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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.  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
3.  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
4.  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
5.  Effects of genital prolapse surgery and hysterectomy on pelvic floor function 
Facts, Views & Vision in ObGyn  2009;1(3):194-207.
This study was aimed to evaluate the effects of hysterectomy on pelvic floor function.
We conducted a prospective observational multicenter study with three-year follow-up in thirteen teaching and nonteaching hospitals in the Netherlands. Four-hundred-thirty females who underwent hysterectomy for benign disease other than symptomatic uterine prolapse were included. Validated disease-specific quality-of-life questionnaire were completed before surgery and at 6 months, 12 months and three years after surgery to assess the presence of micturition symptoms, defecation symptoms and sexual problems.
Micturition symptoms at three year after surgery were more common following vaginal hysterectomy than following abdominal hysterectomy (OR 2.2, 95% CI 1.3-4.0). Micturition symptoms that more often disappeared following ­abdominal hysterectomy included urgency (OR 2.4, 95% CI 1.0-5.5) and obstructive micturition (OR 2.9, 95% CI 1.0-8.2).
Constipation had developed in 2% of the patients without constipation before surgery and persisted in 46% of the ­patients with constipation before surgery.
Sexual pleasure statistically significantly improved in all patients, independently of the performed technique of ­hysterectomy. At six months after vaginal, subtotal abdominal hysterectomy and total abdominal hysterectomy, the prevalence of one or more bothersome sexual problems was 43%, 41% and 39% respectively (Chi-square test: p = 0.88).
From our prospective study it can be concluded that removal of the cervix during hysterectomy does not worsen pelvic floor function. Abdominal hysterectomy might have benefits over vaginal hysterectomy with respect to micturition. Hysterectomy does not cause constipation. Sexual function following hysterectomy does not depend on the performed technique and is on average better than before surgery.
PMCID: PMC4255511  PMID: 25489465
Constipation; hysterectomy; pelvic floor function; prospective study; quality of life
6.  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
7.  Persistent Bleeding After Laparoscopic Supracervical Hysterectomy 
Background and Objectives:
In our clinical experience, there seemed to be a correlation between cervical stump bleeding and adenomyosis. Therefore, we wanted to conduct a study to determine whether there was an actual correlation and to identify other risk factors for persistent bleeding after a laparoscopic supracervical hysterectomy.
The study included women who underwent laparoscopic supracervical hysterectomy from January 1, 2003, through December 31, 2012. Data were collected on age, postmenopausal status, body mass index (BMI), uterine weight, indication for hysterectomy, concomitant bilateral salpingo-oophorectomy (BSO), presence of endometriosis, surgical ablation of the endocervix, adenomyosis, presence of endocervix in the specimen, and postoperative bleeding.
The study included 256 patients, of whom 187 had no postoperative bleeding after the operation, 40 had bleeding within 12 weeks, and 29 had bleeding after 12 weeks. The 3 groups were comparable in BMI, postmenopausal status, uterine weight, indication for hysterectomy, BSO, surgical ablation of the endocervix, adenomyosis, and the presence of endocervix. However, patients who had postoperative bleeding at more than 12 weeks were significantly younger (P = .002) and had a higher rate of endometriosis (P < .001).
Risks factors for postoperative bleeding from the cervical stump include a younger age at the time of hysterectomy and the presence of endometriosis. Therefore, younger patients and those with endometriosis who desire to have no further vaginal bleeding may benefit from total hysterectomy over supracervical hysterectomy. All patients who are undergoing supracervical hysterectomy should be counseled about the possible alternatives, benefits, and risks, including continued vaginal bleeding from the cervical stump and the possibility of requiring future treatment and procedures.
PMCID: PMC4266229  PMID: 25516706
Cervical stump bleeding; laparoscopic supracervical hysterectomy
8.  Safe total intrafascial laparoscopic (TAIL™) hysterectomy: a prospective cohort study 
Gynecological Surgery  2010;7(3):231-239.
This study directly compares total intrafascial laparoscopic (TAIL™) hysterectomy with vaginal (VH) and abdominal (AH) hysterectomy with regard to safety, operating time and time of convalescence. The study is a prospective cohort study (Canadian Task Force classification II-2), including data from patients of a single university-affiliated teaching institution, admitted between 1997 and 2008 for hysterectomy due to benign uterus pathology. Patient data were collected pre-, intra- and postoperatively and complications documented using a standardised data sheet of a Swiss obstetric and gynaecological study group (Arbeitsgemeinschaft Schweizerische Frauenkliniken, Amlikon/Switzerland). Classification of complications (major complications and minor complications) for all three operation techniques, evaluation of surgeons and comparison of operation times and days of hospitalisation were analysed. 3066 patients were included in this study. 993 patients underwent AH, 642 VH and 1,431 total intrafascial hysterectomy. No statistically significant difference for the operation times comparing the three groups can be demonstrated. The mean hospital stay in the TAIL™ hysterectomy, VH and AH groups is 5.8 ± 2.4, 8.8 ± 4.0 and 10.4 ± 3.9 days, respectively. The postoperative minor complications including infection rates are low in the TAIL™ hysterectomy group (3.8%) when compared with either the AH group (15.3%) or the VH group (11.2%), respectively. The total of minor complications is statistically significant lower for TAIL™ hysterectomy as for AH (O.R. 4.52, CI 3.25–6.31) or VH (O.R. 3.16, CI 2.16–4.62). Major haemorrhage with consecutive reoperation is observed statistically significantly more frequent in the AH group when compared to the TAIL™ hysterectomy group, with an O.R. of 6.13 (CI 3.05–12.62). Overall, major intra- and postoperative complications occur significant more frequently in the AH group (8.6%) when compared to the VH group (3%) and the TAIL™ hysterectomy group (1.8%). The incidence of major complications applying the standardised TAIL™ hysterectomy technique is not related to the experience of the surgeons. We conclude that a standardised intrafascial technique of total laparoscopic (TAIL™) hysterectomy using an anatomically developed special uterine device is associated with a very low incidence of minor and major intra- and postoperative complications. The direct comparison of complication rates with either vaginal or abdominal hysterectomy favours the total laparoscopic technique, and therefore, this technique can be recommended as a relatively atraumatic procedure. The operation times are comparable for all three techniques without any statistically significant differences. This technique for laparoscopic hysterectomy is shown to be equally safe when applied by experienced gynaecologic surgeons or by residents in training.
Electronic supplementary material
The online version of this article (doi:10.1007/s10397-010-0569-0) contains supplementary material, which is available to authorized users.
PMCID: PMC2914872  PMID: 20700518
Total intrafascial laparoscopic hysterectomy; TAIL™ hysterectomy; Vaginal hysterectomy; Abdominal hysterectomy; Uterine device; Postoperative complications
9.  Thermal Balloon Endometrial Ablation for Dysfunctional Uterine Bleeding 
Executive Summary
The objective of this review was to evaluate the effectiveness and cost-effectiveness of thermal balloon endometrial ablation (TBEA) for dysfunctional uterine bleeding (DUB).
Background: Condition and Target Population
Abnormal uterine bleeding is defined as an increase in the frequency of menstruation, duration of flow or amount of blood loss. (1) DUB is a diagnosis of exclusion when there is no pelvic pathology or underlying medical cause for the increased bleeding. (1) It is characterized by heavy prolonged flow with or without breakthrough bleeding. It may occur as frequent, irregular, or unpredictable bleeding; lengthy menstrual periods; bleeding between periods; or a heavy flow during periods. Menorrhagia, cyclical HMB over several consecutive cycles during the reproductive years, is the most frequent form of DUB.
The incidence of DUB has not been reported in the literature. For Ontario, an expert estimated that about 15% to 20% of women over 30 years have DUB. The prevalence increases with age and peaks just before menopause. (1) Using 2001 Ontario census-based population estimates, there are about 2 million women between the ages of 30 and 49 years; therefore, of these, about 290,965 to 387,953 may have DUB.
The Technology Being Reviewed: Thermal Balloon Endometrial Ablation
Since the 1990s, second-generation endometrial ablation (EA) techniques developed, the aim to provide simpler, quicker, and more effective treatment options for menorrhagia compared with first-generation EA techniques and hysterectomy. (2) Compared with first-generation techniques these depend less on the people operating them and more on the actual devices to ensure safety and efficacy.
TBEA relies on the transfer of heat from heated liquid within a balloon that is inserted into the uterus. (2) It does not require a hysteroscope for direct visualization of the uterus and can be performed under local anesthesia. In order to use TBEA, patients with DUB cannot have a long (>10–12 cm) or irregularly shaped uterine cavity, because the balloon must be in direct contact with the uterine wall to cause ablation. For Ontario, an expert estimated that about 70% of patients with DUB considered for EA would have a uterus suitable for TBEA based on these criteria. If 70% of Ontario women between 30 and 49 years of age with DUB have a uterus suitable for TBEA, then about 203,675 to 271,567 women may be eligible. However, some of these women will be successfully treated by drugs or will want amenorrhea (the cessation of their periods) and therefore choose to have a hysterectomy.
Review Strategy
The standard Medical Advisory Secretariat search strategy was used to locate international health technology assessments and English-language journal articles published from January 1996 to June 2004. A Cochrane systematic review from 2004 was identified that examined the effectiveness and cost-effectiveness of TBEA for heavy menstrual bleeding. (2) Another literature search was done to update information from the systematic review.
Summary of Findings
A 2004 systematic review of the literature by Garside et al. (2) in the United Kingdom, found that overall, there were few significant differences between outcomes for first-generation techniques and TBEA. The outcomes were bleeding, postoperative complications, patient satisfaction, quality of life, and repeat surgery rates. Significant differences were reported most often by one study by Pellicano et al., (3) but this was a level 2 study with methodological weaknesses. Furthermore, according to Garside et al., there was considerable clinical and methodological heterogeneity among the studies in the systematic review. Therefore, a quantitative synthesis using meta-analysis was not done. In Garfield and colleagues’ review:
TBEA had significantly shorter operating and theatre times (P < .05, < .01, and .0001).
TBEA had fewer intraoperative adverse effects (e.g., reported rates of uterine perforation with RB ablation: from 1% to 5%; TBEA: 0%; rates of cervical laceration with RB: 2% to 5%; TBEA 0%).
They found no studies have directly compared second-generation techniques and hysterectomy; therefore, the comparison can only be indirectly inferred from studies of first-generation techniques and hysterectomy.
Compared with hysterectomy, TCRE and RB are quicker to perform and result in shorter hospitalization stays and a faster return to work.
Hysterectomy results in more adverse effects.
Satisfaction with hysterectomy is initially higher, but there is no difference after 2 years.
Studies (level 2 evidence) published after Garside’s systematic review support these conclusions.
A study with level 2 evidence reported a significantly higher risk overall of intraoperative complications for RB compared with TBEA (P < .001). This included uterine perforation (RB, 5%; TBEA, 0%) and suspicion of perforation (RB, 2%; TBEA, 0%).
A multicentre long-term case series (level 4 evidence) that examined avoidance of hysterectomy after TBEA for menorrhagia reported that 86% of women who had TBEA did not require a hysterectomy, and 75% did not have any further surgery during a follow-up period of 4 to 6 years. (4)
Several TBEA studies did not provide justification for using general anesthesia over local anesthesia.
Patient preferences for different treatments will depend on a woman’s desire for amenorrhea as an outcome and/or avoidance of major surgery. Hysterectomy is the only procedure that can guarantee amenorrhea. TBEA will not totally replace hysterectomy in the treatment of DUB, because some women may want cessation of menstruation.
Ensuring that patient expectations are consistent with the outcomes achievable with TBEA is important to obtain high levels of satisfaction. Vilos et al. (5) noted that up to one-half of patients who underwent a second attempt at TBEA might have avoided the second procedure with proper preoperative counselling. Meyer et al. (6) noted that one consideration for patients with menorrhagia (and no structural lesions) is to return to normal or less blood loss rather than amenorrhea. Patients may have distinct concepts of menstrual bleeding depending on cultural background, and maintaining an acceptable menstrual flow instead of amenorrhea may represent a healthier status. (7)
A budget impact analysis suggests that the net annual budget outlay for TBEA would be between $1.4 million in savings and $2.8 million in additional outlays. (Note: Not all savings would be realized directly by the Ministry of Health and Long-Term Care, because much of the savings would accrue to the global budgets of hospitals).
TBEA is effective, safe, and cost-effective for patients with DUB.
For women who are not worried about amenorrhea, first-generation techniques offer advantages over hysterectomy.
TBEA is a better alternative to first-generation techniques for DUB, because it is associated with fewer intraoperative adverse effects.
PMCID: PMC3387747  PMID: 23074450
10.  Advantages of nerve-sparing intrastromal total abdominal hysterectomy 
Video abstract
The purpose of the prospective study was to evaluate the effect of the nerve-sparing intrastromal abdominal hysterectomy bilateral salpingo-oophorectomy (ISTAH-BSO) on intraoperative, and postoperative complications namely blood loss and length of hospital stay.
Forty female patients were allocated by a block randomization method into a study group and a control group. The study group consisted of 20 patients who underwent ISTAH-BSO over a 2-year period. The control group included 20 patients who underwent conventional hysterectomy by the same surgeon during the same time frame. Both groups were followed for outcomes of interest, which included length of hospital stay, blood loss, and surgical complications. The participants in both groups were as similar as possible with respect to all known or unknown factors that might affect the study outcome.
Postoperative hemoglobin levels were higher in the study group (blood loss 1.0 g/dL versus 1.4 g/dL in control group). Average hospital stay was significantly shorter in the study group (2.7 days versus 3.15 days in the control group, P = 0.028). No significant complications such as urinary fistula, vaginal vault prolapse, blood transfusion, or postoperative infections were identified in the study group.
The nerve-sparing ISTAH-BSO procedure described in this study has the potential to reduce length of hospital stay after abdominal hysterectomy by reducing blood loss and postoperative complications. Follow-up observations suggest that urinary function and sexual satisfaction are also preserved. Since this research, 175 cases have been performed, with an average of 5 years of follow-up. The outcomes of these cases have been reported as similar.
PMCID: PMC3556916  PMID: 23378786
cervical cancer; support system; nerve sparing; complications; blood loss; hospital stay
11.  Outcomes of vaginal hysterectomy for uterovaginal prolapse: a population-based, retrospective, cross-sectional study of patient perceptions of results including sexual activity, urinary symptoms, and provided care 
BMC Women's Health  2009;9:9.
Vaginal hysterectomy is often used to correct uterovaginal prolapse, however, there is little information regarding outcomes after surgery in routine clinical practice. The objective of this study was to investigate complications, sexual activity, urinary symptoms, and satisfaction with health care after vaginal hysterectomy due to prolapse.
We analyzed data from the Swedish National Register for Gynecological Surgery (SNRGS) from January 1997 to August 2005. Women participating in the SNRGS were asked to complete surveys at two and six months postoperatively. Of 941 women who underwent vaginal hysterectomy for uterovaginal prolapse, 791 responded to questionnaires at two months and 682 at six months. Complications during surgery and hospital stay were investigated. The two-month questionnaire investigated complications after discharge, and patients' satisfaction with their health care. Sexual activity and urinary symptoms were reported and compared in preoperative and six-month postoperative questionnaires.
Almost 60% of women reported normal activity of daily life (ADL) within one week of surgery, irrespective of their age. Severe complications occurred in 3% and were mainly intra-abdominal bleeding and vaginal vault hematomas. Six months postoperative, sexual activity had increased for 20% (p = 0.006) of women and urinary urgency was reduced for 50% (p = 0.001); however, 14% (n = 76) of women developed urinary incontinence, 76% (n = 58) of whom reported urinary stress incontinence. Patients were satisfied with the postoperative result in 93% of cases and 94% recommended the surgery.
Vaginal hysterectomy is a patient-evaluated efficient treatment for uterovaginal prolapse with swift recovery and a low rate of complication. Sexual activity and symptoms of urinary urgency were improved. However, 14% developed incontinence, mainly urinary stress incontinence (11%). Therefore efforts to disclose latent stress incontinence should be undertaken preoperatively.
PMCID: PMC2675521  PMID: 19379514
12.  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
13.  Total laparoscopic hysterectomy versus abdominal hysterectomy in the treatment of patients with early stage endometrial cancer: A randomized multi center study 
BMC Cancer  2009;9:23.
Traditionally standard treatment for patients with early stage endometrial cancer (EC) is total abdominal hysterectomy and bilateral salpingo oophorectomy (TAH+BSO) with or without lymph node dissection through a vertical midline incision. While TAH is an accepted effective treatment, it is highly invasive, visibly scarring and associated with morbidity. An alternative treatment is the same operation by laparoscopy. Though in several studies total laparoscopic hysterectomy (TLH+ BSO) seems a safe and feasible alternative approach in early stage endometrial cancer patients, there are no randomized data available yet. Furthermore, a randomized controlled trial with surgeons trained in laparoscopy is warranted in order to implement this technique in a safe manner. The aim of this study is to compare the treatment related morbidity, cost-effectiveness and quality of life in early stage endometrial cancer patients treated by laparoscopy versus the standard open approach.
A multi centre randomized clinical phase 3 trial, including 5 university hospitals and 15 regional hospitals in the Netherlands. Only gynecologists trained in performing a TLH are allowed to participate. Inclusion criteria: Patients with a clinical stage I endometrioid adenocarcinoma or complex atypical hyperplasia are randomized in a 2:1 allocation to receive TLH or TAH. The main outcome measure is the rate of major complications, as assessed by an independent clinical review board. In total, 275 patients are required to have 80% power at α-0.05 to detect a significant difference of 15% complication rate. Secondary outcome measures are 1) costs and cost-effectiveness, 2) minor complications, and 3) quality of life. All data from this multi center study are reported using case record forms. Data regarding quality of life, pain, body Image, sexuality and additional homecare are assessed with self reported questionnaires.
A randomized multi center study in early stage endometrial cancer patients with inclusion criteria for patients and surgeons is designed and ongoing. Results will be presented at the end of 2009.
Trial Registration
Dutch trial register number NTR821.
PMCID: PMC2630311  PMID: 19146684
14.  Vaginal-Assisted Laparoscopic Radical Hysterectomy: Rationale, Technique, Results 
The authors conclude that vaginal-assisted laparoscopic radical hysterectomy is an oncologic viable alternative to abdominal radical hysterectomy, laparoscopic-assisted radical vaginal hysterectomy, totally laparoscopic radical hysterectomy, and robotic radical hysterectomy.
Total laparoscopic radical hysterectomy (TLRH) makes it difficult to resect adequate vaginal cuff according to tumor size and to avoid tumor spread after opening the vagina. Laparoscopic-assisted radical vaginal hysterectomy (LARVH) is associated with higher risk for urologic complications.
The vaginal-assisted laparoscopic radical hysterectomy (VALRH) technique comprises 3 steps: (1) comprehensive laparoscopic staging, (2) creation of a tumor-adapted vaginal cuff, and (3) laparoscopic transsection of parametria. We retrospectively analyzed data of 122 patients who underwent VALRH for early stage cervical cancer (n=110) or stage II endometrial cancer (n=12) between January 2007 and December 2009 at Charité University Berlin.
All patients underwent VALRH without conversion. Mean operating time was 300 minutes, and mean blood loss was 123cc. On average, 36 lymph nodes were harvested. Intra- and postoperative complication rates were 0% and 13.1%, respectively. Resection was in sound margins in all patients. After median follow-up of 19 months, disease-free survival and overall survival for all 110 cervical cancer patients was 94% and 98%, and for the subgroup of patients (n=90) with tumors ≤pT1b1 N0 V0 L0/1 R0, 97% and 98%, respectively.
VALRH is a valid alternative to abdominal radical hysterectomy and LARVH in patients with early-stage cervical cancer and endometrial cancer stage II with minimal intraoperative complications and identical oncologic outcomes.
PMCID: PMC3340952  PMID: 22643498
Laparoscopic radical hysterectomy; Urologic complications; Radical hysterectomy; Cervical cancer
15.  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
16.  The Impact of Different Surgical Modalities for Hysterectomy on Satisfaction and Patient Reported Outcomes 
There is an ongoing debate regarding the cost-benefit of different surgical modalities for hysterectomy. Studies have relied primarily on evaluation of clinical outcomes and medical expenses. Thus, a paucity of information on patient-reported outcomes including satisfaction, recovery, and recommendations exists.
The objective of this study was to identify differences in patient satisfaction and recommendations by approach to a hysterectomy.
We recruited a large, geographically diverse group of women who were members of an online hysterectomy support community. US women who had undergone a benign hysterectomy formed this retrospective study cohort. Self-reported characteristics and experiences were compared by surgical modality using chi-square tests. Outcomes over time were assessed with the Jonkheere-Terpstra trend test. Logistic regression identified independent predictors of patient satisfaction and recommendations.
There were 6262 women who met the study criteria; 41.74% (2614/6262) underwent an abdominal hysterectomy, 10.64% (666/6262) were vaginal, 27.42% (1717/6262) laparoscopic, 18.94% (1186/6262) robotic, and 1.26% (79/6262) single-incision laparoscopic. Most women were at least college educated (56.37%, 3530/6262), and identified as white, non-Hispanic (83.17%, 5208/6262). Abdominal hysterectomy rates decreased from 68.2% (152/223) to 24.4% (75/307), and minimally invasive surgeries increased from 31.8% (71/223) to 75.6% (232/307) between 2001 or prior years and 2013 (P<.001 all trends). Trends in overall patient satisfaction and recommendations showed significant improvement over time (P<.001).There were differences across the surgical modalities in all patient-reported experiences (ie, satisfaction, time to walking, driving and working, and whether patients would recommend or use the same technique again; P<.001). Significantly better outcomes were evident among women who had vaginal, laparoscopic, and robotic procedures than among those who had an abdominal procedure. However, robotic surgery was the only approach that was an independent predictor of better patient experience; these patients were more satisfied overall (odds ratio [OR] 1.31, 95% CI 1.13-1.51) and on six other satisfaction measures, and more likely to recommend (OR 1.64, 95% CI 1.39-1.94) and choose the same modality again (OR 2.07, 95% CI 1.67-2.57). Abdominal hysterectomy patients were more dissatisfied with outcomes after surgery and less likely to recommend (OR 0.36, 95% CI 0.31-0.40) or choose the same technique again (OR 0.29, 95% CI 0.25-0.33). Quicker return to normal activities and surgery after 2007 also were independently associated with better overall satisfaction, willingness to recommend, and to choose the same surgery again.
Consistent with other US data, laparoscopic and robotic hysterectomy rates increased over time, with a concomitant decline in abdominal hysterectomy. While inherent shortcomings of this retrospective Web-based study exist, findings show that patient experience was better for each of the major minimally invasive approaches than for abdominal hysterectomy. However, robotic-assisted hysterectomy was the only modality that independently predicted greater satisfaction and willingness to recommend and have the same procedure again.
PMCID: PMC4129130  PMID: 25048103
hysterectomy; vaginal hysterectomy; robotics; laparoscopy; patient satisfaction; patient outcomes assessment; Internet
17.  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
18.  Laparoscopic assisted vaginal hysterectomy (LAVH) — An effective alternative to conventional abdominal hysterectomy 
To compare LAVH with TAH in terms of indications, operable uterine size, operative time, intraoperative blood loss, complications, postoperative pain and hospital stay, convalescence and average total cost; also to evaluate LAVH for its feasibility in patients with previous abdominal surgery and those requiring other surgical procedures.
Material and Methods
Aretrospective study was conducted on 550 patients (350 patients of LAVH, 200 patients of TAH) who underwent surgery at Fortis Escorts Hospital, Faridabad, between January 2005 and May 2007. Statistical analysis was done using Student-t test and Chisquare test.
On comparing LAVH with TAH, the mean operative time was 63 vs 55 min (p<0.001), blood loss 116 vs 150ml (p<0.001), major complication rate 2% vs 5% hospital stay 2.7 vs 5.7 days (p<0.001). Patients of LAVH had statistically significant lower pain scores, higher activity scores, shorter convalescence and quicker resumption of normal activity. LAVH was marginally costlier than TAH.
LAVH enables the surgeon to convert most of the difficult abdominal hysterectomies into vaginal ones with all the benefits of a vaginal procedure. It is also a feasible and safe procedure in patients with previous abdominal surgery, large uteri and adnexal masses. LAVH enjoys patient’s support with lesser postoperative pain, shorter hospital stay, rapid return to normal activity and better body image.
PMCID: PMC3394619
LAVH; hysterectomy; laparoscopic; assisted vaginal hysterectomy
19.  Readmission to hospital 5 years after hysterectomy or endometrial resection in a national cohort study 
Objectives: To investigate the readmission experience of a large national prospective cohort of women up to 5 years after undergoing either transcervical resection of the endometrium (TCRE) or hysterectomy to assess reasons for readmission and whether TCRE can be viewed as a definitive substitute for hysterectomy.
Design and participants: Data are from the VALUE/MISTLETOE prospective national cohort studies of hysterectomy and TCRE respectively. 5294 women who underwent hysterectomy for dysfunctional uterine bleeding in 1994/5 and 4032 women who underwent TCRE in 1993/4 and who responded to postal questionnaires were included. Surgeons gathered operative details. Women completed postal follow up questionnaires at 3 and 5 years after surgery asking about readmission to hospital and reasons for readmission. Adjusted proportional hazard ratios were calculated for likelihood of readmission in each category comparing types of surgery.
Results: 41.7% of women undergoing hysterectomy and 44.6% of women undergoing TCRE experienced one or more readmissions to hospital overall within 5 years (adjusted hazard ratio for all readmissions (AHR) 0.87 (95% confidence interval (CI) 0.80 to 0.95)). 12.6% of hysterectomy patients and 30.3% of TCRE patients were readmitted for gynaecological reasons (AHR 0.40 (95% CI 0.33 to 0.48)). Rates of readmission for gynaecological reasons were similar up to 6 months but were markedly reduced for hysterectomy compared with TCRE patients towards the end of the follow up period (AHR for readmission at 3–5 years 0.28 (95% CI 0.20 to 0.39)).
Conclusions: There are differences in the pattern of readmission to hospital after hysterectomy and TCRE for dysfunctional uterine bleeding. Women undergoing a hysterectomy are less likely to be readmitted to hospital up to 5 years after their operation overall, and are significantly less likely to be readmitted for reasons related to their operation, particularly for gynaecological reasons. Hysterectomy appears to be a more definitive operation. The different options for surgery for dysfunctional uterine bleeding are not interchangeable; they represent different patterns of care. Information should be available to women and practitioners to inform choices between these options.
PMCID: PMC1743974  PMID: 15692002
20.  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
21.  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
22.  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
23.  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
24.  Assessing the Learning Curve for Laparoscopic Supracervical Hysterectomy 
We assessed the learning curve for laparoscopic supracervical hysterectomy.
This was a prospective cohort study. We analyzed the first 60 consecutive laparoscopic supracervical hysterectomy procedures performed by a team of 2 gynecological laparoscopic surgeons between May 2001 and July 2006 to examine whether a learning curve exists as defined by a decrease in operating time and complications as the sequence increased. Based on previous reports, we defined the first 30 laparoscopic supracervical hysterectomies as “early” cases and the subsequent cases as “late” cases.
The mean operating time for laparoscopic supracervical hysterectomy was significantly reduced from 166 minutes to 142.3 minutes (P≤0.05) between the early and the late cases. The mean first postoperative day drop in hemoglobin between the early and the late cases was from 2.4gm/dL to 2.0gm/dL (P=0.08). Two complications occurred in the series: one delayed bowel injury in the early cases and one conversion to laparotomy due to a cystotomy in the late cases. No difference existed between the early and the late patients regarding age, parity, body mass index, uterine weight, previous abdominal surgery, or hospital stay. There was an overall linear correlation between the operating time and uterine weight (R=0.384).
There is a learning curve for laparoscopic supracervical hysterectomy. After gaining experience in performing 30 cases, the operating time is significantly reduced. The operation can be performed safely during the learning period.
PMCID: PMC3015723  PMID: 17761078
Laparoscopic hysterectomy; Supracervical; Learning curve
25.  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

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