that prophylactic use of antibiotics reduces infectious morbidity in abdominal and vaginal hysterectomies and antimicrobial prophylaxis for this purpose is common. Another method used to reduce postoperative infectious morbidity after hysterectomy is preoperative vaginal cleansing, but evidence for its effectiveness is conflicting. This retrospective cohort study examined the effect of vaginal cleansing on risk of postoperative infectious morbidity after benign abdominal total hysterectomy and also analyzed associated risk factors for infection. The investigators combined data obtained from the Swedish National Register for Gynecological Surgery with information collected retrospectively from a postal survey of clinics in Sweden on routines for preoperative vaginal cleansing and other methods. The study population was comprised of 7193 women who had abdominal total hysterectomy for benign indications between 2000 and 2007. Multivariate logistic regression models were used to analyze the possible association of vaginal cleansing on the risk of occurrence of postoperative infectious morbidity and to assess the association between potential risk factors for infection. Postoperative infections were defined as infections treated with antibiotics within 6 to 8 weeks after hysterectomy. The overall postoperative infection rate requiring antibiotic treatment was 14.4% (893/6084). The data showed no significant association between occurrences of postoperative infections in women who had received prophylactic vaginal cleansing using chlorhexidine in comparison to those without vaginal cleansing. The use of a saline solution for vaginal cleansing also did not reduce risk of infection, and was, in fact, an independent risk factor for postoperative infectious morbidity. In addition to saline, other independent risk factors were age >60, obesity, smoking, preoperative injury of the urinary bladder or ureter, hospital stay exceeding 3 days, and blood transfusion. There was a significant association between the presence of a large uterus (≥500 gm) and less postoperative infectious morbidity. Interestingly, prophylactic antibiotic use was not found to be an independent risk-reducing factor for postoperative infections. These data indicate that preoperative vaginal cleansing with chlorhexidine does not reduce the risk of postoperative infectious morbidity and that vaginal cleansing with saline solution appears to be a significant risk factor for postoperative infections. The investigators believe that prevention of infection should be focused on preventable risk factors, such as smoking, obesity, and surgical techniques.