Uterine Removal Research Articles

Emergency Peripartum Hysterectomy: A Life Saving Procedure in Obstetrics

Emergency peripartum hysterectomy refers to the uterine removal after a caesarean section or normal vaginal delivery for any life saving purpose, immediately after delivery or within the puerperium. In general, abnormal placentation, uterine rupture, and postpartum haemorrhage are the common indications. The prime objective of this study was to determine the frequent indications, peroperative and postoperative complications, maternal and perinatal outcome. This retrospective descriptive study was conducted by analysing recorded data of one year between July 2016 and June 2017 in Faridpur district of Bangladesh. Total 40 cases were analysed. Placenta praevia was the most common indication, whereas uterine rupture was the second one. Urinary bladder injury was the frequent peroperative complication. This bladder injury was common in cases of previous repeated caesarean section associated with placenta praevia. All the patients required three to six unit blood transfusions on average. Four patients expired due to various causes. Most of the patients were elderly aged, multiparous and had previous caesarean sections. The relevant literature analysis was done for comparison, where similarities were found. Total abdominal hysterectomy was the preferred method in this study. Overall, the study will direct the future ways of management.Faridpur Med. Coll. J. Jan 2018;13(1): 12-16

Vaginal Mucosal Implantation After Total Laparoscopic Hysterectomy for an Early Stage Endometrial Cancer

We present an extremely rare case of vaginal implantation of endometrial cancer, which is presumed to have been caused by transvaginal uterine removal during laparoscopic hysterectomy. A 48-year-old woman, nulligravida, had had a bilateral salpingo-oophorectomy due to benign mature cystic teratoma at 46 years old. She presented abnormal genital bleeding and had a total laparoscopic hysterectomy, due to stage Ia endometrial cancer. Postoperative pathology revealed an endometrioid adenocarcinoma G1, showing myometrial invasion, not exceeding the half of the muscular layer. The vascular space invasion and lymphatic space invasion were markedly recognized. Three cycles of combination chemotherapy with paclitaxel and carboplatin, with an interval of 3 weeks, have been postoperatively executed. Four months after the completion of adjuvant chemotherapy, a gross tumor of 6 mm in diameter was found at left vaginal mucosa near hymen. Vaginal biopsy of the lesion revealed a serous adenocarcinoma, and review of the primary endometrial tumor concluded that the primary endometrial carcinoma is corrected to a diagnosis of serous adenocarcinoma. It is considered that the vaginal lesion have been implanted through transvaginal uterine removal during the laparoscopic surgery. The vaginal lesion was surgically resected, however, during the follow-up examination, the other undifferentiated sarcoma was detected at right lung and the treatment was focused on to the sarcoma. And the patient died of the sarcoma, without the further recurrence of endometrial cancer. J Clin Gynecol Obstet. 2018;7(2):57-61 doi: https://doi.org/10.14740/jcgo495w

Effect of Vaginal Estriol Use in Total Laparoscopic Hysterectomy with Gonadotropin-Releasing Hormone Agonist Therapy.

Study Objectives:The aim of this study is to evaluate the effects of vaginal estriol therapy in total laparoscopic hysterectomy (TLH) with gonadotropin-releasing hormone agonist (GnRH-a) treatment.Design:Retrospective analysis.Design Classification:Canadian Task Force classification II-2.Settings:Department of Gynecology, Yokohama City University Medical Center, Japan.Methods:We retrospectively investigated 50 fibroid cases that had TLH with preoperative GnRH-a treatment and compared the surgical outcome with or without vaginal estriol use (1mg). Estriol was used administered for two weeks before TLH.Measurements and Main Results:A total of 12 patients (27%) received vaginal estriol (1 mg) for 14 days before TLH. As a result of vaginal estriol treatment, there were no group differences in uterus size reduction with GnRH-a treatment (22% vs. 15%, P = 0.20), uterine removal time through the vagina (12.5 min vs. 18.5 min, P = 0.18), rate of vaginal dehiscence (3% vs. 0%, P = 0.76) or in the rate of perineal laceration (33% vs. 34%, P = 0.55).Conclusion:The use of vaginal estriol treatment before TLH with GnRH-a therapy did not improve surgical outcomes.

Urinary Dysfunction after Hysterectomy: Incidence, Risk Factors and Management

Hysterectomy is one of the most commonly performed surgical procedures for women. The impact of uterine removal on bladder function can negatively impact a patient’s quality of life. When contemplating route of hysterectomy, surgeons weigh risks and benefits of all potential adverse outcomes, including urinary tract considerations. This review will guide providers based on the effect of hysterectomy on urinary function, as well as summarize risk factors and postsurgical treatment recommendations should urinary dysfunction occur. Prediction of urinary dysfunction after hysterectomy is variable for most routes, however there is strong evidence that nerve-sparing radical hysterectomy decreases postoperative urinary incontinence and retention. While all women are at risk for urinary dysfunction, those with preoperative incontinence and retention, neurologic conditions, and women undergoing uterine removal for cervical cancer or prolapse demonstrate a higher incidence of urinary symptoms. Until more evidence is available regarding predictive factors for urinary dysfunction in benign hysterectomies, comprehensive preoperative counseling and postoperative reassurance will lessen the deleterious effects on patient’s quality of life.

Prognostic Factors for Morcellation During Vaginal Hysterectomy.

To determine prognostic factors associated with cold-knife morcellation during vaginal hysterectomy. We conducted a retrospective cohort study evaluating all consecutive patients undergoing a vaginal hysterectomy between January 1, 2009, and August 31, 2014. The primary outcome was the utilization of uncontained vaginal morcellation performed using cold-knife wedge resection at the time of vaginal hysterectomy. Secondary outcomes included perioperative data. Significant factors were included in a multivariate logistic regression model to the binary variable vaginal morcellation at the time of vaginal hysterectomy. A total of 743 women met study inclusion criteria and underwent vaginal hysterectomy with intact uterine removal (n=383) or with uterine morcellation (n=360) with and without other vaginal procedures. A nonparametric Wilcoxon-rank-sum test and χ test were used to compare the cohorts of patients with and without morcellation. Characteristics associated with significantly increased likelihood of morcellation included younger age, non-Caucasian race, American Society of Anesthesiologists class 1 or 2, lower parity, lower number of prior vaginal deliveries, absence of prolapse, presence of leiomyoma, and an enlarged uterus. A multivariate logistic model utilizing factors most likely associated with morcellation revealed lack of prolapse (adjusted odds ratio [OR] 3.87, P<.001), leiomyoma (adjusted OR 2.77, P=.035), and larger uterine weight (adjusted OR 7.25, P<.001) increased the likelihood of morcellation. Prior vaginal delivery was associated with a decreased likelihood of morcellation (adjusted OR 0.79, P=.005). Vaginal hysterectomy with morcellation is associated with the following factors: absence of prior vaginal delivery, absence of prolapse, presence of leiomyoma, and a uterus larger than normal size.

Benign Metastasizing Leiomyomas of the Lungs: A Case Report

Background: Benign metastasizing leiomyoma (BML) is a very rare condition, which is paradoxically called benign metastases and occurs among patients with previous history of leiomyomas. Case presentation: We report a case of a 46-year-old woman diagnosed with benign metastasizing leiomyomas of the lungs, 16 years after uterine leiomyoma removal. The patient presented with the exertion dyspnea and dry cough lasting for several weeks. CT scan was indicative of metastatic lesions in the lung and no pathological findings within the lesser pelvis and abdominal cavity. The patient underwent right video thoracoscopy followed by thoracotomy with wedge and marginal resections of the right lung tissue containing tumors. The histopathological diagnosis was: benign metastasizing leiomyomas. The patient received a single dose of Triptorelinum (Diphereline SR 3.75)-GnRH analog. Control CT performed 4, 12, 36 months later showed stabilization. The patient has been symptom-free for 5 years. 1. BML is very rare disease-no more than 100 cases have been described. Our treatment methods include: surgical resection, hormonal manipulation and observation. 2. An individual treatment strategy or observation should be consider for each patient with BML

Laparoscopic Supracervical Hysterectomy with Sacrocervicopexy: Colpotomy for Uterine Removal without Morcellation

Laparoscopic Supracervical Hysterectomy with Sacrocervicopexy: Colpotomy for Uterine Removal without Morcellation

腹腔鏡下子宮腟上部切断術・仙骨腟固定術後に子宮体癌が発覚した1例

Since the Food and Drug Administration warning in 2011 against transvaginal mesh operation for pelvic organ prolapse, this operation is avoided owing to its severe complications. Instead, laparoscopic sacrocolpopexy (LSC) is selected by many urogynecologists. For the strong attachment between the cervix and mesh, supracevical hysterectomy is usually performed before LSC. Uterine removal from the intra-abdominal space requires intraperitoneal shredding or morcellation of the specimen. In cases of unexpected uterine malignancy, shredding or morcellation of the uterine specimen may interfere with the appropriate staging and increase the risks of malignant cell dissemination. We here report a case of uterine endometrioid adenocarcinoma diagnosed after supracervical hysterectomy and sacrocolpopexy for pelvic organ prolapse. The patient was 49 years old (gravida 4, para 2). She underwent laparoscopic supracervical hysterectomy and LSC for pelvic organ prolapse. Preoperative transvaginal ultrasound did not show thickening of the endometrium, and the endometrial cytology was negative. However, the pathologic examination after the initial operation showed uterine endometrioid adenocarcinoma, stage I. Accordingly, she was referred to our hospital and underwent trachelectomy, pelvic lymph node dissection, and paraaortic lymph node biopsy. This case indicates that we need to be aware of the possibility of uterine malignancy in cases of laparoscopic supracervical hysterectomy and LSC.

Preferences in cesarean delivery surgical technique: a survey of maternal–fetal medicine fellows

Objective: Our goal was to (1) describe self-reported cesarean delivery (CD) surgical techniques of Maternal–Fetal Medicine (MFM) fellows and (2) determine whether preferences were congruent with recommendations using US Preventive Services Task Force (USPSTF) criteria.Methods: MFM fellows were queried regarding their preferred CD technique via online survey. Preferences were compared to evidence-based recommendations using standard recommendation language and quality of evidence as outlined by the USPSTF. Categorical variables were compared by Chi-square analysis or Fisher’s exact test, with p < 0.05 considered statistically significant.Results: Of 233 active MFM fellows in August 2012, 167 completed the survey, resulting in a response rate of 71%. Statistically significant differences of preferences were noted when stratified by year in fellowship (blunt tip needles), gender (thromboprophylaxis, skin incision, fascial extension, uterine closure suture) and geographic region of fellowship (fascial extension, skin closure). CD techniques preferred by MFM fellows were congruent with recommendations designated as high or moderate level of certainty with regard to prophylactic antibiotics, uterine incision extension, uterine atony prevention and placenta removal, while incongruent with regards to pre-operative vaginal preparation and blunt needle preference.Conclusion: Among MFM fellow respondents, variation exists in preferred CD technique and vis-à-vis evidence-based recommendations.

Difficult vaginal hysterectomy

Vaginal hysterectomy is a safe and cost-effective approach for benign indications for uterine removal. This is well supported by the literature and advocated by the American College of Obstetricians and Gynecologists as the preferred surgical approach. Unfortunately, the relative proportion of vaginal hysterectomy remains low, while laparoscopic and robotic hysterectomies have steadily increased in proportion. This is due in combination to the introduction of new technologies and decreased comfort with the vaginal approach. Additionally, trainees in obstetric/gynecology residency programs are graduating with less experience in vaginal hysterectomy. These factors result in surgeons choosing abdominal, laparoscopic and robotic as their preferred approach, especially in the setting of relative contraindications such as nulliparity, previous cesarean delivery, uterine myomas or decreased mobility. However, these challenging situations can be overcome with adequate exposure, making the posterior colpotomy firs...

Evaluation of Laparoscopic‐Assisted Ovariohysterectomy for Treatment of Canine Pyometra

To describe a technique for treating pyometra in dogs using a 3-portal laparoscopic-assisted ovariohysterectomy (LAOVH) and evaluate outcome. Retrospective case series. Dogs (n = 12). Dogs with open or closed-cervix pyometra with moderately sized (1-4 cm) uterine horn diameters based on preoperative ultrasonography and no evidence of perforation were included in the study. A 3-portal technique for LAOVH was used. A wound retraction device was inserted into the caudal portal after enlargement of the incision to 3-4 cm to simplify removal of the uterus with minimal tension. Twelve dogs (median weight, 23.3 kg; range, 2.1-46.0 kg) met the inclusion criteria. Median uterine diameter was 3.0 cm (range, 1.2-4.0 cm). Median surgical time for LAOVH was 107 minutes (range, 82-120 minutes). Complications included mild hemorrhage from the uterine vessels in 1 dog during uterine removal through the wound retraction device and intra-abdominal uterine rupture in 1 dog which necessitated conversion to an open approach. All dogs recovered from surgery and were discharged. LAOVH can be used for treatment of select cases of canine pyometra. Careful case selection is mandatory to improve success and minimize conversion to an open approach. Gentle handling of the reproductive organs is imperative to avoid iatrogenic uterine rupture.

Laparoscopic uterine tumour removal… are we there yet?

Laparoscopic uterine tumour removal… are we there yet?

Natural orifice hysterectomy

Minimally invasive surgery (MIS) such as natural orifice surgery is perceived as a relatively recent development partly because many MIS techniques utilize new technology and devices. However, a natural orifice/MIS approach for hysterectomy (vaginal hysterectomy, VH) has existed for over a century. VH is typically thought of in the realm of the urogynecologist as a component of reconstructive pelvic surgery for pelvic organ prolapse. However, current evidence supports the use of VH in women with other benign conditions such as uterine fibroids and abnormal bleeding. Despite the evidence and availability of several MIS options for hysterectomy, the majority of hysterectomies continue to be performed via laparotomy. VH is the least invasive approach to hysterectomy, and its use should be encouraged as the preferred MIS option for women requiring uterine removal for benign conditions.

Clinical opinion: guidelines for hysterectomy

Abdominal hysterectomy remains the predominant method of uterine removal in the United States, despite evidence that vaginal hysterectomy offers advantages in regard to operative time, complication rates, return to normal activities, and overall cost of treatment. The predominance of the abdominal approach may be based on factors other than clinical considerations that include resident training, use of obsolete or limited guidelines, a perception rather than a confirmation that pathologic conditions exist that may suggest contraindications to the vaginal approach, misconceptions regarding the cost and safety of vaginal hysterectomy, and increased third-party reimbursement for the abdominal procedure. Evidence-based practice guidelines that were developed by the Society of Pelvic Reconstructive Surgeons and were adopted by the National Guidelines Clearinghouse have demonstrated that, in a number of studies that span several years, a dramatic shift toward the vaginal approach occurred when the guidelines were applied prospectively. The guidelines demonstrate that transvaginal hysterectomy is both feasible and optimal for many patients who long have been considered inappropriate candidates for vaginal hysterectomy. This clinical opinion attempts to address the reasons for the predominant use of the abdominal approach.

A new technique for large uterine removal: Helical incision

A new technique for large uterine removal: Helical incision

Histerectomia Laparoscópica em um Hospital Geral Comunitário Experiência Inicial e Comparação de Custos Hospitalares

Objetivo: comparar os custos hospitalares entre a histerectomia vaginal assistida por laparoscopia (HVAL) e a histerectomia total abdominal (HTA), relatando a experiência inicial com a nova abordagem em um hospital geral comunitário. Pacientes e Métodos: foram comparados 11 casos de HVAL e 23 de HTA, realizados de setembro de 1998 a julho de 1999. Prontuários e demonstrativos das despesas hospitalares de cada paciente foram revistos para coletar as variáveis analisadas. Resultados: não houve diferença estatística entre os grupos quanto à idade, paridade e cirurgia abdominal prévia. A principal indicação cirúrgica para ambos os grupos foi leiomiomatose uterina. O grupo das HVAL apresentou tempo de internação menor, com mediana de 1 dia e o das HTA, de 2 dias (p<0,01). As HVAL mostraram-se 40,2% mais caras que as HTA (p<0,01). Os gastos de centro cirúrgico contribuíram com a maior parte dos custos hospitalares para ambos os grupos, correspondendo a 79,8 e 57,9% do total para as HVAL e HTA, respectivamente. Os gastos de enfermaria para as HVAL foram menores que para as HTA, com diferença estatisticamente significativa (p = 0,002). Conclusão: com menor tempo de internação e com custos de enfermaria menores demonstramos que a HVAL propicia melhores condições de pós-operatório e recuperação mais rápida que a HTA. A HVAL, quando executada em um hospital geral comunitário, apesar de mais cara que a HTA, é uma ótima opção para a remoção uterina, e deve fazer parte do arsenal terapêutico dos cirurgiões ginecológicos.

Assessment of the safety of intrauterine instillation of heated saline for endometrial ablation

Objective: To evaluate the safety of pressure, temperature-controlled, continuously circulating hot saline (EnAbl TM system, InnerDyne Medical, Sunnyvale, CA) for endometrial ablation using the in vivo human uterus. Design: Clinical safety study. Setting: An academic research environment. Patients: Eleven women undergoing abdominal hysterectomy because of abnormal uterine bleeding. Intervention: Before uterine removal, endometrial cavities were exposed to 15 minutes of recirculatory normal saline heated to 70–85°C. Main Outcome Measure(s): The uteri were analyzed for extent of thermal damage using standard histopathological techniques and tissue viability histochemical staining. Intrauterine pressures and serosal and subserosal temperatures were continuously monitored by computer. Result(s): In each treated specimen, histochemical staining demonstrated a depth of necrosis that extended through the entire endometrium and approximately 1–2 mm into the myometrium. The control specimen showed no thermal or mechanical damage. There were no observed negative effects or related complications with this system. Conclusion(s): The computer-controlled system employing continuously circulating hot saline is an effective method to destroy the endometrium. In four cases with clearly patent tubes, no spill was observed. In all 11 patients, serosal and subserosal temperatures were within safe levels (mean temperature, 37°C).

Ureteral injury during laparoscopically assisted radical vaginal hysterectomy

We report on a case of ureteral injury during laparoscopically radical hysterectomy to treat a patient with a stage IA2 carcinoma of the uterine cervix. The advantage of laparoscopically radical hysterectomy is the prevention of the identification and dissecting of the ureter from a vaginal approach, the main problem in the Schauta technique. However, ureteral injury may still occur while resecting the cardinal ligament without good visualization of the ureter during a vaginal procedure. Because the ureter was well identified and freed laparoscopically, a vaginal approach after uterine removal may be an option for treatment. Moreover, using the ureteral stent as a marker during a modified Schauta technique is helpful in the prevention of ureteral injury during laparoscopically assisted radical vaginal hysterectomy.

Anesthesia for Complicated Vaginal Deliveries

Summary Abnormal presentations complicate approximately 4% of all deliveries. The majority of these infants are in the breech presentation. Recent data suggest that vaginal delivery of the breech infant may be as safe as cesarean section. Epidural analgesia is preferred for vaginal delivery of the breech presentation. Sacral block may prevent premature maternal pushing and thus decrease the likelihood of cervical head entrapment. During delivery the obstetrician attempts to minimize trauma to the fetal head and neck. On occasion, general anesthesia is necessary to relieve cervical entrapment. The anesthesiologist should be prepared to administer general anesthesia to every patient with a breech presentation. Multiple gestation complicates approximately 1 to 2% of all pregnancies. The physiologic changes of pregnancy are exaggerated with multiple gestation. For twin gestations, the presentation of the fetuses may influence the mode of delivery. Epidural analgesia is preferred for vaginal delivery. If a spontaneous delivery is planned, the motor block should be minimized. If internal podalic version and extraction of twin B is planned, epidural anesthesia alone may be sufficient. But, on occasion, general anesthesia is required for delivery of the second twin. Specifically, administration of a potent halogenated agent will relax the uterus and facilitate delivery of the second twin. For gestations of greater than two, delivery is generally performed via cesarean section. Either regional or general anesthesia is acceptable depending on the condition of the mother. Shoulder dystocia occurs in up to 2% of vaginal deliveries. The dystocia is often relieved by changing the rotation of the maternal pelvis or changing the fetal position. Rarely, general anesthesia and skeletal muscle relaxation may be necessary. Following delivery the infant tends to be depressed and may require resuscitation. Rarely, the fetus cannot be delivered vaginally, is returned to the uterus, and delivered by cesarean section. Retained placenta occurs in 1% of deliveries. Often there is significant blood loss with a retained placenta. Patients may require anesthesia for uterine exploration and removal of a retained placenta. General anesthesia with a potent halogenated agent provides cervical and uterine relaxation, which facilitates exploration. These patients must be considered to have a full stomach, and precautions must be taken to prevent against regurgitation and aspiration.

Serum and Pelvic Tissue Concentrations of Ceftriaxone and Cefazolin at Hysterectomy

Abstract Ceftriaxone and cefazolin concentrations were assayed by high-pressure liquid chromatography in serum and pelvic tissue. Specimens were obtained at uterine removal subsequent to a 1-g intramuscular preoperative dose given to 117 women scheduled for elective vaginal or abdominal hysterectomy. The mean serum concentration of cefazolin was 43.2 ± 13.1 and 39.8 ± 15.4 μg/ml after vaginal and abdominal hysterectomy, respectively. For ceftriaxone they were 59.2 ± 16.8 and 56.1 ± 18.3 μg/ml for vaginal and abdominal hysterectomy, respectively. Mean tissue concentrations of ceftriaxone were 22.5 ± 10.4, 17.4 ± 6.9, 27.9 ± 10.7, and 16.4 ± 6.3 μg/g for vagina, myometrium, fallopian tube, and ovary, respectively, and respective mean tissue concentrations for cefazolin were 15.8 ± 7.6, 14.4 ± 8.5, 15.6 ± 8.0, and 12.4 ± 5.8 pg/g. Pelvic tissue concentrations of cefazolin were similar, but concentrations of ceftriaxone in fallopian tube and vagina were higher than those in ovary and myometrium. Tissue to ser...