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1.  Long-Term Outcomes of the Total or Supracervical Hysterectomy (TOSH) Trial 
Participants in the multi-center, randomized Total or Supracervical Hysterectomy (TOSH) trial showed within-group improvement in pelvic floor symptoms 2 years post-surgery and no differences between supracervical (SCH) versus total hysterectomy (TAH). This study describes longer term outcomes from the largest recruiting site.
Questionnaires addressing pelvic symptoms, sexual function, and health-related quality of life were administered. Linear models and McNemar’s test were utilized.
Thirty-seven participants (69%) responded (19 TAH, 18 SCH); mean follow up was 9.1±0.7 years. No between-group differences emerged in urinary incontinence, voiding dysfunction, pelvic prolapse symptoms and overall health related quality of life (HRQOL). Within-group analysis showed significant improvement in the ability to have and enjoy sex (P = 0.002) and in the SF-36 physical component summary score (P = 0.03) among women randomized to TAH.
9 years after surgery, TOSH participants continue to experience improvement and show no major between-group differences in lower urinary tract or pelvic floor symptoms conferring no major benefit of SCH over TAH.
PMCID: PMC3252027  PMID: 22229107
2.  Laparoscopic Supracervical Hysterectomy Compared With Abdominal, Vaginal, and Laparoscopic Vaginal Hysterectomy in a Primary Care Hospital Setting 
This study compares the operative parameters of laparoscopic supracervical hysterectomy, laparoscopically assisted vaginal hysterectomy, total vaginal hysterectomy, and total abdominal hysterectomy in patients in a small suburban medical center.
This investigation is a Canadian Classification II-2. It was performed in a 238 bed not-for-profit community general hospital. Charts of 117 patients were reviewed.
These patients had undergone the following procedures: laparoscopic supracervical hysterectomy, laparoscopically assisted vaginal hysterectomy, total vaginal hysterectomy, total abdominal hysterectomy; questionnaires completed by the patients were reviewed. All patients had hysterectomies performed by members of the Ob/Gyn department of Alamance Regional Medical Center.
Comparisons of intraoperative and postoperative events were made in those patients who consented to the study and who returned their questionnaires. Parameters compared were patient age, weight, preoperative diagnosis, operative time, operative complications, blood loss, uterine weight, length of stay, postoperative complications, return to hospital, return to work, resumption of intercourse, dyspareunia, and bowel or bladder problems.
Patient demographics and outcomes are similar. Laparoscopic supracervical hysterectomy showed lower morbidity and quicker return to normal function, but most findings did not reach statistical significance.
The results support the conclusion that the patients in each arm of the study are similar. The operative parameters show a longer operating time for the laparoscopic procedures than for total abdominal hysterectomy and total vaginal hysterectomy, respectively. The other indicators of morbidity show slight advantages of laparoscopic supracervical hysterectomy in blood loss, length of stay, and resumption of normal activities.
PMCID: PMC3015613  PMID: 16121874
Laparoscopic supracervical hysterectomy; Minimally invasive surgery; Hysterectomy; Total vaginal hysterectomy; Total abdominal hysterectomy; Laparoscopic vaginal hysterectomy
3.  Supracervical and total abdominal hysterectomy trends in New York State: 1990–1996 
To describe practice trends for total abdominal hysterectomy (TAH) and supracervical abdominal hysterectomy (SCH) in New York State and to identify fiscal features associated with these two operations, all inpatient discharges for TAH and SCH performed for benign indications from 1990 to 1996 were reviewed using the Statewide Planning and Resource Cooperative System, a centralized data reporting system. For each year examined, the number of TAHs and SCHs performed, the procedure rates adjusted for the total New York State female population, and theper diem charge (calculated from mean institutional charge as a function of average length of stay) were evaluated. While the TAH rate declined in New York State, from 34.0 in 1990 to 28.4 in 1996 (P=.01), the SCH rate increased nearly five-fold during the same period, from 0.62 to 3.07 (P=.0003). Patients tended to be discharged later following SCH than for TAH, although by 1996, the LOS for both operations was equivalent. Theper diem institutional charge for SCH was consistently higher than for TAH in each year studied. The changes in charge and relative frequency of TAH and SCH in New York State invite further study to describe these trends more fully.
PMCID: PMC3455995  PMID: 9854251
Hysterectomy; Supracervical trends; Surgical practice
4.  Laparoscopic Supracervical Hysterectomy for Benign Gynecologic Conditions 
Recent results from metaanalyses and observational studies have suggested that total abdominal hysterectomy (TAH) is superior to laparoscopic supracervical hysterectomy (LSH) for the treatment of benign gynecologic conditions. However, because LSH is associated with fewer intraoperative complications, shorter operative time, and preserves patient anatomy and sexual function in comparison with TAH, clinicians should reconsider the benefits of LSH.
PMCID: PMC3015899  PMID: 19366535
Cervical dysplasia; Laparoscopic supracervical hysterectomy; Gynecologic surgery
5.  Total Laparoscopic Hysterectomy Versus Total Abdominal Hysterectomy: Cohort Review of Patients With Uterine Neoplasia 
Retrospective analysis of surgico-pathologic data comparing total laparoscopic hysterectomy (TLH) with total abdominal hysterectomy (TAH) patients with uterine neoplasia
We conducted a chart abstraction of all patients undergoing hysterectomy for uterine neoplasia from September 1996 to November 2004. Patients were assigned to undergo the abdominal or laparoscopic approach based on established clinical safety criteria.
The study included 105 patients, 29 with TAH and 76 with TLH. TAH patients were older (68 vs. 61, P=0.021); however, both groups had similar body mass indexes (31) and parities (1.6). Controlling for age, surgical duration was similar (152 minutes). Average blood loss was higher for TAH, (504 vs.138 mL, P<0.001). Hospital stays were significantly longer for patients with TAH than for those with TLH (5.4 vs. 1.8 days, P<0.0001). Uterine weight was greater (197 vs. 135 g, P=0.008) and myometrial invasion deeper in the TAH group (48% outer half vs. 17%, P=0.001). More patients had Stage II or higher disease in the TAH group (35% vs. 17%, P=0.038). More TAH patients needed node dissection (79% vs. 28%, P<.001). Node yields from dissections of 23 TAH cases and 21 laparoscopic cases were similar (17 nodes). Total and reoperative complications from TAH versus TLH were not statistically different in our small sample (14.3 vs. 5.2% total, NS; 10.3 vs. 2.6% reoperative). One conversion was necessary from laparoscopy to laparotomy for unsuspected bulky metastatic disease.
Based on clinical selection criteria, TLH performed for endometrial pathology has few complications and is well tolerated by select patients. The advantages are less blood loss and a shorter length of hospital stay for qualified patients.
PMCID: PMC3015616  PMID: 16121872
Total laparoscopic hysterectomy; Total abdominal hysterectomy; Uterine neoplasia
6.  Prevalence and risk factors for mesh erosion after laparoscopic-assisted sacrocolpopexy 
Introduction and hypothesis
The purpose of this study is to identify risk factors for mesh erosion in women undergoing minimally invasive sacrocolpopexy (MISC). We hypothesize that erosion is higher in subjects undergoing concomitant hysterectomy.
This is a retrospective cohort study of women who underwent MISC between November 2004 and January 2009. Demographics, operative techniques, and outcomes were abstracted from medical records. Multivariable regression identified odds of erosion.
Of 188 MISC procedures 19(10%) had erosions. Erosion was higher in those with total vaginal hysterectomy (TVH) compared to both post-hysterectomy (23% vs. 5%, p = 0.003) and supracervical hysterectomy (SCH) (23% vs. 5%, p = 0.109) groups. In multivariable regression, the odds of erosion for TVH was 5.67 (95% CI: 1.88–17.10) compared to post-hysterectomy. Smoking, the use of collagen-coated mesh, transvaginal dissection, and mesh attachment transvaginally were no longer significant in the multivariable regression model.
Based on this study, surgeons should consider supracervical hysterectomy over total vaginal hysterectomy as the procedure of choice in association with MISC unless removal of the cervix is otherwise indicated.
PMCID: PMC3025104  PMID: 20842494
Erosion; Mesh; Hysterectomy; Laparoscopy; Sacrocolpopexy
7.  Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy 
BMJ : British Medical Journal  2003;327(7418):774-778.
Objectives To compare the effects of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy on sexual wellbeing.
Design Prospective observational study over six months.
Setting 13 teaching and non-teaching hospitals in the Netherlands.
Participants 413 women who underwent hysterectomy for benign disease other than symptomatic prolapse of the uterus and endometriosis.
Main outcome measures Reported sexual pleasure, sexual activity, and bothersome sexual problems.
Results Sexual pleasure significantly improved in all patients, independent of the type of hysterectomy. The prevalence of one or more bothersome sexual problems six months after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy was 43% (38/89), 41% (31/76), and 39% (57/145), respectively (χ2 test, P = 0.88).
Conclusion Sexual pleasure improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. The persistence and development of bothersome problems during sexual activity were similar for all three techniques.
PMCID: PMC214074  PMID: 14525872
8.  Supracervical Robotic-Assisted Laparoscopic Sacrocolpopexy for Pelvic Organ Prolapse 
Supracervical robotic-assisted laparoscopic sacrocolpopexy was found to be an effective repair of apical vaginal defects in patients with pelvic organ prolapse who had not undergone previous hysterectomy.
Supracervical robotic-assisted laparoscopic sacrocolpopexy (SRALS) is a new surgical treatment for pelvic organ prolapse that secures the cervical remnant to the sacral promontory. We present our initial experience with SRALS in the same setting as supracervical robotic-assisted hysterectomy (SRAH).
Women with vaginal vault prolapse and significant apical defects as defined by a Baden-Walker score of ≥3 who had not undergone hysterectomy were offered SRALS in combination with SRAH. A chart review was performed to analyze operative and perioperative data. Outcome data also included patients who underwent robotic-assisted laparoscopic sacrocolpopexy (RALS) without any other procedure.
Thirty-three patients underwent RALS, including 12 patients who underwent SRALS. All SRALS were performed following SRAH in the same setting. The mean follow-up for the RALS and SRALS patients was 38.4 months and 20.7 months, respectively. One patient in the RALS group had an apical recurrence. There were no recurrences in the SRALS group.
SRALS is effective for repair of apical vaginal defects in patients with significant pelvic organ prolapse who have not undergone previous hysterectomy. Complications are few and recurrences rare in short- and medium-term follow-up. Greater follow-up and numbers are needed to further establish the role of this procedure.
PMCID: PMC3083043  PMID: 21605516
Robot; Sacrocolpopexy; Prolapse; Supracervical hysterectomy
9.  Robotic Assisted, Total Laparoscopic, and Total Abdominal Hysterectomy for Management of Uterine Cancer 
Journal of cancer therapy  2012;3(2):162-166.
The purpose was to compare robotic assisted total laparoscopic hysterectomy (TRH), laparoscopic assisted hysterectomy (TLH) and total abdominal hysterectomy (TAH) with surgical staging +/- lymphadenectomy for the management of uterine cancer.
Institutional review board approval was obtained and patient characteristics, pathologic data, and data related to the surgical procedure were collected from chart review. Data were analyzed with SAS statistical software.
A total of 102 TRHs were compared to 115 TLHs and 79 TAHs. There were more grade I and endometrial intraepithelial (EIN) lesions in the preoperative pathology of TLHs (P < 0.01). Pelvic lymphadenectomy was performed in 71 (70%) TRH, 46 (58%) TAH, and 28 (24%) TLH cases (P < 0.01). Mean surgical time was 203, 133 and 132 minutes for TRHs, TLHs, and TAHs (P < 0.05). Estimated blood loss was 69, 86, and 215 ml for TRH, TLH, and TAH (P < 0.05). Blood transfusions were 19% in TAHs versus 3% and 2% in TLHs and TRHs (P < 0.01). There were fewer wound infections (2% vs. 10%) in TRHs versus TAHs (P < 0.01). Length of stay was shorter for the TRH and TLH groups (P < 0.05).
Despite longer surgical times, benefits of minimally invasive technology included shortened length of stay, decreased wound infections, transfusions, and blood loss. In our population, procedure selection for TLH versus TRH may have been influenced by lower preoperative grade, with reservation of robotic technology for cases anticipated to be more complex, and therefore justifying increased technology costs and operating times.
PMCID: PMC3904541  PMID: 24482733
Robotics; Laparoscopy; Endometrial Cancer
10.  Indication for Laparoscopically Assisted Vaginal Hysterectomy 
When uterine weight is greater than 800 grams, total abdominal hysterectomy is more appropriate than laparoscopic-assisted vaginal hysterectomy.
Total hysterectomy procedures include total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), and laparoscopically assisted vaginal hysterectomy (LAVH). Our institution has introduced LAVH as a preferred option to the more invasive TAH. To date, no reports have proposed surgical indications for LAVH based on statistical analysis of surgical results. The purpose of this study was to establish criteria for performing LAVH through statistical analysis of a retrospective review of surgical outcomes in LAVH cases at our institution over a period of 15 years.
The medical records of 629 patients scheduled for LAVH for uterine fibroids and/or adenomyosis at our hospital were examined. Surgical results (blood loss, operative time, rates of conversion to laparotomy, and intra- and postoperative complications) were compared among 9 groups classified by uterine weight.
Statistically significant differences in surgical outcomes were found between the group with a uterine weight ≥800g and the other groups.
We found that when the uterine weight was ≥800g, TAH was more appropriate because significant blood loss and/or complications would be expected during LAVH. A removed uterus weighing 800g is reportedly equivalent to a preoperative uterine size of approximately 12cm. Therefore, LAVH may be safely indicated for patients with a uterine size ≤12cm (approximately equivalent to the uterine size at 16-weeks gestation).
PMCID: PMC3183566  PMID: 21985721
Uterine fibroid; Uterine adenomyosis; Laparoscopically assisted vaginal hysterectomy (LAVH); Surgical indication
11.  Incidence of Lower Urinary Tract Injury at the Time of Total Laparoscopic Hysterectomy 
To determine the incidence of and risk factors for injury to the lower urinary tract during total laparoscopic hysterectomy.
All patients who underwent total laparoscopic hysterectomy for benign disease from January 1, 2002 to December 31, 2005, at an academic medical center are included. Subjects undergoing laparoscopic-assisted vaginal hysterectomy, supracervical hysterectomy, or hysterectomy for malignancy were excluded. Intraoperative cystoscopy with intravenous indigo carmine was routinely performed. Relevant data were abstracted to determine the incidence of lower urinary tract injury, predictors of injury, and postoperative complications.
Total laparoscopic hysterectomy was performed in 126 consecutive subjects. Two (1.6%) cystotomies were noted and repaired before cystoscopy was performed. Two (1.6%) additional cystotomies were detected during cystos-copy. Absent ureteral spill of indigo carmine was detected in 2 subjects: 1 (0.8%) with previously unknown renal disease and 1 (0.8%) with ureteral obstruction that was relieved with subsequent suture removal. Only 40% (2/5) of injuries were recognized without the use of cystoscopy with indigo car-mine. The overall incidence of injury to the lower urinary tract was 4.0%. No subjects required postoperative intervention to the lower urinary tract within the 6-week perioperative period. Performing a ureterolysis was associated with an increased rate (odds ratio 8.7, 95%CI, 1.2-170, P=0.024) of lower urinary tract injury.
Surgeons should consider performing cystoscopy with intravenous indigo carmine dye at the time of total laparoscopic hysterectomy.
PMCID: PMC3015849  PMID: 18237504
Laparoscopic hysterectomy; Bladder injury; Ureter injury; Cystoscopy; Complication
12.  Postoperative Patient Satisfaction After Laparoscopic Supracervical Hysterectomy 
This study demonstrates a high degree of postoperative patient satisfaction after laparoscopic supracervical hysterectomy.
Background and Objectives:
The aim of this study was to evaluate postoperative patient satisfaction in women after laparoscopic supracervical hysterectomy (LASH).
A retrospective study by a mailed questionnaire among 2334 women who underwent hysterectomy via LASH at the MIC-Klinik, Berlin, between 1998 and 2004 was conducted. Indications for LASH were uterus myomatosus, adenomyosis uteri, disorders of bleeding, and genital descensus. The LASH operation technique was standardized and remained consistent throughout the observation period. Pearson's test for metric variables, Spearman's rank correlation test for ordinal data, Mann-Whitney U test, and Kruskal-Wallis test were used.
Of the 2334 questionnaires mailed, 1553 were returned and 1431 (61.3%) of those could be analyzed. Almost 94% (93.9%) of the women were highly satisfied with the outcome, 5.6% reported medium satisfaction, and 0.5% were not satisfied. There was no significant difference in patient satisfaction with regard to the different indication for LASH.
This study demonstrates high postoperative patient satisfaction after LASH. The rate of highly satisfied women might be increased by carefully choosing the right indications for LASH and improving operation techniques. This is important for widening acceptance of this innovative new operation standard.
PMCID: PMC3662726  PMID: 23743380
LASH; Hysterectomy; Satisfaction
13.  Laparoscopic Supracervical Hysterectomy Compared to Total Hysterectomy 
The aim of this study was to compare peri-operative results of laparoscopic supracervical hysterectomy (LSH) with those of laparoscopic total hysterectomy (TLH).
A retrospective cohort study was conducted at the Department of Gynecology at a teaching hospital. A group of 157 patients who underwent TLH was compared with a group of 157 patients who underwent LSH with or without bilateral salpingo-oophorectomy (BSO). Both groups had similar baseline characteristics and comparable surgical indications.
We reviewed our 7-year experience with laparoscopic hysterectomies performed at our department between October 2000 and November 2007. The similarities between patient characteristics were tested by using Wilcoxon Rank Sum Statistics. Patient and surgery characteristics as well as surgery outcomes were analyzed with descriptive statistics showing medians and 95% CIs. Women who underwent LSH had a shorter operation time compared with women in the TLH group (100 min vs. 110 min). Major complication rates were higher in the TLH group than in the LSH group (4.5% vs. 1.3%). Minor complication rates were 13.3% in the TLH group compared with 13.4% in the LSH group.
Our data and experience provide specific information about the perioperative performance of LSH compared with TLH. In our experience, LSH proved to be a valid alternative to TLH in the absence of specific indications for TLH. Adequate counseling concerning the risk of cyclical bleeding and reoperation is mandatory.
PMCID: PMC3015973  PMID: 19793479
Total laparoscopic hysterectomy; Laparoscopic supracervical hysterectomy; Bilateral salpingo-oophorectomy
14.  Differences in Epidural and Analgesic Use in Patients with Apparent Stage I Endometrial Cancer Treated by Open versus Laparoscopic Surgery: Results from the Randomised LACE Trial 
Minimally Invasive Surgery  2013;2013:764329.
Objectives. We compared postoperative analgesic requirements between women with early stage endometrial cancer treated by total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH). Methods. 760 patients with apparent stage I endometrial cancer were treated in the international, multicentre, prospective randomised trial (LACE) by TAH (n = 353) or TLH (n = 407) (2005–2010). Epidural, opioid, and nonopioid analgesic requirements were collected until ten months after surgery. Results. Baseline demographics and analgesic use were comparable between treatment arms. TAH patients were more likely to receive epidural analgesia than TLH patients (33% versus 0.5%, P < 0.001) during the early postoperative phase. Although opioid use was comparable in the TAH versus TLH groups during postoperative 0–2 days (99.7% versus 98.5%, P = 0.09), a significantly higher proportion of TAH patients required opioids 3–5 days (70% versus 22%, P < 0.0001), 6–14 days (35% versus 15%, P < 0.0001), and 15–60 days (15% versus 9%, P = 0.02) after surgery. Mean pain scores were significantly higher in the TAH versus TLH group one (2.48 versus 1.62, P < 0.0001) and four weeks (0.89 versus 0.63, P = 0.01) following surgery. Conclusion. Treatment of early stage endometrial cancer with TLH is associated with less frequent use of epidural, lower post-operative opioid requirements, and better pain scores than TAH.
PMCID: PMC3728549  PMID: 23956855
15.  Endometriosis after Laparoscopic Supracervical Hysterectomy with Uterine Morcellation: A Case Control Study 
Study Objective
To compare the incidence of new onset endometriosis after laparoscopic supracervical hysterectomy (LSH) with uterine morcellation to traditional routes.
Single center case-control study
Design Classification
Canadian Task Force Classification II-2
Single Center case-control study of hysterectomies from January, 2006 through December, 2008.
277 laparoscopic supracervical hysterectomies with morcellation (cases) and 187 transvaginal or abdominal hysterectomies without morcellation (controls) performed from January, 2006 to December 2008.
464 women underwent hysterectomy, 277 cases via laparoscopic supracervical approach (LSH) with morcellation and 187 performed either transvaginally or abdominally without morcellation. Repeat operative procedures were performed for other benign indications on 16 of 464 (3.5%) prior hysterectomy patients.
Measurements and Main Results
102 patients had endometriosis at the time of hysterectomy diagnosed by pathologic evaluation or gross visualization. In those without endometriosis, repeat operative procedures were performed for pain and bleeding in 3.3% (12/362). 60% (3/5) of LSH patients and 28.6% (2/7) of the control group were found to have newly diagnosed endometriosis conferring a rate of 1.4% (3/217) for the LSH group and 1.4% (2/145) in the controls. In patients with endometriosis, repeat operative procedures for pain and/or bleeding occurred in 2.9% (3/102); 3/60 of LSH patients and none in the control group (0/42). Two of these 3 patients undergoing a second surgery had recurrent/continued endometriosis.
Newly diagnosed endometriosis was noted in 1.4% of patients after hysterectomy with a similar incidence between the LSH and control groups. Reoperation for those with endometriosis at the time of LSH with morcellation was infrequent, but endometriosis was usually found. Further research is needed to delineate risk factors for development of de novo endometriosis after hysterectomy.
PMCID: PMC3292633  PMID: 22265051
16.  Problems Related to the Cervical Stump at Follow-Up in Laparoscopic Supracervical Hysterectomy 
To evaluate our experience with laparoscopic supracervical hysterectomy (LASH) and to assess the short- and medium-term outcome.
Retrospective analysis of patient and surgery characteristics from chart review and evaluation of patient satisfaction by a questionnaire.
Forty-one patients who underwent LASH were studied with a mean length of follow-up of 27 months. Operative complications consisted of one bladder lesion and one bleeding at the trocar site. Postoperative complications were bladder atony (1), paralytic ileus (1), a pulmonary embolism (1) and vaginal hemorrhage from the colpotomy incision (1). Twenty-five percent of the patients continued to menstruate, and 10% had symptoms of discharge. Overall, 98% of the patients were satisfied with their operation.
Although preservation of the cervix with laparoscopic hysterectomy for benign diseases was satisfactory in most of the cases, several women had complications of the remaining cervix. Special attention should be paid to the careful treatment of the cervical stump. Further prospective studies are needed to evaluate the advantages of retaining the cervix at laparoscopic hysterectomy.
PMCID: PMC3015336  PMID: 10323162
Laparoscopy; Supracervical hysterectomy; Complications; Follow-up
17.  Laparoscopic Management of Transcervical Fallopian Tube Prolapse 
Laparoscopic total salpingectomy appears to provide effective treatment with minimal invasiveness for transcervical fallopian tube prolapse.
Fallopian tube prolapse (FTP) is a rare but increasingly recognized postoperative complication of total hysterectomy, but few reports relate FTP to supracervical hysterectomy.
A 35-year-old, G2P2, patient with a history of recurrent fibroid prolapse received a supracervical hysterectomy. One week postoperatively, she was treated for infection, and 1 month later a scheduled Pap smear returned benign results and noted a rare cluster of glandular cells. Two months after the hysterectomy, the patient presented to the outpatient clinic with vaginal discharge and dyspareunia. The patient was diagnosed with FTP and was treated with total salpingectomy using a combined vaginal and laparoscopic approach.
Transcervical FTP is a rare complication following supracervical hysterectomy. Increasing awareness of the condition will allow for fewer delays in diagnosis and treatment. A laparoscopic total salpingectomy provides effective treatment with minimal invasiveness.
PMCID: PMC3183568  PMID: 21985731
Salpingectomy; Transcervical fallopian tube prolapse; Laparoscopy; Dyspareunia
18.  Immediate Laparoscopic Nontransvesical Repair without Omental Interposition for Vesicovaginal Fistula Developing after Total Abdominal Hysterectomy 
Immediate laparoscopic nontransvesical repair for vesicovaginal fistula may be an effective and feasible alternative to traditional repair in select patients.
Background and Objective:
We conducted this study to evaluate the feasibility and efficacy of immediate laparoscopic nontransvesical repair without omental interposition for vesicovaginal fistula (VVF) developing after total abdominal hysterectomy (TAH), which causes not only social and economic misery for the patient but also considerable stress to the physicians who perform the surgery.
We performed a retrospective review of 5 women who underwent immediate laparoscopic nontransvesical repair without omental interposition for VVFs, developing after TAH from October 2007 to March 2009. In terms of laparoscopic procedure, cystoscopy was performed to confirm the location of fistula and ureteral openings, initially. Without opening the bladder, the fistula tract was identified, and the bladder was dissected from the vagina. The bladder defect was closed by using intracorporeal, continuous, and double-layer suturing, laparoscopically. The vaginal defect was closed using interrupted and single-layer suturing, vaginally. A Foley catheter was inserted for 2 weeks and removed after bladder integrity was confirmed with a retrograde cystogram.
The median age and body mass index of the patients were 47 years and 22.3 kg/m2, respectively. Operating time, hemoglobin change, and hospital stay were 95 minutes, 1.1 g/dL, and 5 days, respectively. There were no complications or laparoconversions. During follow-up (median 56.1 weeks; range 26.6 to 74.0), there was no evidence of recurrence.
Immediate laparoscopic nontransvesical repair without omental interposition might be an effective, feasible alternative to the traditional methods in select patients with small sized (<1 cm) VVF developing after TAH.
PMCID: PMC3043565  PMID: 20932366
Complication; Hysterectomy; Laparoscopy; Vesicovaginal fistula
19.  Evaluation of risk factors of vaginal cuff dehiscence after hysterectomy 
Obstetrics & Gynecology Science  2014;57(2):136-143.
The purpose of this study was to evaluate risk factors of vaginal cuff dehiscence or evisceration according to the type of operation.
Medical records of 604 women who underwent hysterectomies at Korea University Anam Hospital between June 2007 and June 2011 were reviewed. They were allocated to six groups. The six types of hysterectomies included robotic hysterectomy (n = 7), robotic radical hysterectomy and node dissection (RRHND, n = 9), total laparoscopic hysterectomy (TLH, n = 274), laparoscopy assisted vaginal hysterectomy (LAVH, n = 238), laparoscopic radical hysterectomy and node dissection (n = 11), and abdominal radical hysterectomy (ARH, n = 63). The characteristics and outcomes of each groups were compared.
There was no difference in the characteristics of patients between 6 groups. In total of 604 hysterectomies, 3 evisceration (0.49%) and 21 dehiscences (3.47%) occurred. Evisceration were found in RRHND (1/9, 11.1%), TLH (1/276, 0.36%), and ARH (1/63, 1.56%). Dehiscences occurred in TLH (15/274, 5.42%), LAVH (4/238, 1.68%), and ARH (2/63, 3.17%). In 169 cases of TLH with intra-corporeal continuous suture, 1 evisceration and 4 dehiscences occurred, whereas 11 dehiscences occurred in 105 TLH cases with vaginal continuous locking suture (2.96% vs. 10.47%, P = 0.02).
The incidence of vaginal cuff dehiscenceand eviscerationwas significantly higher in TLH than LAVH. The intra-corporeal cuff suture was superior to the vaginal suture to prevent the vaginal cuff complications in TLH.
PMCID: PMC3965697  PMID: 24678487
Complications; Hysterectomy; Surgical wound dehiscence; Suture techniques
20.  Technicity as a Quality Indicator of Excellence in Gynaecology 
The objective of this study was to calculate the technicity index (TI) for hysterectomies at a tertiary care university hospital in Oman.
This is a retrospective chart review of patients who had hysterectomies at Sultan Qaboos University Hospital (SQUH), a tertiary care university hospital. Profiles were reviewed for all patients who had hysterectomies at SQUH in the period 2003–2009. The cumulative frequencies for all types of hysterectomies were tallied and the year-specific TI was calculated.
Overall, we enumerated a total of 258 hysterectomies, of which 6 (2.3%) were laparoscopic assisted hysterectomies, 42 (16.3%) vaginal hysterectomies, and 208 (80.6%) total abdominal hysterectomies. The average TI was 19% (48/258), and it ranged from 11% to 24%. The trend of change fluctuated over the years starting with 16% (2003) and increasing gradually during 2004–2006, but then declining again during 2007–2008 (trend P value 0.02). This low and fluctuating trend was mainly attributed to the inconsistency in the availability of trained surgeons and laparoscopic equipment.
TI at our institution can be improved by increasing the number of minimally invasive hysterectomies through providing more trained surgeons and laparoscopic equipment.
PMCID: PMC3286723  PMID: 22375264
Technicity Index; Hysterectomy; Quality indicator; Gynaecology; Oman
21.  Comparison of Cervical Detachment Using Monopolar Lap Loop Ligature and Conventional Methods in Laparoscopic Supracervical Hysterectomy 
Our aim was to evaluate a new electrosurgical instrument (Lap Loop device) that amputates the uterine corpus from the cervix during a laparoscopic supracervical hysterectomy (LSH) and to compare the time required for cervical amputation with traditional methods.
This comparative trial was conducted at the University of Louisville and Norton Healthcare Hospitals, Louisville, KY. The patients comprised 29 women scheduled for hysterectomy for benign conditions. All patients underwent laparoscopic supracervical hysterectomy. The Lap Loop device was used in 17 patients to section the cervix. Conventional methods with either laparoscopic monopolar scissors or Harmonic scalpel were used in 12 patients.
In the control group, the mean cervical cutting time with laparoscopic scissors or Harmonic scalpel was 14.4 minutes. The mean time for the application of the loop electrode and cutting time was 6.6 minutes and was significantly shorter than the cutting time of conventional methods. Two minor complications (7.4% of cases) and one relatively major complication (3.7%), an incisional hernia, occurred in the study patients. None of the complications were related to the new device.
An electrosurgical loop decreased the time required for resection of the uterine cervix during LSH for benign uterine conditions. This device facilitates and increases the safety of this procedure.
PMCID: PMC3016112  PMID: 16882425
Laparoscopic supracervical hysterectomy; Lap Loop; Electrosurgical transection
22.  Classic Intrafascial Supracervical Hysterectomy (CISH): 10-Year Experience 
We report and review herein our 10-year experience with classic intrafascial supracervical hysterectomy focusing on our long-term experience, evolution of the operative technique, and increased use of this technique.
We performed a parallel, observational study with retrospective data to evaluate classic intrafascial supracervical hysterectomy, a laparoscopic hysterectomy technique, at Fayette Medical Center, a community hospital in Northwestern Alabama, USA. Patients comprised a consecutive series of 579 over a 10-year period from November 1992 through November 2002.
The classic intrafascial supracervical hysterectomy technique, similar to standard supracervical hysterectomy, leaves the cardinal ligament, uterosacral ligament, vascular supply, and innervation to the upper vagina and cervix intact, but unlike supracervical hysterectomy removes the transition zone and endocervical canal. For 579 patients, the average age was 45.4 years (range, 22 to 92), follow- up was 75.3 months (range, 17 to 137), operating room time was 69 minutes (range, 44 to 370), blood loss was 72 mL (range, 10 to 765), length of hospital stay was 23.2 hours (range, 14 hours to 5 days), time to return to work was 13.2 days (range, 3 to 28). Complications include 11 cervical bleedings, 1 uterine artery bleeding, 1 pelvic hematoma, 1 postoperative ileus, and 16 mucoceles of the cervical stump. Three patients were converted from a laparoscopic to an open procedure (0.52%). Long-term follow-up of up to 137 months shows no adverse events thus far.
Classic intrafascial supracervical hysterectomy is a safe procedure with a low short- and long-term complication rate. It has a short recuperation period and high patient satisfaction. It is the procedure of choice when hysterectomy is indicated for benign disease.
PMCID: PMC3015665  PMID: 16709352
CISH; Hysterectomy; Laparoscopy; Complications; Long-term experience
23.  Sexual Outcomes and Satisfaction with Hysterectomy: Influence of Patient Education 
The journal of sexual medicine  2006;4(1):106-114.
Many women experience improved sexual function after hysterectomy. However, a sizeable minority of women report worsened sexual function after the surgery, and concerns about the effect of surgery on sexual function are common among women planning to undergo hysterectomy.
The present study examined the role of education about the potential sexual consequences of hysterectomy in predicting self-reported outcomes and satisfaction with the procedure.
We conducted a cross-sectional survey of 204 women who had undergone simple hysterectomy in the preceding 3–12 months. Participants volunteered in response to a Web-based advertisement.
Main Outcome Measures
Participants indicated their current sexual function using the Female Sexual Function Index (FSFI), and reported positive and negative sexual outcomes experienced after hysterectomy using a checklist. Participants also completed questionnaire items regarding satisfaction with hysterectomy and education from their physicians about sexual risks and benefits prior to surgery.
Current sexual function scores were related to self-reports of positive and negative sexual outcomes following hysterectomy and overall satisfaction with hysterectomy. Education from a physician about possible adverse sexual outcomes was largely unrelated to self-reports of having experienced those outcomes. However, education about possible negative sexual outcomes predicted overall satisfaction with hysterectomy when controlling for self-reports of positive and negative sexual outcomes.
Education about potential negative sexual outcomes after surgery may enhance satisfaction with hysterectomy, independent of whether negative sexual outcomes were experienced. Including a discussion of potential sexual changes after surgery may enhance the benefits of presurgical counseling prior to hysterectomy.
PMCID: PMC2857776  PMID: 17087803
Risk Factors/Comorbidities; Iatrogenic Sexual Dysfunction; Psychological Assessment of Sexual Dysfunction
24.  Hysterectomy Does Not Cause Constipation 
Diseases of the Colon and Rectum  2008;51(7):1068-1073.
This study was designed to evaluate the risk on development and persistence of constipation after hysterectomy.
We conducted a prospective, observational, multicenter study with three-year follow-up in 13 teaching and nonteaching hospitals in the Netherlands. A total of 413 females who underwent hysterectomy for benign disease other than symptomatic uterine prolapse were included. All patients underwent vaginal hysterectomy, subtotal abdominal hysterectomy, or total abdominal hysterectomy. A validated disease-specific quality-of-life questionnaire was completed before and three years after surgery to assess the presence of constipation.
Of the 413 included patients, 344 (83 percent) responded at three-year follow-up. Constipation had developed in 7 of 309 patients (2 percent) without constipation before surgery and persisted in 16 of 35 patients (46 percent) with constipation before surgery. Preservation of the cervix seemed to be associated with an increased risk of the development of constipation (relative risk, 6.6; 95 percent confidence interval, 1.3–33.3; P = 0.02). Statistically significant risk factors for the persistence of constipation could not be identified.
Hysterectomy does not seem to cause constipation. In nearly half of the patients reporting constipation before hysterectomy, this symptom will disappear.
PMCID: PMC2468312  PMID: 18443878
Hysterectomy; Constipation; Defecation; Prognostic factor; Prospective study
25.  Risk of Mesh Erosion With Sacral Colpopexy and Concurrent Hysterectomy 
Obstetrics and gynecology  2003;102(2):306-310.
To examine short- and long-term mesh-related complications in women undergoing abdominal sacral colpopexy with concurrent hysterectomy, compared with women with a prior hysterectomy undergoing sacral colpopexy alone.
Patient characteristics, hospital complications, postoperative clinical course, and long-term graft-related complications were reviewed for all women with genital prolapse who underwent abdominal sacral colopexy between 1996 and 1998. Women with concurrent hysterectomy were compared with women with vaginal prolapse after a prior hysterectomy.
One hundred twenty-four patients, 60 with concurrent hysterectomy and 64 with prior hysterectomy, were observed postoperatively for a median of 35.5 (0–74) months. Demographics of the two groups were similar, with a mean age of 65.1 ± 9.4 years and a mean body mass index of 25.8 ± 4.2 kg/m2. Eighty percent of colpopexies used prolene sythetic mesh and 20% allograft material. Initial operative and hospital complications were rare in both groups and included a blood transfusion of 2 U, a ureteral transection, a wound infection, heart block, and an arrhythmia. Delayed graft complications included one mesh erosion in a patient with a prior hysterectomy that was managed by office resection (0.8%).
Concurrent hysterectomy with abdominal sacral colopopexy has a low incidence of mesh complications and can be used as a first-line treatment for genital prolapse.
PMCID: PMC1364470  PMID: 12907104

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