Pelvic floor and sexual function 3 years after hysterectomy - A prospective cohort study.

INTRODUCTION: Long term effects after hysterectomy, such as a worsening of pelvic floor and sexual function, have been studied with diverse results. Therefore, we investigated the long-term effects of hysterectomy for benign indication on pelvic floor and sexual function as well as differences in outcome depending on mode of hysterectomy. MATERIAL AND METHODS: In a prospective clinical cohort study, we included 260 women scheduled for hysterectomy who answered validated questionnaires; pelvic floor impact questionnaire (PFIQ-7), pelvic floor distress inventory (PFDI-20) and female sexual function index (FSFI). Participants were followed up to 3 years after surgery. Nonparametric statistics and mixed effect models were used in analyses of the data. RESULTS: After exclusions, 242 women remained in the study, with a response rate at the 3-year follow-up of 154/242 (63.6%) for all questionnaires. There was an improvement of pelvic floor function with a mean score of PFIQ-7 at baseline of 42.5 (SD 51.7) and at 3 years 22.7 (SD 49.4), (p < 0.001) and mean score of PFDI-20 at baseline was 69.6 (SD 51.1) and at 3 years 56.2 (SD 54.6), (p = 0.001). A deterioration of sexual function was seen among the sexually active women after 3 years with a mean score of FSFI at baseline 25.2 (SD 6.6) and after 3 years 21.6 (SD 10.1), (p < 0.001). However, this was not consistent with the unaltered sexual function for the whole cohort. No difference in pelvic floor or sexual function was detected when comparing robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy. CONCLUSIONS: Three years after surgery robotic assisted laparoscopic hysterectomy, total laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent. Among the sexually active women, a decline of sexual function was seen after 3 years, not consistent with the entire cohort and independent of surgical methods. Whether this is a trend associated with aging or menopausal transition remains to be studied.

Effects of hysterectomy on pelvic floor function and sexual function-A prospective cohort study.

INTRODUCTION: Hysterectomy is one of the most common major surgical procedures in women. The effects of hysterectomy on pelvic floor and sexual function are uncertain. Our objective was to investigate the effects of hysterectomy for benign indications on pelvic floor and sexual function and to compare different modes of surgery. MATERIAL AND METHODS: We performed a prospective clinical cohort study. In all, 260 women scheduled for hysterectomy answered validated questionnaires (Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory and Female Sexual Function Index). Participants were followed 6 months and 1 year after surgery. Data were analyzed using nonparametric statistics and mixed effect models. RESULTS: Women with subtotal hysterectomy, vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy, and previous prolapse/incontinence surgery were excluded from further analysis, leaving the remaining cohort to 242 patients. The response rate at 6 months and 1 year follow-up was 180/242 (74.3%) and 169/242 (69.8%), respectively. There was an improvement of pelvic floor function at both follow-ups; mean score of Pelvic Floor Impact Questionnaire at baseline was 42.5 (51.7), at 6 months 19.9 (42.2) and at 1 year 23.7 (50.3) (p < 0.001). The mean score of Pelvic Floor Distress Inventory at baseline was 69.6 (51.1), at 6 months 49 (43.2) and at 1 year 49 (43.2) (p < 0.001). There was an improvement of sexual function after 6 months (mean score of Female Sexual Function Index at baseline 17.9 [SD 11.7] and at 6 months 21.0 [SD 11.7]) (p < 0.001). There was no difference in pelvic floor or sexual function when comparing surgical techniques. CONCLUSIONS: Robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent at 6 months and 1 year after surgery. There was an overall improvement of sexual function 6 months after hysterectomy, but this did not persist after 1 year.

Peri- and postoperative outcomes in patients with endometriosis undergoing hysterectomy.

OBJECTIVES: To assess whether hysterectomy in patients with endometriosis is associated with higher proportion of complications compared with patients without, and whether route of hysterectomy affects this outcome. STUDY DESIGN: This is a population-based retrospective cohort study. Data were prospectively obtained from three National Swedish Registers. Patients undergoing a benign hysterectomy between 2015 and 2017 in Sweden were included in the study and were grouped according to a histology-proven diagnosis of endometriosis. Different hysterectomy modes were compared in patients with endometriosis. Perioperative data and postoperative complications up to 1 year after surgery were collected and measured. RESULTS: In all, 8,747 patients underwent a benign hysterectomy, and 1,166 patients with endometriosis was compared with 7,581 patients without. Patients with endometriosis had higher proportion of complications (adjusted Odds ratio aOR 1.2, 95% CI 1.0-1.4), were more often converted to abdominal hysterectomy (aOR 1.7, 95% CI 1.1-2.6), had higher estimated blood loss (EBL) (200-500 ml; aOR 1.8, 95% CI 1.4-2.3, >500 ml; aOR 3.1, 95% CI 2.2-4.4) and a longer operative time (1-2 h; aOR 2.1, 95% CI 1.4-3.2, >2 h; aOR 4.3, 95% CI 2.7-6.6) than endometriosis-free patients. The conversion rate was 13.8 times higher in total laparoscopic hysterectomy (TLH) compared with robotic-assisted laparoscopic hysterectomy (RATLH) (aOR 13.8, 95% CI 3.6-52.4). CONCLUSION: Higher conversion rate, higher EBL and higher frequency of complications were seen in patients with endometriosis. RATLH was associated with lower conversion rate compared to TLH.

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

INTRODUCTION: The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume. MATERIAL AND METHODS: All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses. RESULTS: TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9). CONCLUSIONS: RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.

Vaginal hysterectomy and risk of pelvic organ prolapse and stress urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: This study aims to determine the risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery related to mode of hysterectomy focusing on vaginal hysterectomy. METHODS: We performed a nationwide cohort study. Women exposed to hysterectomy on benign indications (n = 118,601) were compared to women unexposed to hysterectomy (n = 579,200). The outcome was defined as first occurrence of POP or SUI surgery. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs) using Cox proportional-hazards models. RESULTS: The greatest risks of POP (HR 4.9, 95% CI 3.4-6.9) or SUI surgery (HR 6.3, 95% CI 4.4-9.1) were observed subsequent to vaginal hysterectomy for pelvic organ prolapse. Having a vaginal hysterectomy for other reasons also significantly increased the risks of POP and SUI surgery compared to other modes of hysterectomy. CONCLUSIONS: Hysterectomy in general, in particular vaginal hysterectomy, was associated with an increased risk for subsequent POP and SUI surgery.

Risk of pelvic organ fistula in patients undergoing hysterectomy.

PURPOSE OF REVIEW: To summarize and describe present knowledge regarding the incidence, cause and risk factors of pelvic organ fistula related to hysterectomy. RECENT FINDINGS: The reported incidence of pelvic organ fistula after hysterectomy ranges from 0.1 to 4% in different studies, and a higher incidence is generally reported after radical hysterectomy compared with hysterectomy on benign indications. Iatrogenic injury to the urinary tract or bowels during surgery, and postoperative infections, are probably the main etiologic factors involved in the pathogenesis of fistula formation subsequent to hysterectomy. Evidence from observational studies suggests that hysterectomy increases the risk for pelvic organ fistula disease compared with women with an intact uterus and that risk factors include laparoscopic and total abdominal hysterectomy, increasing age, smoking, diverticulitis and pelvic adhesions. SUMMARY: In industrialized countries, where pelvic organ fistula is rare owing to advances in modern obstetric care, hysterectomy is an important cause of fistula disease. This review demonstrates that hysterectomy is associated with pelvic organ fistula and describes a number of predisposing factors. Although rarely encountered in a general population, pelvic organ fistula disease may have a devastating effect on all aspects of quality of life and should be considered in the surgical decision at the time of hysterectomy.

Anal incontinence and bowel dysfunction after sacrocolpopexy for vaginal vault prolapse.

INTRODUCTION: This study aimed to determine the prevalence of bowel dysfunction and anal incontinence in relation to vaginal vault prolapse surgery in women hysterectomized on benign indications. METHODS: This is a case-control study where women having had sacrocolpopexy (n = 78) were compared with hysterectomized women without sacrocolpopexy (n = 233) using a bowel function questionnaire and the Cleveland Clinic Incontinence Score (CCIS). RESULTS: Sacrocolpopexy was performed on average 13.7 years (+/-11.1 SD) after the hysterectomy. Sacrocolpopexy was associated with an increased prevalence of rectal emptying difficulties (p = 0.04), incomplete rectal evacuation (p < 0.001), digitally assisted rectal emptying (p < 0.001), and use of enemas (p = 0.001). There was no overall significant difference in mean CCIS when comparing women having had vaginal vault prolapse surgery (CCIS = 2.78 +/- 4.1 SD) with those without (CCIS = 2.1 +/- 3.3 SD, p = 0.1) CONCLUSIONS: Abdominal sacrocolpopexy is associated with obstructed defecation but not anal incontinence when compared to hysterectomized controls without vaginal vault prolapse surgery.

Hysterectomy for benign indications and risk of pelvic organ fistula disease.

OBJECTIVE: To study the association between hysterectomy for benign indications and pelvic organ fistula disease. METHODS: We conducted a nationwide cohort study based on Swedish health care registers. The cohort consisted of 182,641 women having hysterectomy (exposed cohort) and 525,826 women not undergoing the procedure (unexposed cohort) from the Swedish Inpatient Register 1973-2003. The outcome was defined as surgery for pelvic organ fistula disease. We calculated incidence rates for fistula disease and hazard ratios (HRs) with 95% confidence intervals (CIs) as a measure of relative risk. RESULTS: We identified 853 cases of pelvic organ fistula surgery: 469 among the exposed women and 384 among the unexposed. The overall rate of fistula surgery was four times higher in the exposed compared with the unexposed cohort (rate 23.8 and 6.3 per 100,000 person-years, respectively). Overall number needed to harm was 5,700. Compared with unexposed, the risk for fistula disease was more than 20 times higher the first year after surgery (HR 21.2, 95% CI 14.9-30.2). The most common type of fistula was intestinogenital fistula (404 cases, 47%), followed by urogenital fistula (220 cases, 26%). Laparoscopic hysterectomy was associated with the highest rate of fistula surgery, and subtotal abdominal hysterectomy was associated with the lowest (rate 95.9 and 13.7 per 100,000 person-years, respectively). CONCLUSION: Pelvic organ fistula surgery is four times more common in women after hysterectomy compared with women not having the procedure. The highest fistula rates were observed the first year after surgery, after laparoscopic and total abdominal hysterectomy, and among older women. LEVEL OF EVIDENCE: II.

Hysterectomy on benign indications in Sweden 1987-2003: a nationwide trend analysis.

OBJECTIVE: To investigate the annual rates, types and indications for hysterectomy on benign indications in Sweden 1987-2003. DESIGN: A nationwide register-based cohort study. SETTING: The Swedish Inpatient Register. POPULATION: All women hysterectomized for benign disease in Sweden from 1987 through 2003 (n=121,947). MAIN OUTCOME MEASURE: Hysterectomy on benign indications calculated as proportions or rates/100,000 person-years. RESULTS: From 1987 to 1999, the annual overall hysterectomy rate increased from 178 to 232/100,000 person-years. Thereafter, the overall hysterectomy rate declined and phased out around 210/100,000 person-years in 2003, a decrease of 11%. Comprising only 4% of hysterectomies performed in 1987, vaginal hysterectomy increased to 31% in 2003. Rates of vaginal hysterectomy by prolapse indication increased by a five-fold, whereas rates of vaginal hysterectomy by other benign indications increased by a near 20-fold. Total and subtotal abdominal hysterectomy decreased from 63% and 32%, respectively, in 1987, to 48% and 18% in 2003. CONCLUSION: The overall rate of hysterectomy on benign indications has remained reasonably stable in Sweden over the last decade. Major trends involved a considerable decrease in rates of abdominal hysterectomy, increased use of vaginal hysterectomy and increased number of hysterectomies performed for pelvic organ prolapse.

Risk factors for vaginal vault prolapse surgery in postmenopausal hysterectomized women.

OBJECTIVE: The purpose of this study was to identify risk factors for surgery of vaginal vault prolapse in hysterectomized postmenopausal women. DESIGN: We conducted a case-control study. The cases were 117 consecutive postmenopausal hysterectomized women who underwent vaginal vault prolapse surgery at Danderyd Hospital or Karolinska Hospital, Stockholm, between 1996 and 2005. Control participants were 326 age-matched, randomly selected, hysterectomized women with no vaginal vault prolapse surgery, identified from the Swedish Inpatient Register. For participants and controls alike, data on determinants were extracted from patients' records, the Swedish Inpatient Register, and self-report questionnaires. Data were analyzed using nonparametric statistics and logistic regression. RESULTS: The questionnaire was returned by 90 of 117 participants (77%) and 233 of 326 controls (71%). The mean age at response to the questionnaire was 72.8 (+/- 9.7 SD) and 71.3 (+/- 8.7 SD) years for participants and controls, respectively. In a multivariate analysis, the only predictors at a significant level were age at hysterectomy (odds ratio = 1.04, 95% CI: 1.004-1.08), prolapse or incontinence surgery before hysterectomy (OR = 2.8, 95% CI: 1.0-7.7), and prolapse or incontinence surgery before vaginal vault surgery (OR = 9.1, 95% CI: 3.6-23.4). CONCLUSIONS: Postmenopausal women with surgically managed pelvic floor disorders are at increased risk of developing vaginal vault prolapse subsequent to a hysterectomy.

Symptoms of anal and urinary incontinence following cesarean section or spontaneous vaginal delivery.

OBJECTIVE: The objective of the study was to compare the prevalence of incontinence disorders in relation with spontaneous vaginal delivery or cesarean section. STUDY DESIGN: Two hundred women with spontaneous vaginal deliveries only were compared with 195 women with cesarean deliveries only 10 years after first delivery. RESULTS: When compared with cesarean section, vaginal delivery was associated with an increased frequency of stress urinary incontinence (P = .006) and an increased use of protective pads (P = .008) as well as an increased frequency of fecal urgency (P = .048) and gas incontinence (P = .01). At multivariate regression analysis, mode of delivery showed no significant association with incontinence symptoms other than an increased risk for flatus incontinence in women with a history of obstetric anal sphincter injury (odds ratio 3.1; 95% confidence interval, 1.5 to 8.9). CONCLUSION: Incontinence symptoms are more common following spontaneous vaginal delivery when compared with cesarean section 10 years after first delivery. However, cesarean section is not associated with a major reduction of anal and urinary incontinence.

Effects of hysterectomy on bowel function: a three-year, prospective cohort study.

PURPOSE: This study was a prospective evaluation of the long-term effects of hysterectomy on bowel function using self-reported outcome measures on symptoms of constipation, rectal emptying difficulties, and anal incontinence. METHODS: In this prospective cohort study, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on bowel habits and anorectal symptoms preoperatively. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. Follow-up was performed one and three years postoperatively. Data were analyzed by using multivariate regression and nonparametric statistics. RESULTS: The bowel and anorectal survey was answered by 115 of 120 patients (96 percent) after one year and 107 of 120 patients (89 percent) after three years. Abdominal hysterectomy was associated with increased anal incontinence symptoms at one-year (P < 0.01) and three-year follow-up (P < 0.01). Vaginal hysterectomy was not associated with increased anal incontinence symptoms at one year follow-up, although there was a significant increase in incontinence symptoms at the three-year follow-up (P < 0.05). Risk factor analysis indicated that a reported history of obstetric sphincter injury was correlated to an increased risk of developing posthysterectomy anal incontinence (odds ratio, 2.07; 95 percent confidence interval, 1.05-2.87; P < 0.05). There was no significant rise in constipation symptoms or rectal emptying difficulties in either cohort through the follow-up. CONCLUSIONS: Neither abdominal nor vaginal hysterectomy was associated with constipation, aggravation of constipation, or rectal emptying difficulties three years after surgery. Abdominal and vaginal hysterectomy was, however, associated with an increased risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence.